Early Childhood Education

Interventions Addressing the Social Determinants of Health

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Early childhood is an important time to promote healthy development,[1,2] and early childhood education (ECE) programs are community-level interventions that are proven and effective.[3] Learn more about how implementing evidence-based ECE programs can benefit children, families, and communities.

What is early childhood education?

This page focuses on the subset of early childhood education (ECE) intervention programs that aim to improve learning, behavior, and social development of children, most commonly focusing on children ages 3 or 4 years.[3,4]  ECE interventions can improve child development and act as a protective factor against the future onset of adult disease and disability.[2] ECE programs often aim to increase enrollment among children who are educationally underserved and experience health disparities.  Therefore, ECE programs may help increase health equity.[3]  Healthy People 2030 says that increasing the percent of children who are enrolled in ECE is a high-priority issue,[5] because ECE programs can help support child development and children’s health outcomes.[6]

This evidence review included ECE programs that addressed one or more of the following: reading and math skills, development of thinking and learning, social and emotional development, and motor skills.[3] Some programs “may offer additional components, including recreation, meals, health care, parental supports, and social services.”[3] ECE programs may be delivered in a variety of ways and settings. ECE programs that are funded by states or district programs may be universal, which means they are available to all children regardless of income.[7,8]  Other programs, including federally funded Head Start and evidence-based model programs, such as the Abecedarian and Perry Preschool programs, are provided specifically for children in families with low income.[3,9,10] The Child-Parent Center program is another example of a widely implemented model program; it expanded into 33 sites in Minnesota, Wisconsin and Illinois through a University of Minnesota project funded by the U.S. Department of Education.[11]


What is the public health issue?

Childhood development is an important determinant of health over a person’s lifetime.[2Early developmental opportunities can provide a foundation for children’s academic success, health, and general well-being.[12] Preschool-aged children’s brains grow very quickly  and are about 90 percent of the size of an adult’s brain by age 6.[13] This growth allows children to develop functional skills related to moving their bodies, understanding the world, problem solving, communicating with others, and regulating their emotions and behavior.[13,14]  Experiences during early childhood affect connections within the brain that determine a child’s functional development.[15]

Positive experiences support children’s healthy development, and conversely, adverse experiences can hinder it.[15,16Additionally, adverse early childhood experiences can have biological effects that are strongly associated with numerous adult diseases, including coronary artery disease, chronic pulmonary disease, and cancer.[15,16]

Children in low-income families often are exposed to more adverse early childhood experiences and environmental factors that delay or negatively affect their development and place them at a disadvantage for healthy growth and school readiness.[1,2,17,18] In the United States, 11.6 million children (16.1%) lived in poverty in 2020.[19]  ECE programs may not be reaching the children who might benefit most.[3]  In 2019, over half (54%) of low-income preschoolers in the United States did not attend any program that provided early childhood education.[20]  Eighty-five percent of low-income children who are eligible for childcare subsidies according to federal rules did not receive childcare subsidies in 2018.[21]


What is the evidence of health impact?

Early childhood education interventions can improve children’s development and act as a protective factor against the future onset of adult disease and disability.[2ECE can counteract the disadvantage some children experience, improve their social and cognitive development, and provide them with an opportunity to achieve school readiness, and lifelong employment, income, and health.[2,3]  Systematic reviews of studies examining the effects of ECE programs, found that they were associated with improved:

  • Academic achievement.[3,22]
  • Cognitive development.[3,22-24]
  • Self-regulation skills.[3,22]
  • Social-emotional development.[3,22]

ECE benefit estimates, both short- and long-term, included some or all of the following major components[3,22]:

  • Increases in maternal employment and income.
  • Reductions in crime, welfare dependency, and child abuse and neglect.
  • Improvement in health outcomes associated with education.
  • Increases in high school graduation rates.
  • Better jobs and higher earnings throughout employment years for children participating in these programs.[3,22]

Additional studies have found that ECE is associated with other positive health effects, including healthier weight (such as fewer underweight, overweight, and obese children).[25]


What is the evidence of cost effectiveness?

A systematic review found that the economic benefits exceed costs for different types of ECE programs.[22] Based on earnings gains alone, the benefit-to-cost ratios ranged from

  • 3.06:1 to 5.90:1 for State and District programs
  • 1.58:1 to 2.51:1 for Federal Head Start programs
  • 1.76:1 to 4.39:1 for model programs

The rate of return on investment was much higher when all benefit components including earnings gains were considered. For model programs, based on total benefits, the return on every dollar invested was[22]:

  • $2.49 for the Abecedarian program
  • $8.60 for the Perry Preschool
  • $10.83 for Chicago Child-Parent Center

ECE benefit estimates, both short- and long-term, included some or all of the following major components.[3,22]

  • Savings from reduced grade retention.
  • Savings in healthcare costs.
  • Savings in remedial education and childcare costs.[3,22]


What indicators lead to better quality and better outcomes for ECE?

ECE programs that receive federal or state funding generally need to be licensed.[26] Minimum health and safety standards are set forth through national and state licensing requirements.[27] The Administration on Children and Families sets the performance standards for Head Start early childhood programs for families with low income.[28]

Assessing and strengthening the quality of ECEs may be valuable for two reasons: First, a large percentage of young children are enrolled in ECE,[29] and thus have the potential to be impacted by the quality of the program.[30] Second, policies to support ECE may be used as policy levers to increase equity.[3,31] Specifically, there may be a need for indicators to help assess whether attempts to strengthen ECE meaningfully improve children’s outcomes.[30]

As discussed in a review article by Soliday Hong et al., there are two types of factors associated with better quality of care and better child outcomes: structural factors and process factors.[30]  Structural factors include factors such as lower adult-to-child ratios and use of a curriculum (for example, using a defined curriculum where teachers are trained in using the curriculum).  Studies show that fewer children per adult in the classroom is linked to stronger child social skills.[30]  Studies also show that better curriculum quality is associated with stronger child social skills.[30]  Process factors include factors such as additional training for teachers on curriculum and instruction and better emotional support for children.  Studies show that additional training for teachers on curriculum and instruction was positively associated with better language and reading outcomes for children.[30]  Studies also show that the more emotionally responsive[32] the teacher was, the better the children’s outcomes related to learning to read.[30]

To help measure and track the quality of ECEs, most states and some localities[33] have developed or are developing local standards known as Quality Rating and Improvement Systems (QRIS).[34]  As of 2021, 42 states have implemented QRIS systems.[33]



This overview may help inform state, local, and tribal communities about ECE programs and how they can be implemented to improve children’s health outcomes in their communities.  This information about the specific interventions that are proven, effective, and make a difference in communities may be helpful in conversation with interested partners when making decisions (e.g., which intervention to include in master planning efforts).

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  2. Halfon N, Hochstein M. Life course health development: an integrated framework for developing health, policy, and research. Milbank Quarterly. 2002;80(3):433-479.
  3. Hahn RA, Barnett WS, Knopf JA, et al. Early Childhood Education to Promote Health Equity: A Community Guide Systematic Review. Journal of public health management and practice Sep-Oct 2016;22(5):E1-E8. doi:10.1097/PHH.0000000000000378
  4. Blackman JA. Early intervention: A global perspective. Infants & Young Children. 2002;15(2):11-19.
  5. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Increase the proportion of children who participate in high-quality early childhood education programs — EMC‑D03. Accessed September 23, 2022. https://health.gov/healthypeople/objectives-and-data/browse-objectives/children/increase-proportion-children-who-participate-high-quality-early-childhood-education-programs-emc-d03
  6. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Healthy People 2030: Children. Accessed October 24, 2022. https://health.gov/healthypeople/objectives-and-data/browse-objectives/children
  7. Robert Wood Johnson Foundation, The University of Wisconsin Population Health Institute. County health rankings & roadmaps: Publicly-funded pre-kindergarten programs. Updated February 24, 2022. Accessed May 31, 2022. https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/publicly-funded-pre-kindergarten-programs
  8. National Institute for Early Education Research, Rutgers, The State University of New Jersey. Universal Pre-K: What does it mean and who provides it? January 6, 2016. Accessed September 26, 2022. https://nieer.org/2016/01/06/universal-pre-k-what-does-it-mean-and-who-provides-it.
  9. Campbell FA, Ramey CT, Pungello E, Sparling J, Miller-Johnson S. Early childhood education: Young adult outcomes from the Abecedarian Project. Applied Developmental Science. 2002;6(1):42-57.
  10. Schweinhart LJ, Montie J, Xiang Z, Barnett WS, Belfield CR, Nores M. Lifetime effects: the High/Scope Perry Preschool study through age 40. High/Scope Educational Research Foundation; 2005.
  11. McCormick W. Federal $15M grant supports one of the most comprehensive childhood education programs in the nation. College of Education and Human Development News. December 21, 2011. Accessed September 26 , 2022. http://news.cehd.umn.edu/federal_15m_grant_supports_one_of_the_most_comprehensive_childhood_education_programs_in_the_nation/
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  17. Hahn RA, Rammohan V, Truman BI, et al. Effects of full-day kindergarten on the long-term health prospects of children in low-income and racial/ethnic-minority populations: A community guide systematic review. American journal of preventive medicine. 2014;46(3):312-323.
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  26. Final Rule of September 30, 2016, Making regulatory changes to the Child Care Development Fund (CCDF) based on the Child Care and Development Block Grant Act of 2014, 81 FR 67438. https://www.federalregister.gov/d/2016-22986
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  28. US Department of Health and Human Services, Administration for Children and Families. Head Start Policy and Regulations, Head Start Program Performance Standards. Accessed September 26, 2022. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii
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  30. Hong SLS, Sabol TJ, Burchinal MR, Tarullo L, Zaslow M, Peisner-Feinberg ES. ECE quality indicators and child outcomes: Analyses of six large child care studies. Early Childhood Research Quarterly. 2019;49:202-217.
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  33. The Build Initiative & Child Trends (2021). A Catalog and Comparison of Quality Improvement Systems (Data System). Accessed September 26, 2022. https://qualitycompendium.org/
  34. Early Childhood National Centers, National Center on Early Childhood Obesity Quality Assurance. Continuous Quality Improvement in QRISs. Quality Compendium 2017 QRIS Fact Sheet. 2018.