Barriers to prevention and healthcare-seeking in a fragile humanitarian setting: Evidence from Yemen during the COVID-19 pandemic.

The healthcare system in Yemen is confronted with substantial challenges, especially during pandemics such as COVID-19. In Aden, the COVID-19 pandemic occurred in the context of prolonged conflict, health-system fragility, resource constraints and other ongoing humanitarian challenges.This study aims to explore the barriers community members in Aden face in adopting COVID-19 preventive measures and seeking healthcare during the pandemic, and to identify implications for future outbreak preparedness in fragile humanitarian settings. A qualitative study involving 25 in-depth interviews was conducted with adult community members in Aden. Participants' perceptions of COVID-19 and reported preventive practices were also explored to contextualise the barriers influencing prevention and healthcare-seeking. Interview data were analysed using inductive qualitative content analysis; the Socio-Ecological Model (SEM) was applied as an interpretive framework to contextualise barriers across five interacting levels: intrapersonal/individual, interpersonal, organisational/institutional, community, and public policy/structural. Participants described barriers across five SEM levels: intrapersonal/individual barriers included denial, fear, perceived ineffectiveness of preventive measures and financial constraints; interpersonal barriers included stigma, mockery and social pressure; organisational/institutional barriers included perceived service refusal, concerns about infection prevention and staff preparedness, long waiting times, limited diagnostic testing, increased treatment costs and shortages of medical supplies; community-level barriers included rumours, misinformation and mistrust; and public policy/structural barriers included limited financial support, inadequate implementation of preventive measures, conflict-related constraints and perceived insufficient preparedness. The findings suggest that barriers to prevention and healthcare-seeking were interconnected across the five levels of the socio-ecological context, with individual perceptions and behaviours occurring within interpersonal, organisational, community and wider public policy and structural conditions. Future outbreak preparedness in fragile settings should therefore combine trusted, culturally appropriate risk communication, community engagement, accessible preventive resources, strengthened infection-prevention capacity, diagnostic and referral pathways, and continuity of essential health services.