Health Services in The Head Start Annual Reviews

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REVIEWS Further
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Annu. Rev. Public Health. 1994. 15:511-34

Copyright 1994 by Annual Reviews. All rights reserved
HEALTH SERVICES IN HEAD

START
Annu. Rev. Public Health 1994.15:511-534. Downloaded from www.annualreviews.org
E. Zigler
Access provided by Universidad de Antofagasta on 05/26/17. For personal use only.
Department of Psychology, Yale University, New Haven, Connecticut 06520
c. S. Piotrkowski
NCJW Center for the Child, National Council of Jewish Women , New York,
New York 10010
R. Collins
Collins Management Consulting, Inc . , Vienna, Virginia 22180
KEY WORDS: poverty, children, immunization, disabilities, screening
INTRODUCTION
Head Start is a comprehensive federal program for preschool children and

families living in poverty that has four key components: education, social
services, parent involvement, and health. Initiated in the summer of 1 965 ,
it was part of the "War on Poverty" that aimed to ameliorate the inequalities
in housing, education, employment, and living conditions of 35 million
poor Americans. Although many other programs developed during the War
on Poverty did not survive , Head Start did. It represents "one of the major
social experiments in the second half of the twentieth century" in the United
States (9) .
In general, Head Start has tended to enjoy bipartisan support at the
federal , state, and local levels. During Fiscal Year 1993, Head Start served
an estimated 721,000 children and their families in approximately 2000
communities nationwide, with a commitment by the current administration
to provide full funding during this decade for all eligible three-year-old and
four-year-oIds in families living in poverty. In Fiscal Year 1993 the Head
511
0163-7525/94/0510-0511$05.00
512 ZIGLER, PIOTRKOWSKI & COLLINS
Start budget stood at $2 . 8 billion; the proposed expansion would more than
double this budget.
The prospect of dramatic increases in program funding for Head Start
triggered a sharp debate in the Congress and the media over Head Start's
effectiveness. The ensuing controversy centered on whether or not Head
Start produced tangible benefits that justified the investment of substantial
additional Federal funds. Particular attention was focused on the delivery
of health services, because of the premature release of a "working draft"
report from the Office of Inspector General (OIG) of the US Department
of Health and Human Services (25) . The preexisting consensus around the
program's effectiveness thus was subjected to its most serious challenge in
nearly two decades.
The overarching goals of this chapter are to make more widely known
the important role Head Start has played in improving the health of our
nation's economically disadvantaged young children, to dispel some mis
conceptions about the role of health in Head Start, and to provide a
data-based portrayal of the health services Head Start provides. We rely on
published reports and unpublished data, including our own analyses of Head
Start program information.
The chapter is divided into several sections: (a) the historical context of
health services in Head Start; (b) documentation of the well-known adverse
effects of poverty on children's health and the extent to which Head Start,
in fact, serves poor children; (c) a description of the goals, objectives, and
requirements of the health services component of Head Start, including
services for children with disabilities; (d) assessments of the extent to which
Head Start enhances the delivery of health services to poor children; meets
its stated performance standards for the delivery of health services; and
improves health outcomes for poor children; and (e) policy and program
recommendations to improve the Head Start health services structure, as
Head Start prepares to expand.
THE HISTORICAL CONTEXT
Early Head Start was based on a belief that education served as the route
out of poverty. Coupled with the strong environmentalism of the social
sciences of the 1960s that emphasized the primary role of the social
environment in the formation of intelligence, this belief suggested that
environmental "enrichment" could make poor children smarter and therefore
more successful at school. Such naive environmentalism helped contribute
to the mistaken notion that Head Start primarily was a program designed
to raise children's IQ, with consequent positive effects on educational
attainment (40) . Although this mistaken emphasis on IQ has given way to
HEALTH IN HEAD START 513
a broader notion of Head Start's contribution to the developing child's social

competence, the idea that Head Start was a "silver bullet" to raise children's
IQ has had several negative consequences.
First are periodic assaults on the efficacy of Head Start that are based
on mis underst an ding of the comprehensive nature of the Head Start vision
and the Head Start program itself. For example , neglected in discussions
of Head Start's effectiveness are the provision of social services to Head
Start families and the mandated inclusion of Head Start parents in all aspects
of programming, including decision-making (26). Equally obscured in de
bates about the efficacy of Head Start is the leadership Head Start has taken
as a provider of comprehensive health services for preschool children living
in poverty.
Because the public debate over Head Start's effectiveness arose when
this chapter was being prepared, we became concerned that consideration
of the health services component of Head Start was shaped more by myth
than fact. Therefore, we believed it important to address common miscon
ceptions about the historical role of health in Head Start.
Misconceptions Regarding the Role of Health in Head Start

The first misconception is that Head Start has became concerned with health
services only in recent years, shifting from an emphasis on the program's
primary educational goal. In fact, the overall goal of Head Start, as spelled
out in Head Start regulations, is to promote the child's social competence.
This term is used by Head Start to encompass a holistic view of the child
that includes his/her cognitive, linguistic, social, emotional, and physical
development. Consequently, Head Start's four program components are
education, parent invol vement, social services, and health.
This holistic view-which extended to a recognition of the importance
of the child's family-was explicit from the beginning. Health services have
always been an integral part of Head Start's comprehensive services strategy.
The original planning committee for Head Start was headed by Dr. Robert
Cooke, the pediatrician-in-chief at Johns Hopkins Hospital, who recruited
two other pediatricians and a professor of nursing to serve as members (8).
The committee recognized that "environmental enrichment would not be of
much benefit to children who were ill or hungry" (38) and placed "improving
the child's physical health" first in a list of seven program objectives (39).
It urged the Office of Economic Opportunity to consider the whole child
in Head Start's programmatic development, and a health and nutrition
component was built into Head Start from its inception. Another pediatrician,
Dr. Julius Richmond, served as the first national director of Head Start.
The second misconception is that Head Start's health objectives and
requirements are less clear or of lower priority than for other program
components . On the contrary, from the beginning, children were to receive

pediatric and neurologic physical measurements; an assessment of nutrition,
vision, hearing, and speech; and selected tests for tuberculosis, anemia, and
kidney disease (39). The Head Start Program Performance Standards ,
developed from 1972 to 1975 and first published as regulations in 1975
(29), include detailed requirements regarding health services. These Head
Start standards, described below, are comprehensive, operationally specific,
and enforceable.
The third misconception is that there is little objective evidence concerning
Head Start health services. Ironically, more systematic data have been
collected concerning the delivery of health services than for any other of
Head Start's program components. There are also some data concerning
health outcomes . Although, like researchers and policy analysts everywhere,
we always would prefer more documentation to less, the fact remains that
there is ample evidence to draw responsible conclusions regarding the
delivery of health services to poor children in Head Start.
Support for Health Services in Head Start

In the summer of 1965, when Head Start opened its doors to more than
one-half million children, pediatricians were among those volunteering their
time and services. Over the course of one summer, many children who had
never been to a doctor before received physical and dental exams and
inoculations (24) . Mental health services also were viewed as important,
and psychological services were included in early Head Start guidelines. In
the 1960s mental health professionals also volunteered their services to local
Head Start programs (5) .
Throughout most of the 1970s, the Head Start Bureau had a Health
Services Branch headed by a pediatrician that included a nurse, nutritionist,
and-at least for part of that time-a psychologist. In addition, the Head
Start Bureau also had a special educator with responsibility for children
with disabilities. Staff at the Health Services Branch were supplemented by
an extensive training and technical assistance (TlTA) network and numerous
demonstration projects. Through an interagency agreement, the US Public
Health Service Division of Dentistry provided TITA in the monitoring of
Head Start grantees, virtually without interruption, until October 1992 .
Additionally, from 1968 to 1982, Head Start entered into contracts, first
with the American Academy of Pediatrics (24) and then with Westinghouse
Health Systems, to provide medical support to every Head Start program.
From 1982 through 1986, the national Head Start medical, nutrition, and
mental health training and technical assistance support networks were dis
continued. Instead, a variety of different methods were attempted to provide
support through statewide and regional networks, resulting in considerable
vanatIon in the quality of support (32). In 1 987 , the Head Start Health
Services Branch was abolished, thereby further weakening the administrative
infrastructure that supported health services from within Head Start.
From 1 987 until October of 1992, oversight of training and technical
assistance in the medical, nutrition, mental health, and dental services areas
was placed in the Division of Maternal , Child and Infant Health under
interagency agreements (e.g. 15). In addition, separate TITA support ar
rangements were made for Head Start American Indian grantees , generally
in collaboration with the Indian Health Service. The Maternal and Child
Health Bureau was responsible for providing a part-time physician to

supervise a small part-time staff in the areas of dental , nutrition, mental
health, and public health nursing. There was also some support for Head
Start in the Public Health Service Regional Offices. At its peak, each PHS
Regional Office consisted of one full-time generalist coordinator and varying
numbers of part-time specialists andlor consultants covering medical , dental ,
mental health, and nutrition services. The Public Health Service maintained
a consultant pool with names of over 500 consultants who could be called
upon for on-site monitoring or TITA support to Head Start grantees. In
1992 , the Administration on Children Youth and Families initiated a program
with the American Psychological Association to provide volunteer psychol
ogists to local Head Start programs. As of this writing, 525 psychologists
had signed on as volunteers ( 10).
Despite attempts to strengthen the health services TITA and monitoring
efforts , numerous problems resulted from placing responsibility for training
and technical assistance for health services outside the Head Start Bureau
( 1 , 33) . For example, Public Health Service and Head Start Regional Offices
had wide latitude in setting goals for the number of grantees to site visit
for training and technical assistance , with most choosing the lower end of
the 20% to 33% range pennitted. Some Head Start grantees were unaware
of the free health support services available to them.
The last interagency agreement expired in late 1992 and the central TITA
support for Head Start within the Division of Maternal, Child and Infant
Health ceased operations. Infonnal liaison and support arrangements con
tinued at the regional level , but no documentation of these activities nor
the levels of funding or effort were available to us. At the time this chapter
was written, the Head Start Bureau had a Health and Disability Services
Branch with an acting chief. No information was available concerning plans
for future staffing or the provision of health training and technical assistance.
POVERTY AND CHILDREN'S HEALTH

The ill effects of poverty on children's health are well-recognized. Conditions
to which poor children are particularly vulnerable include inadequate prenatal
care; maternal substance abuse; infant mortality; low birthweight; lead

poisoning; AIDS/HIV; poor nutrition; inadequate immunizations; and lack
of access to adequate health care.
Childrcn's hcalth is inextricably linked to maternal health, and poverty
is associated with a host of poor health outcomes and adverse health
conditions for childbearing women. Over 4 . 5 million of the nearly 59.2
million women in the childbearing years of 15-44 had used an illicit drug
in the previous month, according to the 199 1 National Household Survey
on Drug Abuse. Of these women, more than 600,000 had used cocaine and
3.3 million had used marijuana. The highest percentages of crack and other
hard-core drug abuse were among African Americans, the unemployed, high
school dropouts, and inner-city residents (22). Of the 3432 children under
five years of age with Acquired Immune Deficiency Syndrome , 88% of the
diagnosed exposure was traced to a mother with/at risk for HIV (human
immunodeficiency virus) infection, according to data compiled in December
1992 by the Centers for Disease Control and Prevention . The majority of
mothers who transmit HIV to their infants were infected through intravenous
drug use or heterosexual contact with injecting drug users (3).
Poor women are less likely to receive adequate prenatal care and are
more likely to have low-birthweight babies (2500 grams or less). In 1989 ,
one out of four women in the United States received no prenatal care during
their first trimester. Among African American women, over 40% received
no first trimester prenatal care (35). In addition to poverty and inadequate
prenatal care, factors related to low birthweight include low levels of
maternal education, teenage parenthood, poor nutrition , smoking, and sub
stance abuse. Most of these factors represent preventable social conditions
associated with poverty (37). These problems are compounded by alcohol
consumption. Alcohol consumption during pregnancy, especially heavy
drinking, is associated with miscarriage, mental retardation, low birthweight,
and congenital defects, including Fetal Alcohol Syndrome (FAS) and Fetal
Alcohol Effects (FAE) (35) .
The number of low-birthweight babies increased in 1989 to 7% of births ,
the highest level observed in more than a decade. Rates for African American
babies ( 1 3 .2 children per 100) were roughly double the percentage of white
babies (35). Low-birthweight children suffer two to three times as much
from such disabilities as blindness, deafness , mental retardation , learning
disorders, and hyperactivity as normal-weight children. Extremely low
birthweight children (less than 3.5 pounds) need special education at four
times the rate of children born at normal weight (19, 37).
Low birthweight is the leading cause of infant death. The infant mortality
rate in 1991 was 8.9 deaths before age 1, per 1000 births (2) . While this
represents an improvement over the rate in the previous decade, largely as
a result of advances in medical technology (30), the United States still

compares poorly with other developed countries on this indicator of child
health. The risk of being one of the thousands of babies who died in 199 1
was substantially greater for minority children and children living in poverty,
with the mortality rate for African American babies being substantially
higher than that of white babies ( 17 , 30).
Children living in poor families also are at risk for insufficient dietar y
intake, inadequate diet, and limited access to dietary supplements. Pediatric
anemia, which in the majority of cases is ir on-defi ciency anemia, is one of
the most common nutritional problems in the United States. The child with
iron-deficiency anemia may suffer from listlessness, fatigue, headaches, or
dizziness. Chronic anemia can lead to poor growth and weight gain, mental,
and physical sluggishness, heart problems, impaired immune responses, and
inadequate school performance. Infants from poor families are three times
more likely than nonpoor children to be iron-deficient ( 19) .
Poor children also are more likely to live in deteriorated housing; lead
poisoning is one of the greatest environmental health hazards facing them.
The prevalence of lea d poi soning is highest among African American
children living in poor, inner-city areas ( 12, 20) . Lead poisoning has serious
neurotoxic effects on young children. In severe cases, it can cause death
or permanent brain damage (17).
Not only does poverty place children at greater risk for health problems,
but children living in poverty also have less access to health services.
National survey data reveal major differences in the use of health services
by chil dren in poor families. More than one in five of the nation's poorest
children (famil y incomes under $ 10,000 annually) had no physician contact
in 1990 , compared with one in seven high-income children (family incomes
over $35,000) . Low-income children are more than three times as likely as
affluent children never to have received a preventive health examination
(4). During the 19805, immunization rates for young children eroded,
particularly for polio, measles, rubella, mumps, and DPT (diphtheria,
pertussis, and tetanus). In 1992, the percentage of 24-month-olds appropri
ately immunized ranged from 30% in Texas to 84% in Vermont, with the
m ajority of states reporting vaccination coverage below 60% (4).
Moreover, the changing face of poverty means that today's poor children
are faced with new challenges that may compromise their mental health.
Increased violence, homelessness, AIDS, and parental substance abuse affect
not only a child's physical health, but also his or her socioemotional
development.
Some notion of the magnitude of the problem for Head Start children is
available from an exploratory examination of the records of 290 Head Start
children from five agencies in Maine, conducted in 1991-92 (l5a). In th is
sample of children (representing 1 2% of all enrolled children) , 72% had at

least one serious health problem that required follow-up by their families
and by Head Start staff. Two programs had sufficient data regarding
emotional and family problems for analysis . In one program, more than
one out of five children in the sample were being followed by state agencies ,
such as protective services , or were living in foster homes. Many children
in both programs were experiencing serious emotional stress due to family
losses or dysfunction. Most of these children also had chronic health
problems.
Families Served by Head Start

It is clear from the foregoing discussion that children living in poverty are
at-risk for serious health problems. In assessing Head Start' s effectiveness
in improving access to health services for economically disadvantaged
children, it is important to determine if, in fact, Head Start reaches its
targeted population.
Information is available from two principal sources. One source of data
comes from Head Start programs themselves. Each year, local Head Start
programs submit a Program Information Report (PIR) that includes aggregate
program data, periodically including selected information on characteristics
of children and families participating during that operating year.
Based on recent PIR data, Head Start participants can be described as
follows: The median family income of two thirds of the participants is less
than $9000, and 84% of the families have yearly incomes of less than
$ 1 2,000. Two thirds of children served are minorities. Single parents head
55% of the families. Roughly one half of Head Start families receive Aid
to Families with Dependent Children (AFDC) and therefore are eligible for
other child and family services. Over 63% of Head Start children are enrolled
in Medicaid. Approximately 1 3 .4% of Head Start children have diagnosed
disabilities.
Reliable national estimates of children who participated in Head Start
during the years 1 976 through 1 988 also are available from the National
Health Interview Survey (NHlS) administered by the National Center for
Health Statistics. One of the survey questions asks if any child in the family
was ever enrolled in Head Start. The NHIS was administered in 1 988 to a
nationally representative sample of 1 7 , 1 10 households. An analysis of the
1 988 Child Health Supplement to the NHIS (lOa) on children aged five to
seventeen indicated that there were 1 449 Head Start children and 9978
non-Head Start children in that age range in the survey. After weighting,
these NHIS data reflect a representative sample of the children served by
Head Start during the years 1976 to 1988.
The NHIS-CH data indicate that, compared to children who had not been
in Head Start, children who had been in Head Start were: three times as
likely to live in families with incomes below the poverty level (Head Start,
40%; others, 1 2%); half as likely to live in families earning over $20,000
(Head Start, 35%; others , 7 1 %); half as likely to live in households with
both biological parents present (Head Start 34%; others, 61. 5%); twice as
likely to live in one-parent households, generally with their mother (Head
Start, 42%; others 2 1 %); more than twice as likely to have parents with
less than a high school degree (Head Start, 27%; others, 12%); half as
likely to have parents with some college education or training beyond high
school (Head Start, 25%; others, 5 1 %); three times more likely to live in
households where no adult was currently employed (Head Start, 29%; others,
9%); and less likely to live in families where two adults were both employed
(Head Start, 30%; others , 49%).
Both the data from Head Start programs themselves and the NHIS-CH
are consistent in indicating that the Head Start program serves the population
targeted by legislation, with virtually all families having low incomes and
substantial numbers being single parents and families on AFDC. Thus, the
families and children served by Head Start are at-risk for the health problems
associated with poverty described above.
HEAD START HEALTH SERVICES: GOALS,

OBJECTIVES, AND REQUIREMENTS
In pursuit of the overarching goal of facilitating the development of children' s

social competence, the objectives for Head Start health services as set forth
in the Head Start Program Performance Standards (29) are to improve a
child's health and physical abilities, correct physical and mental problems,
enhance access to a nutritional diet and improve a family's attitude towards
health care. According to Head Start regulations, the health services com
ponent of the program include the following objectives:
To provide a comprehensive health services program that encompasses a

broad range of medical, dental, nutrition, and mental health services,
induding handicapped children;
To promote preventive health services and early intervention;
To attempt to link the child's family to an ongoing health care system to
insure that the child continues to receive comprehensive health care even
after leaving the Head Start program.
By focusing on health promotion, prevention, and early intervention,

these goals represent good medical and public health practices. The specific
health services requirements are detailed and comprehensive, as well. Health
services standards and related guidance account for over half of the content
of the 1992 Head Start Performance Standards.
Health promotion activities include health education for parents, children,
and staff. Parents are to be provided with infomlation about available health
resources and are encouraged to become involved in their children's health
care. Head Start programs encourage, and sometimes require, parents to
accompany their children to medical and dental examinations and appoint
ments.
Head Start centers are required to serve breakfast to children who have
not had it at home. Each child in a part-day program must receive meals
and snacks which provide at least one third of daily nutritional needs. In
a full-day program, the child must receive one half to two thirds of daily
nutritional needs. Parents are to receive nutrition education and are to be
advised about food assistance programs. Head Start nutrition services are
closely coordinated with the Food and Nutrition Service of the US Depart
ment of Agriculture (USDA). The standards also require that nutrition
services be based upon identified nutritional needs and problems of the
target population, taking into account nutrition assessment data (height,
weight, hemoglobin/hematocrit) obtained for each child; special dietary needs
and feeding problems, especially of children with disabilities; family eating
habits; and major community nutrition problems. Virtually all Head Start
programs qualify for reimbursement under USDA's child nutrition programs.
Specific provisions focusing on prevention and intervention include re
quirements to obtain a complete medical, dental, and developmental history
of the child and to obtain a thorough medical and dental screening and
examination, conducted by a physician and dentist, respectively. These
health screenings must include growth assessment (weight, height, and age);
vision testing; audiometric and other hearing testing; speech screening;
hemoglobin or hematocrit determination; tuberculin testing; assessment of
current immunization status; and, where indicated, urinalysis and assessments
for sickle cell anemia, lead poisoning, and intestinal parasites. In addition,
screenings must include a focus on the special needs of children with actual
or suspected disabilities. Children with identified medical and dental prob
lems are required to receive treatment for those problems; children with
professionally diagnosed disabilities must receive appropriate special services
(34).
Mental health standards require that a mental health professional be
available, at least on a consultation basis, to Head Start programs. Activities
of the mental health professional should include periodically observing
children; consulting with and training teachers and other staff; assisting in
developmental screening and assessment; assisting in providing special help
for children with atypical behavior or development, including speech;
orienting parents and working with them to achieve mental health objectives;
and advising in the use of other community resources and referrals.
Regulations focused on children with disabilities were issued in 1 993
(lOb), although the legislative requirement that at least 10 per cent of Head
Start enrollment consist of children with professionally diagnosed disabilities
was enacted in 1972. Otherwise, the health services standards described
above have been in effect, with only minor changes, since 1975 . Prior to
that time, similar health services were called for, but did not have the force
of regulations.
In addition to these regulatory provisions, Migrant Head Start serves

children from birth to age six, as do the Comprehensive Child Development
Program demonstrations. A major future shift toward an even more com
prehensive, family-centered health services strategy for Head Start was
foreshadowed in the Head Start Improvement Act of 1 992. This legislation
authorized Head Start to arrange for younger siblings to obtain health
services. At the time this chapter was written , regulations to implement
these provisions had not yet been promulgated.
Funding of Health Services

Head Start grant funds may be used to fund health services, but only as a
"dollar of last resort." Medicaid, including the Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) Program, has been the principal public
program that pays for health services for low-income families and their
children (for a more complete discussion of Medicaid programs, see ( 14,
28) . Today every state must provide Medicaid to all pregnant women and
children under age six with family incomes at 1 33% or below the Federal
poverty level . Also mandated are coverage for preventive and primary care
services-including well-child care-and a portion of outreach activities to
enroll families also are covered. States have some flexibility in determining
which optional services to cover and to set payment rates for providers, so
there is considerable variability among states in their Medicaid programs.
Under the EPSDT Program states also must provide early and periodic
screening for illness and physical and mental conditions; diagnosis and
treatment; and follow-up care and case management to eligible children.
New policy also requires all eligible children aged 6 months to 72 months
to be screened for lead poisoning (12). Since the early 1980s, an interagency
agreement between the Health Care Financing Administration and Head
Start has facilitated reimbursements for certain medical services for Head
Start participants (28).
Despite improvements in Medicaid, not all low-income children and their
families who are potentially eligible are actually enrolled. Neither eligibility
for Medicaid nor having a Medicaid card guarantees access to health care,
for the nonfinancial barriers can be numerous and daunting (e. g. 1 6 , 30).
The complex Medicaid system itself can pose significant barriers. Families
may be denied coverage because of failure to comply with the complex
procedural requirements , such as filling in forms properly and not missing
appointments. States have had particular problems in reaching out and
enrolling eligible children in EPSDT programs and in finding adequate
supplies of pediatricians willing to participate. There is wide variation in
enrollment among states; on average only 39% of eligible children in a state
are enrolled (14). Thus, states are still finding it difficult to fully implement
EPSDT programs.
ASSESSING HEALTH SERVICES IN HEAD START
In 1 993, Head Start grantees and delegate agencies included community

action agencies, city and county government agencies, nonprofit organiza
tions, single-purpose agencies, school systems, Indian Tribes, and other
organizations. Health services typically are provided in coordination with a
diverse system of local health providers, including hospitals, neighborhood
health centers, private physicians and dentists, and community mental health
centers. Indian and Migrant Head Start grantees face special health chal
lenges and tend to collaborate with the Indian Health Service and the Migrant
Health Service.
Above we described the goals and requirements of health services in
Head Start. Those provisions delineate what should be happening, according
to Head Start regulations . This section examines what actually is happening
by focusing on three related questions: Does Head Start improve the delivery
of health services to children living in poverty? Do the health services
delivered meet the Head Start Performance Standards? What is the health
impact of Head Start health services?
Does Head Start Improve the Delivery of Health Services to

Children Living in Poverty?
Available data indicate that Head Start increases access to preventive health
services and treatment for children living in poverty. An early evaluation
of Head Start's health services was conducted by Abt Associates, Inc. ( 1 1 ).
This study examined Head Start's medical , dental, and nutritional sub-com
ponents (not mental health), using a longitudinal experimental design. The
study was conducted at four sites, selected nonrandomly from counties
identified by the US Public Health Service as "underserved" in terms of
medical and dental services. Within each of the four sites , 200 to 300
children eligible to enter Head Start in the fall of 1 980 were recruited for
the evaluation. Groups of children, matched by age and sex, were randomly
assigned to a Head Start experimental or non-Head Start control group.
Although the methodology was generally sound in concept, the researchers
experienced serious operational problems, including differential attrition in
the experimental and comparison groups. There were apparent diffusion
effects, resulting in the comparison group receiving health services they
normally might not have obtained. Nonetheless, the report concluded that
non-Head Start children were less likely to receive preventive services and
treatment for diagnosed or known medical problems than children in Head
Start.
More specifically , Head Start children were more likely to receive medical
examinations and screenings than non-Head Start children. Head Start
ch ildren also were more likely to receive treatment for pediatric health
problems, and there were likely to be fewer problems at the post-test.
Compared to children in the control group, Head Start children also were
more likely to receive dental examinations, to receive more dental services,
to visit the dentist with their families and to make such visits regularly.
The nutritional intake evaluation showed Head Start children who regularly
attended the centers consumed appreciably more calories and protein than
non Head Start children or children who were frequently absent from the
-
centers. Head Start families served meals that were richer in nutrient quality
than non-Head Start families.
The Head Start Synthesis Project, which reviewed over 1 600 published
and unpublished research documents related to Head Start, was one of the
most comprehensive assessments of Head Start's impact (7, 18). Thirty-four
research reports in the area of health care met the criteria for inclusion in
the review. The reviewers concluded that Head Start children received better
dental care and that they were, "considerably more likely than non-Head
Start children to receive medical and dental examinations; speech , language,
and developmental assessments; nutritional evaluations; and biochemical ,
vision and hearing screenings." Head Start children with disabilities also
were successfully "mainstreamed" into the programs (36) .
Almost no Head Start research was supported by the Federal government
during the 1980s. However, one small study stands out as particularly
noteworthy. Hale et al (13) examined the medical records of 40 children
enrolled in Head Start, 18 low-income children on a Head Start waiting
list, and 20 children in a nursery school serving middle-class families. These
groups of children were compared with regard to health screenings and
dental examinations. Moreover, medical records were examined for im
munizations and pediatric check-ups since birth. Although the sample was
not large, the methodology was sound and the inclusion of a middle-class
comparison group (primarily white) is noteworthy.
Findings are consistent with those described above. During the time they
were in Head Start, the Head Start children were more likely than low-income
waiting-list children to receive dental examinations (95% versus 39%) and
age-appropriate health screenings. Head Start children were significantly
more likely than waiting-list children to be screened for lead, hematocrit,
tuberculin, blood pressure, hearing, and vision. Parental motivation as an
explanatory factor for these group differences was ruled out by the fact that
the children of highly involved Head Start parents did not differ from those
of parents with low involvement. Moreover, prior to Head Start, the groups
did not differ in the number of well-child check-ups to age 3. In fact, prior
to Head Start, children of highly involved Head Start parents received fewer
immunizations than the waiting-list low-income children to 18 months of
age. Thus, it appears that, for these low-income children, the formal Head
Start health services delivery system made an important difference in their
access to preventive care.
What is even more striking about the findings is that children in Head
Start fared as well or better than the middle-class children on a number of
indicators! While in Head Start, Head Start children were significantly more
likcly than the middle-class comparison children to receive dental exami
nations (95% versus 75%). Head Start children also were more likely to
receive tuberculin, blood pressure, hearing, and vision screenings than the
middle-class children. Again, the impact of the Head Start program itself
is reflected in the fact that prior to Head Start, the middle-class children
had more well-child physicals by age 3 than the Head Start children and
more immunizations than the Head Start children of highly involved parents.
Along with earlier research, this study also clearly indicates that Head Start
effectively improves access to preventive health services for low-income
children. Although one cannot readily generalize from one study, the findings
also suggest that children in Head Start may be receiving some health
services comparable to those received by middle-class children, at least
while they are enrolled in the program.
Do Health Services Meet the Head Start Performance

Standards?
To address this question, two principal sources of information were used.
The first is the Program Information Report (PIR), completed by all Head
Start programs in June of eaeh year. Categories of the PIR are based on
the Head Start Program Performance Standards, although some subsets of
questions vary annually. One potential drawback of the PIR is that it is
based on program self-report (L Brush, A Gaidurgis, & C Best, unpublished
data). However, these data have been relied upon for many years for such
purposes as internal Federal Head Start management and for reports to
Congress. Although PIR reports reveal dramatic improvements over the past
two decades in health indicators, the national pattern for the past five years
is remarkably stable. We therefore have focused our presentation on selected
performance indicators for operating year 1991-92, which reflect reports
from Head Start grantees and delegate agencies as of June 1992. When
data from previous years must be used, it is noted in the text.
The second source of information comes from the Self Assessment
Validation Instrument (SAVI) or, in its most recent version, the Head Start
On-Site Program Review Instrument (OSPRI).! The OSPRI is based on an
annual self-assessment to be conducted by the Head Start program, supple

mented once every three years by an on-site multidisciplinary team that

visits the program for approximately a week. The on-site team relies on
multiple methodologies, including interviews with staff and parents and a
review of a sample of child and family records, as well as other written
documents. The OSPRI also parallels the Performance Standards and leads
to a judgment of whether or not the grantee is in compliance with a particular
requirement. If found out of compliance, the Head Start grantee must take
corrective action or risk defunding.
Data2 available for Fiscal Years 1991 and 1992 summarize the major
areas of noncompliance with Performance Standards that resulted from
on-site multidisciplinary team visits using the OSPRI (or SAVI). In 1991,
355 grantees were monitored; in 1992, 410 grantees were monitored. Below
we note the major areas ofnoncompliance for Fiscal Year 1992 and provide
the 1991 data for comparison purposes.
It should be noted that the national summary indicates the percentage of
Head Start grantees not in compliance with a particular requirement at the
time of the site visit. This is a very conservative estimate because a grantee
with many Head Start delegate agencies may be found out of compliance
if one delegate agency is.
NUTRITION Data from the 1988-89 PIR indicate that 91% of Head Start
children received complete nutrition screenings. These included growth,
hemoglobin/hematocrit, eating habit, and dietary needs assessment. About
one in six of these children had nutritional problems; two thirds of them
were referred for professional evaluations (about 5% of them were anemic);
and almost three quarters received treatment. On-site evaluations indicated
IOf the 57 pages of program checklists, 22 pages relate to the health component and 5 pages
relate to disabilities.
2Thcsc data arc rcported in an unpublished document, made available by the US Department
of Health and Human Services as an attachment to a Request for Proposal for contractor support
for Head Start training and technical assistance in March, 1993 (Major Areas of Noncompliance:
Head Start Monitoring Tracking System, National Summary).
the following percentages of grantees who were out of compliance with the
nutrition guidelines in Fiscal Year 1992: 2 1 . 5 % were not supervised by a
qualified nutritionist; 16% lacked an organized nutrition education program;
23% did not adequately involve parents in nutrition services; 20% were out
of compliance in assessing nutritional needs and identifying problems using
child assessment data; and 1 7% were out of compliance with regard to
discussing the nutritional status of children with parents. (The comparable
figures for Fiscal Year 1 99 1 were: 24%; 1 3%; 1 7%; 1 3%; 1 1.5%.)
MEDICAL SCREENINGS AND TREATMENT According to the PIR data, 98%

of children in Head Start were medically screened . One out of five children
(22.5%) screened was identified as needing medical treatment. Most children
(96%) who needed medical treatment received it, and eight out of ten (8 1 %)
completed treatment. Data from the on-site monitoring teams indicated that
in Fiscal Year 1 992, 23% were out of compliance with keeping medical
records; 25% were out of compliance with health screenings; 23% were out
of compliance with regard to the treatment of all health problems detected;
18% were out of compliance in their plans for medical and dental emer
gencies; and 25% were out of compliance with having a functioning Health
Services Advisory Committee. (Comparable figures for Fiscal Year 1 99 1
were: 1 8%; 25%; 1 7 . 5 %; 1 3%; 25%.)
DENTAL EXAMINATIONS AND TREATMENT According to the PIR data, more

than nine out of ten (95.5%) children received dental exams. Almost one
third (32%) of the children examined needed dental treatment, and most
(96.5%) of them received it. Eight out of ten (82%) completed treatment.
In Fiscal Year 1 992, 24% of grantees were not in compliance with regard
to dental records. (The comparable figure for Fiscal Year 1991 was 26% ) .
CHILDREN WITH DISABILITIES The PIR data indicate that over one out of
eight children ( 1 3%) enrolled in Head Start had been diagnosed as having
a disability. (These include mental retardation, health impairments, visual
handicaps, hearing impairments , emotional disturbance, speech and language
impairments, orthopedic handicaps, and learning disabilities). This is over
the 1 0% required by the Performance Standards . On-site monitoring teams
found the following levels of noncompliance with Performance Standards
in Fiscal Year 1 992: 1 8% of grantees did not include at least 1 0% of
children with disabilities; in 22%, parents were not adequately involved in
the diagnostic process and in planning an individualized program to meet
the special needs of their child; 18% did not meet requirements for staff
and volunteer training; in 1 5 % , disability conditions were not confirmed by
licensed/certified professionals; and in 1 7 % , individualized services for
defined conditions were not provided according to individual child plans.

(Comparable figures for 1991 were 15 . 5%; 19%, 13%, 17%; 17%. )
IMMUNIZATIONS The PIR data indicate that almost nine out of ten (88%)
Head Start children were fully immunized and an additional 8% were
up-ta-date on their immunizations. Immunization was not indicated as a
major area of noncompliance cited by the on-site review teams. These data
are not seriously inconsistent with those reported recently by the Office of
Inspector General (26), whose report was based on information gathered
from on-site visits or telephone interviews with a sample of 80 Head Start

grantees and delegate agencies. The OIG found that "84% of children are
fully immunized" (25), using the Head Start Program Information Report
criteria for immunization. However, using the definitions of the Centers
for Disease Control and Prevention and the American Academy of
Pediatrics, the GIG report concluded that only 43.5% were fully im
munized.
MENTAL HEALTH According to the PIR data, 2% of children enrolled in

Head Start were referred for mental health treatment, with 77% of them
receiving treatment. On-site monitoring teams indicate that in Fiscal Year
1 992, 1 9 . 5 % of grantees did not have a mental health professional available;
and 2 1 % did not have regular group meetings of parents and staff. (Com
parable figures for 199 1 are 1 5% and 1 7 . 5 % . )
FUNDING According to PIR data, children enrolled in MedicaidJEPSDT

accounted for 63% of total actual Head Start enrollment in 1 991-92. Head
Start programs did succeed in improving their showing on this performance
indicator, rising from 52% in 1 987-88 to 66% in 1 990-9 1, and then declining
slightly . Nine out of ten Head Start children enrolled in MedicaidJEPSDT
received at least some medical services paid for by MedicaidJEPSDT. All
told, four out of ten Head Start children (42%) received medical services
at low or no cost to Head Start. This represents an increase from 30% in
the proportion of children benefiting from services paid for largely by
non-Head Start sources in 1 987-88.
COMMENTS ON HEALTH SERVICES Despite the problems associated with

changes in the health services training and technical support infrastructure
at the federal level (see above), these analyses confirm the important role
Head Start continues to play in providing health services to three- and
four-year-old children in low-income families. Most Head Start children are
brought up-to-date on their immunizations, participate in comprehensive
health screenings, and eight or more out of ten complete the needed medical
and dental treatments, conclusions that are consistent with a recent report
prepared for the Administration on Children, Youth and Families (L Brush,
A Gaidurgis, & C Best, unpublished) .
As indicated by the on-site monitoring teams and the PIR data, the vast
majority of programs appear to comply with Performance Standards with
regard to required health services. The noncompliance reports are deliberately
conservative yardsticks of performance and represent worst-case scenarios .
Because the requirements generally call for 100% compliance, a finding of
noncompliance of a grantee does not mean that no children are receiving
the mandated service. It means only that not all children are receiving the
requisite level of care. It is not uncommon for a grantee to be found out
of compliance because one of the delegate agencies to whom it subcontracts
services for some children might be operating below standard, while other
grantee activities or other delegate agencies are in full compliance.
At the same time, improvements can be made . For example , the early
Abt study ( 1 1) conducted in the 1980s found that record-keeping was a
particular problem. Similarly , the Office of Inspector General's report (25)
underscored preexisting concerns about health record-keeping in Head Start
programs and the need for corrective action. Consistent with the on-site
monitoring data reported above, a review of two studies of 15 Head Start
programs indicated that inadequate record-keeping was the major form of
noncompliance with regard to dental services (L VandeWiele, unpublished).
Problems of record-keeping have been known to those involved with
Head Start for some time. The Head Start Health Coordinators , in a Task
Force Report dated July 1 990, flagged concerns about the quality of health
record-keeping among Head Start programs and made specific recommen
dations to improve the monitoring system , including the PIR and the
SAVI/OSPRI (3 1 ) . The Task Force further recommended that a system of
computerized child health records be developed. The Head Start Bureau is
currently testing a Head Start Family Information System (HSFIS) that
would include computerized child health records, with the objective of using
the grantee's HSFIS data base, in lieu of the PIR, for reporting child health
data at the national levcl.
The Abt study ( 1 1 ) found considerable variability in the quality of
management of health services among the four Head Start sites examined.
But many problems were due, not to the Head Start programs , but rather
to the broader context in which Head Start programs are embedded . Particular
problem areas identified were shortage of follow-up treatment, the inade
quacy of community health delivery systems for low-income children and
their families, the lack of ready availability of Head Start direct funding
for services, and difficulty in obtaining Medicaid funding for services, even
whcn children were eligible. In other words, while the comprehensive health
services program as outlined in the Head Start requirements represents good

practices, Head Start programs face practical problems in meeting them. A
recent study of health needs in Head Start programs in Maine identified
similar problems ( 1 5a) .
Although the researchers in the Abt study deliberately selected medically
underserved communities for the study sample, they still exemplify health
delivery issues that persist. Funding is one example. There have been
important improvements in Medicaid since the Abt study was done , and
current data indicate that six out of ten Head Start children are enrolled in
Medicaid/EPSDT , with most of those children receiving medical services

paid for by Medicaid. Although new opportunities exist under the EPSDT
Program and Public Law 99-457 to fund some of the health services Head
Start provides-such as outreach , case management, transportation, screen
ing and "medical day care"-----<:aseloads for health coordinators can be
excessive and Head Start grantees arc not always able to adequately use
new regulations to fund services (28). For example , a recent survey of
states by the Alliance to End Childhood Lead Poisoning ( 1 2) found that
Head Start programs in only seven states were reimbursed by Medicaid for
lead screening. 3 As another example, a review of two recent studies of 1 5
Head Start programs indicated that, while the dental services received were
generally of high quality-programs provided age-appropriate dental educa
tion, fluoridation , and followed appropriate oral hygiene practices-inade
quate funding was the reason given for being unable to meet every child' s
needs ( L VandeWiele, unpublished) .
What is the Health Impact of Head Start Health Services?

Available data are most sparse here, as evaluations of Head Start have
tended to focus on cognitive, rather than on socioemotional and physical
outcomes (6; E Zigler, unpublished data) . Nonetheless, the data that do
exist are promising. Immunization against childhood infectious diseases is
the single most effective intervention to reduce illness and mortality in
children (27). Given what appear to be high rates of immunization of Head
Start children (according to Head Start PIR reporting criteria) , on its face,
Head Start is effectively promoting positive health outcomes.
The ABT study ( 1 ) found that children in Head Start had less dental
plaque and were more likely to have fillings than control children and that
Head Start children' s diets had higher levels of vitamins A, B 12 , and C,
calcium, magnesium, phosphorus, and riboflavin than those of non-Head
Start children. At post-test, Head Start children were more likely than
3Haie et ai (13) found that fewer than one third of the Head Start children in their small study
were screened for lead.
children in the control group to have no problems identified by a battery

of developmental measures , and Head Start children were less likely to have
speech and language deficiencies. It should be recalled that the study had
some problems with differential attrition from the control and experimental
groups.
The Head Start Evaluation, Synthesis and Utilization Project's review of
early research on health and Head Start also found that Head Start produced
meaningful improvements in physical health, motor coordination, and de
velopment ( 1 8 ) . Head Start children experienced a lower incidence of
pediatric problems and a level of health comparable to more advantaged

children. Head Start children tended to have higher protein , calorie, and
essential nutrient intake and tended to be healthier according to biochemical
indices. Head Start children received better dental care, had fewer cavities
and practiced better dental hygiene. The largest gains in motor development
were for children with physical handicaps and those with developmental
delays. Vogel et al (36) found that speech-impaired Head Start children
showed communication gains of six months over those of nonserved com
parison children.
Head Start can promote mental health in at least two ways: indirectly,
through the program itself as it enhances the social competence of children,
and directly, through the management and treatment of children with
identified psychological problems. Unfortunately, mental health services
remain a neglected area of evaluation. The Head Start Evaluation, Synthesis
and Utilization Project located no evaluations of the Head Start mental
health services component ( 1 8) . A recent review (L. VandeWiele, unpub
lished, 1 992) shows similar gaps , although some innovative programs to
improve mental health services delivery in Head Start do exist and warrant
closer examination. Similarly, health outcomes for Head Start children with
disabilities has been a neglected area of research . A 1 985 study by Roy
Littlejohn Associates identified by VandeWiele reported that six years
following Head Start, mainstream environments generally were not available
to Head Start children with disabilities.
CONCLUSIONS AND RECOMMENDATIONS
As the program expands to serve all eligible children, with over 27 years
of experience Head Start has immense potential to provide a comprehensive,
integrated health services delivery system for young children living in
poverty . OUf analysis of available data leads to the conclusion that children
in Head Start receive more and better preventive health services and treatment
than low-income children not in Head Start. Nutrition, medical and dental
screenings, and the integration of children with disabilities are especially

strong components of the program.
Head Start not only provides some services directly, but it also helps
link children and families to a community network of health services and
to a "medical home" that may lead to ongoing participation in preventive
and remedial health activities (28). This "brokering" function of Head Start
is especially important because of the barriers poor families face in gaining
access to health care. Moreover, Head Start plays an invaluable role in
helping to educate parents about the importance of health promotion and
prevention.
Despite these positive conclusions, the benefits of Head Start still are not
available to the maj ority of children eligible for the program, as Head Start
currently does not serve most eligible children. Moreover, the record of
Head Start's health services is not uniformly successful , as not all enrolled
cbi ldren receive tbe full complement of medical and dental services. These
difficulties have been recognized by the Head Start community for some
time (21) . Although the available data lead us to conclude that Head Start
is effective in ensurin g that most en rol led chil dren are immun ized gi ven,
the importance of immunizations, further research would be especially

welcome to confirm this. The effectiveness of mental health services remains
unknown, and more data are needed on lead screenings and treatment. In
part, what Head Start can deliver is constrained by local health resources .
There i s variation i n what services states pay for, and there are communities
in which Head Start is unable to effectively gain access to the health delivery
system, sometimes because public health agencies may be nonexistent or
underfunded and because insufficient providers are available.
With an eye to improving quality we make the following recommenda
,
tions that focus on strengthening the infrastructure that supports health

services in Head Start and evaluating health services and health outcomes .
1 . The management of the health services component should be strengthened

at the federal , regional, and local levels with:
(a) A full-time Director of Health within the Head Start Bureau, with additional
qualified staff in the areas of nutrition, mental health, disabilities, and health
promotion.
(b) A qualified health coordinator in each Head Start Region, with lines of
reporting and accountability carefully and clearly delineated. Each Regional
federal health coordinator should be supported by expert consultants in the
medical, dental , mental health, nutrition, and disabilities fields.
(c) A qualified nurse or health assistant to serve as a health coordinator for
each Head Start program, with full-time coordinators in Head Start centers
serving 100 or more children, in accordance with the recommendations of the
Head Start Health Coordinators Task Force (31) . This person should function
as part of a multid iscip linary program team that includes qualified staff from
the parent involvement, social services, and education components. The team
should focus services on children and families based upon assessed needs .
2. The Head Start Bureau should establish a Health Services Task Force
to develop a plan for improving the health services component. The
Task Force should concentrate on several areas:
(a) The effects of changes in national health care policy on Head Start.
Currently , Medicaid EPSDT supports an array of preventive services, including
outreach and case management. How will changes in national health care policy
affect these important services?
(b) Technical assistance to Head Start programs to take full advantage of

Medicaid and other public funding sources. This would include a state-by-state
knowledge base of variations in Medicaid outreach and supplemental programs
and other public health services. Such technical assistance will be extremely
important with any changes in national health care policy.
(c) A systematic plan for improving the health services component to accompany
expansion that would emphasize continuity and integration of services. This
plan should be based on all available monitoring and performance data and
data from Head Start demonstrations and special programs . Currently, there
are 32 demonstrations on the transition from Head Start to school . There also
are over 100 Head Start programs that begin at birth . These should be examined
for what can be learned about how best to provide for early , comprehensive,
family-based continuity of health services within Head Start .
(d) Review policies with regard to immunizations. Given the importance of
immunization and the concerns raised by the Office of Inspector General' s
report (25), criteria proposed b y the CDC and American Academy of Pcdiatrics
for immunization should be reviewed to determine if they are appropriate for
Head Start.
(e) An improved record-keeping and monitoring system that would provide a
systematic "report card" on health services . Such an improved system would
include computerizing child and family health records, including immunizations
and health services tracking , preferably as part of an overall child and family
information system. The on-site monitoring system tu determine compliance
with the Performance Standards should be strengthened through the improve
ment of health monitoring tools and training of site visitors that increase
reliability of judgments about the quality of health services.
if) A plan for systematic , planned research on health delivery and on health
outcomes to produce information for policy and program planning. Priority
areas should be Medicaid participation and barriers to it; immunizations,
screenings, and treatment for lead poisoning; and mental health . In the area of
mental health, for example , it is important to know how effective different
types of mental health services are (e . g . case cunsultation, education of staff,
identification of children with problems, outcomes of treatment or referrals for
treatment) .
Head Start has an excellent record overall in helping to deliver health

services to economically disadvantaged children. The proposed expansion
of Head Start provides a unique opportunity to build on this history to
further improve health services for children living in poverty.
Any Annual Review chapter, as well as any article cited in an Annual Review chapter,
may be purchased from the Annual Reviews Preprints and Reprints service.
1800347.8007; 4152595017; email: arpr@cIass.org
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ANNUAL

Annu. Rev. Public Health. 1994. 15:511-34

HEALTH SERVICES IN HEAD

Department of Psychology, Yale University, New Haven, Connecticut 06520

KEY WORDS: poverty, children, immunization, disabilities, screening

Head Start is a comprehensive federal program for preschool children and

THE HISTORICAL CONTEXT

a broader notion of Head Start's contribution to the developing child's social

Misconceptions Regarding the Role of Health in Head Start

components . On the contrary, from the beginning, children were to receive

Support for Health Services in Head Start

Health Bureau was responsible for providing a part-time physician to

POVERTY AND CHILDREN'S HEALTH

care; maternal substance abuse; infant mortality; low birthweight; lead

a result of advances in medical technology (30), the United States still

sample of children (representing 1 2% of all enrolled children) , 72% had at

Families Served by Head Start

HEAD START HEALTH SERVICES: GOALS,

In pursuit of the overarching goal of facilitating the development of children' s

To provide a comprehensive health services program that encompasses a

By focusing on health promotion, prevention, and early intervention,

In addition to these regulatory provisions, Migrant Head Start serves

Funding of Health Services

ASSESSING HEALTH SERVICES IN HEAD START

In 1 993, Head Start grantees and delegate agencies included community

Does Head Start Improve the Delivery of Health Services to

Do Health Services Meet the Head Start Performance

annual self-assessment to be conducted by the Head Start program, supple

mented once every three years by an on-site multidisciplinary team that

MEDICAL SCREENINGS AND TREATMENT According to the PIR data, 98%

DENTAL EXAMINATIONS AND TREATMENT According to the PIR data, more

defined conditions were not provided according to individual child plans.

from on-site visits or telephone interviews with a sample of 80 Head Start

MENTAL HEALTH According to the PIR data, 2% of children enrolled in

FUNDING According to PIR data, children enrolled in MedicaidJEPSDT

COMMENTS ON HEALTH SERVICES Despite the problems associated with

services program as outlined in the Head Start requirements represents good

Medicaid/EPSDT , with most of those children receiving medical services

What is the Health Impact of Head Start Health Services?

children in the control group to have no problems identified by a battery

pediatric problems and a level of health comparable to more advantaged

CONCLUSIONS AND RECOMMENDATIONS

screenings, and the integration of children with disabilities are especially

the importance of immunizations, further research would be especially

tions that focus on strengthening the infrastructure that supports health

1 . The management of the health services component should be strengthened

(b) Technical assistance to Head Start programs to take full advantage of

Head Start has an excellent record overall in helping to deliver health

57 Admin. Child. , Youth Families. Ad

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