The Relationship between Clndernutrition and
Behavioral Development in Children
Malnutrition and Cognitive Development: Evidence from
Experimental/Quasi-Experimental Studies among
the Mild-to-Moderately Malnourished1
KATHLEEN S. GORMAT12
Psychology Department, University of Vermont, Burlington, VT 05405
ABSTRACT The purpose of this paper is to provide a
review of the current literature on the relationship between
malnutrition and cognitive development, with particular
emphasis on data from experimental and quasi-experi
mental studies. The review provides a discussion of rel
evant issues of concern, including current knowledge re
garding the specific outcomes affected by malnutrition,
the significance of the timing of such insults, issues of
differential responsivity, the role of specific nutrients, and
the potential mechanisms. The implications of such find
ings for policy and directions for future research are
discussed. J. Nutr. 125: 2239S-2244S, 1995.
INDEXING KEY WORDS:
•malnutrition •cognitive development
•protein deficiency
The purpose of this paper is to present what is cur
rently state-of-the-art knowledge on the relationship be
tween malnutrition and behavior. The particular focus
is on the literature from experimental and quasi-experi
mental studies, i.e., supplementation studies. The data
discussed are primarily from interventions conducted in
the late 1960s and early 1970s in Guatemala (Pollitt et
al. 1993), Bogotá,Colombia (Waber et al. 1981), Cali,
Colombia (McKay et al. 1978), Taiwan (Jóoset al. 1983),
Mexico (Chavez 1975), New York City (Rush et al. 1980)
and, more recently, Jamaica (Grantham-McGregor 1991)
and Indonesia (Husaini et al. 1991).
Until the late 1980s, research in the malnutrition and
behavior literature focused primarily on determining the
validity of this hypothesized relationship. Despite flaws
in methodology, design and implementation, results from
these earlier studies provided enough evidence to con
clude that early supplementary feeding of nutritionally
at-risk children resulted in small, yet statistically signif
icant, effects on some developmental outcomes (Pollitt
1988). More recent data from studies with stronger de
signs and from follow-up analyses have contributed to a
significant shift in emphasis from determining the exis
0022-3166/95 $3.00 ©1995 American Institute of Nutrition.
2239S
tence of such effects to understanding the processes un
derlying these effects.
This paper, then, reviews the information from these
studies in light of this new evidence in an attempt to
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understand the processes by which malnutrition may af
fect cognition and behavior. All the studies were selected
from endemic populations of mild to moderately, rather
than clinically, malnourished children. In most studies,
subjects were identified by populationwide indicators of
poverty and malnutrition (e.g., anthropométrie indica
tors). With the exception of the Cali study, in which nu
tritional and educational components were combined, we
will address the studies to the extent that data are avail
able on nutritional intervention alone. Before proceeding,
we will briefly summarize the studies, which are identi
fied by geographical location.
The Guatemala study (Freeman et al. 1980, Klein et
al. 1976, Townsend et al. 1982) consisted of an early sup
plementary feeding trial in four rural Guatemalan villages
between 1969 and 1977. The major hypothesis being
tested was whether protein deficiency during the prenatal,
infancy and early childhood periods affects cognitive de
velopment among moderately malnourished subjects.
Randomization occurred at the village level; two villages
received a high-energy, high-protein supplement (Atole),
whereas two villages received a low-calorie supplement
(Fresco). Supplements were administered twice daily ad
libitum to all pregnant women, infants and children 7 y
of age and under, and data were collected from over 2300
subjects.
The Bogota study (Waber et al. 1981) consisted of sup
plementation of nutritionally at-risk pregnant women
1 Paper prepared for the International Dietary Energy Consul
tative Group (IDECG) Task Force workshop on malnutrition and
behavior at the University of California, Davis, CA, December 6-
10, 1993. This workshop was supported by IDECG, the Nestlé
Foundation, Kraft Foods and the International Union for Nutritional
Science. Guest editor for this supplement was Ernesto Pollitt, De
partment of Pediatrics, University of California, Davis, CA 95616.
1 To whom correspondence should be addressed: Psychology
Department, John Dewey Hall, University of Vermont, Burlington,
VT 05405.
2240S SUPPLEMENT
and their infants up to 3 y of age. Food (e.g., oil, dried
milk and bread) was distributed weekly in quantities suf
ficient for entire families. Subjects (n = 433) were ran
domly assigned to experimental groups that received
supplementation during different development periods;
two groups received early stimulation as well. The major
hypothesis tested was whether the timing of the supple
mentation (i.e., prenatal vs. postnatal) is associated with
cognitive development during the first 3 y of life. A sec
ondary focus of the study was to test the independent
and interactive effects of educational stimulation and
nutritional supplementation on cognition.
The Cali study (McKay et al. 1978) was a combined
nutritional, health and educational program for pre
school-age, chronically malnourished children. Preschool-
age children (n = 133) were randomly assigned to treat
ment groups consisting of health care, preschool educa
tion and nutritional supplementation (e.g., meals served
at the preschool). Treatment groups varied by duration
of the intervention with subjects receiving between 9 and
42 mo of intervention. The major focus of this study was
to test the effects of a fairly comprehensive intervention
on cognitive development and school achievement in
children beyond the critical period. The study design also
tested the differential effects of the duration of the in
tervention.
The study conducted in Taiwan by Bacon Chow (Jóos
et al. 1983) consisted of nutritional supplementation of
pregnant and lactating women (n = 294). Women were
randomly assigned to two treatment groups soon after
the birth of one infant and then followed through lacta
tion, the interpregnancy period, and the pregnancy and
lactation of their next child. The supplementation con
sisted of a high-calorie, high-protein drink, with a low
calorie beverage as placebo. All women were provided
with a vitamin and mineral supplement. The hypothesis
tested was whether improved maternal nutrition was as
sociated with improved growth and development in in
fants.
The study in Mexico (Chavez et al. 1975) was a sup
plementation study of nutritionally at-risk infants during
the first year of life in a small rural community. Pregnant
women were provided with milk, vitamin and mineral
supplementation starting at 45 d gestation. Infants (n =
20) began milk and food supplementation between the
12th and 16th wk of life, in quantities sufficient to main
tain growth. Twenty additional dyads of mothers and in
fants born during the previous year were included as con
trols. This study focused on the effects of improved nu
trition on mother-child interaction.
The New York City trial (Rush et al. 1980) identified
nutritionally at-risk pregnant women and randomly as
signed them to one of three treatment groups: high pro
tein and calorie supplementation, moderate protein and
calorie supplementation and a control. All women (n =
770) received standard multivitamin and mineral tablets.
The major hypothesis tested was whether improved ma
ternal nutrition is associated with improved infant out
comes, including mortality rate, growth and cognitive
development.
The Indonesia study (Husaini et al. 1991) consisted of
a 90-d supplementary feeding trial of nutritionally at-
risk infants (n = 113) in day care centers located on tea
plantations throughout West Java, Indonesia. Day care
centers were randomly assigned to either continuing their
normal dietary practices or to allowing intervention with
dietary supplements in the form of nutritionally prepared
snacks. Infants between 6 and 20 mo of age were in
cluded. The main hypothesis was that improved nutrition
was associated with improved growth and mental and
motor development.
The Jamaica study (Grantham-McGregor et al. 1991)
was a 2-y nutritional supplementation of growth-stunted
children between 9 and 24 mo of age. Subjects (n = 129)
were randomly assigned to either a control group, a nu
tritional supplementation group, a psychosocial stimu
lation group or a supplementation plus stimulation group.
Supplementation consisted of a milk-based formula pro
vided weekly. At issue were the effects of nutritional
supplementation and psychosocial stimulation on chil
dren's mental development.
As is clearly illustrated in these summaries, none of
the studies is directly comparable with any of the others
in its critical elements: type of supplement, duration of
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supplementation, recipient of supplement or outcomes
assessed. (See Table 1 for descriptive data on each of the
studies reviewed.) Therefore, a basic limitation of any
inferences drawn is the design and methodological char
acteristics of the studies. For example, any attempt to
make inferences about the specificity of outcomes (e.g.,
motor development) is limited by differences in the re
cipient of the supplement (e.g., mother vs. infant). This
limitation in turn contributes to the difficulty of making
inferences about the mechanisms involved. Similarly, our
understanding of sensitive periods is limited by the spec
ificity inherent in each study design, e.g., all but one study
included supplementation during at least a portion of the
sensitive period. Finally, inferences about the effects of
specific nutrients will be limited by the precision with
which actual subject intakes were measured.
In subsequent sections, we will address what is known
about the specific outcomes affected by malnutrition, the
significance of the timing of such insults, the issue of
differential responsivity (i.e., individual differences), and
the role of specific nutrients. We will then discuss po
tential mechanisms that may account for these data and
conclude with a discussion of their implications for policy
and future directions for research.
Specificity of effects
The first question refers to what is known about the
specific outcomes or processes affected by malnutrition
during each particular stage of development.
Infancy. One of the strongest conclusions we can
draw regarding the specific effects of supplementary
feeding is on motor development during infancy. Despite
variation in the measures of motor development across
studies (e.g., Bayley Scales of Psychomotor performance,
Griffiths Subscales), a strong and consistent association
has been reported (Grantham-McGregor et al. 1991, Hu
saini et al. 1991, Jóoset al. 1983, Pollittetal. 1993, Waber
et al. 1981). This finding is reinforced by the results of a
meta-analysis that concluded beneficial effects on motor
development among younger (8-15 mo) as well as older
infants (18-24 mo) (Pollitt and Oh 1994).
 MALNUTRITION AND COGNITIVE
TABLE 1
Description of studies included in this review
characteristics
supplementEducationalKCalXXXXXXXXProtXXXXXXXXMicroXXXXXXControl1
of
atinitiationGestation-79
of SS
Guatemala1969-1977JamaicaCali y2y3yGestation
&. 7
y4y+Gestation-6
mo-2
1971-1974BogotáIndonesiaTaiwanNew
mo6-20 y3 &. 3
moMaternal moGestation
onlyMaternal &lactationGestation5yrNutrient
CityMexicoAge
York onlyMaternal
3mo+SupplementationdurationGestation
&.
1Supplement administered to control group: N, none; MV, multivitamin
2 Consumption quantifiable.
3 Education not separate from nutritional intervention.
Less consistent effects have been reported on mental
development during this same developmental period with
the meta-analysis indicating effects of supplementary
feeding on mental development only among the older (18
mo and older) infants (Pollitt and Oh 1994). In this case,
mental development is nonprocess specific.
Preschool. The available evidence (i.e., Guatemala,
Jamaica, Cali and Bogota) indicates that there are signif
icant effects of supplementation on broad measures of
cognitive development during the preschool period, de
spite differences across studies. It is important to note
that the Bogota and Guatemala studies included both pre-
and postnatal supplementation, whereas the Jamaica
study was solely postnatal. The Cali study, as noted, refers
to a combined nutritional and educational intervention.
Furthermore, the reported effects are limited by the na
ture of the outcome measures used, i.e., broad measures
of cognitive abilities (e.g., developmental quotient [DQ],
general cognitive ability, preschool battery factor scores,
vocabulary and various subscales of the Griffiths and Pre
school Battery) rather than more specific process vari
ables.
Post intervention follow-up. For three studies, fol
low-up data are available to test whether there are en
during effects once the intervention had been discontin
ued. In the first, Taiwan, children were tested on an IQ
measure at 5 y of age, and no effects were reported. In
Bogota, subjects were followed up at about 6 y of age,
and differences were reported on achievement-related
abilities (Griffiths) but not on more basic cognitive com
petencies (e.g., Einstein). In the longest follow-up (e.g.,
Guatemala) through adolescence, supplementation effects
were evident across a wide variety of tests termed psy-
choeducational reflecting skills in such domains as read
ing, numeracy and other achievement-related areas. Fewer
effects were evident on tests of basic processes: memory,
simple and choice reaction time.
DEVELOPMENT 2241S
OutcomesQ2 component
MVNNNQ
C, scale,Preschool
infant
School,Psychoeducational
battery,
testX
GriffithsX3
WISCX Preschool battery,
Griffiths,
EinsteinBayleysBayleys,
NQ
C,
MVMVNComposite IQBayleys,5-y-old
permanence,Play,
Obj
habit/deshabitM-I
activity,maternal
contract
care & concern
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and mineral supplement; C, calorie.
It is important to caution that the apparent strength
and consistency of effects may be related to types of out
comes most frequently used and the strength of their
psychometric properties. Lack of evidence for effects on
information-processing measures may reflect weaker
statistical properties of the tests used to measure these
constructs (e.g., lower reliability and internal consistency)
rather than the absence of an effect. Furthermore, it could
be expected that information-processing measures, such
as attention, would show an immediate sensitivity to
supplementation and that these effects could potentially
mediate long-term effects such as the achievement-related
behaviors observed in the Guatemalan study. Further
more, it should be pointed out that by limiting outcomes
to typical developmental scales and IQ tests, those mea
sures most sensitive to changes associated with malnu
trition may have been overlooked (e.g., social and affec
tive behaviors). This is particularly important in light of
the research on early interventions that has shown de
clines in IQ gains over time but long-term effects on more
socially mediated behaviors such as teen pregnancy, high
school completion, and delinquency (Haskins 1989).
Critical periods
The underlying assumption of a critical (or sensitive)
period is that there is a specific time during which de
velopment is particularly sensitive or vulnerable to insult,
and that period is one characterized by rapid brain growth
and development. The actual definition of the boundaries
of this period (e.g., gestation, first 2 y of life) and the
degree to which it is either critical or sensitive vary from
study to study.
Not coincidentally, with the exception of the Cali
study, all of the studies addressing malnutrition and be
havior focused the intervention on at least some period
considered part of the sensitive period, and only the Bo-
2242S SUPPLEMENT
gota study design allowed for testing contrasting periods
of sensitivity. As a consequence, although most of the
reported effects occur during periods considered sensi
tive, the majority of the designs do not allow for dis
counting other periods or actually determining the
boundaries of these effects.
Prenatal. Those studies that actually built in a spe
cific test of the critical period hypothesis did not find
evidence to support it. For example, data from Bogotá
(Waber et al. 1981) found that supplementation during
the first 6 mo was not critical (e.g., subjects who began
supplementation after 6 mo of age did comparatively
better) and more importantly, was not sufficient (e.g., if
treatment was not continued beyond 6 months, the ben
efits were lost).
Postnatal. The significant effects reported in the Bo
gotástudy of supplementation beginning after a critical
period (defined as 6 mo) were also supported by data from
Jamaica (intervention after 9 mo) and Cali (after 3 y),
although, again, the Cali intervention included an edu
cational intervention as well.
Prenatal and postnatal. In Guatemala, those with
both pre- and postnatal supplementation over extended
periods of time (e.g., minimum 2 y) evidenced the greatest
effects, corroborating the data from other studies (e.g.,
Bogota}. Because of design limitations, small sample sizes
precluded the ability to test hypotheses with regard to
specific groups (prenatal only and postnatal only).
We can conclude, then, that the periods of gestation
and the first 2 y of life continue to be important periods
in the development of young children and have important
implications for subsequent development. The evidence
indicates, however, that nutritional interventions can be
effective even when initiated outside of this sensitive pe
riod and that our consideration of nutritionally at-risk
children should be expanded to include children of all
ages. Furthermore, given the mixed findings regarding
prenatal supplementation alone, efforts at improving in
fant nutrition should focus on duration as well as early
targeting.
Differential responsivity
The most common analytic strategy employed in most
of the studies reviewed has been to assume a linear re
lation between nutrition and outcome, with the focus
being on testing between-group differences—very few
attempts have been made to examine the role of individ
ual differences (e.g., potential interactions). However, in
keeping with current developmental theory as well as the
available evidence, those studies that tested for interac
tions provide some interesting information regarding
important individual differences that may affect respon
sivity to nutritional interventions.
For example, data from Guatemala show that children
from lower socioeconomic status (SES) families were
more likely to respond to treatment than those from up
per SES families. The question that these analyses raise
is whether the effects observed were a function of greater
nutritional need or of greater consumption. In other
words, did poorer children consume more and hence show
greater improvement (i.e., dose response), or did children
consume equivalent amounts but improve more because
of greater initial deprivation, hence, a catch-up type
mechanism (cursory attempts to answer this question
suggest support for this latter explanation). The evidence
from Bogota—that families with greater resources had
children who responded most significantly to the supple
mentation, although in the opposite direction—raises
similar questions. What were the characteristics of the
children in the Bogota study (those from families with
greater resources) that allowed them to benefit from the
supplement? Although it is less likely that the effects were
purely nutritional (dietary)—families with greater re
sources could be expected to have had better diets—it
may be that supplementation allowed for greater utili
zation of either nutritional resources or other behavioral
resources. Methodologically, the data do not provide de
finitive answers to these questions.
In the only other study to explore the issue of inter
actions (Jamaica), the authors focused their discussion of
interactions on differences between treatment types (nu
tritional vs. psychosocial) without addressing specifics of
individual differences. Further analyses are warranted to
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address these issues.
Beyond issues of differential responsivity based on SES
and family background, individual characteristics re
flecting the health and nutritional status of subjects may
be important factors to consider. For example, among
populations where the incidence of parasitic infection is
high, malnutrition rates also tend to be high, and mal
nourished children are less able to ward off parasitic in
fections. Furthermore, treatment of parasitic infection
has been associated with increased appetite, food intake
and growth (Stephenson 1989, Stephenson et al. 1989).
Similarly, because the role of micronutrients is particu
larly relevant to infection (e.g., iron and blood loss), the
confounding role of infection and the potential role of
interactions between nutritional status and infection
must be considered.
Nutrients
One of the most important advances in our under
standing of the relations between malnutrition and be
havior has been in the shift in recent years from a focus
on either calories or protein to a more complex under
standing of nutritional needs and diets. Despite these ad
vances, all of the studies reviewed here were designed
with the notion of calories (and in some cases protein) as
the limiting factor. Consequently, they are seriously lim
ited in their ability to address concerns relating the spe
cific roles of micro-vs. macronutrients or dietary quality.
There are three major concerns in terms of our under
standing of nutrients that need to be addressed.
The increased recognition of the importance of both
quality and quantity of intake has not been paralleled
with adequate measurement of intakes. To our knowl
edge, only two studies coded the actual consumption of
the supplement: Guatemala and Taiwan. In Guatemala,
analyses led to the conclusion that no one type of nutrient
(e.g., protein, calorie or micronutrient) was solely re
sponsible for the observed effects (Oh, S.-Y. and Pollitt,
E., unpublished results). In New York City, Bogota and
Cali, the consumption data were estimated from dietary
recall. In general, these measures have low reliability.
 MALNUTRITION AND COGNITIVE DEVELOPMENT
In addition to the issue of the accuracy of measuring
dietary and supplementation intakes, the studies re
viewed here are limited by the fact that no consideration
was given to the potential effects of micronutrient (in
most cases, a multivitamin) supplements provided to the
control groups. Although at least five of the studies (i.e.,
Guatemala, Bogotá,Cali, New York City and Taiwan)
gave supplements that included micronutrients (usually
a multivitamin) in addition to protein and calories, most
of the comparisons between treatment and control groups
did not account for the potentially confounding role of
micronutrient supplementation to the control group.
Finally, a third difficulty is the actual role of specific
nutrients. There is now evidence that clearly shows that
micronutrients may have independent as well as cumu
lative or interactive effects on behavior (see other articles,
this volume for discussions of specific nutrient effects).
None of the study designs or analyses considered poten
tial interactions of specific nutrient deficiencies with the
nutritional intervention.
Mechanisms
Before discussing the data in terms of mechanisms, it
may be helpful to summarize the conclusions from the
previous discussion:
1. There is evidence to support nutritional effects on
behavior independent of social and environmental
factors.
2. Differential responsivity, i.e., that the effects (or re
sponse) of nutritional supplementation are not
equally distributed across all individuals.
3. Nutrient quality and quantity are not independent
contributors but rather they may be additive or in
teractive components. Malnutrition is the result of
the inadequate intake of foods within a diet rather
than simply as specific nutrient deficiency.
Despite advances in many areas, the accumulated
knowledge was not particularly useful in specifying
actual mechanisms (via CNS function) linking nutrition
to behavior. The most common explanatory model,
nutrition -*• brain development -*• behavior, suggests
that malnutrition affects brain growth and development
and hence future behavioral outcomes. The literature
reviewed here provides no insight as to what brain
structures and/or brain functions were affected. A fre
quently proposed alternative explanation argues that
the effects of malnutrition are the result of a complex
process of behavioral and socioenvironmental depri
vation. Again, none of the studies reviewed here ac
tually collected data to support this hypothesis.
In contrast, more recent studies have taken into ac
count these weaknesses and postulated actual processes
by which malnutrition may affect behavioral develop
ment. Illustrative of this approach is an ongoing study in
Indonesia (Pollitt, E., personal communications). In part
on the basis of the accumulated evidence for consistent
effects of supplementation on early measures of motor
development, Pollitt and his colleagues recently hypoth
esized that the association between nutritional status and
cognitive development is mediated by motor maturation,
activity level and exploratory behavior. The data being
2243S
collected include both process variables as well as stan
dard outcome measures.
With regard to other types of models that can be hy
pothesized and tested, it follows that the significance of
motor development is at least due in part to the match
between timing of the intervention and the sensitivity of
development of the particular behavior being measured.
For example, motor development may be particularly
sensitive to intervention during the period of acquisition
of motor milestones and after which no effects would be
observed. At later (or earlier) periods, the effects of nu
tritional deprivation will be manifested in other behav
iors.
The data reviewed here raise some important questions
regarding the pathway(s) by which nutritional effects oc
cur. For example, how do we reconcile the fact that sup
plementation to mothers and supplementation to infants
result in similar behavioral effects in infants (e.g., im
proved motor development) or that different nutritional
deficiencies (e.g., iron and protein energy) appear to have
similar effects? Although one might argue that as the re
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cipient of the intervention changes, so must our inter
pretation of the mechanisms involved, it is also possible
to think about the possibility that there may be common
pathways that lead to similar outcomes. The data re
viewed here do not provide answers to these questions
but rather illustrate the need to explore more closely the
implications of such explanations.
One of the most promising avenues for understanding
mechanisms comes from the data on environment by or
ganism interactions. The evidence, however, is not easily
interpreted: whereas data from Guatemala suggest that
children from poorer families benefited more from sup
plementation, children from Bogotáseemed to benefit
more when they came from environments that had more
resources. It may well be that both need (e.g., poor SES)
and resources (e.g., maternal education) interact to influ
ence outcome. In this case then, individual differences
based on these characteristics (socioeconomic status,
wealth and education) will determine the degree of effects
of a totally nutritional nature. Both greater specificity of
design and more precise clarification of hypothesized in
teractions will improve our ability to understand the
pathways by which behavioral, environmental and CNS
functions interact with nutritional status. Finally, the de
gree of sophistication in specifying the role of particular
nutrients (see Chapters on Iron and Zinc in this volume)
is probably one the greatest contributions that this field
has made in the past 20 years to our understanding of
the nutrition-behavior literature. However, this notable
scientific advancement has not been paralleled in terms
of solving the problems of the endemically malnourished
poor. Although meritorious in its own right, the study
of the relation of specific nutrients to specific develop
mental processes becomes significantly more meaningful
when it guides our actions to provide better diets to un
dernourished children.
Avenues for future research
This paper attempts to highlight ongoing concerns in
understanding the relations between malnutrition and
cognition and the availability of knowledge to address
2244S SUPPLEMENT
such concerns. At the present time, there is insufficient
information available to provide definitive answers to
questions of processes, mechanisms and outcomes, but
we are much closer to being able to design studies that
will provide better answers to such questions. From the
review presented here it can be argued that future research
should:
1. Imbed within the design appropriate questions of
processes and collect data that would illustrate links
between malnutrition and behavior. For example,
data from correlational studies should be specific
enough to provide clues to actual behaviors that may
mediate cognitive changes.
2. Conceptualize potential interactions among vari
ables that may be particularly relevant to the pop
ulation under study. Researchers need not consider
every possible interaction but rather target data
collection efforts to test explicitly defined interac
tions.
3. Include studies of children beyond the ages typically
considered sensitive. Available evidence, although
limited, suggests that these children can respond to
improved nutrition, and the implications for large
numbers of children not currently targeted for in
terventions (i.e., school-age children) would be sig
nificant.
4. Include outcome measures that may be sensitive to
nutritional manipulations. Cognitive change and
school learning are mediated by affective and mo
tivational variables that may be particularly sensitive
to nutritional status.
Policy implications
A paper such as this would be remiss without a dis
cussion of policy. In short, we can state that malnutrition
has detrimental effects on infants, young children and
school-age children that can be improved by better diets.
At the same time, our understanding of the complex re
lations between poverty, malnutrition and child devel
opment is still incomplete, and many questions remain.
It is certain that for children in developing countries to
reach their potential, not only will their diets need to be
improved but so will the conditions in which they live.
Attention to diet, both quality and quantity, will be en
hanced by attention to health, infection, education, so-
cioeconomic status and other conditions of poverty.
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