Confluence of crises: COVID-19, "gassings", blood draws and the continued importance of community engagement in Zambia.

Nationally representative, household-based, health-related surveys are an invaluable source of health information, but face implementation challenges. In sub-Saharan Africa, these challenges are exacerbated when surveys include the collection of biological specimens. In this study, we describe the potential implementation challenges identified during field practice leading up to the 2020 Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey, and explore the role of two crises on community mistrust of, and apprehension to, participate in the survey. Using focus group methodology to better understand the influence of crises on ZAMPHIA participation, we conducted 12 focus group discussions (FGDs) in five districts across two provinces. FGDs were conducted with three purposively sampled study groups: recognized household heads, community leaders, and young adults aged 18-24 years. We used reflexive thematic analysis to develop themes from across the FGDs. We identified two key themes: the ever-present threat a stranger posed to the community is enhanced by crises, and endorsement of community awareness through sensitization can mitigate outsider challenges in medical research. We argue that these crises emphasized underlying mistrust that can only be addressed with substantial investment in community engagement efforts to build trust and partnership in medical research endeavors. Our findings underline the importance of prioritizing community engagement through substantial investment in varied and extensive approaches to sensitization to facilitate community engagement toward community acceptance of ZAMPHIA and similar studies.