Institutional versus non-institutional settings.
CBVs
EVENTS, WEDDINGS
Although respondents were largely positive when discussing community-level adherence to COVID-19 prevention methods, they repeatedly described instances of widespread non-adherence within these rural communities. Social motivators appeared to play a major role in general community adherence, particularly in high-risk settings. Institutional settings, including clinics, church services, and meetings with traditional leadership, were described as experiencing higher levels of perceived adherence among the community at large. Institutional settings generally had stronger adherence enforcement measures in place and had clear leaders who supported guideline adherence. Additionally, respondents explained that visits to institutional settings frequently began with COVID-19 sensitization sessions, which systematically reinforces messages community members may have heard through other channels.Informal, non-institutional community settings, such as at weddings, funerals, and football (soccer) matches, often lacked similar social expectations and leaders to model or enforce adherence. These settings were described as problematic and often had lower levels of general adherence for hand washing, mask wearing, social distancing, and restricted group sizes. Although health center staff and CBVs discussed repercussions for individuals not following prevention guidelines at the clinics (refusal of services), churches (revoking permits for gatherings), or meetings with traditional leaders (disbanding and rescheduling), such repercussions were not discussed for these other informal community events. These findings are consistent with concurrent quantitative data from these same communities, which found that rural Zambian participants reported attending large gatherings throughout the pandemic; higher levels of prevention behavior adherence were perceived at clinics and churches, whereas funerals experienced larger crowds with much lower levels of reported mask wearing among participants.In addition to low social pressure for adherence, the high (positive or negative) emotions of the crowds at informal community events may override personal-level motivators for adherence and perceived risk. A few respondents discussed non-adherence in this way, stating that joy at weddings and football matches and grief at funerals made attendees “forget” about COVID-19 and the need to practice prevention behaviors in these settings. Similarly, long-engrained cultural expectations around physical touch while greeting (i.e., shaking hands, hugging), particularly in emotional or ceremonial settings, could potentially override perceived risk. A systematic review of COVID-19 risk communication and community engagement in 13 African countries acknowledged widespread resistance to attendance guidelines at funerals and resistance to stop shaking hands or hugging in many communities.During a resurgence of COVID-19 or during a potential future pandemic, efforts to increase community-level adherence to prevention guidelines should target these informal, non-institutional, low-adherence community events that continued to occur outside of regulations. Although respondents repeatedly stated that more information dissemination was needed to convince doubters and outstanding non-adherers at these informal, non-institutional community events, this is unlikely to have drastically changed behaviors because lack of information did not seem to be a major influencer of non-adherence here or in other KAP studies.On the other hand, increasing social pressure through greater enforcement measures and provision of needed supplies (i.e., handwashing stations) could have more widely affected general adherence in these informal settings and affected potential transmission occurring during these community gatherings. Engaging with local leaders in religious, civic, and traditional leadership positions has been shown as critical for many health-related interventions