Lessons from a Year of COVID-19 in Zambia: Reported Attendance and Mask Wearing at Large Gatherings in Rural Communities

Abstract

Zambia instituted prevention behavior guidelines for social gatherings before the first case of COVID-19 was confirmed on March 18, 2020. Guidelines included nonpharmaceutical interventions (NPIs) including mask wearing, social distancing, and reducing sizes of gatherings. Within a larger cluster randomized trial of community-based parenting groups in four rural districts (three in Southern Province, one in Eastern Province), we collected 5,711 questionnaires from intervention participants between August 2020 and September 2021, during which the country saw two COVID-19 waves. Questionnaires asked about participation and behaviors at community gatherings. Generally, perception of risk of contracting COVID-19 was low for respondents in districts in Southern Province but higher for those in Eastern Province. The highest compliance to mask wearing was reported at clinics (84%) and church services (81%), which were the most frequently attended gatherings. Many funerals were attended by 200 to 300 people, but individuals were 30% less likely to report wearing masks (odds ratio [OR] = 0.71, 95% confidence ratio [CI]: 0.6-0.8) than those attending a clinic visit. After controlling for other variables, the odds of self-reported mask wearing at events were higher in January to March 2021 (adjusted OR = 1.5, 95% CI: 1.3, 1.7) and July and September of 2021 (adjusted OR = 3.0, 95% CI: 2.5-3.5), timepoints that broadly overlay with two COVID-19 peaks observed in Zambia. Results suggest guideline dissemination penetrated the rural areas. However, there is need to optimize the messaging to increase compliance to NPIs at high-risk gatherings, including funerals. The findings from this analysis should be considered as the COVID-19 pandemic continues to evolve.

Figure 1.

COVID-19 case trends, government policy, and guidance in Zambia between March 2020 and March 2021.

Figure 2.

COVID-19 behaviors study sample sizes for respondents, questionnaires, and reported gatherings. Because of the nature of data collection, individual gatherings are not necessarily unique. Some respondents living in the same catchment areas may be reporting on the same events but from their own perspectives.

Figure 3.

Respondents’ perceptions of risk of contracting COVID-19, stratified by district and timepoint. * Bars in gray represent months in which sample sizes were too small to present.

Figure 4.

Self-reported mask use and perceived behaviors of other attendees by gathering type and location, including perceived number of attendees. * The vertical line at 50 perceived number of attendees serves to display the number of events that exceeded the government’s guideline of suggested gathering size.