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In recent decades there has been much debate on the extent to which income inequality affects health outcomes. The majority of studies in this literature have examined the relationship between income distribution and health outcomes in the contexts of high-income nations. This dissertation evaluates both the ecological and individual-level relationship between income inequality and mortality in the context of a middle-income country, Costa Rica. The Costa Rican case is particularly interesting because its strong social safety net, political organization, and history limit the effects of income inequality on health through indirect channels. Using 20 years of household data, this study begins by documenting changes in income inequality at the canton level. These data reveal that on average inequality has been growing at an annual rate of 0.5%. Using these inequality data, Vital Statistics Mortality records, and longitudinal methods, this study next examines whether cantons with greater growth in inequality also experienced increasing mortality. The analyses indicate that there is no relationship between changes in income inequality and changes in all-cause mortality; however, a relationship does exist for specific causes of death. Area-level inequality was found to be associated with an increase in suicide mortality rates, and a decrease in cardiovascular, respiratory cancer, and breast cancer mortality rates. At the individual-level survival analysis was applied to a new census-mortality linked dataset that allows for a 20-year prospective follow-up. These individual level analyses also test whether income inequality disproportionately affects the poor. In the case of all-cause mortality, the results suggest that there is no association between income inequality and time to death for either the entire sample or for the poor. Contrary to expectations the magnitudes of the estimated effects indicate that residents living in areas with increasing income inequality had a survival advantage for cardiovascular mortality, which further confirms the results found at the ecological level. Overall, this study finds that while inequality has been increasing in Costa Rica, it had limited effect on mortality, indicating that in an environment where safety net services are available, the negative effects of income inequality may be limited to suicide mortality.

Iran experienced a dramatic decline in fertility from 1984 to 2001, which was most rapid in rural areas. Although many attribute the decline to the government's active participation in providing family planning services, most services were provided after the initial fertility decline that took place after 1984. We assess the extent to which timing of exposure to basic healthcare is related to fertility outcomes. We estimate the association between a woman's age of exposure to a health house (clinic) and number of children, using the 2001 Iranian Household Expenditure and Income Survey and the 2006 Iranian Census, and the location and dates of operation for each rural health house. We also look at the probability of a woman's giving birth one year after a clinic opened in her village. We use Poisson and logistic multivariate regressions and we control for individual, household, and village characteristics. Exposure to a health house in a woman's most fertile years (20–34) is associated with an 18 percent decrease in number of children ever born relative to those exposed after age 40. This negative association gets progressively stronger as length of exposure increases. Our findings suggest that early exposure to health services in rural areas contributed to Iran's fertility decline.

In Nigeria, access to malaria diagnostics may be expanded if drug retailers were allowed to administer malaria rapid diagnostic tests (RDTs). A 2012 pilot intervention showed that short message service (SMS) reminder messages could boost treatment adherence to RDT results by 10-14% points. This study aimed to replicate the SMS intervention in a different population, and additionally test the effect of an expanded message about anticipated RDT access policy change on customers' acceptability for drug retailers' administration of RDTs. One day after being tested with an RDT, participants who purchased malaria treatment from drug shops were randomized to receive (1) a basic SMS reminder repeating the RDT result and appropriate treatment actions, (2) an expanded SMS reminder additionally saying that the 'government might allow pharmacists/chemists to do RDTs' or (3) no SMS reminders (i.e. control). Using regression analysis, we estimate intent-to-treat (ITT) and treatment effects on the treated for 686 study participants. Results corroborate previous findings that a basic SMS reminder increased treatment adherence [odds ratio (OR) = 1.53, 95% CI 0.96-2.44] and decreased use of unnecessary anti-malarials for RDT-negative adults [OR = 0.63, 95% CI 0.39-1.00]. The expanded SMS also increased adherence for adults [OR = 1.42, 95% CI 0.97-2.07], but the effects for sick children differed-the basic SMS did not have any measurable impact on treatment adherence [OR = 0.87, 95% CI 0.24-3.09] or use of unnecessary anti-malarials [OR = 1.27, 95% CI 0.32-1.93], and the expanded SMS actually led to poorer treatment adherence [OR = 0.26, 95% CI 0.10-0.66] and increased use of unnecessary anti-malarials [OR = 4.67, 95% CI 1.76-12.43]. Further, the targeted but neutral message in the expanded SMS lowered acceptance for drug retailers' administration of RDTs [OR = 0.55, 95% CI 0.10-2.93], counter to what we hypothesized. Future SMS interventions should show consistent positive results across populations and be attuned to message ...

In Nigeria, access to malaria diagnostics may be expanded if drug retailers were allowed to administer malaria rapid diagnostic tests (RDTs). A 2012 pilot intervention showed that short message service (SMS) reminder messages could boost treatment adherence to RDT results by 10–14% points. This study aimed to replicate the SMS intervention in a different population, and additionally test the effect of an expanded message about anticipated RDT access policy change on customers' acceptability for drug retailers' administration of RDTs. One day after being tested with an RDT, participants who purchased malaria treatment from drug shops were randomized to receive (1) a basic SMS reminder repeating the RDT result and appropriate treatment actions, (2) an expanded SMS reminder additionally saying that the 'government might allow pharmacists/chemists to do RDTs' or (3) no SMS reminders (i.e. control). Using regression analysis, we estimate intent-to-treat (ITT) and treatment effects on the treated for 686 study participants. Results corroborate previous findings that a basic SMS reminder increased treatment adherence [odds ratio (OR) = 1.53, 95% CI 0.96–2.44] and decreased use of unnecessary anti-malarials for RDT-negative adults [OR = 0.63, 95% CI 0.39–1.00]. The expanded SMS also increased adherence for adults [OR = 1.42, 95% CI 0.97–2.07], but the effects for sick children differed—the basic SMS did not have any measurable impact on treatment adherence [OR = 0.87, 95% CI 0.24–3.09] or use of unnecessary anti-malarials [OR = 1.27, 95% CI 0.32–1.93], and the expanded SMS actually led to poorer treatment adherence [OR = 0.26, 95% CI 0.10–0.66] and increased use of unnecessary anti-malarials [OR = 4.67, 95% CI 1.76–12.43]. Further, the targeted but neutral message in the expanded SMS lowered acceptance for drug retailers' administration of RDTs [OR = 0.55, 95% CI 0.10–2.93], counter to what we hypothesized. Future SMS interventions should show consistent positive results across populations and be attuned to message ...

Protests are one of the most common expressions of modern political conflict, and the wave of demonstrations that marked the onset of the Arab Spring contributed to a global increase in protest activity. Yet few studies have examined the effects of exposure to protests on population well-being even though such exposure may have profound and lasting effects, especially if experienced at critical stages of development over the life course. The aim of our study is to estimate the effects of exposure to political protests on the human capital accumulation and well-being of youth during the tumultuous political transition experienced in Egypt from 2011 - 2014. For a nationally representative panel of youth captured in the 2009 and 2013/2014 waves of the Survey of Young People in Egypt (SYPE), we exploit exogenous geospatial variation in the occurrence of political protests from the Armed Conflict Location & Event Data (ACLED) Project, to estimate individual-level changes in social trust, uncertainty, education, and health outcomes for youth exposed to protests. In our panel, 31.1% of the sample lived in districts where riots or protests occurred. Exposure to protests increased overall perceptions of uncertainty about the future. Young men ever exposed to protests were slightly more likely to report good overall health, but experienced sizable worsening in mental health compared to young women ever exposed. Differences by own and family participation in protest events were found for perceptions of uncertainty and mental health. In the aftermath of the Arab Spring and other mass protest movements around the globe, these findings highlight the importance of examining the population-level impacts of different forms of political conflict, particularly as substantial numbers of youth in Middle East and North Africa and elsewhere progress to adulthood under conditions of political instability.