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Promoting Health Equity Through Education Programs and Policies: Center-Based Early Childhood Education

Task Force Finding

The Community Preventive Services Task Force recommends center-based early childhood education programs (ECE) based on strong evidence of effectiveness in improving educational outcomes that are associated with long-term health and sufficient evidence of effectiveness in improving social- and health-related outcomes. When provided to low-income or racial and ethnic minority communities, ECE programs are likely to reduce educational achievement gaps, improve the health of these student populations, and promote health equity.

Read the full Task Force Finding and Rationale Statement for more detailed information on the finding, including considerations for implementation, potential benefits and harms, and evidence gaps.

Intervention Definition

ECE programs aim to improve the cognitive or social development of children ages 3 or 4 years.

  • Programs must include an educational component that addresses one or more of the following: literacy, numeracy, cognitive development, socio-emotional development, and motor skills.
  • Programs may offer additional components including recreation, meals, health care, parental supports, and social services.
  • Programs may enroll children before they are 3 years of age.

Three ECE types may be distinguished: state and district programs, the federal Head Start program, and model programs such as the Perry Pre-School and Abecedarian programs (Campbell et al., 2002; Schweinhart et al., 2005). Many ECE programs target children from low-income families.


Children in low-income families often experience delays in language and other development by the age of three. Compensating for these delays before children begin regular schooling can be critical to providing them with equal opportunities for lifelong employment, income, and health. In 2010, less than half of children in families in the lowest income quartile were enrolled in center-based early childhood education programs (Duncan & Magnuson 2013).

About the Systematic Review

The Task Force finding is based on evidence from a 2014 meta-analysis of 49 studies of center-based preschool programs for low-income children ages 3 and 4 years (Kay & Pennucci, 2014). The report was published by the Washington State Institute for Public Policy—a non-partisan research institution that evaluates programs for the Washington State legislature to inform policy decisions. The meta-analysis (search period through November 2013) met Community Guide systematic review standards in terms of intervention definition, outcome assessment, study design and execution evaluation, and synthesis of effect estimates. This finding replaces the 2000 Task Force finding on Promoting Health Equity Through Education Programs and Policies: Comprehensive, Center-Based Programs for Children of Low-Income Families to Foster Early Childhood Development.

This review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to the use of educational interventions for the promotion of health equity.


Education-related outcomes:
  • Test scores: mean increase of 0.29 standard deviations (95% Confidence interval (CI): 0.23 to 0.34; 27 study arms)
  • High school graduation: mean increase of 0.20 standard deviations (CI: 0.07 to 0.33; 7 study arms)
  • Grade retention (in which children are held back from the next grade because they have not succeeded in required learning): mean decrease of 0.23 standard deviations (CI: ‑0.43 to ‑0.02; 12 study arms)
  • Assignment to special education (in which children are taken out of the standard learning track and assigned to receive extra attention because of learning difficulties): mean decrease of 0.28 standard deviations (CI: ‑0.49 to ‑0.08; 6 study arms)
Social- and Health-related outcomes:
  • Crime rates: mean decrease of 0.23 standard deviations (CI: ‑0.45 to 0.05; 5 study arms)
  • Teen birth rates: mean decrease of 0.46 standard deviations (CI: ‑0.92 to 0.00; 3 study arms)
  • Self-Regulation: mean increase of 0.21 standard deviations (CI: 0.14 to 0.28; 5 study arms)
  • Emotional development: mean increase of 0.04 standard deviations (CI: ‑0.05 to 0.12; 7 study arms)

*While findings for the three ECE types were reported separately in their meta-analysis, authors Kay and Pennucci aggregated the results for this systematic review.

Results for each program type:
  • All effects were in a favorable direction for each program type (for which they were evaluated), but not all effects were statistically significant at the 0.05 level.
    • Standardized achievement tests – significant beneficial effects were found for all three program types (state and district, 0.32 SD, 95%CI 0.25, 0.38; Head Start, 0.17 SD, 95%CI 0.12, 0.23; model, 0.57 SD, 95%CI 0.24, 0.81).
    • High school graduation – a statistically significant positive effect was found for Head Start programs, but not for the other program types (Head Start, 0.18 SD, 95%CI 0.03, 0.33; state and district, 0.23 SD, 95%CI ‑0.04, 0.50; model, 0.31 SD, 95%CI ‑0.21, 0.83).
    • Grade retention or assignment to special education –non-significant effects were found for all program types (state and district: ‑0.39 SD, 95%CI ‑0.26, 0.19; Head Start, ‑0.08 SD, 95%CI ‑0.34, 0.19; model: ‑0.46 SD, 95%CI ‑0.96, 0.03).
    • Assignment to special education –non-significant favorable effects were found for state and district and model program types, and this outcome was not evaluated for Head Start (state and district: ‑0.12 SD, 95%CI ‑0.51, 0.04; model: ‑0.47 SD, 95%CI ‑0.99, 0.05).
    • Crime–non-significant effects were found for all program types (state and district, ‑0.25 SD, 95%CI ‑0.59, 0.09; Head Start, ‑0.18 SD, 95%CI ‑0.71, 0.35; model, ‑0.32 SD, 95%CI ‑0.74, 0.10).
    • Teen birth rates – no studies of state and district programs evaluated this outcome, and non-significant effects were found for the other two program types (Head Start, ‑0.47 SD, 95%CI ‑1.04, 0.11; model, ‑0.44 SD, 95%CI ‑1.22, 0.33).
    • Self-regulation – a statistically significant effect was found for state and district programs, a non-significant benefit was shown for Head Start, and no studies of model programs evaluated this outcome (state and district, ‑0.23 SD, 95%CI 0.12, 0.33; Head Start, 0.16 SD, 95%CI ‑0.09, 0.41).
    • Emotional development – effects were negligible and statistically non-significant for state and district programs and Head Start programs, and no studies of model programs evaluated this outcome (state and district, 0.04 SD, 95%CI ‑0.08, 0.17; Head Start, 0.03 SD, 95%CI ‑0.07, 0.13).
  • Persistence of program effects:
    • Program effects for students' scores on standardized achievement tests and other cognitive tests persisted over time following students' completion of early childhood education programs. There remained a statistically significant program benefit when program participants were 9 years old, with effects slowly declining in later years.
  • Effect modification:
    • Data were insufficient to determine the most effective class size, hours, duration, program foci, or the benefit of additional program components (e.g., health care, parental involvement, or meals).

Study Characteristics

  • 17 studies of state and district programs assessed standardized achievement, 7 of Head Start, and 3 of model programs.
  • Fewer studies assessed other academic or social- or health-related outcomes, including rates of high school graduation (7 studies), grade repetition (12 studies), assignment to special education (6 studies), crime (5 studies), self-regulation (4 studies), and emotional development (7 studies).
  • Seven of the included studies assessed the effects of teacher qualifications, and three assessed the effects of program quality.
  • State and district programs included in the review only allowed children in families at or below 110% of the poverty level (or with special needs or challenges such as homelessness), and Head Start was similarly restricted to children from families at or below 130% of the poverty level. Model programs also have targeted low-income and otherwise challenged families.
  • Some programs also provided health screening and referral and services for parents.


  • Based on the available evidence, programs directed toward low-income or racial and ethnic minority communities are expected to advance health equity.
  • While the meta-analysis did not include studies of programs directed to higher income or predominantly white communities, programs in these communities are generally of higher quality (Duncan and Magnusson, 2013) and it is expected they would also improve educational, social, and health outcomes.

Economic Evidence

Economic evidence indicates there is a positive return on investment in early childhood education. The benefits from students' future earnings gains alone exceed program costs.

The economic review included 7 studies from the U.S. with additional analysis from one of the studies. All monetary values reported are in 2014 U.S. dollars.

  • The median benefit-to-cost ratio from eleven estimates of students' future earnings gains was 3.39:1 (IQI: 2.48 to 4.39), suggesting that for every $1 invested in the program, there was a return of $3.39 in earnings gains alone.
  • The overall median benefit-to-cost ratio from seven estimates reported in four studies and the national-level analysis was 4.19:1 (IQI: 2.62 to 8.60).
  • The benefits were greater than the costs for all three types of early childhood education programs including state and district, federal Head Start, and model programs.
  • Intervention cost estimates were based on funding per participant.
  • Intervention benefit estimates, both short and long term, included some or all of the following major components:
    • Increases in maternal employment and income
    • Reductions in crime, welfare dependency, and child abuse and neglect
    • Savings in remedial education and child care costs
    • Improvement in health outcomes associated with education
    • Earnings gains associated with high school graduation

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.

  • Research from the broader literature indicates that inadequate staff training and turnover make it difficult to maintain program quality and consistency.
  • Programs are more likely to succeed if they are well-staffed and implemented as intended.
  • Model programs may require extensive resources, including highly trained teachers and close monitoring of implementation; needs may thus exceed budgets commonly allocated.
  • Though the effect was not statistically significant, included studies showed programs that hired teachers who had at least a bachelor's degree had greater effects on standardized achievement tests. In 2011, Head Start programs began requiring applicants have at least an associate's degree in early childhood education.
  • In the three included studies that rated programs using the Early Childhood Environmental Rating Scale, those with higher scores tended to show greater (but not statistically significant) effects on educational outcomes. These scores are based, in part, on staff training, teacher-student ratios, periodic program evaluation, health screening, and the provision of meals.

Supporting Materials


Hahn RA, Barnett WS, Knopf JA, Truman BI, Johnson RL, Fielding JE, Muntaner C, Jones CP, Fullilove MT, Hunt PC, Community Preventive Services Task Force. Early childhood education to promote health equity: a Community Guide systematic review. Journal of Public Health Management & Practice 2016;22(5):E1-8.

Community Preventive Services Task Force. Recommendation for center-based early childhood education to promote health equity. Journal of Public Health Management & Practice 2016;22(5):E9-10.

Read other Community Guide publications about Promoting Health Equity in our library.

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Campbell FA, Ramey CT, Pungello EP, Sparling J, Miller-Johnson S. Early childhood education: Young adult outcomes from the Abecedarian project. Applied Developmental Science 2002;6(1):42-57.

Duncan GJ, Magnuson K. Investing in preschool programs. Journal of Economic Perspectives 2013;27:109-31.

Kay N, Pennucci A. Early childhood education for low-income students: A review of the evidence and benefit-cost analysis (Doc. No. 14-01-2201). Olympia (WA): Washington State Institute for Public Policy; 2014. Available at URL:

Schweinhart LJ, Montie J, Xiang Z, Barnett WS, Belfield CR, Nores M. Lifetime effects: The High/Scope Perry preschool study through age 40. Ypsilanti (MI): High/Scope Press; 2005.


The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Promoting health equity through education programs and policies: center-based early childhood education. Last updated: MM/DD/YYYY.

Review completed: March 2015