DISCUSSION
DISEASE TRANSMISSION, WEDDINGS, EVENT, EVENTS, REGRESSION, EVENTS
We assessed perceived risk of contracting COVID-19, attendance at community gatherings, and adherence to the government recommended NPIs for COVID-19 among a sample of women in rural Zambia. Attendance at community events fluctuated over the timepoints, possibly in response to the waves of COVID-19 that overlayed T2 and T4. Although we found that odds of protective behaviors increased over those timepoints, individuals continued to gather and interact with their communities. Observed attendance to community gatherings was high over the course of our study period.Mask wearing, both self-reported and perceived behaviors of others, was highest in clinics and church services. These gatherings, occurring in institutional settings, showed similar trends but are unique in the nature of the gatherings. Clinics and clinic staff have regulation over visitors, inherent knowledge about safety and health practices, and the greatest stake in the health and well-being of visitors. Thus, clinic visits had the highest proportion of respondents reporting wearing masks. Additionally, less than 2% of respondents reported that masks were not worn by peers at the clinic. Not surprisingly, the clinic infrastructure is conducive to enforcing NPIs for COVID-19 prevention. Qualitative data from the parent study suggests that facility-affiliated community health workers ensure that all patients wear masks upon entering the facility, handwashing stations are available, and social distancing measures are enforced while patients are awaiting treatment (Cite qual). Church services, a different type of institutional setting, display similarly high rates of self-reported mask use (80.8%). Mask wearing is a critical prevention measure in this context where churches are often crowded, poorly ventilated and attendees sing, releasing respiratory droplets and aerosols. Such settings have been reported to be high risk for disease transmission.Events including funerals and other community events (including weddings, community meetings, and football games) were less broadly attended by study respondents than the institutional gatherings. These events most often occurred outdoors but drew large crowds of attendees: 83% of funerals had more than 50 attendees, with 25% of respondents reporting event sizes greater than 300. Many community members attend, and often sing, talk, hug, and otherwise comfort the family of the deceased. Although only about a third of respondents attended funerals, more than 80% of those who attended reported that funerals had more than 50 attendees. With 10% of our study sample attending funerals of more than 350 other attendees, and reporting mask use ∼60%, there is a potentially high risk of COVID-19 transmission. The median size of other gatherings was lower (45), but some events also drew crowds of more than 500. Although 70% to 80% of these events were hosted outdoors, mask wearing was low, and social distancing data was not collected. Lower rates of mask use and higher attendance may be attributed to the informal nature of the events. In the absence of community leadership or an institution, there may be less enforcement of guidelines. A systematic review identified COVID-19 risk communication and community engagement plans in 13 African countries, and many strategies included leveraging community leaders, including community health workers and religious leaders. In the Democratic Republic of Congo, the country also leveraged community members including women leaders, civil society organization leaders, and young people.Respondent behaviors with regard to funerals proved to be risky. In Zambia, funerals are often large community-based events. In July 2021, South Africa limited funerals to 50 attendees and banned all after-funeral gatherings to reduce risk of spreading COVID-19.We found substantial differences in COVID-19 risk perception between the two provinces in which we conducted the questionnaires. In the three districts in Southern Province, risk perception was generally reported to be low, whereas in the study district in Eastern Province, Nyimba, perceived risk was much higher. Interestingly, in our regression models, respondents from Nyimba had reduced odds of wearing masks or seeing their peers wear masks, a notable contradiction to their reported risk perception. Nyimba contributed only 6% of the questionnaire data, so some of the differences may be attributed to sample size, but there are other factors to consider. Most cases of COVID-19 were centralized to Lusaka, but Southern Province reported some of the highest numbers of cases in the country in the early months of the pandemic.The takeaways from this analysis are especially important as we consider the future of the COVID-19 pandemic. The Delta variant was first detected in Zambia in June 2021, and spread rapidly through the country, causing a third wave lasting through June and July 2021. The Delta variant was highly contagious, making safety precautions of vital importance. In November 2021, the Ministry of Health notified the public of the threat of the Omicron variant, preparing for a “possible eminent fourth wave.” Public health guidelines including surveillance, quarantining travelers, mask mandates, vaccination mandates for government and civil service workers, limiting church services, and limiting sizes of weddings and funerals were reinstated.