Rural-urban disparities and associated factors of SARS-CoV-2 infection in Zambia: A convergent mixed-methods study using the Proximate Determinant Framework.

Background Rural-urban disparities in SARS-CoV-2 infection epidemiology remain poorly quantified and understood in Zambia despite differences in healthcare access, services and preventive interventions. This study examined the geographical distribution and associated factors of SARS-CoV-2 cases across selected rural and urban districts of Zambia. Methods A convergent mixed-methods study comprised of quantitative survey and qualitative interviews was conducted in; Ndola (Urban), Kafue (Peri-urban) and Lufwanyama (Rural). The proximate determinant framework guided variable selection and interpretation. Quantitative combined (Hospital-surveillance data with community survey), while qualitative included In-depth interviews. Participants were sampled using multistage sampling technique. Quantitative data were analysed using STATA version 17, while qualitative data were analysed thematically. Findings were integrated through triangulation. Results A total of 528 participants were included, with a median age 31 years (15-71). Overall SARS-CoV-2 positivity was 12.6%, varying across rural (16.5%), peri-urban (14.9%), and urban (9.9%) settings, though residence was not associated with infection (P<0.132). Participants aged [&ge;]49 years had significantly higher odds of infection (aOR=8.78; 95% CI:1.15-66.99), whereas secondary education (aOR=0.37; 95% CI:0.16-0.86) and hospital-based testing (aOR=0.37; 95% CI:0.15-0.92) were associated with lower odds of infection. Vaccine uptake was highest in urban areas but was not independently associated with infection. Qualitative findings revealed marked rural-urban differences in perceived susceptibility, testing access, vaccine decision-making, and adherence to preventive measures, explaining several quantitative observations. Conclusion SARS-CoV-2 infection across rural and urban settings in Zambia was influenced by demographic, behavioral, and health-system factors rather than geographic residence alone. These findings highlight the need for context-specific prevention strategies, equitable access to testing, strengthened community surveillance, and targeted risk communication to improve preparedness and response for future respiratory disease outbreaks.