Early Childhood Programs: Local Perspectives on Barriers to Providing Head Start Services (Letter Report, 12/21/94, GAO/HEHS-95-8). To gather information on problems that Head Start programs face in trying to provide services, GAO surveyed a sample representing about 46 percent of all Head Start programs nationwide. Head Start program directors identified three barriers as significantly affecting their ability to provide services to children and families: insufficient qualified staff to meet the complex needs of children and families; a limited availability of health professionals in the community willing to help Head Start staff in providing services; and difficulties in getting suitable facilities at reasonable costs. --------------------------- Indexing Terms ----------------------------- REPORTNUM: HEHS-95-8 TITLE: Early Childhood Programs: Local Perspectives on Barriers to Providing Head Start Services DATE: 12/21/94 SUBJECT: Children Disadvantaged persons Head-start programs Preschoolers Child care programs Education program evaluation Personnel recruiting Funds management Aid for education Teacher salaries IDENTIFIER: AFDC Medicaid Program ************************************************************************** * This file contains an ASCII representation of the text of a GAO * * report. 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We are unable to accept electronic orders * * for printed documents at this time. * ************************************************************************** Cover ================================================================ COVER Report to the Chairman, Subcommittee on Children, Family, Drugs and Alcoholism, Committee on Labor and Human Resources, U.S. Senate December 1994 EARLY CHILDHOOD PROGRAMS - LOCAL PERSPECTIVES ON BARRIERS TO PROVIDING HEAD START SERVICES GAO/HEHS-95-8 Early Childhood Programs Abbreviations =============================================================== ABBREV ACF - Administration for Children and Families AFDC - Aid to Families with Dependent Children CAA - Community Action Agency CDA - Child Development Associate Certificate HHS - U.S. Department of Health and Human Services OMB - Office of Management and Budget PIR - Program Information Report Letter =============================================================== LETTER B-252284 December 21, 1994 The Honorable Christopher J. Dodd Chairman, Subcommittee on Children, Family, Drugs and Alcoholism Committee on Labor and Human Resources United States Senate Dear Mr. Chairman: Head Start, a $3.5 billion program currently serving nearly 750,000 children each year, has been the centerpiece of federal early childhood programs for almost 30 years. Head Start is a major factor in ensuring that disadvantaged children start school ready to learn.\1 However, recent concerns have been raised about the uneven quality of Head Start programs. This report responds to your request to identify barriers that Head Start staff believe limit their ability to provide quality services, the extent to which staff believe programs experience these barriers, and the techniques or approaches programs have used to overcome these barriers; and how local Head Start programs use Quality Improvement Funds to enhance and strengthen service quality.\2 To gather information on problems that Head Start programs face in trying to provide services, we surveyed a nationally representative sample of 870 Head Start grantees and delegates from a universe of 1,898 programs.\3 Directors of these programs provided information for school year 1992-93 on staff salaries and fringe benefits, training, facilities, service providers in their communities, and funding--including the use of Quality Improvement Funds. Our overall survey response rate was 76 percent. (See app. II for a full description of our survey methodology and app. III for a copy of our survey instrument.) -------------------- \1 Goals 2000: Educate America Act (P.L. 103-227) states that by the year 2000 all children in America will start school ready to learn. \2 The Head Start Expansion and Quality Improvement Act of 1990 authorized set-aside funds to be used by programs to enhance and strengthen the quality of Head Start services. \3 The 870 grantees and delegates in our survey represent approximately 46 percent of all Head Start programs nationwide. Because only a portion of the universe was selected for analysis, each estimate has a measure of uncertainty, or sampling error, associated with it. The size of the sampling error reflects the precision of the estimate; the smaller the sampling error, the more precise the estimate. Sampling errors for the estimates in this report were calculated at the 95-percent confidence level. RESULTS IN BRIEF ------------------------------------------------------------ Letter :1 Head Start program directors identified three barriers as significantly affecting their ability to provide services to children and families. Over 90 percent of the Head Start directors responding to our survey reported experiencing at least one of the following barriers: insufficient qualified staff to meet the complex needs of the children and families, a limited availability of health professionals in the community willing to help Head Start staff in providing services, and difficulties getting suitable facilities at reasonable costs.\4 More specifically, over 86 percent of Head Start directors reported insufficient qualified staff to provide one or more types of services: education, medical, dental, mental health, disability, nutrition, parent involvement, and social services. According to the directors, the areas most frequently cited as needing more qualified staff were social services, mental health, and parent involvement. Low salaries hamper local Head Start programs' ability to hire qualified staff, particularly teachers. On average, Head Start teachers typically earn less than teachers with similar positions in the community. About 25 percent of the directors indicated difficulty in getting help from health professionals in the community to assist them in providing services. Directors attributed the lack of available health providers and providers' unwillingness to donate services or accept Medicaid as the main reasons why programs had health service related difficulties. About two-thirds of the directors reported difficulties finding space. They cited lack of suitable space, licensing requirements, and high renovation costs as the major obstacles. Program directors reported trying a variety of techniques, sometimes involving Quality Improvement Funds, to help overcome or eliminate some of these barriers. Directors interviewed during our site visits said that they work closely with community medical facilities to ensure that children receive health services, and they negotiate with local public schools for unused space. In addition, survey results showed that the primary use of Quality Improvement Funds during school year 1992-93 was to increase staff salaries and fringe benefits and generally to recruit and retain qualified staff. -------------------- \4 Unless otherwise cited, references to Head Start directors reporting a particular barrier are based on survey results. BACKGROUND ------------------------------------------------------------ Letter :2 Since its inception in 1965, Head Start has provided a wide range of services to over 13 million children and their families nationwide. Head Start is targeted by law to children from poor families, and Head Start regulations require that 90 percent of the children enrolled in each program be low income.\5 All programs must meet performance standards, established by the Department of Health and Human Services (HHS), in the areas of education and medical, dental, nutritional, mental health, and social services.\6 Head Start programs work with various sources in their communities to provide these services. For example, some programs coordinate with Public Health agencies to obtain health services, while other programs contract with local physicians. Another essential part of every program is the involvement of parents in parent education, program planning, and operating activities. Head Start is administered by HHS' Administration for Children and Families (ACF). Services are provided at the local level by public and private nonprofit agencies that receive their funding directly from HHS. These include public and private school systems, community action agencies, government agencies, and Indian tribes. In fiscal year 1993, grants were awarded directly to about 1,400 local agencies (grantees), and the national average Head Start cost per child was $3,758. A grantee may contract with one or more other public or private nonprofit organizations (delegates) in the community to run all or part of its Head Start program. Grantees may choose to provide center-based services, home-based services, or a combination of both. Although Head Start is authorized to serve children at any age before the age of compulsory school attendance, most children enter the program at age four. To serve more children, the federal government has increased Head Start funding annually from 1989 through 1994. In total, increased funding provided services for an additional 263,000 children over the 5-year period. (See app. I for enrollment and funding information.) For fiscal year 1995, $3.5 billion was made available for the Head Start program, an increase of $208 million over fiscal year 1994 funding. Despite expansion efforts, only 17 percent of eligible three-year olds and 41 percent of eligible four-year olds attended Head Start in fiscal year 1993.\7 In addition to providing funds to increase the number of children served, the Congress has increased emphasis on the quality of program services. In 1990, the Congress passed the Head Start Expansion and Quality Improvement Act, which reauthorized Head Start and also set aside funds to be used by programs to enhance and strengthen the quality of Head Start services. The legislation provided that 25 percent of the increase over the previous year's allocated funds be designated for quality improvements. Programs must spend at least one-half of the Quality Improvement Funds to increase staff salaries or fringe benefits. The remainder of the funds may be spent on transportation, hiring additional staff, nonstructural improvements to facilities, and training. Despite the emphasis on quality, some early childhood experts and the Advisory Committee on Head Start Quality and Expansion are still concerned about the uneven quality of some Head Start programs.\8 While research shows a positive correlation between high-quality early childhood programs and positive outcomes on students, most of this research was conducted on programs that have far more resources than the typical Head Start program.\9 In addition, a 1993 report by the HHS Office of Inspector General indicates that programs are facing difficulties in meeting performance standards.\10 This report, based on a random sample of 80 programs nationwide, showed that only 54 percent of children in the programs received complete medical screening, and 47 percent of the families with identified social service needs had all or most of their needs met. The environment in which children live today has changed greatly during the years. About one out of every five children in the United States today lives in poverty, and, for minority children, the segment is almost twice as large--40 percent. Between 1980 and 1990, the number of poor preschool-aged children increased by 28 percent--from 1.1 million to 1.4 million.\11 Research has shown that family income is the most important predictor of children's success or failure in school; children from low-income families are more likely to experience difficulties. Children in poverty are at greater risk for developmental problems resulting from poor maternal nutrition, undeveloped caregiving skills, drug abuse, and unstable family setting. Recent research shows that environmental deficits--such as too little cognitive stimulation and inadequate health care--undermine disadvantaged children's development and affect their school performance. A 1991 study of children whose families were recipients of Aid to Families with Dependent Children (AFDC), the federal assistance program, found that two-thirds of these children did not live in home environments that stimulated their cognitive growth and did not receive sufficient emotional support from their parents.\12 The study revealed similar findings for the children of low-income families that were not receiving AFDC. Other factors associated with low income of families--minimal parent education attainment and single parenting--increase children's risk of doing poorly in school. The parents of poor preschool-aged children are less educated than in the past. Between 1980 and 1990, the number of families in which neither parent had completed high school increased by 20 percent. In addition, during the 1990-91 operating year, more than 50 percent of Head Start families were headed by a single parent. Given these changes in the environment, it is not surprising that Head Start staff encounter children and families with more complex problems requiring urgent and extensive intervention. According to a 1989 report by the HHS Inspector General, the major family problems encountered by Head Start staff were substance abuse, child abuse, domestic violence, lack of parenting skills on the part of teenage parents, and crime-infested, inadequate housing.\13 About 84 percent of the Head Start grantees surveyed by the Inspector General reported increased demands on staff time for such activities as one-to-one counseling, assistance to families, and dealing with troubled children in the classroom. -------------------- \5 The Head Start program uses the Office of Management and Budget (OMB) poverty income guidelines to determine a child's eligibility for services--$14,350 for a family of four in 1993. \6 Head Start Program Performance Standards (45 C.F.R. 1304). \7 Early Childhood Programs: Many Poor Children and Strained Resources Challenge Head Start (GAO/HEHS-94-169BR, May 17, 1994), p.13. \8 The Secretary of HHS initiated a bipartisan task force, the Advisory Committee on Head Start Quality and Expansion, to review the Head Start program and make recommendations. The committee issued a report in December 1993 titled Creating a 21st Century Head Start. \9 For example, the most cited study on the benefits of early childhood education (High/Scope Education Research Foundation study of the Perry Preschool program, 1980) spent almost twice as much per child as expenditures for Head Start programs. In addition, the Perry Preschool had a low child-to-staff ratio, and almost all teachers had advanced degrees in early childhood education. \10 Evaluating Head Start Expansion Through Performance Indicators, HHS Office of Inspector General (OEI-09-91-00762) (Feb. 1993), pp. 8-13. \11 Poor Preschool-Aged Children: Numbers Increase but Most Not in Preschool (GAO/HRD-93-111BR, July 21, 1993), p. 2. \12 Nicholas Zill, Kristin A. Moore, Ellen Wolpow Smith, and others, The Life Circumstances and Development of Children in Welfare Families: A Profile Based on National Survey Data, Child Trends, Inc., (Washington, D.C.: 1991), p. 19. \13 Dysfunctional Families in the Head Start Program: Meeting the Challenge, HHS Office of Inspector General, (OAI-09-89-01000) (Nov. 1989), p. i. HEAD START DIRECTORS SAID STAFFING PROBLEMS HAMPERED SERVICE PROVISION ------------------------------------------------------------ Letter :3 Survey results show that most Head Start directors believe they have insufficient qualified staff to meet the needs of the children and families they serve. The lack of staff leads to large caseloads, which researchers indicate may jeopardize service quality. Moreover, many program directors reported that low salaries hampered their ability to hire qualified staff. Directors also reported that their staff need more training, particularly in the areas of mental health, disabilities, parent involvement, and social services. Through research and interviews, we found that a lack of minimum staff qualifications and maximum caseload requirements also contributed to staffing problems. To help overcome these problems, directors reported increasing salaries and fringe benefits and providing more opportunities for staff training and development. HEAD START DIRECTORS REPORTED A LACK OF QUALIFIED STAFF ---------------------------------------------------------- Letter :3.1 According to our survey data, more than 86 percent of Head Start directors believe that at least one type of Head Start service in their program lacks enough qualified staff. In each of two areas, social services and mental health services, at least 60 percent of the directors reported that they had insufficient qualified staff. (See fig. 1.) Figure 1: Programs Reporting Insufficient Staff by Type of Service (See figure in printed edition.) A lack of qualified staff was a problem for programs of all sizes and all geographic locations. For example, 84 percent of directors from urban programs and 87 percent of directors from rural programs reported insufficient qualified staff. Similarly, directors from small, medium, and large programs all reported a lack of qualified staff--87 percent, 90 percent and 82 percent, respectively.\14 Insufficient staff can lead to large caseloads, which may jeopardize Head Start's ability to provide quality services. Research shows that over half of the Head Start programs have average social service caseloads of 100 or more--at least three times the HHS recommended level of 35 families per social worker.\15 Similarly, about one-third of the programs have average health and parent involvement caseloads of 250 or more. Several researchers have reported that large caseloads limit the number of home visits and family needs assessments staff can conduct.\16 While Head Start requires a minimum of two home visits and one family needs assessment per year, HHS guidance suggests that more family contact is beneficial. As Head Start programs expand to serve more children and families, caseloads of already overworked staff may get even larger, further jeopardizing service quality. -------------------- \14 We defined small programs as those with less than 150 participants, medium programs as those with 151 to 350 participants, and large programs as those with more than 350 participants. \15 Caseload figures prepared by Pelavin Associates, Inc. based on data from the 1992 Program Information Report and the HSCOST system as reported in Head Start Staffing Data, June 1993. \16 Edward Zigler and Susan Muenchow, Head Start: The Inside Story of America's Most Successful Educational Experiment, (New York: BasicBooks, 1992), p. 217. HEAD START DIRECTORS REPORTED THAT LOW SALARIES HAMPER THEIR ABILITY TO HIRE QUALIFIED STAFF ---------------------------------------------------------- Letter :3.2 One reason why programs lack enough qualified staff is that low salaries reportedly hamper their ability to hire qualified staff. Survey respondents indicated that their salaries are often lower than those other employers offer to individuals with similar qualifications and experience their communities. In every service area except nutrition, at least 50 percent of the directors reported that the salaries paid to their staff were lower. (See fig. 2.) Of the directors reporting that their salaries were lower than those offered by other employers in their community, at least 75 percent said it hampered their ability to hire qualified education staff, social service staff, and parent involvement staff. Figure 2: Programs Reporting Lower Salaries by Type of Service (See figure in printed edition.) On average, Head Start teachers typically earn lower salaries than others with similar positions in the community. A 1990 Department of Education study performed by Mathematica Policy Research Inc. showed that the average hourly wage for Head Start teachers was $9.67, or $4.73 less than the average hourly wage of public school-based child care center teachers ($14.40). According to HHS data, the average salary for the most tenured Head Start teachers was $15,039 in 1992, while the average salary for the least tenured teachers was $12,077. Directors we interviewed attributed low salaries to the following: Despite recent increases, salaries have been low for so long that it will likely take quite a while for them to catch up to competitive levels. Because Head Start staff may lack certain qualifications, they are more likely to earn less than other professionals in their fields. While Head Start directors generally have a fair amount of discretion on salary decisions, some are not taking full advantage of this discretion. Several directors from programs administered by community action agencies indicated they were not allowed to raise the salaries of Head Start staff because it would not be fair to the staff of the other community action agency's programs. Low teacher salaries appear to be less of a problem in Head Start programs administered by public schools because in these programs Head Start teachers usually receive the same wages as other teachers in the school system. However, higher wages may lead to other problems. For example, one large program we visited is currently in the process of leaving the local school district because it could not afford to pay the salaries negotiated by the teachers' union.\17 -------------------- \17 Letter to Senator Paul Simon (GAO/HEHS-93-1100, Aug. 25, 1994). HEAD START DIRECTORS REPORTED NEED FOR ADDITIONAL STAFF TRAINING ---------------------------------------------------------- Letter :3.3 In every area, many directors reported a need for additional training to better prepare their staff to handle the multiple problems of dysfunctional families. In both the mental health and disabilities areas, nearly half of the directors reported a need for more staff training, and, in each of the other areas, at least 30 percent of the directors reported a similar need. (See fig. 3.) Head Start directors typically attributed the lack of training to (1) the unavailability of needed courses and (2) insufficient tailoring of available courses to meet the specific training needs of their staff. Figure 3: Programs Reporting Insufficient Training by Type of Service (See figure in printed edition.) OTHER FACTORS CONTRIBUTING TO STAFFING PROBLEMS ---------------------------------------------------------- Letter :3.4 We found that HHS does not require minimum educational qualifications for its nonteaching staff. While a program may have an adequate number of staff, these staff may not be qualified to handle the complex needs of the children and families they serve. The 1990 Head Start Amendments require each classroom to have at least one teacher with a minimum of a Child Development Associate (CDA) certificate or equivalent. However, similar qualifications are not required for staff providing health or social services. Several Head Start staff we interviewed emphasized the need for requirements, similar to the CDA, for health and social service staff because of the complex needs these staff are trying to address. Others believe that staff should have at least a bachelor's or master's degree in their field. However, minimum educational qualifications would likely interfere with Head Start's goal of providing parents with opportunities to participate in the program as paid employees or volunteers. We also found that, with the exception of teaching staff, HHS does not have maximum caseload requirements for other Head Start staff. HHS recommends, but does not require, a caseload of 35 families per social service worker. As stated above, caseloads are well above this level. Without caseload requirements, no mechanism exists for holding local programs accountable for their caseloads. However, reducing caseloads would result in either serving fewer children or hiring more staff, which would increase operating costs. EFFORTS TO OVERCOME STAFFING PROBLEMS ---------------------------------------------------------- Letter :3.5 Many Head Start directors said that they are increasing salaries and benefits and providing more opportunities for staff training and development to help attract and retain qualified staff. They reported spending the majority of their Quality Improvement Funds on increasing salaries and fringe benefits. (See p. 20 for additional information on Quality Improvement Funds.) Further, directors said that they are providing additional opportunities for staff training and development to help reduce staffing problems. To identify specific staff training needs, many directors said that they have started conducting periodic training needs assessments. To help meet the identified needs, many directors reported coordinating efforts with local training providers, such as community colleges, and conducting in-house training sessions. HHS ACTIONS TO ADDRESS STAFFING PROBLEMS CITED BY HEAD START DIRECTORS ---------------------------------------------------------- Letter :3.6 HHS officials agreed that staffing problems have hampered the ability of local Head Start programs to provide services. To help with staffing problems and improve program quality, the Department provided $344 million in discretionary funds to local programs in fiscal year 1994.\18 HHS urged programs to consider the following areas in applying for funds: Does the local program have sufficient staff to meet the increasing complex needs of Head Start families, particularly in the service areas of social services and parent involvement? (The Department cited the Advisory Committee's recommended goal of a ratio of at least 1:35 for staff who work directly with families.) Are staff wages reasonable and competitive, and do programs provide adequate fringe benefit packages in order to attract and retain qualified and competent staff? Do staff have access to training that will help them better meet the needs of the families they serve? While HHS lacks specific information on how individual programs improved quality, an additional 4,000 staff were hired by local Head Start programs this year, many of which were family service workers who provide social services to children and families. Further, each Head Start staff received at least a 2.7-percent salary increase. In addition, the officials recognized that nonteaching Head Start staff do not have minimum qualifications, which can impact quality. They stated that this issue will be addressed in fiscal year 1995 as a result of requirements in the 1994 Head Start reauthorization legislation to update staffing patterns and identify competency-based credit (similar to teacher CDA requirements) for family service workers providing social services. -------------------- \18 This amount was in addition to the legislatively mandated set-aside amount of $119 million to be used for quality improvements. SOME HEAD START PROGRAMS FACE DIFFICULTIES IN GETTING SERVICES FROM LOCAL HEALTH PROFESSIONALS ------------------------------------------------------------ Letter :4 An important premise of Head Start has always been community involvement in helping meet the needs of children and their families. However, some Head Start directors reported that it is difficult to get support from the community to ensure children's required services. About one-fourth of Head Start programs, accounting for over 150,000 children, had difficulty getting help from local health professionals in the community. Directors of large programs reported difficulty more often than directors of small ones--29 percent of large programs compared to 14 percent of small programs. However, statistically significant differences were not apparent between urban and rural programs. Head Start directors reported that these difficulties were due to (1) the lack of available resources in the community and (2) the reluctance of health professionals to accept Medicaid reimbursements to treat Head Start children.\19 In addition, some directors we interviewed told us that health professionals are less willing to donate services than they were in the past. To ensure access to health services, some programs have had to pay directly for services, develop in-house expertise, or transport children long distances to services. Head Start Performance Standards require programs to provide a thorough health screening for each child enrolled in the Head Start program. Health screenings include assessments of dental, disability, medical, and mental health needs. While many programs provide initial assessments, they typically rely on the community for the more complicated screenings and much of the follow-up care. A 1993 HHS Inspector General report showed that, while programs completed a high percentage of medical and dental assessments, a much smaller percentage provided the full range of assessments.\20 For school year 1991-92, only 54 percent of children received all required health screening assessments. In addition, the report showed that children did not receive all the necessary follow-up treatment. Only 76 percent of Head Start children had all their medical needs met, and 67 percent of children had all their dental needs met. The Inspector General also reported that directors from these programs cited diminishing community support as a major concern in meeting program requirements.\21 Nearly all of the 25 percent of directors who, in our survey, reported difficulties in getting help from the local community attributed this to the unavailability of health professionals. Several directors we interviewed said that health professionals do not open practices in some of the poorer and more rural areas. One director attributed this to the low wages offered in rural communities. Another director from a rural area said she found a dentist in town willing to provide screenings, but she could not find one to provide follow-up care. About 30 percent of the children in her program require follow-up treatment each year with a pediatric dentist. These children, accompanied by a parent, must be bused 50 miles for such dental care. Another problem Head Start directors reported is the reluctance of health professionals to accept Medicaid payments for Head Start children. Over 75 percent of the directors having difficulty getting community support reported a reluctance by medical and dental providers to accept Medicaid. Head Start directors we interviewed attributed these difficulties to the added expense of processing Medicaid paperwork and delays in reimbursement for services. One director told us that a local dentist's office said that if it accepted Medicaid patients it would have to hire a full-time person just to handle the paperwork involved in getting reimbursed for services. The Physician Payment Review Commission also found that low reimbursement for Medicaid services and paperwork and billing concerns were the major reasons why medical providers are reluctant to accept Medicaid patients.\22 The Commission found that only 65 percent of physicians who were accepting new patients agreed to take Medicaid patients in 1992. Further, some directors we interviewed saw a decline in the number of health professionals willing to donate services to Head Start children and their families. In the past, programs usually had several sources of free or low-cost services, and people were more willing to pull together to help the poor. Several directors we interviewed noted that health professionals have become overextended because of greater needs in the community as a whole. For example, several directors said that it is difficult to get a contract for mental health services because of increasing demand. As a result, their clients face waiting lists for mental health services. In addition, because of recent increases in Head Start funding, some health professionals perceive Head Start as a wealthy program today and now expect to receive payment for their services. To cope with the lack of community support, Head Start directors tried various approaches, including establishing staff positions to provide in-house screening and counseling services, paying directly for health services, transporting children long distances for services, making arrangements with university medical centers to provide needed health services, coordinating with local school districts for health screening, creating "shared" staff positions for disability services with other agencies because the pool of disability specialists is limited, securing donations from corporations and local businesses for substance abuse programs and family support groups, and obtaining agreements with mobile dentists who bring equipment to the Head Start center to provide dental screenings. While some of these methods help to ensure service provision, they may raise Head Start's costs for providing services to children and their families. -------------------- \19 The reluctance of health professionals to accept Medicaid is a problem because many Head Start children qualify for Medicaid coverage. \20 Evaluating Head Start Expansion Through Performance Indicators, p. 8. \21 Head Start Expansion: Grantee Experiences, HHS Office of Inspector General (OEI-09-91-00760) (Washington D.C.: 1992), p. 10. \22 Annual Report to Congress, Physician Payment Review Commission (Washington D.C.: 1994). The Commission reports annually on issues related to health system reform as well as Medicare and Medicaid policy. HHS ACTIONS TO ADDRESS PROBLEMS IN GETTING HELP FROM HEALTH PROFESSIONALS -------------------------------------------------------- Letter :4.0.1 HHS officials recognize that some programs continue to have difficulty getting services from local health professionals, which can impact Head Start's ability to provide services to all children and families. To help local programs get cooperation from local health care professionals, HHS officials told us that they are exploring the feasibility of advance payment to health care providers for services covered under Medicaid. If Head Start is allowed to provide advance payment, the Department believes more health providers would be willing to accept Medicaid. In addition, the Department plans to emphasize coordination at the national level with various health care groups in fiscal year 1995. HHS officials believe that developing better coordination with health care groups at the national level will result in better coordination and commitment at the local level in providing health services to Head Start children and families. HEAD START DIRECTORS REPORTED DIFFICULTIES FINDING SUITABLE SPACE ------------------------------------------------------------ Letter :5 Although providing appropriate facilities is an essential component of program quality, finding such space is difficult for many Head Start programs. On the basis of our survey results, we estimate that about 1,300 programs tried to rent or purchase space in school year 1992-93, and about two-thirds of those programs had difficulty doing so. Programs nationwide had difficulties finding space, regardless of whether they were in urban or rural areas. Survey respondents cited a limited number of facilities suitable for preschool-aged children located in the areas that Head Start serves. When they did find space, respondents said that they struggled to meet licensing requirements or pay for costly renovations needed to upgrade facilities into suitable Head Start classrooms. According to Head Start officials we interviewed, difficulties in finding space impact services for some children and impede Head Start efforts to expand services to more children. To ensure that suitable classroom space is found, survey respondents told us they have coordinated with local school districts, federal agencies, and other community resources. SUITABLE SPACE IN THE COMMUNITY IS LACKING ---------------------------------------------------------- Letter :5.1 According to survey results, about 95 percent of the directors reporting difficulties renting space during school year 1992-93 cited lack of available space in their community as a reason. When rental space is available, often it is not suitable for Head Start needs. Head Start Performance Standards require buildings to be located in safe environments for children and have appropriate playground space. In addition, buildings must be functional for early childhood learning, which includes sufficient space, lighting, ventilation, heat, and other health and safety standards. Finally, buildings must be located in an area that is zoned for an early childhood program. According to Head Start officials we interviewed, few available buildings, especially in high poverty areas, meet these requirements. Before 1992, Head Start programs were prohibited by law to build or purchase their own facility. As a result, programs either leased space in the community or relied on local landlords to donate space. However, according to Head Start experts, many churches and schools where Head Start centers have traditionally been located are reclaiming previously donated space, forcing many Head Start programs to look for alternative space in the community. LENGTHY PROCESS OF MEETING LICENSING REQUIREMENTS DELAYS PROGRAMS ---------------------------------------------------------- Letter :5.2 While licensing requirements for facilities are important to ensure a high-quality Head Start program, meeting the various licensing requirements can be lengthy and difficult. About 80 percent of the directors that reported difficulty renting space cited licensing requirements as a reason. According to program directors we interviewed, licensing requirements are lengthy and burdensome and have delayed the opening of new centers and forced other centers to relocate. For a Head Start facility to be licensed, it must meet a variety of federal, state, and local child care requirements, as well as county and municipal fire and safety codes. A Head Start director in one state we visited said that the licensing process in her area generally takes up to 9 months and requires approval from four different city agencies. Another director we visited told us that it took over 2 years to get her center licensed. She said the lengthy delays and paperwork made it difficult for her to negotiate with landlords to secure space. Even after centers are licensed, meeting licensing requirements is a continual process. Programs are periodically--as often as once every 2 years--reviewed to ensure that they continue to meet licensing requirements. Head Start directors we interviewed told us that licensing requirements often change from year to year, forcing some programs to look for alternative space. In one state, Head Start officials told us recent changes to state licensing requirements, including specific requirements for stairway size and room ventilation, will force many Head Start programs to vacate their space and relocate. Another director told us her program was forced to vacate a newly renovated center because of a new local fire code that restricts Head Start from using two-story buildings. This program must find facilities for almost 500 children with few space alternatives available. While Head Start directors we interviewed are concerned that meeting licensing requirements may increase the cost of finding and operating Head Start facilities, they also agree that a high-quality and safe learning environment is an important goal of Head Start. RENOVATING AVAILABLE SPACE IS COSTLY ---------------------------------------------------------- Letter :5.3 Even when space is available, sometimes renovation costs are so high the space cannot be used. Directors in over 90 percent of the programs that had difficulties renting cited high renovation costs as a reason. Many of the buildings in areas that Head Start serves have inadequate plumbing, low ceilings, poor lighting, and asbestos and lead paint problems, which are very costly to fix. For example, one Head Start program we visited had rent-free space available but could not use it because of asbestos problems. The Head Start program could not afford the estimated $210,000 to remove the asbestos. Head Start spends millions of dollars each year renovating space it does not own. While HHS does not collect data on the total dollar amount spent on renovations, one HHS official estimated that Head Start spends $20 to $30 million each year. However, because of short-term leases, Head Start programs have little control over long-term use of these buildings. According to the National Head Start Association study on facilities, the average lease agreement is between 1 to 3 years, and about half the Head Start programs vacated at least one center in the past 3 years. Once a facility is renovated, landlords sometimes refuse to renew Head Start's lease. The Association estimates that Head Start spent $13 million between 1987 and 1990 to renovate buildings Head Start no longer uses. DIFFICULTIES FINDING SUITABLE SPACE DELAY SERVICES AND EXPANSION ---------------------------------------------------------- Letter :5.4 The difficulties associated with finding suitable space delay services to some children and impact future plans for expansion. Head Start directors we spoke with said it can take from 6 months to 2 years to locate space, causing Head Start centers to delay opening. One of the country's largest Head Start programs delayed opening several new centers scheduled to serve about 3,000 children. Centers scheduled to open in the fall did not open until the following spring. According to regional HHS officials, delays result in fewer services to children, and in some cases, parents lose interest in the program by the time the center opens and do not enroll their children. Head Start directors we interviewed were also concerned that finding classroom space will become more difficult and may impede future expansion plans as Head Start moves toward expanding services to more children. In 1992, the HHS Inspector General reported that nearly all programs, in a random sample of 80 programs, believed that locating adequate facilities will be the biggest challenge facing their programs during expansion.\23 -------------------- \23 Head Start Expansion: Grantee Experiences, p. 7. EFFORTS TO OVERCOME DIFFICULTIES LOCATING SPACE ---------------------------------------------------------- Letter :5.5 According to survey results, Head Start programs that located space coordinated efforts with other resources in the community. Several programs negotiated with local schools for classroom space or school buildings no longer in use. Directors of programs we visited also told us that coordinating efforts with other community resources helped locate space. For example, several directors we interviewed said that the Department of Housing and Urban Development was a good resource to coordinate efforts with because of their experience with space in high-poverty areas. Several directors we spoke with negotiated with the Department of Defense for use of vacant buildings on closed military bases. In addition, the Congress passed legislation in 1992 to help Head Start programs overcome difficulties in finding space. The Head Start Improvement Act allows Head Start programs to purchase existing facilities. However, our survey showed that less than 25 percent of the programs even attempted to purchase space during school year 1992-93. Head Start directors told us they did not want the liability or the long-term maintenance required with owning a building. In 1994, the Congress passed legislation allowing Head Start programs to build new facilities, but it is too early to determine what impact this legislation will have. HHS ACTIONS TO ADDRESS FACILITY PROBLEMS CITED BY HEAD START DIRECTORS ---------------------------------------------------------- Letter :5.6 HHS officials agreed that local programs often face difficulties in locating usable space. According to the HHS officials, facility issues will be a major emphasis in fiscal year 1995. They believe that facility options available to programs, such as long-term leasing without taking title to the property, purchasing, and construction, will alleviate many difficulties. The Department has established a facilities work group to ensure that local programs know about the various facility options and how to use them. While the HHS officials strongly support high standards and licensing requirements, they are often frustrated by the inspection process for licensing. They stated in many cases that the delays occur due to a lack of staff at the local and state agencies responsible for inspecting and licensing facilities. HEAD START DIRECTORS REPORTED QUALITY IMPROVEMENT FUNDS USED PRIMARILY TO IMPROVE SALARIES AND BENEFITS ------------------------------------------------------------ Letter :6 According to our survey results, nearly all Head Start programs received Quality Improvements Funds during school year 1992-93. These funds were used primarily to improve the salaries and benefits of Head Start staff. On average, programs spent 58 percent on either salary increases or fringe benefits (41 percent for increasing staff salaries and 17 percent on improving or providing new fringe benefits). In addition, programs spent on average 16.7 percent on hiring new staff, 7.9 percent on purchasing equipment, 4.4 percent on renovating space, 2 percent on providing transportation, 2.6 percent on training, and 8.4 percent on other purposes. (See fig. 4.) Figure 4: How Programs Used Quality Improvement Funds During School Year 1992-93 (See figure in printed edition.) Head Start directors maintained that Quality Improvement Funds are important for improving program quality. For example, they indicated that Quality Improvement Funds help them attract and retain more qualified staff, increase staff morale, provide more services to children, and improve the quality of classroom facilities. Directors said they hope Quality Improvement Funds will continue, and many believe these funds should be increased. HHS officials told us that, in addition to Quality Improvement Funds, programs received $344 million in discretionary funds in fiscal year 1994 to improve program quality. While the Department did not have specific information on the impact of these funds, they believed the funds helped local programs reduce turnover by increasing salaries and adding new staff and upgrade facilities by purchasing classroom and playground equipment. ---------------------------------------------------------- Letter :6.1 We conducted our work between February 1993 and September 1994 in accordance with generally accepted government auditing standards, except we did not obtain written agency comments on this report. However, we did discuss a draft of this report with HHS officials. They generally agreed with our findings. As arranged with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days after its issue date. At that time, we will send copies of this report to the Secretary of Health and Human Services and other interested parties. Should you have any questions or wish to discuss the information provided, please call me at (202) 512-7014. Other GAO contacts and staff acknowledgments are listed in appendix V. Sincerely yours, Linda G. Morra Director, Education and Employment Issues HEAD START ENROLLMENT AND FUNDING FISCAL YEAR 1989-1995 =========================================================== Appendix I (in mill ions Year ) ------------------------------------------------ ---- ---- 1989 450, $1,2 970 35 1990 540, $1,5 930 52 1991 583, $1,9 471 52 1992 621, $2,2 078 02 1993 713, $2,7 903 76 1994 740, $3,3 300 26 1995 NA\a $3,5 34 ------------------------------------------------------------ \a Not applicable. GAO'S SURVEY METHODOLOGY ========================================================== Appendix II QUESTIONNAIRE DEVELOPMENT AND PRETESTING -------------------------------------------------------- Appendix II:1 We designed a questionnaire to obtain information about the barriers Head Start programs faced during the 1992-93 school year. We discussed development of the questionnaire with several Head Start directors, regional Health and Human Services staff, and representatives from the National Head Start Association. In addition, some of these individuals reviewed drafts of our survey. Before mailing our questionnaire, we conducted eight pretests--three in California, four in Michigan, and one in Washington, D.C.--involving Head Start directors from 14 different programs. These directors represented programs from a range of sizes, geographic locations, and administrative structures. Using the pretest results, we revised the questionnaire to try to ensure that (1) respondents would easily be able to answer the questions and (2) all questions were relevant, clear, and free from bias. SAMPLE DESIGN -------------------------------------------------------- Appendix II:2 Using the 1992-93 Program Information Report (PIR), a database of self-reported information for all Head Start grantees and delegates nationwide, we identified 1,898 directly operated Head Start programs. Because our goal was to receive enough responses to analyze the results by various types of programs, we chose a stratified, random sampling design. On the basis of information in the PIR, we stratified the 1,898 programs by type of administrative structure.\24 We developed weights for estimation based on the ratio of the sample to the universe in each stratum. After drawing random samples from each stratum, we had a total of 870 programs for our survey. In February 1994, we mailed the questionnaire to the 870 grantees and delegates in our sample. To encourage participation and increase response rates, we mailed a second copy of the questionnaire to all nonrespondents in early April and a third copy in early June. -------------------- \24 The types of administrative agencies are (1) community action agencies, (2) school districts, (3) public and private nonprofit organizations, (4) government agencies, and (5) Indian tribes. SAMPLE ADJUSTMENT AND RESPONSE RATE -------------------------------------------------------- Appendix II:3 From the 870 questionnaires we mailed, we received 654 valid responses. Based on returned questionnaires, we adjusted our sample size to 855 to exclude 15 grantees that delegated management of all of their centers and did not directly manage any portion of their program. The 654 valid responses resulted in an overall response rate of 76 percent. VERIFICATION OF SURVEY DATA -------------------------------------------------------- Appendix II:4 While we did not verify the information obtained through the survey, we did the following to reasonably ensure that the information gathered through our survey accurately described the programs. We reviewed relevant literature on Head Start and early childhood education to supplement the data collected in our survey. (See app. IV for a bibliography of related literature.) We contacted or visited Head Start programs in 18 states and interviewed officials from the Department of Health and Human Services in 9 of the 10 federal regions. We judgmentally selected the sites to reflect differences in program size, geographic location, and type of administrative agency. (See app. V for a list of sites we contacted or visited.) We also discussed our work with representatives from the National Head Start Association. SAMPLING ERRORS -------------------------------------------------------- Appendix II:5 Statistical sampling allows us to draw conclusions about a population on the basis of information from a randomly selected sample of that population. The data used in this report are estimates, therefore, based on a sample of Head Start programs. Each estimate has a measure of uncertainty, or sampling error, associated with it because only a portion of the universe was selected for analysis. The size of the sampling error reflects the precision of the estimate; the smaller the sampling error, the more precise the estimate. Sampling errors for the estimates in this report were calculated at the 95-percent confidence level. This means that the chances are about 19 out of 20 that the actual percentage (or number) being estimated falls within the range defined by the estimate plus or minus the sampling error. For example, if we estimated that 30 percent of the Head Start programs had a particular characteristic and the sampling error for that estimate were 4 percentage points, there would be a 95-percent chance that the actual percentage is between 26 and 34. Unless otherwise noted, sampling errors for the estimates in this report do not exceed +/- 6.3 percentage points. SURVEY INSTRUMENT ========================================================= Appendix III In this section, we present our survey instrument and a summary of the responses. Each question includes the weighted summary statistics and the unweighted actual number of respondents that answered each question. In each case, we use the format we believe best represents the data, including frequencies, medians, means, and ranges. (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) SITES CONTACTED OR VISITED ========================================================== Appendix IV HHS REGIONAL OFFICES -------------------------------------------------------- Appendix IV:1 Region I - Boston, Mass. Region II - New York, N.Y. Region IV - Atlanta, Ga. Region V - Chicago, Ill. Region VI - Dallas, Tex. Region VII - Kansas City, Mo. Region VIII - Denver, Colo. Region IX - San Francisco, Calif. Region X - Seattle, Wash. HEAD START PROGRAMS -------------------------------------------------------- Appendix IV:2 REGION I ------------------------------------------------------ Appendix IV:2.1 Center Inc. - Cambridge, Mass. Citizens for Citizens, Inc. - Fall River, Mass. Holyoke/Chicopee Head Start, Inc. - Holyoke, Mass. Community Teamwork, Inc. - Lowell, Mass. Community Action Program Belknap-Merrimack Counties - Concord, N.H. C.H.I.L.D., Inc. - Warwick, R.I. REGION II ------------------------------------------------------ Appendix IV:2.2 East Orange Child Development Corporation - East Orange, N.J. Leaguers Inc. - Newark, N.J. Westchester Community Opportunity - Elmsford, N.Y. Washington County Head Start - Hudson Falls, N.Y. Chautaqua Opportunities Inc. - Jamestown, N.Y. Bloomingdale Family Program, Inc. - New York, N.Y. Council for Preschool Children - Rio Piedras, P.R. Municipality of Bayamon - Bayamon, P.R. REGION IV ------------------------------------------------------ Appendix IV:2.3 Randolph County Board of Education - Cuthbert, Ga. Dekalb County Economic Opportunity Authority - Decatur, Ga. Southwest Georgia Community Action Council - Moultrie, Ga. Concerted Services, Inc. - Waycross, Ga. REGION V ------------------------------------------------------ Appendix IV:2.4 Chicago Department of Human Services - Chicago, Ill. Macomb County Community Services Agency - Clinton Twp., Mich. Saginaw County Child Development Centers Inc. - Saginaw, Mich. Wayne County Regional Education Service Agency - Wayne, Mich. Wayne/Westland School District - Westland, Mich. Washtenaw County Community Services - Ypsilanti, Mich. REGION VI ------------------------------------------------------ Appendix IV:2.5 Child Development, Inc. - Russellville, Ark. Regina Coeli Child Development Center - Covington, La. Dona County Head Start - Las Cruces, N. Mex. Day Care Assoc. of Fort Worth/Tarrant Counties - Fort Worth, Tex. Parent and Child, Inc. - San Antonio, Tex. Terrell Independent School District - Terrell, Tex. Economic Opportunity Advancement Corporation - Waco, Tex. REGION VII ------------------------------------------------------ Appendix IV:2.6 Mid-Iowa Community Action, Inc. - Marshalltown, Iowa Northeast Kansas CAP - Hiawatha, Kans. Economic Opportunity Foundation, Inc. - Kansas City, Kans. Missouri Valley Human Resource Development - Marshall, Mo. Hall County Human Resources - Grand Island, Nebr. REGION IX ------------------------------------------------------ Appendix IV:2.7 Neighborhood House Association - San Diego, Calif. Long Beach Unified School District - Signal Hill, Calif. REGION XII - MIGRANT PROGRAMS ------------------------------------------------------ Appendix IV:2.8 East Coast Migrant Project - Arlington, Va. GAO CONTACTS AND STAFF ACKNOWLEDGMENTS =========================================================== Appendix V GAO CONTACTS --------------------------------------------------------- Appendix V:1 Robert Rogers, Assistant Director, (313) 256-8011 ACKNOWLEDGMENTS --------------------------------------------------------- Appendix V:2 The following team members also contributed to this report: Karen Barry, Donna Bright Howard, John Leahy, and Laura Miner-Kowalski, Evaluators; Joel Grossman, Clarita Mrena, and Mark Vinkenes, Survey Design Specialists; and Kathy Ward, Technical Specialist. BIBLIOGRAPHY ============================================================ Chapter 0 Annual Report to Congress, Physician Payment Review Commission. Washington, D.C.: 1994. Besharov, Douglas J. "A New Start For Head Start." American Enterprise, Vol. 3, Mar.-Apr. 1992, pp. 52-59. Brady, Joanne P., and Irene F. Goodman. Lessons Learned: Head Start's Experience with State Activities. Education Development Center, Inc. Newton, Mass.: 1991. Cole, O. Jackson, and Valora Washington. "A Critical Analysis of the Assessment of the Effects of Head Start on Minority Children." Journal of Negro Education, Vol. 55, No. 1 (1986), pp. 91-106. Collins, Raymond C. Head Start Facilities Study. National Head Start Association. Vienna, Va.: 1992. Creating a 21st Century Head Start: Final Report of the Advisory Committee on Head Start Quality and Expansion. U.S. Department of Health and Human Services. Washington, D.C.: 1993. Early Childhood Education: What Are the Costs of High-Quality Programs? (GAO/HRD-90-43BR, Jan. 24, 1990). Early Childhood Programs: Many Poor Children and Strained Resources Challenge Head Start (GAO/HEHS-94-169BR, May 17, 1994). Evaluating Head Start Expansion Through Performance Indicators. U.S. Department of Health and Human Services, Office of Inspector General (OEI-09-91-00762), Feb. 1993. Head Start Expansion: Grantee Experiences. 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Brooks-Gunn, Elizabeth Schnur, and others. "Are Head Start Effects Sustained? A Longitudinal Follow-up Comparison of Disadvantaged Children Attending Head Start, No Preschool, and Other Preschool Programs." Child Development, Vol. 61 (1990), pp. 69-81. Management Advisory Report: Summarization of Head Start Grantee Audit Findings. U.S. Department of Health and Human Services, Office of Inspector General (A-07-91-00425), Jan. 1992. Phillips, Deborah, Kathleen McCartney, and Sandra Scarr. "Child-Care Quality and Children's Social Development." Developmental Psychology, Vol. 23, No. 4 (1987), pp. 537-543. Phillips, Deborah A., Carollee Howes, and Marcy Whitebook. "The Social Policy Context of Child Care: Effects on Quality." American Journal of Community Psychology, Vol. 20, No. 1 (1992), pp. 25-51. Poor Preschool-Aged Children: Numbers Increase but Most Not in Preschool (GAO/HRD-93-111BR, July 21, 1993). Robinson, Dale. Federal Programs For Children and Their Families: An Overview. Congressional Research Service. Washington, D.C.: 1993. Silver Ribbon Panel. Head Start: The Nation's Pride, A Nation's Challenge. National Head Start Association. Washington D.C.: 1990. Starting Points: Meeting the Needs of Our Youngest Children. Carnegie Corporation of New York. New York: 1994. Stewart, Anne C. Head Start Fact Sheet. Congressional Research Service. Washington, D.C.: 1994. ---. Head Start: Funding, Eligibility, and Participation. Congressional Research Service. Washington, D.C.: 1992. ---. Head Start Reauthorization Amendments Enacted During the 101st Congress. Congressional Research Service. Washington, D.C.: 1990. Vinovskis, Maris A. "Early Childhood Education: Then and Now." Paper prepared for the American Academy of Arts and Sciences Conference on America's Children, Three to Eleven, May 1992. Zigler, Edward, and Susan Muenchow. Head Start: The Inside Story of America's Most Successful Educational Experiment. New York: BasicBooks, 1992. Zigler, Edward F., Matia Finn-Stevenson, and Karen W. Linkins. "Meeting the Needs of Children and Families with Schools of the 21st Century." Yale Law & Policy Review, Vol. 10, No. 1 (1992), pp. 69-81. Zill, Nicholas, Kristin A. Moore, Ellen Wolpow Smith, and others. The Life Circumstances and Development of Children in Welfare Families: A Profile Based on National Survey Data. Washington, D.C.: Child Trends, Inc., 1991.