Abstract
OBJECTIVES: To identify the individual and community-level factors associated with barriers to accessing healthcare services among currently married women in Somalia. DESIGN: A cross-sectional analysis using data from the 2020 Somalia Demographic and Health Survey. SETTING: Somalia. PARTICIPANTS: A nationally representative sample of 30 311 currently married women aged 15-49 years with complete data on outcome and explanatory variables. PRIMARY OUTCOME MEASURES: The primary outcome was 'reporting at least one barrier to accessing healthcare', a composite binary variable based on four specific problems: obtaining permission to go for treatment, getting money for treatment, distance to the health facility and not wanting to go alone. RESULTS: A substantial majority (77.06%) of married women reported experiencing at least one barrier to accessing healthcare. Financial cost was the most common barrier (69.91%), followed by distance to health facilities (65.95%), reluctance to go alone (49.64%) and the requirement for permission (46.03%). Multilevel analysis confirmed that higher household wealth was strongly protective (richest vs poorest: adjusted OR (aOR)=0.27, 95% CI 0.24 to 0.32). Paradoxically, factors typically considered protective were associated with increased barriers: women with secondary education (aOR=1.19, 95% CI 1.00 to 1.41) and those with educated husbands (aOR=1.23, 95% CI 1.14 to 1.33) reported more obstacles. Similarly, urban residents faced higher odds of barriers than their nomadic counterparts (aOR=1.40, 95% CI 1.27 to 1.55). Significant regional disparities were evident, with community-level context explaining 26.30% of the total variance in reporting barriers. CONCLUSION: Access to healthcare for married women in Somalia is predominantly hindered by economic, educational and community-level constraints. Targeted interventions addressing socioeconomic disparities, infrastructural deficits and specific community contexts are essential to alleviate these barriers.