Barriers to care and internalized gender stigma among women in Zambia: a DHS-based analysis of psychosocial vulnerability

Abstract

BACKGROUND: Structural and cultural determinants such as access barriers and gender-based stigma are key psychosocial stressors affecting women's health in sub-Saharan Africa. While education and wealth are known to influence health access and gender norms, few studies have quantified these associations using nationally representative data. OBJECTIVES: To assess how women's education, household wealth, and urban - rural residence are associated with (1) reported barriers to healthcare and (2) acceptance of wife-beating as a proxy for internalized gender stigma. METHODS: An analysis was performed on data from 13,683 women aged 15-49 years in the 2018 Zambia Demographic and Health Survey. Barriers included cost, distance, permission, or not wanting to go alone. Household wealth was measured using the DHS wealth index, constructed from household assets, housing quality, and access to water/sanitation. All households were ranked by index score and divided into five quintiles (poorest to richest). Logistic regression models, adjusted for key sociodemographic variables, estimated odds ratios (AORs) and 95% confidence intervals (CIs). RESULTS: Over half of rural women (53%) reported barriers to care compared with 25% of urban women. In adjusted analyses, women in the richest quintile had significantly lower odds of barriers than those in the poorest (AOR = 0.28; 95% CI 0.22-0.36), and rural residence was associated with higher odds of barriers (AOR = 1.65; 95% CI 1.28-2.13). Education level was not independently significant once wealth and residence were controlled. Nearly half of women (46%) justified wife-beating in at least one circumstance, with acceptance highest among women with only primary education (54%) and the poorest households (57%), and lowest among women with higher education (11%) and those in the richest quintile (27%). In adjusted models, higher education was associated with reduced odds of justification (AOR = 0.25; 95% CI 0.18-0.36), and women in the richest quintile had similarly reduced odds (AOR = 0.34; 95% CI 0.27-0.45). CONCLUSION: Economic disadvantage and rural location are major drivers of structural barriers to care, whereas higher education and wealth protect against internalized gender stigma. These findings suggest that policy solutions must pair economic empowerment strategies with gender‑transformative strategies. In practical terms, expanding health infrastructure and reducing out‑of‑pocket costs in rural areas should be coupled with initiatives that promote women's education and challenge norms that legitimize violence.