Strengths and limitations.
Although this was a purely qualitative study, it included a rigorous design with a large sample size of respondents at different levels who confirmed each other’s responses at two different points in time. Furthermore, the qualitative results were interpreted against the IMB model, a well-known socio-behavior model from the HIV literature that has only been posited once before for use with COVID-19, making this analysis a unique contribution of the literature.Second, responses from participants may have been subject to social desirability bias. Adherence to guidelines may have been emphasized, whereas unfavorable views and non-adherence may have been downplayed. We attempted to limit the likelihood of social desirability bias in the data by asking questions “about the community” instead of about the respondents themselves. Because the data sources are IDIs and FGDs, we are only able to report on what people perceive. Additionally, respondents were not asked to demonstrate proper prevention behavior techniques. Observational data would be needed to confirm accurate performance of these behaviors, determine actual adherence rates in various settings, and confirm reported perceptions.Additionally, approximately one-third of the participating community women received additional health education around COVID-19 twice monthly through the ECD intervention. However, we did not find any noteworthy differences between the overarching study arms. Nonetheless, caution should be taken when generalizing these data outside of the immediate communities from which they were collected.Lastly, the qualitative instruments did not include questions on COVID-19 vaccine perceptions or uptake due to the timing of data collection. During our first round of data collection (November 2020), COVID-19 vaccines were still in testing internationally and had not yet been distributed. During the second round of data collection (April/May 2021), the first shipments of vaccines were only just reaching Zambia and were concentrated in urban areas. At the time of instrument development, ethics approval, and data collection, there was no vaccine distribution within our study areas. Futher information on COVID-19 vaccine perceptions and uptake among these rural community members and stakeholders is important.