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Health Equity: Center-Based Early Childhood Education


What the CPSTF Found

About The Systematic Review

The CPSTF 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 CPSTF 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 pdf icon [PDF - 315 KB].

This review was conducted on behalf of the CPSTF 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.


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 may provide them with equal opportunities for lifelong employment, income, and health.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 639 KB].

This review included evaluations of three types of early childhood education programs:

  • State and district programs
  • The federal Head Start program
  • Model programs such as the Perry Pre-School and Abecedarian programs (Campbell et al., 2002; Schweinhart et al., 2005)

Education-related outcomes*:

  • Test scores: mean increase of 0.29 standard deviations (27 study arms)
  • High school graduation: mean increase of 0.20 standard deviations (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 (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 (6 study arms)

Social- and Health-related outcomes*:

  • Crime rates: mean decrease of 0.23 standard deviations (5 study arms)
  • Teen birth rates: mean decrease of 0.46 standard deviations (3 study arms)
  • Self-Regulation: mean increase of 0.21 standard deviations (5 study arms)
  • Emotional development: mean increase of 0.04 standard deviations (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 standard deviations
      • Head Start: 0.17 standard deviations
      • Model: 0.57 SD standard deviations
    • High school graduation – a statistically significant positive effect was found for Head Start programs, but not for the other program types:
      • State and district: 0.23 standard deviations
      • Head Start: 0.18 standard deviations
      • Model: 0.31 SD standard deviations
    • Grade retention or assignment to special education – non-significant effects were found for all program types:
      • State and district: ‑0.39 standard deviations
      • Head Start: ‑0.08 standard deviations
      • Model: ‑0.46 standard deviations
    • 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 standard deviations
      • Model: ‑0.47 standard deviations
    • Crime – non-significant effects were found for all program types:
      • State and district: ‑0.25 standard deviations
      • Head Start: ‑0.18 standard deviations
      • Model: ‑0.32 standard deviations
    • 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 standard deviations
      • Model: ‑0.44 standard deviations
    • 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 standard deviations
      • Head Start: 0.16 standard deviations
    • 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 standard deviations
      • Head Start: 0.03 standard deviations
  • Persistence of program effects:
    • Effects of early childhood programs persisted on scores of standardized achievement tests and other cognitive tests. A statistically significant program benefit remained until students were 9 years old; effects slowly declined 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).

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 639 KB].

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, 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.
  • 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


  • Based on the available evidence, ECE 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.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • How old should children be when they enroll in an ECE program?
  • What should the teacher to student ratio be to assure program benefits?
  • What is the minimum program length (in months or years) required to achieve beneficial and long-lasting effects? How many days a week should programs be offered, and for how many hours each day?
  • What are the core components that should be included in program curricula, and how can they best be adapted for different groups and settings?
  • What are the independent effects of additional program components, such as recreation, meals, health care, parental supports, and social services?
  • Why does program effect diminish over time? Are there school, family, or environmental conditions that could be developed to improve the maintenance of early benefits?
  • What are the costs and benefits of providing students with meals and health care, engaging parents, and offering other services with programs?
  • What are the monetized benefits of self-regulation and emotional development resulting from early childhood education?
  • If longitudinal studies of state and local ECE programs were conducted, would they find long term benefits similar to those that have been demonstrated through economic modeling?

Study Characteristics

  • Standardized achievement was reported for 17 studies of state and district programs, 7 studies of Head Start programs, and 3 studies 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 enrolled children in families at or below 110% of the poverty level (or with special needs or challenges such as homelessness). 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 provided health screening, referral, and services for parents.