Perceived Difficulty Accessing Primary Health Care and Its Associations With Sociodemographic Factors and Exposure to Violence in a Violent Urban Community in Rio de Janeiro, Brazil: Cross-Sectional Study.

BACKGROUND: Urban communities affected by chronic violence face persistent challenges in accessing primary health care (PHC). Although violence is widely recognized as a determinant of health inequities, there exists limited evidence on how direct exposure to violent events is related to individuals' perceptions of difficulty in accessing PHC services in highly vulnerable urban environments.

OBJECTIVE: The study aims to examine how sociodemographic characteristics and exposure to violent events are associated with perceived difficulty in accessing PHC in standardized hypothetical mental health scenarios among residents of a community affected by chronic urban violence in Rio de Janeiro.

METHODS: A cross-sectional survey was conducted between October 8 and November 1, 2024, with 1006 adult residents who completed 4 PHC vignettes and reported past-year exposure to violent events. Participants completed a structured questionnaire that included sociodemographic information, past-year exposure to interpersonal violence, and evaluations of 4 hypothetical vignettes describing different clinical or social situations. Vignette responses were recorded using an ordinal Likert-type scale ranging from "very easy" to "extremely difficult." Descriptive analyses were performed for all variables, and associations between sociodemographic characteristics and violence indicators were examined using Pearson chi-square tests, with effect sizes estimated using the φ coefficient or Cramér V, as appropriate, and their respective 95% CIs. Differences in vignette ratings across sociodemographic groups were assessed using Kruskal-Wallis tests. To explore the underlying relationships among violence indicators, vignette responses, and sociodemographic variables, exploratory factor analysis and multiple correspondence analysis were conducted.

RESULTS: Violence exposure was frequent. Threats of harm were reported by 27.7% (157/567) of Black participants and 30.5% (72/236) of non-Black participants. Slapping was reported by 20.8% (118/567) of Black individuals and 28% (66/236) of non-Black individuals, while being pushed or restrained affected 21.2% (50/236) and 26.7% (63/236), respectively. Significant sex differences emerged for being punched or kicked (female 17.2% [75/435] vs male 23.9% [88/368]; P=.02). Kruskal-Wallis tests indicated few differences in vignette-based perceptions across groups, except for race in the alcohol-dependence vignette (χ²1=7.384, P=.006). Factor analysis identified 2 dimensions: violence variables loaded strongly on one factor (0.83-0.96) and vignette responses on another (0.66-0.83). Multiple correspondence analysis results showed that forms of violence contributed mainly to Dimension 1 (9%-15%) and vignette categories to Dimension 2 (7%-12%).

CONCLUSIONS: Exposure to violence was widespread, with differences in some forms of violence observed between men and women. Violence-related variables and vignette-based perceptions of difficulty accessing PHC were predominantly represented by distinct dimensions in the exploratory multivariate analyses. Strengthening PHC in violence-affected urban settings requires addressing structural barriers that shape residents' access to health care.