Sacramento Head Start Alumni Association

PediatriciansÂ’ Reported Practices Regarding Head Start Referral

Aug 13, 2003

Pediatricians?’ Reported Practices Regarding Early Education and Head
Start Referral
Michael Silverstein, MD*?‡; David C. Grossman, MD, MPH*?‡; Thomas D. Koepsell, MD, MPH*?§; and
Frederick P. Rivara, MD, MPH?‡?§
ABSTRACT. Background. Early learning programs
have proven benefits for impoverished children; Head
Start is the most widespread of such programs. The current
involvement of pediatricians in the Head Start enrollment
process is unknown.
Objectives. 1) To assess the knowledge, attitudes, and
reported practices of pediatricians on referring families
to Head Start; 2) to assess pediatricians?’ receptivity to a
potential practice-based intervention to enhance their
ability to make Head Start referrals.
Methods. Mail survey to stratified random sample of
pediatricians practicing in poor and non-poor US zip
codes. Prevalence estimates and logistic regression models
were estimated using weighted data.
Results. Of 1000 surveys distributed, 472 of 772 presumed-
eligible subjects completed surveys for a response
rate of 61%. Respondents and nonrespondents
were similar with regard to age, gender, years in practice,
and urban/rural practice setting. Eighty percent of pediatricians
reported discussing child care arrangements
with a majority of their preschool-aged patients?’ families,
while only 14% reported actually assisting these families
in applying to Head Start. Lack of time (77% of pediatricians)
and nonphysician office staff (71%) were listed as
the most significant barriers to helping families apply to
Head Start. Unfamiliarity with early childhood education
(10%) was generally not seen as a barrier to this practice.
Head Start knowledge (adjusted odds ratio [aOR]: 1.43;
95% confidence interval [CI]: 1.01, 2.02), self-efficacy in
advising families how to access local Head Start programs
(aOR: 3.49; 95% CI: 1.46, 8.38), and the belief that it
is the pediatrician?’s responsibility to do so (aOR: 9.98;
95% CI: 3.91, 25.48) were significantly associated with
assisting families with Head Start enrollment. The majority
of respondents (77%) reported a willingness to
participate in a proposed computer-based intervention to
aid eligible families in applying to Head Start. Having
access to a social worker (aOR: 2.48; 95% CI: 1.17, 5.21)
and respondent age (aOR: 0.96 for each year; 95% CI: 0.93,
0.99) were significantly associated with likely participation
in the intervention.
Conclusions. Although pediatricians report commonly
discussing child care issues, few actively assist
patients in the application process for Head Start. An
intervention to facilitate Head Start referral from the
physician?’s office must address time and staff limitations;
education of pediatricians is a secondary need.
Pediatrics 2003;111:1351?–1357; Head Start, early childhood
development, early childhood education, education, pediatrician
practices, pediatrics.
ABBREVIATIONS. CI, confidence interval; aOR, adjusted odds
ratio.
Early childhood development programs can
produce lasting benefits for children and society.
Longitudinal studies of experimental programs
have demonstrated sustained cognitive, social,
and educational benefits for both medically
fragile1?–3 and low-income children. The High/Scope
Perry Preschool Project has demonstrated positive
effects on income, educational achievement, divorce,
and crime rates into adulthood.4 The Carolina Abecedarian
Project has demonstrated effects on academic
achievement through the midteen years.5 The Chicago
Child-Parent Center Program has demonstrated
lower rates of juvenile arrest and grade retention,
and higher rates of high school completion.6 Programs
in Syracuse7 and Houston8 have each demonstrated
similar benefits. A Cochrane Collaboration
systematic review of these interventions confirms
their findings.9
Head Start, a federally funded preschool program
for low-income families, is often considered a national
model of early educational intervention. Any
family at or below the federal poverty level is eligible
to enroll their 3- to 5-year-old children in Head Start,
and their 0- to 3-year-old children in Early Head
Start. Nationally, Head Start serves 850 000 children;
its curriculum incorporates child development,
school readiness, health, nutrition, and linkage to
other social services.10 Head Start outcome data are
controversial in part because the program was never
implemented as a controlled experiment and because
its per capita funding is significantly less than that of
the experimental programs cited above. Nevertheless,
substantial social and educational benefits have
been observed among Head Start graduates,11 and
early results of a randomized controlled trial of Early
Head Start supports its efficacy across a wide range
of outcome parameters.12
Through frequent contact with families during a
child?’s first few years of life, the pediatrician may be
in a unique position to affect Head Start enrollment
and ultimately facilitate access. Two important orga-
From the *Robert Wood Johnson Clinical Scholars Program, University of
Washington, Seattle, Washington; Departments of ?‡Pediatrics and ?§Epidemiology,
University of Washington, Seattle, Washington.
Received for publication May 17, 2002; accepted Oct 8, 2002.
Address correspondence to Michael Silverstein, MD, Robert Wood Johnson
Clinical Scholars Program, University of Washington, H-220 Health Sciences
Center Box 357183, Seattle, Washington 98195. E-mail:
msilve@u.washington.edu
PEDIATRICS (ISSN 0031 4005). Copyright ?© 2003 by the American Academy
of Pediatrics.
PEDIATRICS Vol. 111 No. 6 June 2003 1351
nizations have advocated this concept. The American
Academy of Pediatrics has recommended that pediatricians
contribute to universal access to early child
care and education.13 Most recently, the Centers for
Disease Control and Prevention has strongly recommended
publicly funded, center-based development
programs for impoverished preschool-aged children,
and suggested the promotion of such programs as
part of routine well-child care.14
The extent to which the medical community plays
a role in the Head Start recruitment and enrollment
process, however, is unknown, as are pediatricians?’
current knowledge and practices with regard to early
childhood development programs in general. Therefore,
our main goal in this study was to assess the
knowledge, attitudes, and reported practices of pediatricians
with regard to referring families to early
childhood development programs, particularly Head
Start. We also sought to assess pediatricians?’ receptivity
to a potential clinic-based intervention to enhance
their ability to assist families in the Head Start
enrollment process.
METHODS
Sample
We generated our study sample from the American Medical
Association?’s Masterfile (Axciom Corporation, Skokie, Illinois),
considered the most comprehensive list of all physicians practicing
in the United States. In addition to physician names and
addresses, it contains information on subspecialty, practice setting,
date of birth, and years since completion of medical school
and residency. From this list, we selected a national sample of
general pediatricians practicing in the United States, limiting eligibility
to residency graduates, age 25 to 65, practicing in hospitals,
offices, and teaching institutions. We excluded researchers
and administrators. A total of 26 833 pediatricians fulfilled these
inclusion criteria.
Our intention was to over-sample pediatricians working with
low-income, Head Start eligible children, while allowing valid
national estimates to be obtained by appropriate weighting. To
generate our sample of 1000 pediatricians, we divided the 40 000
US zip codes into quartiles based on median household income.
We obtained income data from a 1998 Claritas Corporation data
set, a validated database derived from the 1990 US Census, but
updated to reflect interval changes.15 We randomly chose half of
our sample (500) from the pool of 3561 pediatricians practicing in
the bottom quartile of zip code incomes (median household income
below $25 074). We randomly chose the other half of our
sample from the pool of 23 272 pediatricians practicing in the 3
higher zip code quartiles (Fig 1).
Sample Size
We estimated that 250 subjects in each zip code stratum were
necessary to make prevalence estimates to 6% precision or better
with 95% confidence. We predicted a survey response rate of 50%.
Instrument
The survey was divided into 6 domains representing potential
predisposing, enabling, and reinforcing factors theorized in Green
and Kreuter?’s PRECEDE-PROCEED model to support behavioral
or environmental change.16 We assessed knowledge about Head
Start with a series of 6 true/false questions. We used a 5-point
Likert scale to assess pediatrician self-efficacy and sense of responsibility
in performing a number of items involved in early education
and Head Start referral. We used the same Likert scale to
assess barriers to helping families access Head Start. We scored all
survey Likert items positively if respondents ?“agreed?” or ?“strongly
agreed?” with the statements.
We assessed reported practices by asking respondents to recall
the last 5 preschool-aged children they saw for well-child care,
and to report with how many they performed each of 5 items.
Although this type of bounded recall procedure is reported to
reduce over-reporting,17 we still assumed a social desirability bias,
and thus scored items as positive only if respondents reported
them with a majority (3) of patients.
We assessed willingness to participate in a potential clinic-based
intervention to promote Head Start referral by asking subjects to
respond to the following paragraph: ?“With a family?’s permission,
the demographic information of a preschool-aged child is transferred
electronically from your clinic database onto a Head Start
application. No additional data entry is required. As part of a
well-child visit, clinic staff review the application with the family
and send it to Head Start.?” To account for possible social desirability
biases in their responses, respondents were considered
?“likely participants?” only if they indicated a willingness to participate
and indicated that the program would be ?“very important?”
or ?“important?” to their clinic population.
The demographics portion of the instrument comprised a series
of questions validated by the American Academy of Pediatrics?’
Department of Research.18 Additionally, we assessed the proportion
of Medicaid patients seen by each respondent by asking them
to estimate on a visual analog scale what proportion of their
practice received Medicaid.
Fig 1. Sampling strategy and survey response.
1352 PEDIATRICIANS AND HEAD START
We piloted the survey by face-to-face, semistructured interviews
with 20 pediatricians in a variety of practice settings in the
Puget Sound area. Items were included in the survey instrument
only if there was near universal consensus on their meaning. We
then piloted the survey by mail with another 20 pediatricians
belonging to the King County Medical Society. One of the authors
(D.G.) followed up the pilot mailing with brief telephone interviews
with a subset of the pilot cohort.
Survey Protocol
Using a modification of Salant and Dillman?’s procedures,19 we
sent up to 5 mailings to those from whom we received no initial
response. Participants received a $1 inducement.
Secondary Data Sources
Zip codes of practice addresses were linked to the Rural-Urban
Commuting Area Code database, a validated instrument for ruralurban
status generated jointly by the United States Department of
Agriculture and the WWAMI (Washington-Wyoming-Alaska-
Montana-Idaho) Rural Health Research Center.20 These codes represent
continuous variables ranging from 1.0 to 11.0, with lower
numbers denoting urban areas. From the Claritas dataset, we
obtained an estimate of population and number of pediatricians
practicing in each zip code.
Statistical Analysis
We weighted cases based on the size of the pool from which each
subject was chosen. With the exception of comparing respondents
to nonrespondents, we analyzed all data in their weighted form.
Interval data were compared across groups using the Student t
test for equality of means. Ordinal and categorical data were
compared using the 2 test. We calculated 2 multivariable logistic
regression models: 1 with reported practices as the outcome of
interest; the other, with likely participation in the proposed intervention
as the outcome. Covariates were included in the base
models based on their theoretical relevance as supportive factors
for behavioral or environmental change; private practice was
added to these base models because of the magnitude of its
bivariate association with both outcomes of interest. Statistical
analyses were conducted using Stata 7.0 (Stata Corporation, College
Station, TX).
The University of Washington granted official exemption from
institutional board review.
RESULTS
Response
Of the 1000 surveys mailed, 65 were returned with
no forwarding address. A total of 572 of the remaining
935 pediatricians returned surveys. Of the 572
respondents, 100 (17%) were excluded for not providing
health supervision to preschool-aged children.
Assuming an equal proportion of ineligible
pediatricians among respondents and nonrespondents,
472 eligible respondents of 772 presumedeligible
subjects returned surveys, for a response rate
of 61% (Fig 1). (In the implausible case that all nonrespondents
were actually eligible for the study, our
response rate would have been 57%.) There was no
significant difference in response rate across zip code
sampling strata.
Respondents and nonrespondents were similar in
age, sex, and years in practice. The zip codes of their
practice addresses were similar in population size,
median household income, rural-urban score, and
estimated number of pediatricians (Table 1).
Demographic Data
Table 1 represents a weighted description of all respondents.
The proportion of respondents in private
practice was lower in low-income zip codes (48% vs
73%; P  .0001), the mean proportion of patients
receiving Medicaid was higher in these areas (53% vs
31%; P  .0001), and the proportion of clinics to
employ a social worker was higher (42% vs 22%; P 
.0001).
Head Start Knowledge and Self-Efficacy
Pediatricians?’ responses to individual knowledge
items related to Head Start are represented in Table
2. Of the 6 items, respondents answered an average
of 3.5 correctly (95% confidence interval [CI]: 3.3,
TABLE 1. Demographics
Respondents
N  472
Nonrespondents
N  363
Mean age in y (SD) 47.5 (8.8) 48.3 (8.8)
Male (%) 53 56
Mean number of years in practice (SD) 20.7 (9.1) 21.7 (9.3)
Mean zip code household income, 1998 (SD) $35,747 (18,369) $37,835 (23,278)
Mean zip code population, 1998 (SD) 26,930 (16,156) 28,361 (20,573)
Mean number of pediatricians in zip code,
1998 (SD)
10.8 (17.0) 11.7 (17.4)
Mean rural-urban score (SD) 1.7 (1.8) 1.8 (2.0)
Practice setting*
University 8%
Community Hospital 2%
Private practice 70%
Staff model HMO 7%
Public health/community clinic 6%
County Hospital 1%
Other 6%
Mean hours/week of direct patient care (SD) 37 (14)
Mean % of time in general pediatrics (SD) 91 (23)
Employs social worker 24%
10% Non?–English-speaking families, % 29
Mean proportion of patients on Medicaid (SD) 33 (28)
SD indicates standard deviation; HMO, health maintenance organization.
* The lower half of table reflects weighted estimates; the data, therefore, reflect a greater influence of
respondents from non-poor zip codes.
ARTICLES 1353
3.6). Pediatricians reporting a majority of Medicaid
clients answered slightly more questions correctly
than those reporting 50% Medicaid participation
(3.7 vs 3.4; P  .06). Of note, 44% of respondents
were aware that Head Start offers services to children
ages birth to 5 years (Early Head Start, birth to
3; standard Head Start, 3?–5), and 23% of respondents
were aware of Head Start?’s eligibility criteria (federal
poverty level) relative to their state?’s Medicaid eligibility
for preschool-aged children.21 A total of 37%
(95% CI: 32, 42) of pediatricians expressed self-confidence
in their ability to advise families how to
access local area preschool programs, including
Head Start.
Physician Responsibility, Reported Practice, and
Barriers to Practice
A total of 36% of all respondents agreed that assisting
families with Head Start enrollment was the
pediatrician?’s responsibility, yet only 14% reported
assisting families in applying to Head Start (Table 2).
Respondents reporting caring for a majority of Medicaid
patients more often agreed that assisting families
with enrollment was the pediatrician?’s responsibility
(57% vs 29%; P  .0001), and were more likely
to report assisting families with enrollment (33% vs
8%; P  .0001) than those seeing a 50% Medicaid
clientele.
Fig 2 shows the prevalence of reported practices
among pediatricians considering such practices their
responsibility. Of those considering assistance with
Head Start enrollment their responsibility, only 34%
reported this practice.
The most commonly reported barriers to helping
families apply to Head Start were time constraints
and lack of office staff (Table 2). Respondents reporting
a majority of Medicaid patients were more likely
to report as a barrier the perception of full Head Start
classrooms (49% vs 26%; P  .0001), but less likely to
report difficulty identifying eligible families (36% vs
48%; P  .05) or unfamiliarity with local Head Start
programs (45% vs 57%; P  .07) than those reporting
a 50% Medicaid clientele.
Controlling for all other covariates in a logistic
regression model, considering Head Start enrollment
assistance the pediatrician?’s responsibility was associated
with a nearly 10-fold increase in the likelihood
of providing such assistance (adjusted odds ratio
[aOR]: 9.98; 95% CI: 3.91, 25.48). Self-efficacy in advising
families how to access local preschool programs
(aOR: 3.49; 95% CI: 1.46, 8.38) and Head Start
knowledge score (aOR: 1.43; 95% CI: 1.01, 2.02) were
also significantly associated (Table 3). The model
produced similar results when applied to the subpopulation
of respondents reporting 50% Medicaid
participation (data not shown).
Receptivity to Potential Intervention
A total of 77% (N  354) of respondents indicated a
willingness to participate in a potential office-based
intervention to assist in the Head Start application
process. The majority of respondents felt that the
program would need to be free, not disrupt patient
flow, and that there be an easy way to identify eli-
TABLE 2. Prevalence of Head Start-Related Knowledge, Perceptions, and Reported Practices
Knowledge Items Proportion Answered
Correctly % (95% CI)
[Correct Answer]
Perception of Responsibility
and Reported Current Practice
Reported as
Pediatricians?’
Responsibility
% (95% CI)
Reported as
Current Practice
% (95% CI)
Potential Barriers to Assisting
Families in the Head Start
Application Process
Proportion to Report
Item as Barrier
% (95% CI)
Head Start is free-of-charge to
families
79 (75, 84) [True] Discuss child care arrangements
with families
78 (73, 83) 80 (75, 84) Time limitations 77 (72, 81)
Head Start excludes children
with disabilities
73 (68, 78) [False] Counsel families about
educational preschool
programs, including Head
Start
66 (60, 71) 47 (42, 53) Lack of office staff 71 (66, 76)
Head Start will accept children
who do not meet income
eligibility criteria if certain
needs are documented
65 (59, 70) [True] Designate clinic staff to screen
families for eligibility to
Head Start
32 (27, 37) 22 (18, 27) Unfamiliarity with local Head
Start programs
54 (48, 59)
Head Start automatically contacts
families of eligible children
63 (58, 69) [False] Assist families (or designate
clinic staff to assist families)
in applying to Head Start
36 (30, 41) 14 (10, 18) Identification of eligible
families
46 (40, 51)
Head Start runs preschool
programs for children aged
birth to 5 y
44 (38, 49) [True] Perception of full Head Start
classrooms
32 (27, 38)
Medicaid eligibility and Head
Start eligibility criteria are the
same in your state
23 (18, 28) [False] Belief this is an inappropriate
role for pediatricians
13 (9, 17)
Unfamiliarity with early
childhood education
10 (6, 13)
1354 PEDIATRICIANS AND HEAD START
gible families. Only a minority (37%) indicated that
they would have to feel more comfortable discussing
early childhood education. Of the willing responders,
52% (N  180) indicated that such a program
would be important or very important to their clinic
population; these subjects were considered ?“likely
participants?” in the intervention.
We estimated a multivariable logistic regression
model with likely participation in the proposed intervention
as the outcome of interest. Significantly
associated with likely participation were the presence
of a clinic social worker (aOR: 2.48; 95% CI: 1.17,
5.21) and the age of the respondent (aOR: 0.96 for
each year of life; 95% CI: 0.93, 0.99; Table 4). When
the model was applied to the subpopulation of respondents
reporting a majority Medicaid clientele,
similar trends remained; however, because of sample
size limitations, no single covariate remained statistically
significant (data not shown).
DISCUSSION
The majority of pediatricians in this national sample
considered it their responsibility to discuss child
care arrangements with families; of these, nearly 90%
reported doing so. By contrast, fewer pediatricians
considered it their responsibility to assist families
Fig 2. Reported current practices among respondents who considered each action to be a pediatrician?’s responsibility. Error bars reflect
95% confidence intervals on weighted data.
TABLE 3. Likelihood of Assisting Families With Head Start Enrollment
Provide
Head Start
Enrollment Assistance
N  72
Mean (SD)
Do Not Provide
Head Start
Enrollment Assistance
N  393
Mean (SD)
aOR (95% CI)
Mean physician age in years 47 (10) 48 (9) 0.99* (0.94, 1.03)
Mean proportion of patients receiving Medicaid 58 (27) 29 (26) 1.03?† (1.01, 1.04)
Accessible social worker present (%) 45 20 .84 (.28, 2.47)
10% non?–English-speaking families in clinic (%) 53 26 1.05 (.43, 2.54)
Self-efficacy in advising families how to access
Head Start (%)
72 30 3.49 (1.46, 8.38)
Mean Head Start knowledge score 4.2 (1.2) 3.3 (1.5) 1.43?‡ (1.01, 2.02)
Agree that pediatricians should assist families in
applying to Head Start (%)
84 28 9.98 (3.91, 25.48)
Private practice (%) 50 74 1.01 (.34, 2.99)
SD indicates standard deviation.
* aOR for each additional year of physician age.
?† aOR for each additional 1% of Medicaid patients.
?‡ aOR for each incremental survey knowledge question answered correctly.
ARTICLES 1355
with Head Start enrollment, and of these, only a third
reported this practice. Those who expressed selfefficacy
in advising families how to access Head Start
and considered it their responsibility to help families
do so were more likely to provide assistance with
enrollment. In contrast to reported practices, likely
participation in the proposed intervention was more
strongly associated with the presence of a clinic social
worker and the age of the pediatrician.
Over the decades, pediatricians have become increasingly
concerned about child care and early
childhood education. Scurletis and others22 reported
in 1966 that over one third of pediatricians they
surveyed had never been asked for their advice
about child care, and nearly all had no comment
concerning the potential educational value of out-ofhome
care. By the late 1980s, Guralnick and others23
reported that most pediatricians they surveyed consulted
regularly with infant stimulation programs,
preschools, Head Start programs, or other such agencies.
In 2002, the Centers for Disease Control?’s Task
Force on Community Preventive Services strongly
recommended publicly funded, center-based, early
childhood development programs for impoverished
preschool-aged children, and suggested that health
care providers promote participation in such programs
as part of well-child care.12
This study represents a first step in trying to
translate such recommendations into programmatic
action. In the context of Green and Kreuter?’s
PRECEDE-PROCEED model of health intervention,
16 our study results are noteworthy for a number
of reasons. First, the divide between pediatricians?’
sense of responsibility and reported practice with
regard to providing Head Start enrollment assistance
suggests a set of predisposing factors that may facilitate
motivation for change, particularly among pediatricians
caring for a large proportion of poor families.
Second, time and staff limitations?—examples of
potentially modifiable enabling factors?—appear the
primary explanations for this divide. Although
knowledge and attitude appear to drive current
practice, clinic characteristics (ie, presence of a social
worker) are strongly associated with likely participation
in the proposed intervention. These results suggest
that an effective Head Start enrollment intervention
should aim to harness the resources and abilities
of the clinic more so than the pediatrician him/
herself, and that an automated, action-oriented program
is a potentially effective method to motivate
Head Start referrals from pediatric offices. Pediatrician
education is a secondary concern.
Our study was limited by a number of factors.
First, as with many surveys, social desirability biases
may have compelled respondents to overestimate
their attitudes and practices. Although we have dealt
with this by defining positive responses conservatively,
our cutoff values for certain variables are admittedly
arbitrary. Additionally, although our 61%
response rate is consistent with norms for survey
research,24,25 restricting our survey to pediatricians
who provide health supervision to preschool-aged
children precludes a precise quantification of response
rate attributed to an unknown proportion of
ineligible pediatricians among the nonrespondents.
However, given the likelihood that the ineligible rate
is higher among the nonrespondents (they don?’t see
the right patient population, so they don?’t respond),
we have likely estimated our response rate conservatively.
The early education literature shows that experimental,
university-based preschool programs with
high parental participation are most effective. The
Perry Preschool project, Abecedarian project, and
Chicago Child-Parent Center program are examples
of such meticulously implemented and rigorously
tested programs.4?–6 Exactly where Head Start lies on
the quality spectrum is controversial. However,
Head Start is the most widely available, comprehensive
development program for low-income children
in the United States; and, although its outcomes may
be less clear than the university-based experiments,
it has been shown to improve vocabulary and writing
skills during the Head Start academic year, improve
social skills, and enhance school readiness and
subsequent academic performance.11 Therefore, implementing
a systematic mechanism that enables pediatricians
to make effective Head Start referrals
would constitute evidence-based practice.
TABLE 4. Likely Participation in Head Start Enrollment Intervention
Likely
Participants
N  180
Mean (SD)
Unlikely
Participants
N  271
Mean (SD)
aOR 95% CI
Mean physician age in years 46 (9) 48 (9) .96* (.93, .99)
Mean proportion of patients receiving Medicaid 45 (30) 27 (25) 1.01?† (1.00, 1.02)
Accessible social worker present (%) 42 15 2.48 (1.17, 5.21)
10% non?–English-speaking families in clinic (%) 49 20 1.96 (.99, 3.90)
Self-efficacy in advising families how to access
Head Start (%)
40 36 .69 (.36, 1.33)
Mean Head Start knowledge score 3.8 (1.3) 3.3 (1.6) 1.17?‡ (.97, 1.41)
Agree that pediatricians should assist families in
applying to Head Start (%)
61 23 3.97 (2.12, 7.48)
Private practice (%) 55 78 1.07 (.51, 2.22)
SD indicates standard deviation.
* aOR for each additional year of physician age.
?† aOR for each additional 1% of Medicaid patients.
?‡ aOR for each incremental survey knowledge question answered correctly.
1356 PEDIATRICIANS AND HEAD START
ACKNOWLEDGMENTS
We thank Gary Hart, PhD, for his expertise in medical geography;
Charlotte Lewis, MD, and Karen O?’Connor for their experience
in survey design; and Nancy Hutchins, PhD, and George
Askew, MD, for their knowledge of the Head Start system.
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COST OF SMOKING
?“Each pack of cigarettes sold in the United States costs the nation more than $7
in medical care?—the total is $157.7 billion a year.?”
AP cigarettes cost US $7 per pack, Sold study says. New York Times. April 12, 2002
Submitted by Student
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