IntroductionHypertension remains a major public health concern in Tanzania, yet evidence on the combined adoption of healthy lifestyle behaviors across rural and urban populations remains limited. This study assessed healthy lifestyle adoption and associated socio-demographic factors among adults in contrasting rural and urban settings in Morogoro Region, Tanzania, using a composite healthy lifestyle index (HLI) approach.MethodsAn analytical cross-sectional study involving 838 adults was conducted in Kilombero District Council and Morogoro Municipal Council. A composite HLI incorporating body mass index, physical activity, smoking, alcohol use, and fruit and vegetable intake was constructed. Participants were divided into high or low behavior adoption groups, and stratified multivariable logistic regression models were used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs).ResultsHigh healthy lifestyle adoption was more common in rural Kilombero than urban Morogoro (55.5% vs. 47.0%; p=0.017). In rural areas, lifestyle adoption varied by income, employment, and age, while in urban Morogoro, income was the primary socio-demographic factor associated with healthy lifestyle adoption. The findings also suggest that behavioral transitions commonly associated with urbanization may already be emerging in rural settings.ConclusionsHealthy lifestyle adoption differed between rural and urban populations, highlighting the need for context-specific and integrated prevention strategies. Urban interventions should prioritize improving access to healthy foods and opportunities for physical activity, while rural strategies should support the preservation of currently favorable lifestyle behaviors alongside prevention of emerging behavioral risks.