Title: The Effects of Violence on Health Service Utilization and Access in Mexico
Description: This dissertation analyzes the effects of community violence on health care service utilization and access in Mexico. Given the widespread effects of violence, there is good reason to believe that health service delivery might be affected, but it is largely unknown. This study looks at potential channels through which violence may impact the supply and demand of health care services in Mexico, through qualitative and quantitative methods. It posits that violence can have heterogeneous effects on service utilization and provides a deeper exploration of factors that may have negative and positive effects on service utilization. Supply-side effects point towards deterring effects of violence in service utilization out of fear of travel and fear among medical staff to go to their workplaces or shortening the hours of operation out of fear of exposure. Mixed effects logistic regression models reveal demand-side effects through a significant increase in health care service utilization as violence increases possibly related to worsening health (e.g. through stress or other mechanisms), which may drive individuals to seek more services.

In sensitivity analysis, increased primary care service utilization as a result of an increase in the homicide rate remains significant when predictors of service use such as having a chronic condition, insurance status and urban areas are included in the models. Qualitative findings also reveal an increased demand for mental health services at the primary care level as a result of increased community violence. Findings underscore the importance of access to outpatient services and mental health services at the primary care level in contexts of high violence. The significant increase in the use of outpatient service utilization point towards potentially protective behaviors driving the increase of use of services as violence increases. This analysis highlights the responsibility and need for providing safe access to medical services in contexts of violence that may translate to natural disasters or other man-made conflicts.