Dissertations and Theses
Date of Degree
6-2-2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy (Ph.D.)
Department
Health Policy and Management
Advisor(s)
Professor Nasim Sabounchi
Committee Members
Professor David Lounsbury
Professor Karen Florez
Subject Categories
Public Health
Keywords
men’s health, Hispanic/Latino men, healthcare utilization, structural barriers to care, erectile dysfunction as a health signal, systems dynamics
Abstract
Introduction
In the United States, researchers caution that a growing proportion of men are falling into a state of invisibility within our healthcare systems. Drivers of this trend reflect fragmented health service delivery, changes in demand associated with growing chronic disease burden, and challenges in accessing timely care that result in low health utilization and delayed health seeking. Since the early 2000s, the life expectancy gap between men and women has been five years or greater, with men around the globe living shorter and sicker lives compared to women. Hispanic/Latino males sit at a dangerous intersection where a disproportionate burden of disease meets low healthcare service utilization within a growing population, and increasingly restrictive federal policies and laws regarding migrants and access to health and social benefits. Together, individual, structural, and systemic factors create an urgent public health issue, highlighting the need to reconsider how healthcare services are provided to these men.
The body of work presented here addresses several gaps in healthcare services research focused on Hispanic/Latino males. First, there are limited studies that explore healthcare utilization as a primary outcome and denote the vast heterogeneous ethnic backgrounds among Hispanic/Latinos. Substantial qualitative research highlights important healthcare service uptake patterns among Hispanic/Latinos, however many have smaller sample sizes and limited applications to the rich heterogenous population that exists among the Hispanic/Latino population. Second, over the past few decades, significant strides have been made to quantify disease distributions among the Hispanic/Latino population in the United States. However, there has been limited work on identifying if certain disease manifestations or symptoms are associated with a healthcare visit among Hispanic/Latino men. Lastly, the onus of seeking healthcare services has traditionally been placed on the patient. Exploring facilitators and barriers from clinical providers and administrators within a healthcare system can espouse key avenues to develop more effective delivery models that engage and retain men in healthcare services.
Objective
These gaps are addressed in Chapters 2, 3, and 4, which are organized around the following specific aims: Aim 1 examines how healthcare-visit patterns in the last 12 months differ across Hispanic/Latino male subgroups, and how these patterns correlate to key demographic, socioeconomic, and other health factors; Aim 2 explores erectile dysfunction (ED) status and its correlation to healthcare visits reported in the last 12 months among Hispanic/Latino men. Men who have no healthcare visits in the last 12 months and do experience any ED symptoms would be considered a high-risk population, as research indicates men with self-reported ED may carry greater risks of undiagnosed diseases; and Aim 3 applies virtual system dynamics group model building (GMB) as a method to engage a multidisciplinary team of providers and administrators in systems thinking activities informed by their clinical perspectives on and their aspiration to better organize care to mitigate barriers to men’s healthcare service engagement and retention.
Methods
This study applied a mixed methods approach that combines descriptive statistics, bivariate analysis, multinomial regression, and group model building (GMB) activities. All quantitative methods used data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) cohort study. HCHS/SOL is a multisite population-based study that evaluates health risks and disease burden across the diverse heritage and background of Hispanic/Latinos. This analysis focuses on one visit within the prospective cohort data. There were three GMB activities used in a virtual setting which aimed to 1) identify variables through the 5Rs Framework, 2) describe trends in key variables via Behavior Over Time Graphs (BOTG), and 3) create a qualitative system dynamics model of facilitators and barriers to men’s healthcare service engagement and retention through Causal Loop Diagramming (CLD).
Results
The fully adjusted model in aim 1 identified healthcare access factors, heritage differences, health status, employment status, and recruitment site as the strongest correlates. A positive correlation was statistically significant among men who had insurance (aOR = 1.86, CI 1.42 – 2.43), identified as Dominican (aOR = 2.15, CI 1.02 – 4.50), Puerto Rican (aOR = 2.26, CI 1.30 – 3.93), or South American heritage, were diabetic (aOR = 1.96, CI 1.34 – 2.88), or had one or more personal doctors (aOR = 5.59, CI 4.25 – 7.37). Men recruited from the San Diego SOL center also had a positive correlation to having a healthcare visit (aOR = 2.31, CI 1.32 – 4.05). A negative aOR was observed in men with a household yearly income lower than $30,000 (aOR = 0.77, CI 0.59 – 1.00), and those with part-time or full-time employment (aOR = 0.44, CI 0.29 – 0.66).
Aim 2 findings in the unadjusted odds ratio model showed that the increasing severity of self-reported erectile dysfunction (ED) among Hispanic/Latino men was associated with an increase in odds of having a healthcare visit in the last 12 months. However, the fully adjusted model yielded no statistically significant findings when comparing men who were always able to get and keep an erection adequate for satisfactory intercourse versus men who were never able (aOR = 1.14, CI 0.59 – 2.21), sometimes able (aOR = 1.35, CI 0.87 – 2.08), or usually able (aOR = 1.16, CI 0.85 – 1.59) to sustain an erection. Hispanic/Latino men who did not report having a healthcare visit in the last 12 months indicated reasons of not needing a doctor, visits being too expensive, or delaying care.
The group model building (GMB) exercises in aim 3 resulted in a causal loop diagram (CLD) that captured 12 causal links across two domains of barriers and facilitators. Themes of affordability of care, fear of receiving a diagnosis, fear of losing income or job security, and delaying care were prominent within the barrier domain of the CLD model. Whereas self-awareness and empowerment, provider trust, and comprehensive and efficient care contributed to the facilitator domain. A key loop within the facilitator domain was a creation of a multidisciplinary care team dedicated to men’s medical needs.
Conclusion
These collective findings expand how we understand facilitators and barriers to healthcare utilization among Hispanic/Latino men by identifying correlates to healthcare visits, impacts of ED status to healthcare use, and the interconnectedness of key variables through a shared qualitative mental model created by clinical providers and administrators who serve these men. The value of this work is derived from its unique application to the vast diaspora of Hispanic/Latino men who are understudied and underreported. Furthermore, another key contribution are the points of intervention highlighted in the CLD that can inspire sustainable policy changes dedicated to developing effective healthcare service delivery models for men.
Recommended Citation
Moreta, Alexander, "Drivers of Healthcare Utilization and Engagement Among Hispanic/Latino Men: A Mixed Methods Study of Facilitators and Barriers to Care" (2026). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/134
