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Background This study analysed perceptions of barriers to primary healthcare (PHC) access in a socially vulnerable and violence-affected community in Rio de Janeiro.Methods A cross-sectional survey was conducted in the Manguinhos community, with approximately 1000 residents interviewed face to face in 2024. Data were collected using a structured questionnaire via REDCap, including sociodemographic variables, self-reported health conditions and Patient Health Questionnaire-2 and Generalised Anxiety Disorder-2 scales. Adapted narrative vignettes were used to describe profiles of individuals with or without mental health problems and socially stigmatised behaviours, allowing the assessment of perceived difficulty in accessing health services. Results showed no significant differences in perceived difficulty of access between Black and non-Black participants. However, men reported greater perceived difficulty in scenarios involving common mental disorders, suggesting the influence of internalised stigma. Younger participants perceived greater barriers in situations involving socially marginalised behaviours, reflecting a lack of trust in the responsiveness of health services. Conversely, formal diagnoses and medication use for diabetes and hypertension were associated with lower perceived barriers, indicating that prior engagement with the health system fosters greater familiarity and lower perceived difficulty. Item response theory analysis demonstrated good psychometric performance of the vignettes, confirming their methodological utility.Conclusions The findings highlight the need to strengthen PHC to address mental health and social vulnerability demands and to reduce subjective barriers, particularly for men and younger individuals. They also underscore the importance of targeted strategies to promote equity in access to care in vulnerable settings.