Management of COVID‐19 and vaccination in Nepal: A qualitative study

Abstract Objective The aim of this research is to investigate the perspective of citizens of Nepal on the management COVID‐19, the roll‐out of the vaccine, and to gain an understanding of attitudes towards the governments' handling of the COVID‐19 pandemic. Method A qualitative methodology was used. In‐depth interviews were conducted with 18 males and 23 females aged between 20 and 86 years old from one remote and one urban district of Nepal. Interviews were conducted in November and December 2021. A thematic approach was used to analyse the data, utilising NVivo 12 data management software. Result Three major themes were identified: (1) Peoples' perspective on the management of COVID‐19, (2) people's perception of the management of COVID‐19 vaccination and (3) management and dissemination of information. It was found that most participants had heard of COVID‐19 and its mitigation measures, however, the majority had limited understanding and knowledge about the disease. Most participants expressed their disappointment concerning poor testing, quarantine, vaccination campaigns and poor accountability from the government towards the management of COVID‐19. Misinformation and stigma were reported as the major factors contributing to the spread of COVID‐19. People's knowledge and understanding were mainly shaped by the quality of the information they received from various sources of communication and social media. This heavily influenced their response to the pandemic, the preventive measures they followed and their attitude towards vaccination. Conclusion Our study concludes that the study participants' perception was that testing, quarantine centres and vaccination campaigns were poorly managed in both urban and rural settings in Nepal. Since people's knowledge and understanding of COVID‐19 are heavily influenced by the quality of information they receive, we suggest providing contextualised correct information through a trusted channel regarding the pandemic, its preventive measures and vaccination. This study recommends that the government proactively involve grassroots‐level volunteers like Female Community Health Volunteers to effectively prepare for future pandemics. Patient and Public Contribution This study was based on in‐depth interviews with 41 people from diverse socioeconomic backgrounds. This study would not have been possible without their participation.


| INTRODUCTION
COVID-19 was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. 1 Since the outbreak, the WHO urged governments to prioritise their actions in response to the COVID-19 infection. Beyond the disease itself, unprecedented social and economic hardship has been experienced across the globe due to this infection. 2 Furthermore, emerging new variants of COVID-19, causing subsequent waves of infection have caused concern worldwide, hastening the urgency for disease control, and the necessity for a plan to facilitate the end of the pandemic. 3 The first step to controlling a pandemic like COVID-19 is to stop the spread of infection. This responsibility falls under the preview of state governments. Good governance is paramount towards the effective management of COVID-19. 4 Many countries have adopted preventive measures such as social distancing, issuing advice on the use of hand sanitizers and wearing masks to curb the spread of the virus. After a continuous rise in cases, a rigorous lockdown was imposed to stop the spread of COVID-19 in countries including Italy, Spain, France and the United Kingdom. 5,6 The government of Nepal (GoN) also imposed a complete lockdown on 24 March 2020, during the first phase of COVID-19. 7 The effectiveness of wearing masks, and other preventative measures have been proven to slow the spread of infection, 8 and it is, therefore, essential for the government to educate the public on these health messages.
There have been 1,000,631 confirmed cases of COVID-19 with 12,019 deaths with 5,958,956 polymerase chain reaction(PCR) tests as of 2 November 2022, in Nepal. 9 Nepal has been responding to the pandemic through the implementation of public health prevention and hospital-based interventions. Key interventions such as management of quarantine, screening and testing have been carried out.
Dissemination of information related to COVID-19 to the public, and managing vaccination campaigns were conducted to slow the spread of infection. 4 Different management committees and task teams were also formed to minimise the adverse impact of COVID-19 in Nepal. 10 However, some of these committees were criticised for not being able to effectively implement such preventive strategies. Some academics have expressed the opinion that the potential risk of coronavirus transmission at the community level was not taken seriously in Nepal. 11 Preventive initiatives, mass testing of COVID-19 and quarantine measures are all equally important interventions in stopping the spread of the disease. 12 Mass testing helps people to determine COVID-19 infection regardless of symptom status, and being at risk of spreading the infection. Several international studies have found a reluctance towards COVID-19 testing due to long queues, exposure risks and late reporting. 13 Concerns were raised regarding testing disparities between rural and urban residents in Florida. 14 Despite several efforts, Nepal was also not able to conduct sufficient diagnostic tests, and perform timely contract tracing in the initial phase of COVID-19 transmission. COVID-19 testing sites were limited by higher costs and longer time for test results. 2 The lack of coordination and blame games among different stakeholders were found to be a prominent obstacle towards the management of COVID-19 testing and quarantine services in Nepal. During the first wave, the authorities failed to manage effective provision for testing, isolation and quarantine services despite these being the heart of effective public health measures against COVID-19. 11 However, the government corrected the loopholes from the first wave (2020), which resulted in a contrasting response strategy during the second wave (2021). 11 Besides several preventive measures, the development of a vaccine against COVID-19 is considered a crucial moment in the efforts to curb disease spread and resume a normal life. 15 Nepal began its first vaccination campaign in January 2021, with donations received from India. 16 The GoN succeeded in managing vaccines through strong bilateral coordination, during global concern around the scarcity of vaccines. 11  | 1171 country such as Nepal. The most high-risk and vulnerable groups were prioritised for vaccination following the prioritisation protocol of WHO. Some concern was expressed on the way in which vaccination centres were managed, with particular concerns about the spread of infection due to crowding in vaccination centres. 2 However, despite several challenges, the GoN has fully vaccinated 76.5% of the total population. 17 It is imperative that governments are prepared for future waves of COVID-19. It is essential that the management of pandemic preparedness and response is organised and sustainable. 18 The effective management of COVID-19 is the most urgent health issue globally today, and to this end, much research has been conducted to assess public knowledge and attitudes perceptions towards the disease. 19,20 However, to our knowledge, the management of COVID-19 and government effectiveness in the management of COVID-19 vaccines at the community level has not been studied yet in Nepal. Therefore, this study aims to gain the perspectives of the public towards the management of COVID-19 and its vaccination in Nepal. This research will be useful for developing strategies and formulate contextualised plans and policies based on urban and rural settings in the event of future outbreaks, if any. Questions this study aims to answer:

| Research participants
In-depth interviews 23

| Data collection
Semistructured interview guidelines were used to conduct IDIs. 24 All the interviews were conducted between November and December 2021. Interview guidelines were developed in the Nepali language and then translated into English. We included questions on the interviewees' sociodemographic characteristics and their knowledge, attitudes and perceptions of COVID-19, and in particular, their opinions on the government's role in the management of testing and vaccination against the disease. Face-to-face interviews were conducted with the participants at their place of convenience, mostly at their homes and field, with the researcher, the interviewee and noone else present. Before commencing the interviews, the purpose of the study was explained to the participants, as well as the benefits and possible harms. Participants were given an information sheet, and their right to withdraw from the study at any point was emphasised. Participants were also asked to consent, verbally and in written form, to participate and to digitally record the interview. All of the interviews were audio-recorded on an encrypted digital recorder and stored on a password-protected computer. The audiorecorded interviews were transcribed into Nepali and further translated into English. All of the personal identifiers of participants were replaced with unique codes. The confidentiality and anonymity of the research participants were maintained at all stages of the study. All necessary safety precautions were adhered to during the entire process of the interview, considering the risk of the COVID-19 pandemic.
The data collection tool was pretested and necessary changes were made before the data collection. Participants were interviewed on one occasion only, and transcripts were not returned to interviewees for comments or clarifications. Among the participants approached for conducting IDIs, two of them declined to participate due to their personal work. We piloted four interviews before conducting the data collection at the study sites.

| Data analysis
A thematic approach based on the work by Clarke et al. 25 was used to analyse the qualitative data. In the first step, all of the recorded interviews were carefully listened to multiple times, and then transcribed verbatim and translated into English, to ensure familiarity with the contents. Other co-authors collaborated to identify the commonalities and differences in the interview transcripts and worked to develop an initial set of themes. Potential themes were reviewed and named, ensuring coherence and a good representation of data. After thematic identification, the first and second authors completed open coding manually with five of the interview transcripts chosen based on the representativeness of the entire data set. The first author refined the coding framework and applied this framework to the rest of the data set. We exported the framework matrix as a spreadsheet and then summarized it into relevant themes. Any alterations to the themes or codes were discussed collectively and agreed upon by the research team. The codebook was finalised through regular team meetings during the data analysis process. Five researchers coded the entire data set and 10 interview transcripts were double-coded. Similarly, five researchers were involved in generating themes. We used NVivo 12 (Version 12 pro; QSR International), 26 a qualitative data management software for codebook management and data analysis. R., B. K., S. J. and S. B.) were involved in data analysis and manuscript preparation. Other members of the writing team contributed to drafts and to refining the manuscript. Table 1  The average length of interviews was 30 min, and field notes were also taken. After data saturation was obtained and no new information was generated, we stopped recruiting participants for the interview.   In rural areas, people had limited access to hygiene products such as masks, soaps and sanitizers, and used them only when they were freely distributed, indicating both affordability and access problems.

| Qualitative findings
People wore masks when they were distributed by the local government, but they didn't buy them by themselves after that and also didn't continue wearing them. (SR_20) To control the spread of COVID-19, quarantine centres were also available in both rural and urban areas, specifically targeting returnee migrants. However, as time passed, such practices were not followed strictly. Participants from urban areas voiced their concerns that quarantine centres were not properly managed and due to overcrowding, their use posed a high risk of infection.

Managing access
The participants in the study had difficulty accessing COVID-19 vaccinations, indicating discrepancies in vaccine distribution and management. Initially, vaccination was provided to health workers and frontline workers such as security personnel, and politicians.
Study participants voiced appreciation for these measures, but concerns were espoused regarding the manner in which the vaccination programme was managed and rolled out. Several participants responded that there was initially a scarcity of vaccines, which was only within the reach of high-ranking officials, politicians or those with good connections. Furthermore, there were also complaints and doubts over the delayed and inequitable distribution of vaccines, especially in rural areas, signalling a gap and an inefficient supply of available vaccines. Some health professionals shared that they also struggled to access vaccines. Nepal, people were found to be reluctant to test themselves against  This mirrors the findings of research conducted overseas, including in the United Kingdom. 35 The refusal of at-risk individuals to test drastically impedes effective contact tracing and presents a barrier to control of the disease at the community level.
Additionally, this contributes to delays in diagnosis and appropriate isolation of suspected cases, exacerbating the difficulties further.

| CONCLUSIONS
The study concludes that testing, quarantine centres and vaccination campaigns were poorly managed in both urban and rural settings in

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.

ETHICS STATEMENT
The