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Early childhood development: an imperative for action and measurement at scale

Linda richter.

1 Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa

Maureen Black

2 RTI International, Research Triangle Park, North Carolina, USA

3 Early Childhood Development, Unicef USA, New York City, New York, USA

Bernadette Daelmans

4 Department of Maternal, Newborn, Child and Adolescent Health, WHO, Geneva, Switzerland

Chris Desmond

5 DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa

Amanda Devercelli

6 Early Childhood Development, World Bank Group, Washington, District of Columbia, USA

7 Department of Mental Health and Substance Abuse, WHO, Geneva, Switzerland

Günther Fink

8 Household Economics and Health Systems, Swiss Tropical and Public Health Institute, Basel, Switzerland

9 Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA

Jody Heymann

10 Fielding School of Public Health and WORLD Policy Analysis Center, University of California, Los Angeles, California, USA

Joan Lombardi

11 Early Opportunities, Washington, District of Columbia, USA

Chunling Lu

12 Division of Global Health, Brigham and Women's Hospital and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA

Sara Naicker

Emily vargas-barón.

13 RISE Institute, Washington, District of Columbia, USA

Experiences during early childhood shape biological and psychological structures and functions in ways that affect health, well-being and productivity throughout the life course. The science of early childhood and its long-term consequences have generated political momentum to improve early childhood development and elevated action to country, regional and global levels. These advances have made it urgent that a framework, measurement tools and indicators to monitor progress globally and in countries are developed and sustained. We review progress in three areas of measurement contributing to these goals: the development of an index to allow country comparisons of young children’s development that can easily be incorporated into ongoing national surveys; improvements in population-level assessments of young children at risk of poor early development; and the production of country profiles of determinants, drivers and coverage for early childhood development and services using currently available data in 91 countries. While advances in these three areas are encouraging, more investment is needed to standardise measurement tools, regularly collect country data at the population level, and improve country capacity to collect, interpret and use data relevant to monitoring progress in early childhood development.

Summary box

• New knowledge of the extent to which experiences during early childhood shape health, well-being and productivity throughout the life course has prompted action to improve early childhood development at the country, regional and global levels.
• Advances have been made in three areas of measurement needed to achieve these goals: population-level child assessments, population proxies of children at risk of poor childhood development, and country and regional profiles of drivers and supports for early childhood development.
• Regular, country-comparable, population-level measurements of childhood development, as well as threats to development and available supports and services, are needed to drive progress and accountability in efforts to improve early childhood development.

Introduction

Scientific findings from diverse disciplines are in agreement that critical elements of lifelong health, well-being and productivity are shaped during the first 2–3 years of life, 1 beginning with parental health and well-being. 2 The experiences and exposures of young children during this time-bound period of neuroplasticity shape the development of both biological and psychological structures and functions across the life course.

Adversities during pregnancy and early childhood, due to undernutrition, stress, poverty, violence, chronic illnesses and exposure to toxins, among others, can disrupt brain development, with consequences that endure throughout life and into future generations. 3 4 Children whose early development is compromised have fewer personal and social skills and less capacity to benefit from schooling. These deficits limit their work opportunities and earnings as adults. 5 A corollary of early susceptibility to adversity includes responsiveness to opportunities during these early years. As a result, interventions during the first 3 years of life are more effective and less costly than later efforts to compensate for early adversities and to promote human development. 6

It is estimated that, in 2010, at least 249 million (43%) children under the age of 5 years in low-income and middle-income countries (LMICs) were at risk of poor early childhood development (ECD) as a consequence of being stunted or living in extreme poverty. 7 This loss of potential is costly for individuals and societies. The average percentage loss of adult income per year is estimated at 26%, increasing the likelihood of persistent poverty for these children, families and societies. 5 Assuming 125 million children are born each year with a global average of poor infant growth, 8 the estimated annual global income loss is US$177 billion. 9 These impacts have serious consequences on economic growth. Recent World Bank estimates suggest that the average country’s per capital gross domestic product would be 7% higher than it is now had stunting been eliminated when today’s workers were children. 10 At the global level, human capital accounts for as much as two-thirds of the wealth differences between countries. ECD is the foundation of human capital. 11

Supported by a growing body of evidence and increasing global interest in this field, ECD is included in the 2015 United Nations Sustainable Development Goals (SDGs). Target 4.2 is ‘improved access to quality early childhood development, care and pre-primary education’. Progress towards achieving this target is measured by indicator 4.2.1, ‘the proportion of children under 5 years of age who are developmentally on track in health, learning and psychosocial well-being, by sex’. ECD is closely linked to other SDGs as well, for example, eradicate poverty (1), end hunger and improve nutrition (2), ensure healthy lives (3), achieve gender equality (5), reduce inequality in and among countries (10), and promote peaceful societies (16), and it is implied in several more. 5

The United Nations Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016–2030 synthesises the 17 SDGs in three strategies: survive, thrive and transform. Survive refers to sustained and increased reductions in preventable deaths of women, newborns, children and adolescents, as well as stillbirths; thrive refers to children receiving the nurturing care necessary to reach their developmental potential; and transform refers to comprehensive changes in policies, programmes and services for women, children and adolescents to achieve their potential. 12

ECD has also become an important component of other global agendas, including Scaling Up Nutrition, the Global Partnership for Education, the Global Financing Facility for Every Woman Every Child, the Every Woman Every Child movement, the work plans of the WHO, Unicef and the World Bank Group, the G20, 13 international funding agencies, and philanthropic foundations. 7

These multifaceted findings have generated political momentum to improve ECD as a critical phase in the life course, making it urgent to develop measurement tools and indicators to monitor progress globally and in countries. Advances in measurement are needed to support efforts to motivate and track political and financial commitments, and to monitor implementation and impact. This means that we must be able to determine how many and which children are thriving, and on track in health, learning and psychosocial well-being.

Measurement of children’s progress in childhood is acknowledged to be challenging because development is by nature dynamic and children have varying individual trajectories. Well-validated instruments of individual development are complex and require extensive training and expertise. These challenges are amplified in efforts to make measurements across populations of children. Taking these limitations into account, we review progress in three areas of measurement that are contributing data to the current political momentum for ECD and efforts to monitor implementation and impact. Progress is being made to construct a feasible country-comparable measure of young children’s development that could be incorporated into national surveys, to improve proxies of population levels of young children at risk of poor early development, and to generate country profiles of determinants, drivers and coverage for early childhood development and services, using currently available data.

A new initiative to construct a population measure of ECD

A direct measure of the development of children 0–5 years that could be administered globally and used both within and across countries is urgently needed. Efforts have been made since the 1980s to develop a globally applicable measure of ECD, with the major challenges being individual and cultural variations in the onset of early skills. 14

Currently, the Early Child Development Index (ECDI) is included as the indicator of SDG goal 4, target 4.2. It is a composite index, first introduced in Unicef’s fourth Multiple Indicator Cluster Survey (MICS) in 2010. It is derived from 10 caregiver-reported questions designed for children aged 36–59 months to assess four domains of development: literacy-numeracy, learning/cognition, physical development and socioemotional development. Some items are acknowledged to be unsuitable for assessing development, 15 and efforts are under way to revise the index, as well as to include items applicable to children younger than 3 years of age.

Three research efforts have collaborated to create the Global Scale for Early Development (GSED): the Infant and Young Child Development from the WHO, 16 the Caregiver-Reported Early Development Instrument from the Harvard Graduate School of Education, 17 and the Developmental Score from the Global Child Development Group at the University of the West Indies. 18 The goals of the GSED are to develop two instruments for measuring ECD (0–3 years) globally: a population-based instrument and a programme evaluation instrument, as described in table 1 .

Global Scale for Early Development: population and programme measures

The GSED takes advantage of large-scale and cohort studies from many countries and is harmonising efforts to generate population-based and programmatic evaluation measures of the development of children aged 0–3 years old that can be used globally ( table 2 ). The scale will be available for country testing in 2019. The aim is to have the population-based measure incorporated into national surveys, including Unicef’s MICS and the US Agency for International Development’s Demographic and Health Surveys (DHS), to produce globally comparable monitoring data. Efforts are also under way to harmonise the revision of ECDI and the development of GSED to align on child outcome measurement from birth to 59 months of age.

Development and validation of the Global Scale for Early Development

CREDI, Caregiver-Reported Early Development Instrument; D-score, Developmental Score; IYCD, Infant and Young Child Development.

A country-comparable proxy for population levels of risk of poor childhood development

Information about children’s risk for poor development is important, as is identifying areas for intervention. To track these, a proxy measure of population levels of young children at risk of suboptimal development has been calculated.

Stunting and poverty were used in the first published estimation in 2007 of the global prevalence of risk to children’s development. The initial choice of indicators was based on evidence that they both predict poor cognitive development and school performance. 19 20 Additional advantages are that their definitions are standardised and many countries have data on both indicators. 21

Lu et al 21 updated the earlier values to 2010, using the 2006 WHO growth standards and World Bank poverty rates (US$1.25 per person per day), leading to an estimate of 249 million children or 43% of all children under 5 years of age in LMICs being at risk of poor childhood development. The accuracy and comparability of the later estimates benefited greatly from major advances in both data availability and estimation methods. 21

To estimate the long-term consequences of poor ECD, studies focus on estimating the impact on subsequent schooling and labour market participation and wages. The current estimate, that the average percentage of annual adult income lost as a result of stunting and extreme poverty in early childhood is about 26%, is supported by follow-up adult data from early life interventions. Two programmes have found wage increases between 25% in Jamaica attributed to a psychosocial intervention 22 and 46% in Guatemala attributed to a protein supplement. 23

In order to improve the estimate of risk, efforts are under way to include additional risks experienced in ECD known to affect health and well-being across the life course. For example, adding low maternal schooling and exposure to harsh punishment to stunting and extreme poverty, for 15 countries with available data from MICS in 2010/2011, increased the number of children estimated to be at risk of poor childhood development substantially. 5

Country profiles of ECD

Population-based measures of early child development and proxies of children at risk give an indication of prevalence, and indicators of disparity can be derived according to gender, urban–rural location and socioeconomic status. However, they do not include drivers, determinants nor coverage of interventions that could improve childhood development.

The Countdown to 2015 for Maternal, Newborn and Child Survival , established in 2005, set a precedent by creating mechanisms to portray multidimensional aspects of progress towards improving maternal and child health, and is testimony of its value. 24 Countdown to 2030 , which tracks maternal, child and adolescent health and nutrition goals, has expanded to address the broader SDG agenda, including ECD, health in humanitarian settings and conflict, and adolescent health and well-being. 25 26 It includes coverage and equity of essential interventions, as well as indicators of determinants and the enabling environment provided by policies.

This approach has been applied to ECD using the Nurturing Care Framework, 27 launched at the 71st World Health Assembly. The concept of nurturing care was introduced in the 2017 Lancet Series Advancing Early Child Development: From Science to Scale . Nurturing Care Framework comprises conditions for early development: good health and nutrition; protection from environmental and personal harm; affectionate and encouraging responses to young children’s communications; and opportunities for young children to learn through exploration and interpersonal interactions. 7

These early experiences are nested in caregiver–child and family relationships. In turn, parents, families and other caregivers require support from a facilitating environment of policies, services and communities. Policies, services and programmes can protect women’s health and well-being, safeguard pregnancy and birth, and enable families and caregivers to promote and protect young children’s development. 6

The Nurturing Care Framework has been used to produce ECD profiles for 91 LMICs. 28 Countries were selected either to ensure alignment of ECD with Countdown to 2030 , or because more than 30% of children are estimated to be at risk of poor ECD in 2010, using the methods described in Lu et al 21 and Black et al . 7

These country profiles, which consist of currently available data from LMICs, are laid out to represent the Nurturing Care Framework. The profiles consist of the following sections:

• Selected demographic indicators of the country relevant to early child development: total population, annual births, children under 5 years of age and under-5 mortality.
• Threats to ECD, including maternal mortality, young motherhood, low birth weight, preterm births, child poverty, under-5 stunting, harsh punishment and inadequate supervision.
• The prevalence of young children at risk of poor child development disaggregated by gender and rural–urban residence, and lifetime costs of growth deficit in early childhood in US dollars.
• The facilitating policy environment for caregivers and children, as indexed by relevant conventions and national policies.
• Support and services to promote ECD in the five areas of nurturing care: early learning, health, nutrition, responsive caregiving, and security and safety.

Most of the existing data are published in Unicef’s annual State of the World’s Children. Convention and policy data come from, among others, the United Nations Treaty Collections and the International Labour Organization.

Figure 1 shows an example of the country profiles, with the country name replace by ‘Country Profiles’.

An example of an early childhood development (ECD) country profile. CRC, convention on the rights of the child.

In a forthcoming paper, Lu and Richter (2019) describe in detail the updated estimates of children at risk of poor childhood development using the newly released poverty line of US$1.9 per person per day to estimate that, in 2015, 233 million children or 40.5% of children under 5 years of age were at risk of poor childhood development. Figures 2 and 3 show the estimates of risk for poor ECD across a decade, from 2005 to 2010 and 2015, and using the 2010 data variations between children at risk living in rural and urban areas. Gender is not illustrated here because, in most countries, the differences are small and not statistically significant.

Decline in the number of countries with high proportions of young children at risk of poor development between 2005 and 2015.

Differences in risk of poor development among urban and rural children in 63 countries (most recent years with available data).

Figure 2 shows that, between 2005 and 2010, countries with two-thirds of young children at risk (>67%) declined in both central Europe and South-East Asia. There was little change in countries with high proportions of young children at risk in sub-Saharan Africa during this period, and by 2015 countries with the highest proportion of children at risk were in Central and Southern Africa.

Estimates on the prevalence of children at risk of poor development in urban and rural areas were derived using DHS, MICS and country data for 63 countries with available data in most recent years ( figure 3 ). The differences are strikingly high, with more rural children at risk than their urban counterparts in 50 countries (differences of more than 20%). Almost all countries with 40% point differences were in sub-Saharan Africa. 28

There are additional indicators that ideally should be included in a monitoring framework, but currently lack comparable country data. Data are usually unavailable because reliable, valid instruments feasible for multicountry administration are still in development, or the instruments are not yet included in representative surveys. In particular, there are as yet no global population-based indicators for assessing responsive caregiving. Suggestions have been made that data should be collected on whether information about ECD and caregiver–child interaction is publicly disseminated, whether home visits or groups are provided for parents at high risk of experiencing difficulties providing their children with nurturing care, and whether affordable good quality child day care is available for families who need it. 29 National data on laws and policies that support responsive caregiving are also insufficient, for example, wages and other forms of income to enable families to provide for their young children. 30

Additional data gaps concern risks arising from poor parental mental health, 31 low maternal schooling, and maternal tobacco and alcohol use, among others, prevalence of childhood developmental delays and disabilities, 32 and maltreatment and institutionalisation of young children. 33 There is also no comparable information on government budget allocation to ECD or household expenditure on ECD services care, among others.

Multidisciplinary scientific evidence and political momentum are focusing on ECD as a critical phase in enhancing health and well-being across the life course. Additional measurements and indicators for monitoring and evaluation are urgently needed to support expansions in implementation and investment, and to report progress. New data will stimulate global, regional and national action, and in turn motivate for more areas of ECD to be covered in national surveys.

The Nurturing Care Framework provides a platform for three important areas of work. First, very significant progress is being made through the revision of the ECDI and the development of the GSED, a short caregiver-reported population measure of ECD that could feasibly be included in DHS, MICS and other nationally representative household surveys. The GSED will enable ECD to be tracked at population levels, and for programmes and services to be monitored and evaluated in comparable ways.

Second, a country-comparable proxy of the risk of poor ECD developed from 2004 data and updated with 2010 data has been extended to 2015, enabling comparisons to be made globally, regionally and by country across the last decade. Plans are in place to update these estimates regularly, and to add new risks as data for more countries become available.

Third, using these estimates, data included in Countdown to 2030 , and additional data from MICS and policy databases, initial profiles have been constructed for 91 LMICs. The profiles are organised according to the ecological model of the Nurturing Care Framework with policies, services and programmes supporting families and caregivers to provide good health and nutrition, security and safety, opportunities for early learning, and responsive caregiving for young children to thrive. The further development of these profiles is overseen by a multiagency committee as part of Countdown to 2030 and are freely available ( http://www.ecdan.org/countries.html and https://nurturing-care.org/?page_id=703 ). Unicef will update the country data annually and the profiles will be reproduced every 2 years.

However, as indicated earlier, substantial gaps in national and global data on topics of concern to ECD remain. The current global estimation on burden of risks, for example, does not include known risk factors other than stunting and extreme poverty, as a result of which the existing burden calculation is considerably underestimated. 5 The limited information on ECD investments at the country and global levels is exacerbated by the lack of appreciation of what constitute essential and continuous services, standard indicators for measuring ECD interventions and policies, as well as systematically collected data. Country capacity needs to be strengthened and ECD costing modules integrated into existing household income or expenditure surveys, and routinely collected from specific types of programmes. Clear definitions are needed to track donor contributions to ECD, and efforts should be made to address data issues, including collecting data from emerging donor countries (eg, China), foundations and international non-governmental organisations that are playing an increasing role in financing ECD, as has been called for by the G20. 33 National policies, strategic plans and laws which support ECD through nurturing care should be tracked for this intersectoral area.

To improve measurements of risks, intervention coverage, policies, financial commitments and impact on young children’s development, more investment is needed to regularly collect and disseminate data at the national and subnational levels. Analytical gaps at the country and global levels exist, especially with respect to equity analyses by household wealth, maternal education and rural–urban location, as well as by gender and child age within 0–5 years.

In conclusion, progress has been extremely positive, but too slow and too fragmented for the bold global agenda of ECD and the Nurturing Care Framework. The alliance with Countdown to 2030 is helpful as there is much to be learnt from the initiative’s experience under the Millennium Development Goals (MDGs), as well as collaboration with the SDGs. The country profiles boldly portray what we currently know about ECD in some of the most at-risk conditions and will prove a valuable tool for advocacy and implementation, including to improve measurement. Successful implementation and impact are dependent on accountability supported by regularly updated reliable and valid information.

Acknowledgments

Robert Inglis (Jive Media Africa, Pietermaritzburg, South Africa) and Frank Sokolic (EduAction, Durban, South Africa) for assistance with the country profiles and maps.

Handling editor: Seye Abimbola

Contributors: All authors meet the conditions for authorship: substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data; drafting the work or revising it critically for important intellectual content; final approval of the version published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding: This study has been funded by Conrad N Hilton Foundation and the Bill and Melinda Gates Foundation.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: Data on the country profiles are publicly available on the websites cited in the paper.

Early Childhood Development: the Promise, the Problem, and the Path Forward

Subscribe to the center for universal education bulletin, tamar manuelyan atinc and tamar manuelyan atinc nonresident senior fellow - global economy and development , center for universal education emily gustafsson-wright emily gustafsson-wright senior fellow - global economy and development , center for universal education.

November 25, 2013

• 17 min read

Access more content from the Center for Universal Education here , including work on early childhood education .

Early Childhood: The Scale of the Problem

More than 200 million children under the age of five in the developing world are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities (Lancet 2007).  In addition, 165 million children (one in four) are stunted, with 90 percent of those children living in Africa and Asia (UNICEF et al, 2012).  And while some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs.  Child death is a tragedy.  At 6 million deaths a year, far too many children perish before reaching the age of five, but the near certainty that 200 million children today will fall far below their development potential is no less a tragedy.

There is now an expanding body of literature on the determining influence of early development on the chances of success later in life.  The first 1,000 days from conception to age two are increasingly being recognized as critical to the development of neural pathways that lead to linguistic, cognitive and socio-emotional capacities that are also predictors of labor market outcomes later in life. Poverty, malnutrition, and lack of proper interaction in early childhood can exact large costs on individuals, their communities and society more generally.  The effects are cumulative and the absence of appropriate childcare and education in the three to five age range can exacerbate further the poor outcomes expected for children who suffer from inadequate nurturing during the critical first 1,000 days.

The Good News: ECD Interventions Are Effective

Research shows that there are large gains to be had from investing in early childhood development.  For example, estimates place the gains from the elimination of malnutrition at 1 to 2 percentage points of gross domestic product (GDP) annually (World Bank, 2006).  Analysis of results from OECD’s 2009 Program of International Student Assessment (PISA) reveals that school systems that have a 10 percentage-point advantage in the proportion of students who have attended preprimary school score an average of 12 points higher in the PISA reading assessment (OECD and Statistics Canada, 2011).  Also, a simulation model of the potential long-term economic effects of increasing preschool enrollment to 25 percent or 50 percent in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 6.4 to 17.6, depending on the preschool enrollment rate and the discount rate used (Lancet, 2011).

Indeed, poor and neglected children benefit disproportionately from early childhood development programs, making these interventions among the more compelling policy tools for fighting poverty and reducing inequality.  ECD programs are comprised of a range of interventions that aim for: a healthy pregnancy; proper nutrition with exclusive breast feeding through six months of age and adequate micronutrient content in diet; regular growth monitoring and immunization; frequent and structured interactions with a caring adult; and improving the parenting skills of caregivers.

Related Content

Emily Gustafsson-Wright, Izzy Boggild-Jones, Sophie Gardiner

September 5, 2017

Brookings Institution, Washington DC

3:00 pm - 5:30 pm EDT

The Reality: ECD Has Not Been a Priority

Yet despite all the evidence on the benefits of ECD, no country in the developing world can boast of comprehensive programs that reach all children, and unfortunately many fall far short.  Programs catering to the very young are typically operated at small scale and usually through external donors or NGOs, but these too remain limited.  For example, a recent study found that the World Bank made only $2.1 billion of investments in ECD in the last 10 years, equivalent to just a little over 3 percent of the overall portfolio of the human development network, which totals some $60 billion (Sayre et al, 2013).

The following are important inputs into the development of healthy and productive children and adults, but unfortunately these issues are often not addressed effectively:

Maternal  Health. Maternal undernutrition affects 10 to 19 percent of women in most developing countries (Lancet, 2011) and 16 percent of births are low birth weight (27 percent in South Asia).  Malnutrition during pregnancy is linked to low birth weight and impaired physical development in children, with possible links also to the development of their social and cognitive skills. Pre-natal care is critical for a healthy pregnancy and birth. Yet data from 49 low-income countries show that only 40 percent of pregnant women have access to four or more antenatal care visits (Taskforce on Innovative International Financing for Health Systems, 2009). Maternal depression also affects the quality of caregiving and compromises early child development.

Child Care and Parenting Practices. The home environment, including parent-child interactions and exposure to stressful experiences, influences the cognitive and socio-emotional development of children.  For instance, only 39 percent of infants aged zero to six months in low and middle-income countries are exclusively breast-fed, despite strong evidence on its benefits (Lancet, 2011).  Also, in half of the 38 countries for which UNICEF collects data, mothers engage in activities that promote learning with less that 40 percent of children under the age of six.  Societal violence and conflict are also detrimental to a child’s development, a fact well known to around 300 million children under the age of four that live in conflict-affected states.

Child Health and Nutrition. Healthy and well-nourished children are more likely to develop to their full physical, cognitive and socio-emotional potential than children who are frequently ill, suffer from vitamin or other deficiencies and are stunted or underweight.  Yet, for instance, an estimated 30 percent of households in the developing world do not consume iodized salt, putting 41 million infants at risk for developing iodine deficiency which is the primary cause of preventable mental retardation and brain damage, and also increases the chance of infant mortality, miscarriage and stillbirth.  An estimated 40 to 50 percent of young children in developing countries are also iron deficient with similarly negative consequences (UNICEF 2008).  Diarrhea, malaria and HIV infection are other dangers with a deficit of treatment in early childhood that lead to various poor outcomes later in life.

Preprimary Schooling. Participation in good quality preprimary programs has been shown to have beneficial effects on the cognitive development of children and their longevity in the school system.  Yet despite gains, enrollment remains woefully inadequate in Sub-Saharan Africa and the Middle East and North Africa.  Moreover, national averages usually hide significant inequalities across socio-economic groups in access and almost certainly in quality. In all regions, except South Asia, there is a strong income gradient for the proportion of 3 and 4 year olds attending preschool.

Impediments to Scaling Up

So what are the impediments to scaling up these known interventions and reaping the benefits of improved learning, higher productivity, lower poverty and lower inequality for societies as a whole?  There are a range of impediments that include knowledge gaps (especially in designing cost-effective and scalable interventions of acceptable quality), fiscal constraints and coordination failures triggered by institutional organization and political economy.

Knowledge Gaps . Despite recent advances in the area, there is still insufficient awareness of the importance of brain development in the early years of life on future well-being and of the benefits of ECD interventions.  Those who work in this area take the science and the evaluation evidence for granted. Yet awareness among crucial actors in developing countries—policymakers, parents and teachers—cannot be taken for granted.

At the same time much of the evaluation evidence from small programs attests to the efficacy of interventions, we do not yet know whether large scale programs are as effective. The early evidence came primarily from small pilots (involving about 10 to 120 children) from developed countries. [1] ;While there is now considerable evidence from developing countries as well, such programs still tend to be boutique operations and therefore questions regarding their scalability and cost-effectiveness.

There are also significant gaps in our knowledge as to what specific intervention design works in which context in terms of both the demand for and the provision of the services. These knowledge gaps include the need for more evidence on:  i) the best delivery mode – center, family or community based, ii) the delivery agents – community health workers, mothers selected by the community, teachers, iii) whether or not the programs should be universal or targeted, national or local, iv) the frequency and duration of interventions, of training for the delivery agents and of supervision, v) the relative value of nutritional versus stimulative interventions and the benefits from the delivery of an integrated package of services versus sector specific services that are coordinated at the point of delivery, vi) the most effective curricula and material to be used, vii) the relative effectiveness of methods for stimulating demand – information via individual contact, group sessions, media, conditional cash transfers etc.  In all these design questions, cost-effectiveness is a concern and leads to the need to explore the possibility of building on an existing infrastructure.  There is also a need for more evidence on the kinds of standards, training and supervision that are conducive to Safeguarding the quality of the intervention at scale.

Fiscal Constraints .  Fiscal concerns at the aggregate level are also an issue and force inter-sectoral trade-offs that are difficult to make.  Is it reasonable to expect countries to put money into ECD when problems persist in terms of both access and poor learning outcomes in primary schools and beyond?  Even though school readiness and teacher quality may be the most important determinants of learning outcomes in primary schools, resource allocation shifts are not easy to make for policymakers.  In addition, as discussed above, we do not yet have good answers to the questions around the cost implications of high quality design at scale.

Institutional Coordination and Political Context.   Successful interventions are multi-sectoral in nature (whether they are integrated from the outset or coordinated at the point of delivery) and neither governments nor donor institutions are structured to address well issues that require cross-sectoral cooperation.  When programs are housed in the education ministry, they tend to focus on preprimary concerns.  When housed in the health ministry, programs ignore early stimulation.  We do not know well what institutional structure works best in different contexts, including how decentralization may affect choices about institutional set ups.

There are also deeper questions about the nature of the social contract in any country that shapes views about the role of government and the distribution of benefits across the different segments of the population.  Some countries consider that the responsibilities of the public sector start when children reach school age and view the issues around the development of children at a younger age to be the purview of families.  And in many countries, policies that benefit children get short shrift because children do not have political voice and their parents are imperfect agents for their children’s needs.  Inadequate political support then means that the legislative framework for early year interventions is lacking and that there is limited public spending on programs that benefit the young.  For example, public spending on social pensions in Brazil is about 1.2 percent of GDP whereas transfers for Bolsa Familia which targets poor children are only 0.4 percent of GDP (Levy and Schady 2013).  In Turkey, only 6.5 percent of central government funds are directed to children ages zero to 6, while the population above 44 receives a per capita transfer of at least 2.5 times as large as children today (World Bank, 2010).  Finally, the long gestation period needed to achieve tangible results compounds the limited appeal of ECD investments given the short planning horizon of many political actors.

The Future: An Agenda for Scaling Up ECD

Addressing the constraints to scaling up ECD requires action across a range of areas, including more research and access to know how, global and country level advocacy, leveraging the private sector, and regular monitoring of progress.

Operational Research and Learning Networks. Within the EDC research agenda, a priority should be the operational research that is needed to go to scale.  This research includes questions around service delivery models, including in particular their cost effectiveness and sustainability.  Beyond individual program design, there are broader institutional and policy questions that need systematic assessment. These questions center on issues including the inter-agency and intergovernmental coordination modalities which are best suited for an integrated delivery of the package of ECD services.  They also cover the institutional set-ups for quality assurance, funding modalities, and the role of the private sector.  Finally, research is also needed to examine the political economy of successful implementation of ECD programs at scale.

Also necessary are learning networks that can play a powerful role in disseminating research findings and in particular good practice across boundaries. Many of the issues regarding the impediments for scaling up are quite context specific and not amenable to generic or off-the-shelf solutions.  A network of peer learning could be a powerful avenue for policymakers to have deeper and face-to-face interactions about successful approaches to scaling up.  South-South exchanges were an enormously valuable tool in the propagation of conditional cash transfer schemes both within Latin America and globally. These types of exchanges could be equally powerful for ECD interventions

Advocacy. There is a need for a more visible global push for the agenda, complemented by advocacy at country or regional levels and a strong role for business leaders.  It should be brought to the attention of policymakers that ECD is not a fringe issue and that it is a matter of economic stability to the entire world. It is also in the interest of business leaders to support the development of young children to ensure a productive work force in the future and a thriving economy.  Currently, there is insufficient recognition of the scale of the issues and the effectiveness of known interventions. And while there are pockets of research excellence, there is a gap in the translation of this work into effective policies on the ground.  The nutrition agenda has recently received a great deal of global attention through the 1000 days campaign and the Scaling up Nutrition Movement led by the United States and others.  Other key ECD interventions and the integration and complementarities between the multi-sectoral interventions have received less attention however.  The packaging of a minimum set of services that all countries should aspire to provide to its children aged zero to six would be an important step towards progress.  The time is ripe as discussions around the post-2015 development framework are in full swing, to position ECD as a critical first step in the development of healthy children, capable of learning and becoming productive adults.

Leveraging the Private Sector.   The non-state sector already plays a dominant role in providing early childhood care, education and healthcare services in many countries.  This represents both a challenge and an opportunity.  The challenge is that the public sector typically lacks the capacity to ensure quality in the provision of services and research evidence shows that poor quality child care and education services are not just ineffective; they can be detrimental (Lancet 2011).  The challenge is all the greater given that going to scale will require large numbers of providers and we know that regulation works better and is less costly in markets with fewer actors.  On the opportunity side of the ledger, there is scope for expanding the engagement of the organized private sector.  The private sector can contribute by providing universal access for its own workforce, through for-profit investments, and in the context of corporate social responsibility activities.  Public-private partnerships can span the range of activities, including providing educational material for home-based parenting programs; developing and delivering parent education content through media or through the distribution chains of some consumer goods or even financial products; training preprimary teachers; and providing microfinance for home or center-based childcare centers. Innovative financing mechanisms, such as those in the social impact investing arena, may provide necessary financing, important demonstration effects and quality assurance for struggling public systems.  Such innovations are expanding in the United States, paving the way for middle and low-income countries to follow.

ECD Metrics.  A key ingredient for scaling up is the ability to monitor progress. This is important both for galvanizing political support for the desired interventions and to provide a feedback loop for policymakers and practitioners. There are several metrics that are in use by researchers in specific projects but are not yet internationally accepted measures of early child development that can be used to report on outcomes globally.  While we can report on the share of children that are under-weight or stunted, we cannot yet provide the fuller answer to this question which would require a gauge of their cognitive and socio-emotional development.  There are some noteworthy recent initiatives which will help fill this gap.  The UNICEF-administered Multiple Indicator Cluster Survey (MICS) 4 includes an ECD module and a similar initiative from the Inter-American Development Bank collects ECD outcome data in a handful of Latin American countries.  The World Health Organization has launched work that will lead to a proposal on indicators of development for zero to 3 year old children while UNESCO is taking the lead on developing readiness to learn indicators (for children around age 6) as a follow up to the recommendations of the Learning Metrics Task Force (LMTF) which is co-convened by UNESCO and the Center for Universal Education at Brookings.

The LMTF aims to make recommendations for learning goals at the global level and has been a useful mechanism for coordination across agencies and other stakeholders.  A related gap in measurement has to do with the quality of ECD services (e.g., quality of daycare). Overcoming this measurement gap is critical for establishing standards and for monitoring compliance and can be used to inform parental decisions about where to send their kids.

ECD programs have a powerful equalizing potential for societies and ensuring equitable investment in such programs is likely to be far more cost-effective than compensating for the difference in outcomes later in life.  Expanding access to quality ECD services so that they include children from poor and disadvantaged families is an investment in the future of not only those children but also their communities and societies.  Getting there will require concerted action to organize delivery systems that are financially sustainable, monitor the quality of programming and outcomes and reach the needy.

Lancet (2007). Child development in developing countries series. The Lancet, 369, 8-9, 60-70, 145, 57, 229-42.  http://www.thelancet.com/series /child-development-in-developing-countries.

Lancet (2011). Child development in developing countries series 2. The Lancet, 378, 1325-28, 1339- 53.  http://www.thelancet.com/series/child-development-in-developing-countries-2.

Levy, S. and Schady, N. (2013). Latin America’s Social Policy Challenge: Education, social Insurance, Redistribution. Journal of Economic Perspectives 27(2) , 193-218.

OECD and Statistics Canada (2011). Literacy for Life: Further Results from the Adult Literacy and Life Skills Survey. Paris/Ottawa: Organisation for Economic Co-operation and Development/Canada Minister of Industry.

Sayre, R.K., Devercelli, A.E., Neuman, M.J. (2013). World Bank Investments in Early Childhood: Findings from Portfolio Review of World Bank Early Childhood Development Projects from FY01-FY11. Draft, March 2013, Mimeo.

Taskforce on Innovative International Financing for Health Systems (2009). More money for health, and more health for the money: final report. Geneva: International Health Partnership. http://www.internationalhealthpartnership.net//CMS_files/documents/taskforce_report_EN.pdf

United Nations Children’s Fund (2005). Multiple Indicator Cluster Survey 3. UNICEF. http://www.childinfo.org/mics3_surveys.html.

United Nations Children’s Fund (2008). Sustainable Elimination of Iodine Deficiency: Progress since the1990 World Summit on Children. New York: UNICEF.

United Nations Children’s Fund, World Health Organization and The World Bank (2012). UNICEF- WHO-World Bank Joint Child Malnutrition Estimates. New York: UNICEF; Geneva: WHO; Washington D.C.: The World Bank.

World Bank (2006). Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. Directions in Development series. Washington D.C.: The World Bank.

World Bank (2010). Turkey: Expanding Opportunities for the Next Generation-  A Report on Life Chances. Report No 48627-TR. Washington D.C.: The World Bank.

World Bank (2013). World Development Indicators 2013. Washington D.C.: The World Bank.

[1] The Perry preschool and Abecedarian programs in the United States have been rigorously studied and show tremendous benefits for children in terms of cognitive ability, academic performance and tenure within the school system and suggest benefits later on in life that include higher incomes, higher incidence of home ownership, lower propensity to be on welfare and lower rates of incarceration and arrest.

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Social & Emotional Development: For Our Youngest Learners & Beyond

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Perhaps more than ever, mental health and social interactions have been on the minds of many over the past year. A pandemic, ongoing systemic injustices, and a contentious political season combined to create uncertainty and stress for adults and children alike. What do these stressors mean for the mental health of our youngest learners? In what ways can early childhood educators nurture the social and emotional lives and learning of children from birth through age 8?

This issue of  Young Children  offers research-supported responses to these questions with a cluster of articles devoted to intentional practices that promote social and emotional development: The first four articles in this cluster focus on the specific social and emotional needs of infants and toddlers, and the development of these important articles represents a unique collaboration between NAEYC and ZERO TO THREE to collectively concentrate our respective journals on the emotional health of infants and toddlers.

The catalyst for this issue was threefold:

• the shared interest in supporting the early childhood education workforce to have the resources and tools necessary for meeting the needs of the youngest children in their care
• the understanding that social and emotional development is critical to learning and a fundamental aspect of infant and early childhood mental health (IECMH)
• the recognition of the power of collaboration to elevate the vital role of early childhood educators in supporting IECMH

Mary Jane Maguire-Fong opens this  Young Children  cluster with “What Babies Ask of Us: Contexts to Support Learning about Self and Other.” She details how early childhood educators can listen to, observe, and guide infants and toddlers through thoughtfully prepared play spaces, daily routines, and everyday interactions. In “‘You’re Okay’ May Not be Okay: Using Emotion Language to Promote Toddlers’ Social and Emotional Development,” Elizabeth K. King harnesses that keen awareness and planning to outline how educators can use anti-oppressive emotion language strategies with toddlers.

Tapping into these same powers of observation and reflection, Claire Vallotton, Jennifer Mortensen, Melissa Burnham, Kalli Decker, and Marjorie Beeghly present “Becoming a Better Behavior Detective: Applying a Developmental and Contextual Lens on Behavior to Promote Social and Emotional Development.” Educators can use this 5-Step Reflective Cycle to identify and be responsive to infants’ and toddlers’ behaviors and needs. Of course, following these steps depends on our own emotional presence and well-being. In an accompanying piece to this article, Holly Hatton-Bowers and colleagues offer recommendations for “Cultivating Self-Awareness in Our Work with Infants, Toddlers, and Their Families: Caring for Ourselves as We Care for Others.”

Finally, in “When in Doubt, Reach Out: Teaming Strategies for Inclusive Early Childhood Settings,” Christine Spence, Deserai Miller, Catherine Corr, Rosa Milagros Santos, and Brandie Bentley capture how an early childhood educator learns to actively participate in early intervention processes through effective communication and collaboration. This cluster also features a special Rocking and Rolling column defining IECMH and outlining how early childhood educators play a role in fostering infants’ and toddlers’ emotional well-being.

For educators of older children, it is vital to understand that the roots of social and emotional learning begin in infancy. In addition to the cluster articles, you’ll find pieces devoted to social and emotional learning in preschool and elementary settings, including articles that

• outline the ARC framework to help children learn to recognize and manage their emotions, particularly those who have experienced trauma
• describe effective strategies for fostering responsibility in young children
• distinguish between friendship and kindness in preschool settings

The articles in the  ZERO TO THREE Journal  explore a variety of issues related to IECMH in early childhood education settings, including: how infants’ and toddlers’ mental health is paramount to their ability to form healthy relationships, regulate their emotions, and learn; the role of IECMH consultation, the impact of COVID, and equity and power dynamics; and trauma-informed care and the importance of teachers’ mental health, particularly in the context of multiple, long-term stressors affecting every layer of the early childhood education system and society as a whole. The issue also recognizes the valuable role of advocacy and policy and provides suggestions for how early childhood professionals can bring their expertise to influence effective policy change for babies and families.

We hope that the readers of  Young Children  and the  ZERO TO THREE Journal  will turn to both publications to discover perspectives and find valuable resources to support their work with infants, toddlers, and their families. Links to selected articles from each issue are available on each journal’s web page.

—Annie Moses, editor in chief, with Stefanie Powers, editor in chief,  ZERO TO THREE Journal , and Kathy Reschke, editorial assistant,  ZERO TO THREE Journal

Above: Children in Maureen Linnane’s toddler class used cardboard materials to create a collage.

Below: This piece comes from Chandler, the young toddler son of an NAEYC staff member, as he explored art materials.

Is your classroom full of children’s artwork? To feature it in  Young Children , see the link at the bottom of the page or email  [email protected]  for details.

Send your thoughts on this issue, and on topics you’d like to read about in future issues of Young Children, to  [email protected] .

Would you like to see your children’s artwork featured in these pages? For guidance on submitting print-quality photos (as well as details on permissions and licensing), see  NAEYC.org/resources/pubs/authors-photographers/photos .

Annie Moses, PhD, is director of periodicals at NAEYC and serves as editor in chief of  Young Children  and  Teaching Young Children .

Stephanie Powers is the editor in chief at ZERO TO THREE Journal.

Kathy L. Reschke, PhD, is senior content specialist for ZERO TO THREE. Dr. Reschke contributes to the design and development of competency-based professional development products and services. She developed the content for the ZERO TO THREE Critical Competencies for Infant-Toddler Educators™ course manuals, online course, and coaching program. [email protected]

Vol. 76, No. 1

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Linking quality and child development in early childhood education and care: Technical report

Government investment in early childhood education and care (ECEC) supports children’s ongoing development, learning and wellbeing, and delivers the skills and knowledge required for a thriving society and economy. Assessing the efficiency of this investment, as well as methods for ongoing monitoring are important steps in delivering effective early experiences for children that optimise early learning and improve life chances for all Australian children.

The Australian Education Research Organisation (AERO) aims to lay the groundwork for a stronger, smarter ECEC system – one that maximises the potential of education data to improve policy and practice, towards excellence and equity in learning and development for all Australian children. In 2023, AERO partnered with the Queensland Brain Institute (QBI) Child Development and Early Education Group at The University of Queensland to examine how specific aspects of quality in ECEC relate to learning and development outcomes for children in Australia.

For this study, the researchers analysed 2 pre-existing population datasets:

• the Person Level Integrated Data Asset (PLIDA; formerly Multi-Agency Data Integration Project [MADIP])
• the Effective Early Educational Experiences (E4Kids) longitudinal study.

This technical report presents the findings from this study. Our related research summary summarises the key findings.

AERO would like to acknowledge QBI for preparing this technical report.

Keywords: child development, actionable insights

• Evidence - use & generation
• Linking quality and child development in early childhood education and care: Research summary
• Actionable insights into Australian education
• Promoting equity for multilingual children in early childhood
• Early childhood data in Australia: Scoping report

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The Case for Early Childhood Education as Health and Economic Policy

Table of Contents

Jessica n. wise, katarina reyes, sandra mckay, share this publication.

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Jessica N. Wise, Katarina Reyes, and Sandra McKay, “The Case for Early Childhood Education as Health and Economic Policy” (Houston: Rice University’s Baker Institute for Public Policy, September 6, 2024), https://doi.org/10.25613/TEZ6-RW62 .

Families across the United States are facing significant challenges due to the limited availability and affordability of high-quality early childhood care options for children under the age of 6. Child care access is especially challenging for those seeking to reenter the workforce. Rethinking child care, especially early childhood education, as health care is essential for achieving a better future and economic security for children, families, and caregivers across the U.S.

Early Childhood Education: Health and Economic Challenges

Children and their families experience more hardships throughout their lifetimes because the U.S. lacks quality early childhood education for children whose parents want to join the workforce during their children’s infancy and toddler years. Families with young children lose the opportunity for better health and increased wealth over their lifetimes when child care, including early childhood education, is unavailable to them.

What Is the Magnitude of Child Care in the U.S.?

Per data from the U.S. Census Survey,  over 17 million households had young children under the age of 6 in 2022, and nearly 19 million children under the age of 5 in the U.S. as of 2023, according to UNICEF. In 2022, the U.S. Census Survey noted over one in three parents with children under the age of 6 reported that they did not work because they did not have any type of child care arrangement. A conservative estimate from a recent U.S. Department of Labor’s Women Bureau report reports that “more than $775 billion in additional economic activity per year” is lost because of the lack of labor force participation. The lack of accessible high-quality child care in general and particularly early childhood education, not only affects families, depriving them of opportunities for improved health and wealth, but also has a significant impact on the economic health of the country.

What Is the Effect on the Well-Being of Children?

Children’s brain development is fundamentally shaped by the quality of their early interactions and experiences, producing either robust or lacking foundations for their ability to learn, overall health, and behavior as they mature throughout their lives. During a child’s first few years, the brain forms over one million neural connections every second, “ a pace never repeated again .” A recent U.S. Department of Health and Human Services (HHS) report from the Administration for Children and Families echoes that children benefit from high-quality early childhood education by learning important “foundational skills for math, reading, self-control, and positive relationships.” There are short-term effects on child cognitive development, executive functioning, and social skills at the kindergarten level and similar intermediate effects through primary and secondary school. There are also estimated long-term effects , including “higher educational attainment, better adult health,” and, according to the Centers for Disease Control and Prevention (CDC), “higher earnings throughout employment years.”

What Is the Effect on the Well-Being of Families?

Without high-quality early child care available, unpaid caregivers suffer the loss of the opportunity to achieve better health, wealth, and well-being through workforce participation. The long-term consequences include lower wages, missed promotions, lost job tenure, loss of skills, and less contribution to retirement plans, when they become employed or reemployed. The average lifetime cost of unpaid caregiving is $420,000 in lost earnings and retirement income for college-educated mothers, and $295,000 for all mothers in the U.S. This is economically significant for many families.

Further, the recent COVID-19 pandemic provided important insights into the support structure of early childhood care necessary for families with young children to thrive. During the pandemic, the CDC’s Morbidity and Mortality Weekly Report found that one out of four unpaid caregivers of children reported that their mental health had worsened. Resenting the caregiving role was associated with higher odds of an adverse mental health symptom while having support was associated with lower odds. The availability of high-quality early childhood education could mitigate the negative mental health effects that unsupported caregivers experience. It is time to rethink child care as essential health care for families , both children and caregivers.

Why Is High-Quality Early Childhood Care and Education Out of Reach?

Simply put, the market for early childhood education does not work well. There is an excess in demand and not enough child care slots offered. Multiple causes for this include:

• Workforce challenges including lack of competitive pay and high turnover.
• High costs associated with providing quality care.
• Fragile business models vulnerable to economic shocks.

Child Tax Credit

In comparison to other countries, the U.S. invests very little in family benefits at slightly more than half a percent of GDP compared to the Organization for Economic Co-operation and Development (OECD) average of 2.1% of GDP in 2019.

The Child Tax Credit is a tax break for families raising children. For 2021, the American Rescue Plan expanded the Child Tax Credit to $3,600 for a child under the age of 6 for families that qualify. In 2022 and 2023, the Child Tax Credit is again limited to $2,000, with $1,600 being refundable, for children under the age of 6.

Figure 1 — Child Care Employment, Total Employment (Thousands)

The Child Care Stabilization Act was a part of the American Rescue Plan Act, which was enacted to recover from the COVID-19 pandemic. Through this program, the federal government provided $24 billion in subsidies to child care providers and indeed did stabilize the market for child care according to a working paper by the Council of Economic Advisors (CEA) cited by the White House (Figure 1). The program supported “ over 225,000 care providers serving as many as 10 million children ”; eight out of ten licensed care providers in the U.S. received assistance. According to the same CEA report , funds from the Child Care Stabilization Act both increased the number of child care workers and increased the wages for those workers. Since the program’s expiration in November 2023, some individual state legislative and executive branches have been moving to address the child care crisis through various programs. However, child care providers feel the sting of losing federal support.

Policy Recommendations

A multipronged policy approach could provide affordable, high-quality early childhood education for any family who would like to access it by offering both demand and supply-side solutions to the problem. Stabilization efforts through the American Rescue Plan brought the industry back to baseline in terms of child care employment, but continued efforts are needed to address the crisis and improve the availability and affordability of child care in years to come:

• Expand the Child Tax Credit for families with young children aged 5 and under to $3,600 with full refundability, making the high cost of child care more affordable for working families.
• Continue the Child Care Stabilization Act through the next five years to expand the availability and affordability of early childhood care by fortifying existing care centers and investing in new ones.

The resulting policy effect would be an increase both in supply and demand to the benefit of children, their parents, and society. 

To treat child care as health care is to recognize the short- and long-term effects on the well-being of families both in health and wealth. The existing child care market is failing families by not providing the early child care education that is needed and wanted. To address both the supply and demand for child care, tax credits, and child care subsidies provide opportunities that benefit children, their parents, and society. Indeed, investing in children is investing in the future.

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.

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A scoping review of early childhood caries, poverty and the first sustainable development goal

• Maha El Tantawi 1 , 2 ,
• Dina Attia 1 , 2 ,
• Jorma I. Virtanen 1 , 3 ,
• Carlos Alberto Feldens 1 , 4 ,
• Robert J. Schroth 1 , 5 ,
• Ola B. Al-Batayneh 1 , 6 , 7 ,
• Arheiam Arheiam 1 , 8 &
• Morẹ́nikẹ́ Oluwátóyìn Foláyan 1 , 9  

BMC Oral Health volume  24 , Article number:  1029 ( 2024 ) Cite this article

Metrics details

Poverty is a well-known risk factor for poor health. This scoping review (ScR) mapped research linking early childhood caries (ECC) and poverty using the targets and indicators of the Sustainable Development Goal 1 (SDG1).

We searched PubMed, Web of Science, and Scopus in December 2023 using search terms derived from SDG1. Studies were included if they addressed clinically assessed or reported ECC, used indicators of monetary or multidimensional poverty or both, and were published in English with no date restriction. We excluded books and studies where data of children under 6 years of age could not be extracted. We charted the publication year, study location (categorized into income levels and continents), children age, sample size, study design, measures of ECC, types and levels of poverty indicators and adjusted analysis. The publications were also classified based on how the relation between poverty and ECC was conceptualized.

In total, 193 publications were included with 3.4 million children. The studies were published from 1989 to 2023. Europe and North America produced the highest number of publications, predominantly from the UK and the US, respectively. Age-wise, 3–5-year-olds were the most studied (62.2%). Primary studies (83.9%) were the majority, primarily of cross-sectional design (69.8%). Non-primary studies (16.1%) included reviews and systematic reviews. ECC was mainly measured using the dmf indices (79.3%), while poverty indicators varied, with the most common used indicator being income (46.1%). Most studies measured poverty at family (48.7%) and individual (30.1%) levels. The greatest percentage of publications addressed poverty as an exposure or confounder (53.4%), with some studies using poverty to describe groups (11.9%) or report policies or programs addressing ECC in disadvantaged communities (11.4%). In addition, 24.1% of studies requiring adjusted analysis lacked it. Only 13% of publications aligned with SDG1 indicators and targets.

The ScR highlight the need for studies to use indicators that provide a comprehensive understanding of poverty and thoroughly examine the social, political, and economic determinants and impact of ECC. More studies in low and middle-income countries and country-level studies may help design interventions that are setting- and economic context-relevant.

Peer Review reports

Introduction

The National Library of Medicine’s Medical Subject Heading (MeSH) defines poverty as the situation where people have a living standard that is below that of the community because of their income level [ 1 ], thus using income to define poverty. This monetary poverty definition considers a person or a household to be poor if their standard of living is below the national poverty line which captures the ability to meet basic needs in food, shelter, clothing, and other goods obtained through purchase [ 2 , 3 ].

Poverty can be classified based on how it is measured into absolute poverty referring to the percentage of the population having an income below the national or international poverty line and thus, unable to meet their basic needs [ 4 ]; and relative poverty where persons have living standards less than others in their community/ country and thus represents income inequality [ 5 ]. Income inequalities are measured by indices of inequality such as the Gini coefficient or the Lorenz curve [ 6 ]. Monetary poverty equates poverty with financial resources. On the other hand, multi-dimensional poverty uses a wider perspective of poverty [ 7 , 8 ] which includes, in addition to the monetary dimension, education, basic infra structure such as water, sanitation and electricity in addition to health, nutrition and security [ 9 ].

The sustainable development goals (SDGs), established in 2015, replaced the millennial development goals (MDGs) [ 10 ]. Compared to the MDGs, the SDGs targeted all countries and not only developing countries, and addressed economic growth, social inclusion and environmental protection and not only social development [ 11 , 12 ]. The first goal of the SDGs, however, remained the same as for the MDGs: to end poverty.

The SDG1 has seven targets aiming to build the resilience of the poor and those in vulnerable situations by reducing their exposure to environmental, economic, social shocks and disasters [ 12 ]. The seven targets of SDG1 define poverty in the monetary dimension as absolute poverty such as living below the international poverty lines (target 1.1) and below the national poverty lines (target 1.2) indicating extreme poverty. The targets also refer to multidimensional poverty including people in need of social protection systems (target 1.3) and people in need of basic services (target 1.4) [ 12 ]. Two targets, 1.a.2 and 1.b.1 aim to promote governmental spending to support the poor by providing essential services. A central goal in the SDGs is to end extreme poverty in all its forms everywhere by 2030.

Early childhood caries (ECC), which is the presence of any untreated, restored or extracted tooth with caries in a child below the age of 72 months [ 13 ], is linked to poverty. At country level, low and middle-income countries, which are resource-limited economies, have higher percentage of children with ECC than high income countries [ 14 ]. Monetary poverty is also associated with higher risk of ECC with higher ECC prevalence in countries with greater percentage of population living below the poverty line [ 15 ]. Also, multi-dimensional poverty is associated with high prevalence of ECC [ 16 ]. However, an ecological study suggested that not all forms of poverty are similarly linked to the risk of ECC [ 17 ].

The theory of economic, political, and social distortions suggests that poverty is linked to economic, political, and social systems, which limit the opportunities and resources to achieve well-being [ 18 ]. The SDG1 recognises the multiple dimensions of poverty, and how inequitable economic, political, and social structures impact health. The efforts to achieve the SDG1 targets may also have direct and indirect impact on shaping children’s oral health and their risk of ECC [ 14 , 19 ]. The eradication of poverty, institution of social protection systems, efforts to reduce the impact of disasters, increased governmental spending on essential services including health and education, and increased pro poor spending can have a positive impact on reducing the risk of ECC. On the other hand, ECC treatment and cost of care may have great financial implications on families of children with ECC. However, the pathways for this possible bidirectional relationship between ECC and poverty need to be identified.

The aim of this scoping review (ScR), therefore, was to identify research linking ECC and various types of poverty using the SDG1 targets and indicators. This ScR was guided by the question: what is the status of research on the relationship between ECC, poverty and the SDG1?

This ScR was performed in accordance with the Joanna Briggs Institute guidelines [ 20 ] and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines (PRISMA-ScR) [ 21 ].

Eligibility criteria

Studies were included if they addressed ECC which is caries including untreated, filled or extracted primary teeth in children younger than 6 years of age as defined by Drury et al. [ 22 ] and endorsed by the American Association of Pediatric Dentistry [ 13 ] whether assessed clinically or reported by parents. Various ECC indicators were used including the presence of ECC experience (yes/no), the presence of untreated ECC (yes/no), ECC severity measured by the number of teeth/surfaces with ECC experience or the number of teeth/surfaces with untreated ECC. The studies had to include a measure of monetary poverty, multi-dimensional poverty, or both. Studies of any design or publication date were included.

Publications not written in English and books, book chapters and book reviews were excluded. We also excluded studies where data specific to children under 6 years of age could not be extracted. Studies with indicators exclusively associated with socioeconomic status that were addressed by SDG 4 (education), SDG 15 (migrants and refugees), and SDG 11 (urban/rural differences) were excluded. Publications with no full texts were excluded.

Information sources

Three electronic databases were searched: PubMed, Web of Science, and Scopus. The searches were conducted in March and April 2023 and updated in December 2023. The search terms for poverty were based on the terms for the SDG1 defined in Scopus [ 23 ] and adapted to the two other electronic databases. The search strategies can be seen in Appendix 1 . Expert members of the Early Childhood Caries Advocacy Group (ECCAG) were also consulted for other sources that might have been missed by the search strategy.

Selection of sources of evidence

Retrieved publications were exported to the reference management software Mendeley version 1.19.8. Duplicate publications were removed. Title and abstract screening was performed independently by two researchers (MET and DA) using the pre-defined inclusion and exclusion criteria. Full-text review of screened-in publications from the first level was then performed independently by the same two researchers. Uncertainty regarding whether publications met the inclusion criteria was resolved through consensus. The results were shared with two experts (RJS and MOF) for their review. Publications were retained when there was consensus between the experts and the reviewers. The final list of included publications was shared with members of the ECCAG for further confirmation. No external authors or institutions were contacted to identify additional sources.

Data charting

We extracted details on publication year (grouped into decades) and study location, defined as the country in which the study was conducted. The countries were grouped by continent and by income level (low-income countries (LICs), lower middle-income countries (LMICs), upper middle-income countries (UMICs) and high-income countries (HICs)) based on the World bank 2022-23 classification [ 24 ].

We also extracted the age of children included in the study in years. The publications were grouped into studies conducted among 0-2-year-olds, 3-5-year-olds, and 0-5-year-olds. The age grouping was done following the recommendation in our previous publication based on differences in data availability, ECC prevalence and age-related determinants of risk [ 25 ]. Information on sample size was also extracted.

The design of each study was identified and classified into primary and non-primary studies. Primary studies were further classified into cross-sectional, ecological, case control, cohort, randomized clinical trial (RCT) and protocols of any of the above. Non-primary studies included reviews, systematic reviews, scoping reviews, guidelines and opinions.

We extracted information on the measures of ECC and classified them into non-clinically assessed (parent reported, years lived with disability (YLDs)) [ 26 ] and clinically assessed including the presence/absence of untreated decay or caries experience, the number of surfaces/teeth with untreated decay or caries experience whether caries was measured using the dmf index, its variants or ICDAS [ 27 ] as well as pufa for caries complications [ 28 ].

In addition, we extracted information on poverty indicators and classified the publications into those using single or multiple indicators. We identified the publications using indicators of monetary poverty (absolute or relative) and multidimensional poverty. We defined absolute poverty as the percentage of the population below national or international poverty lines [ 4 ] and relative poverty as inequalities in ECC due to socio-economic position measured by the Lorenz curve, the Gini index, or both [ 5 , 6 ]. Multidimensional poverty was defined by at least two indicators of poverty exclusive of monetary poverty. Indicators of multidimensional poverty include crowding, occupation, school type, federal assistance, qualification for school meal, ownership of commodities, and food insecurity. We also assessed if poverty was measured at the individual, family, area, community, school, city and country levels by adapting the Fisher Owens conceptualization of the influences on child’s oral health [ 29 ].

In addition, we adapted Locker’s description of MacIntyre’s method [ 30 ] to classify primary studies according to how the relation between poverty and ECC was conceptualized. The method encompasses a view of poverty that includes economic, social, and cultural dimensions, and frames poverty within a broader historical and societal narrative, acknowledging its roots and evolution over time. This allows poverty-related actions to reach beyond the alleviation of material deprivation to the overall well-being and flourishing of individuals and communities. There were eight ways poverty could be conceptualized in relation to ECC: (1) defining a group or community of people; (2) in a causal relation with ECC (dependent variable) where poverty is an independent or a confounding variable; (3) measured by income level, and used to compare ECC among administrative units/countries in ecological studies; (4) assessing trends or changes across time in ECC based on poverty; (5) assessing a gradient of ECC or effect modification of ECC risk by levels of poverty; (6) the effect of poverty on ECC at different ages in life course studies; (7) evaluating the effect of policies or programs, including fluoridation, on ECC at different levels of poverty; and (8) ECC as independent factor and poverty as dependent or confounding factor. We also identified whether these relations were analyzed using bivariate or multivariable methods to adjust for confounders.

The extracted data were presented using descriptive statistics as numbers, frequencies, and sums. Excel was used for graphical presentation to generate bars/clustered bars, tree maps, and map. A word cloud was created to demonstrate study designs [ 31 ].

The initial search from the three databases yielded 3,377 potentially relevant publications. Thereafter, 614 duplicates were removed, and 2,354 publications were removed after screening the titles and abstracts, leaving 409 for full text screening. Of these, 40 publications could not be retrieved. On reading the full text of the remaining 369 publications, 176 publications did not meet the inclusion criteria and were removed leaving 193 publications to be included in this ScR. Figure  1 is a flowchart of the selection process. The details of the publications included in the ScR are in Appendix 2 .

Flowchart of study selection process [ 32 ]

Fifteen (7.8%) papers were published in the 1990s or before, 54 (28.0%) in the 2000s, 81 (42.0%) in the 2010s and 43 (22.3%) from 2020 to December 2023 (Fig.  2 ). The publications increased in number since 2016, the year the SDGs came into effect, except for the year 2020 when the COVID-19 pandemic brought the world to a standstill. The average number of publications till 2015 was 5 and it doubled afterwards from 2016 to become 10.

Number of publications on ECC and poverty by year

Twenty-two publications were multi-country, while 171 publications were country-specific (Fig.  3 ). The greatest number of publications were from Europe (49, 25.4%), mostly the UK (31 publications), and North America (46, 23.8%), mostly the US (42 publications), followed by South America (35, 18.1%) mainly Brazil (29 publications), Asia (20, 10.4%) mainly India (5 publications) then Australia and New Zealand (12 and 4 publications) and Africa (5, 2.6%) with three publications from South Africa and one each from Nigeria and Tanzania. Of all publications from specific countries, two (1.0%) were from LICs, 11 (5.7%) from LMICs, 40 (20.7%) from UMICs and 118 (61.1%) from HICs.

Number of publications on ECC and poverty by country (darker shade of green indicates more publications from the country)

Twenty (10.4%) of the publications included 0–2-year-old children, 120 (62.2%) included 3–5-year-old children, and 40 (20.7%) included 0-5-year-old children. Also, 13 (6.7%) did not specify the age of the included children and 33 (17.1%) publications did not specify the number of children in the sample. The total number of children included in the remaining 160 publications was 3,404,236 with a median of 892 children per study, a minimum of 24 children and a maximum of 995,003 children. There was a much greater number of 3–5-year-old ( n  = 3,249,261) than 0–2-year-old children ( n  = 21,549).

Figure  4 shows that 162 (83.9%) publications were primary studies and 31 (16.1%) were non-primary studies. Most primary studies were cross-sectional in design (113, 69.8%), and there were 23 (14.2%) cohort studies. Most of the 31 publications about non-primary studies were reviews (14, 45.2%) or systematic reviews (10, 32.3%).

Design of studies on the association between poverty and ECC (RCT: randomized controlled trial, CC: case-control, SR: systematic review, GL: guidelines, ScR: scoping review)

Most publications (153, 79.3%) measured ECC using dmf scores and 10 (5.2%) publications used ICDAS. One recent publication used the pufa index. Six publications assessed ECC non clinically, with five relying on parent reporting, and one using YLDs. Four publications used a mixture of indices and 19 publications did not specify how ECC was measured.

Figure  5 shows the poverty indicators used in the publications. There were 113 (58.5%) publications with a single poverty indicator and 71 (36.8%) with more than one indicator, whereas 9 (4.7%) did not specify the indicators used. The most common indicator was income (89, 46.1%) followed by area-based indicators such as the Jarman deprivation index, the Townsend deprivation index and the Carstairs index of deprivation in the United Kingdom, the Socio-Economic Indexes for Areas (SEIFA) in Australia, the area deprivation index in the United States of America (37, 19.2%) and occupation (36, 18.7%). Four (2.1%) publications explicitly used indicators of multidimensional poverty. Relative poverty was measured in 8 (4.2%) publications, including four (2.1%) using the Gini coefficient. Thirteen (6.7%) publications reported the percentage of the population below the national poverty line.

Most (157, 81.4%) publications used poverty indicators measured at one level and the remaining 18.6% assessed it at two ( n  = 28), three ( n  = 7) or four ( n  = 1) levels. Poverty was measured at the family (94, 48.7%), or individual (58, 30.1%) levels followed by area (34, 17.6%) or community (31, 16.1%) levels. Some publications assessed poverty at the school level (16, 8.3%) and only a few measured it at city or country levels (2 and 3 respectively).

Word cloud of poverty indicators used in the publications included in the ScR (ABI: area-based index, GDP: gross domestic product, GNI: gross national income, GNP: gross national product, SES: socio economic status, SE: socio economic)

Figure  6 shows that more than half of the publications (103, 53.4%) addressed poverty as an exposure or confounder. Less studies used poverty as descriptor of participants (23, 11.9%), reported on policies, or programs addressing ECC in disadvantaged communities (22, 11.4%), or assessed effect modification by poverty on ECC (21, 10.9%). Five publications reported on the cost implications of ECC. Adjusted analysis was not indicated in 56 (29.0%) of the included studies. In the remaining 137, adjusted analysis was used in 104 (75.9%) while 33 (24.1%) publications that required adjusted analysis did not have this done.

Classification of publications according to conceptualization of poverty and use of adjusted analysis (NA = use of adjusted analysis not applicable)

In addition, 25 (13.0%) publications addressed absolute, relative or multidimensional poverty (SDG targets 1.1 to 1.4). Furthermore, from 2016 to 2023, only 11 publications addressed programs and policies on ECC in disadvantaged populations (SDG1 targets 1.a.2 and 1.b.1).

This ScR showed that most studies on ECC and poverty were conducted after 2010, focused on 3–5-year-old children, used a cross-sectional design, and measured ECC clinically. Poverty was mainly assessed using single indicators, indicators of monetary poverty, or measures of poverty at the family level. Studies aligning with the SDG1, including the impact of social protection systems, access to basic services, governmental spending on essential services and pro poor public spending, were few. Most publications linked poverty to ECC as a confounder or an independent variable, some evaluated the impact of policies and programs on ECC, and few studies assessed trends or effect modification. Few studies also assessed the cost of ECC or its impact on oral and general health. Most studies were conducted in HICs and UMICs, and more than half of the studies originated from UK, US and Brazil. There was minimal evidence on the link between country-level poverty indicators and ECC.

There was a large number of publications that used multiple and diverse indicators of ECC and poverty, with different levels at which they were measured and limited use of adjusted analysis. Because of this, we could not provide a summary of the association between ECC and poverty. Therefore, we opted to present this ScR as a preliminary step to a systematic review that would allow better assessment of the quality of included studies and the impact of poverty on ECC at different units and levels.

The strengths of this study include the comprehensive review of publications in English, searching the three main electronic databases, and identifying knowledge gaps that need to be addressed to improve our understanding of the studied association. One of the limitations was the inclusion of publications in English only which may underestimate the number of identified papers. Also, we included reviews and study protocols, and it is possible that there would be some duplication because of this. However, the aim of the scoping review was to map the literature and not to extract estimates to quantify relationships like in a systematic review where estimate duplication would pose a problem. In addition, we did not include all potential databases where publications on ECC and poverty might be indexed. However, the study provides insights about the research on the link between ECC and poverty and the gaps in this area. There are several important findings.

First, this ScR aimed to align the literature on ECC and poverty with the United Nations’ SDG1 targets and indicators. The dental scientific community seems to be responding to the SDGs as more research in this area has been published on average starting from 2016 than before. However, there was can be better alignment with how the SDG1 defined poverty. Thus, despite the increasing number of publications in the field, more alignment is needed to ensure that dental research supports the achievement of SDG1 in relation to ECC.

Second, the current review identified that studies from LICs or LMICs were few. This affects our full understanding of the relationship between ECC and poverty. ECC research in LICs and LMICs faces several challenges including the need to build research capacity [ 33 , 34 ] and secure data sources. Few LICs and LMICs routinely collect nationally representative data on ECC [ 25 ]. The 2022 Global Oral Health Status Report [ 35 ] used advanced computational methodologies to infer disease estimates for countries where there are none based on the Global Burden of Diseases (GBD) studies. However, the GBD studies reported only on untreated caries in primary teeth regardless of age, and did not include the sequalae, such as extraction and filling [ 36 ], which are part of the ECC definition [ 13 ]. Thus, global comparisons using the GBD estimates do not adequately assess the ECC burden. However, the World Health Organization included 5-year-olds as one of the index age groups for surveys up to the 2013 edition of their oral health survey manual [ 37 ]. At the same time, data are routinely collected to monitor maternal and child health in LICs and LMICs using global health surveys such as the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys [ 38 ]. If ECC indicators are incorporated into these surveys, ECC can be embedded in the surveillance systems of these countries. This may require the use of non-clinical indicators of ECC such as self-reporting which reduces the necessity for labour-intensive clinical examinations. However, research is needed to improve the accuracy of these non-clinical indicators. This approach may help address the current gap we noticed wherein only few studies used poverty indicators at country level. When data is available, it would be possible to better understand the impact of poverty on the risk of ECC in Africa and Southeast Asia where most LICs and LMICs are located, where the greatest number of people with caries live [ 35 ], and where the largest number of 0–5-year-old children are resident [ 39 ].

Third, only 10% of studies focused on 0-2-year-old children. Our previous research showed that 0-2- and 3–5-year-old children have different ECC profiles and disease determinants and hence, the need to differentiate between these two age groups [ 25 ]. In addition, 0-2-year-old children may require different, non-clinical ECC indicators due to the relative difficulty of examining children at this young age. Also, different level of measuring poverty may be needed since children at this age are less likely to be in schools [ 40 ]. Greater focus on younger age would enable better understanding of the life course of caries at different age groups and allow the design of interventions for ECC prevention tailored to this age.

Fourth, several studies used multiple indicators to assess monetary poverty at individual, family and to a lesser extent at the community, city or country levels. There were, however, no studies focusing on polices about the impact of poverty on ECC at the sub-regional or country levels. This is a gap that limits the implementation of country specific programs. Policies aiming to control poverty can affect individuals, families, and community level experiences of ECC, and cumulatively impact country-level ECC experience than vice-versa. Future ECC-poverty research needs to align with the SDG1 and enable the promotion of poverty alleviation programs and policies that have greater potential of inducing large scale and sustained impact on populations. Greater country-focused economic development and reduced poverty are expected to reduce the burden of poor oral health including ECC [ 16 ].

Though far-reaching progress has been made to eliminate poverty in countries like China and India [ 41 , 42 ], progress has been slow in South Asia and sub-Saharan Africa, where about 80% of those living in extreme poverty reside and where there is a huge burden of ECC [ 43 , 44 ]. New threats brought on by climate change, conflict, food insecurity and COVID-19 mean that more work needs to be done to bring people out of poverty [ 44 ] and reduce the risk of ECC as a public health threat in deprived settings and developing countries. Socioeconomic inequalities drive higher disease burden in disadvantaged populations within and across societies, and over the life course [ 35 ]. The causes of these inequalities are often complex and related to country-specific cultural, economic, historical, social, or political factors, and reflect the inequitable distribution of resources in society including power, money, and agency among others [ 5 , 45 ]. Research disentangling the complexities of cultural, economic, healthcare system and political factors at country level is needed to guide policy formulation, and to set international agendas for oral health.

Fifth, most studies used poverty as an independent factor affecting ECC, as a descriptor for participants, or a modifier for the association between ECC and other factors. More studies are needed to investigate the impact of ECC on the risk for poverty as untreated ECC can increase the risk of reduced productivity and has high management associated costs for parents [ 46 ]. Studies on the economic impact of ECC can support advocacy efforts that call for greater investment in poverty-alleviation programs controlling ECC. There is currently limited information on the cost of ECC care and the extent to which it contributes to catastrophic oral healthcare expenditure since ECC has a socioeconomic gradient and is concentrated in the most disadvantaged [ 47 ]. ECC places further stressors on already strained healthcare systems due to the increased demand for treatment under general anaesthesia. In addition, information on dental insurance that covers ECC is scarce. This information is critical to advocate for the inclusion of ECC prevention and management within universal healthcare care schemes in settings with high disease burden.

In addition, there has been recent interest in the impact of ECC on oral and general health in children and adults in later life [ 48 , 49 , 50 ]. This line of research sheds light on how ECC affects child growth, nutritional status and wellbeing. Such evidence helps better advocacy for ECC care and bridges the gap separating oral and general healthcare of children. In addition, it directly puts ECC on the agenda of child healthcare.

Sixth, the use of adjusted analysis to control confounders was limited in the studies in this ScR. Confounders obscure the effect of exposures on dependent variables [ 51 ] and if not controlled, produce biased estimates of the relation between ECC and poverty, threatening internal validity and leading to incorrect conclusions either over- or underestimating the effect [ 52 ]. This problem has been previously reported in dental research with differences among dental journals in the use of adjusted analysis [ 53 ]. Also, a ScR of waste in dental research [ 54 ] showed that confounding was ignored in 17% of non-randomized studies and 21% of different types of studies. Journals need to emphasize the use of adjusted analyses.

In conclusion, this ScR suggests that research on the link between poverty and ECC is growing and currently occurs in limited settings and economic contexts. More research is needed using indicators based on a more comprehensive definition of poverty, to assess the social, political and economic determinants and impact of ECC. More studies are also needed in Africa and South Asia where the burden of ECC is high and there are currently very few studies. In addition, country-level studies about poverty and ECC are also needed to support context-specific responses for ECC management.

Data availability

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Maha El Tantawi, Dina Attia, Jorma I. Virtanen, Carlos Alberto Feldens, Robert J. Schroth, Ola B. Al-Batayneh, Arheiam Arheiam & Morẹ́nikẹ́ Oluwátóyìn Foláyan

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Maha El Tantawi & Dina Attia

Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Bergen, Norway

Jorma I. Virtanen

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Arheiam Arheiam

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MOF conceived the study. The project was managed by MET and MOF. Data curation was done by MET. Data analysis was conducted by MET and DY. MOF and MET developed the first draft of the document. MET, DA, JIV, CAF, RJS, OBA, AA, MOF read the draft manuscript, made inputs prior to the final draft and approved the final manuscript for submission.

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Jorma I. Virtanen, Ola B. Al-Batayneh and Arheiam Arheiam are editorial Board members with BMC Oral Health. Morenike Oluwatoyin Folayan and Maha El Tantawi are Senior Editor Board members with BMC Oral Health. All other authors declare no conflict of interest.

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El Tantawi, M., Attia, D., Virtanen, J.I. et al. A scoping review of early childhood caries, poverty and the first sustainable development goal. BMC Oral Health 24 , 1029 (2024). https://doi.org/10.1186/s12903-024-04790-w

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DOI : https://doi.org/10.1186/s12903-024-04790-w

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• [Docket ID ED-2024-OPE-0072]

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Request for information.

This notice is a request for information in the form of written comments that include information, research, and suggestions regarding operational aspects of the possible inclusion of for-profit early childhood education providers as eligible employers for the purpose of Public Service Loan Forgiveness.

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Congress created the Public Service Loan Forgiveness (PSLF) Program in 2007 as part of the College Cost Reduction and Access Act, Public Law 110-84 , to encourage individuals to enter into and remain employed in public service professions. The program alleviates financial burdens associated with Federal Direct Loans for borrowers working for certain public service providers by forgiving all remaining loan balances following 10 years of public service while the borrower makes qualifying student loan payments. Since its creation in 2007, PSLF has been available to borrowers working for government at all levels, non-profit organizations that are tax-exempt under section 501(c)(3) of the Internal Revenue Code, and other non-profits that provide at least one of the specific services listed in the statute. This includes early care educators who work in the public sector or for non-profit organizations.

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On July 13, 2022, the Department published a notice of proposed rulemaking (NPRM) in the Federal Register ( 87 FR 41878 ). [ 2 ] In the NPRM, the Department proposed improvements to PSLF that reduce regulatory and administrative barriers that have historically made it more difficult for borrowers to make progress toward forgiveness under PSLF. This included simplifying criteria to help borrowers certify employment, helping borrowers earn progress toward PSLF for months that did not count before, and providing borrowers with more opportunities to correct problems with PSLF.

Additionally, in the NPRM, the Department asked directed questions about the possibility of allowing ECE providers who are private for-profit businesses to be considered eligible employers for the purposes of PSLF. In response, the Department received many detailed comments about early childhood education as well as a range of comments in support of making other for-profit employers eligible to serve as qualifying employers for PSLF for individuals in certain occupations.

On November 1, 2022, the Secretary published final regulations  [ 3 ] in the Federal Register . Those final regulations did not include regulations regarding whether, and under what circumstances, private for-profit ECE providers employing borrowers working as early childhood educators, should be treated as qualifying employers for PSLF. [ 4 ]

Solicitation of Comments:

Early care educators are among the lowest-paid workers in the country; and the Administration has committed through Executive Order 14095 , to better supporting the care workforce. [ 5 ] The E.O. states that investments in the care workforce are foundational to helping to retain care workers and improving health and educational outcomes for those in their care. The purpose of this Request for Information (RFI) is to gather information about ECE providers. This RFI and the comments received in response to this RFI will not be considered as part the Affordability and Student Loans proposed rule ( 87 FR 41878 ) and any subsequent related final rules. The comments received in response to this RFI will not be used as part of the rulemaking related to the treatment of for-profit employers, including ECE providers, and eligibility for PSLF. Instead, the feedback from this RFI will help inform the Department's understanding of different approaches that might be considered when implementing non-rulemaking solutions related to this issue.

Given the operational and implementation hurdles associated with PSLF, the Department is interested in understanding whether there are ways that eligibility could be streamlined if all ECEs became eligible. The Department is soliciting information and data from the public on how the Department could determine employer eligibility and related considerations if for-profit ECE employers were to be considered eligible employers if they provided one of the services listed in the statute. The Department encourages ( print page 51880) comments from researchers, academics, policy experts, and other individuals familiar with ECE employer data; organizations that work directly with ECE workers; State and Tribal government officials who oversee and administer ECE programs; ECE practitioners; and other members of the public. The Department will review all comments received, but does not intend to respond to comments.

The Department seeks feedback on the following questions:

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(3) If in consultation with the Department, the U.S. Department of Health & Human Services (HHS), issued a voluntary Public Records Act request from the States to create a nationwide registry of EINs of ECE providers, are State and Tribal agencies that oversee and administer ECE programs in a position to collect this information? Do commenters believe that all States would provide this information? Are there any additional considerations the Department should be aware of should HHS issue this request?

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Nasser Paydar,

Assistant Secretary, Office of Postsecondary Education.

1.  These estimates are from the Administration for Children and Families' National Survey of Early Care and Education, both the 2019 Home-Based NSECE chartbook and the 2019 Center-Based NSECE chartbook. These data show that approximately three-fourths of home-based providers had at least some college, and 72 percent of for-profit ECE workers had some college or higher.

2.   https://www.federalregister.gov/​documents/​2022/​07/​13/​2022-14631/​student-assistance-general-provisions-federal-perkins-loan-program-federal-family-education-loan .

3.   https://www.federalregister.gov/​documents/​2022/​11/​01/​2022-23447/​institutional-eligibility-under-the-higher-education-act-of-1965-as-amended-student-assistance .

4.  Section 103(8) of the Higher Education Act contains a definition of ”early childhood education program” that includes public preschool, Head Start, and State licensed and regulated child care programs. It does not speak to the tax-status of providers. Unlike the public Kindergarten through 12th grade system, which provides free access to education for all age-eligible children and youth, there is no parallel system for our country's youngest children. As a result, ECE is delivered through a system of mixed delivery that includes public programs, non-profit settings, and for-profit settings. https://www.acf.hhs.gov/​ecd/​policy-guidance/​dear-colleague-letter-mixed-delivery . The vast majority of ECE settings are home-based, and do not carry non-profit tax designations. Compensation across settings is low generally, regardless of the tax-status of the ECE provider. https://www.bls.gov/​oes/​current/​oes_​va.htm .

5.   Federal Register : Increasing Access to High-Quality Care and Supporting Caregivers.

[ FR Doc. 2024-13446 Filed 6-18-24; 8:45 am]

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