Social Determinants of Health: Center-Based Early Childhood Education

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends center-based early childhood education programs (ECE) to improve educational outcomes that are associated with long-term health as well as social- and health-related outcomes. 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.

If targeted 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.

The full CPSTF Finding and Rationale Statement and supporting documents for Social Determinants of Health: Center-Based Early Childhood Education are available in The Community Guide Collection on CDC Stacks.

Intervention

Center-based early childhood education 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

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.

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

Summary of Results

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

State and district programs
Federal Head Start program
Model programs such as the Perry Pre-School and Abecedarian programs

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)

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 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.

Summary of 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, 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

Applicability

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

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?

Implementation Considerations and Resources

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. For these reasons, program needs may 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 effects on educational outcomes (though the differences were not statistically significant). These scores are based, in part, on staff training, teacher-student ratios, periodic program evaluation, health screening, and the provision of meals.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.