1 INTRODUCTION

The rapid spread of COVID-19 from its inception in Wuhan, China, in December 2019 has generated shockwaves in all spheres of growth and development.^1-3 Furthermore, COVID-19 has contributed to exposing the flaws in health system security across borders, leading to a global pandemic declared by the World Health Organization within three months of the first case detection.⁴ Characterised by typical symptoms like fever, dry cough, sore throat, and fatigue along with documentation of its asymptomatic nature, COVID-19 is often difficult to distinguish, leading to its underreporting in the healthcare infrastructure with limited diagnostic capabilities.⁵

A reported total of 178 million confirmed COVID-19 cases with 3.9 million deaths as of June 2021 resulting from contact-based transmission and multiple waves of infections across the borders (⁶). The unavailability of proven therapeutic options resulted in the uptake of preventive measures in the form of isolation, restricted movement, and complete lockdowns at the core of the global COVID-19 response.⁷ However, the efficacy of these preventive measures was often questioned in terms of effectiveness and timing to the reduction of overall case numbers along with the trust in the public authorities.⁸ Furthermore, a sustained period of economic shutdown resulted due to the implementation of these preventive measures, leading approximately 100 million people to extreme poverty on account of shrinkage of per capita income, and this number is expected to rise to nearly 150 million by the end of 2021.⁹

As a response, the global community has been pushing for mass vaccination at an accelerated rate for protecting public health and resuming economic activity at the earliest phase. After the initial publication of the genome sequence of SARS-COV-2, manufacturers and the scientific community have undertaken an unprecedented effort to develop effective vaccines.^{10, 11} The accelerated approval of COVID-19 vaccines within a year is a landmark success, overtaking the previous record of a four-year approval period for mumps vaccine in the history of vaccination manufacturing.¹²

However, with the emergence of the newer COVID-19 variants and the circulation of dubious information in the social and electronic print media, the public is often in doubt about the necessity and efficacy of these vaccines.^{13, 14} Many of the health system determinants in the development of public trust in vaccination service include paucity of trained health workers, fragile infrastructure, limited storage capacities and insufficient funding to sustain the immunization programs.¹⁵ Additionally, past adverse experiences in accessing health services and the growing distrust in institutions and healthcare providers in the context of corruption, weak governance and limited capacity seem to be key determinants in vaccine acceptance and the resulting hesitancy.^{16, 17} Moreover, with the availability of limited vaccination with regard to the population's health needs, the negotiation power of the individual states in the availability of vaccines from multiple sources will be crucial in improving access and building public trust in the efforts to deliver safe and effective vaccination.^{18, 19}

Initial early assessment from the World Bank has demonstrated that only 30% of the countries have the capacity to develop an adequate process for training the large number of vaccinators needed for the vaccination and only 27% of the countries have strategies in place for public engagement and social mobilization needed for vaccination.²⁰ This is quite surprising given that around 85% of the countries are said to have vaccination plans and 68% with vaccine safety systems.²⁰

Bangladesh, a country with a fragile, inadequate, and fragmented health system, was no exception regarding the availability of information, evidence-based decision making and supply chain logistics during the pandemic.^{21, 22} As of 7 July 2021, a reported total of 977,568 COVID-19 cases with 15,593 deaths in the country have not only exposed the flaws in the healthcare infrastructure but also contributed to the erosion of public trust as evidenced by the non-adherences to various public health measures.²³ An effective immunization system has been one of the notable public health progresses with respect to expanded programs of immunization in developing effective vaccine storage and distribution capacity in Bangladesh in recent times.²⁴ However, the existing expanded programme on immunization (EPI) infrastructure and vaccine distribution capacity are built in conformation with the vaccines employed in combating childhood major infectious diseases. This involves having cold storage facilities of 2–4° across the countries that limited the options for deploying COVID-19 vaccines excluding Moderna and Pfizer-BioNTech vaccines from the planning schedules at the earliest of the COVID-19 vaccination campaign. Additionally, as the routine EPI vaccination is focused on the vaccination effort focused on the childhood population, there is a dearth of expertise in human resources and vaccination in delivering a large-scale vaccination involving the adult population as required in COVID-19 vaccination in Bangladesh. Despite such progress and confidence, a ripple effect over the potential erosion of trust in the government and public health authorities during the COVID-19 response is built upon the limited utilization of clear contingency planning and lack of coordinated informed decision-making is likely to be translated into the deployment of the COVID-19 vaccination.

Furthermore, the vaccination campaign was started with exclusive sourcing from the Serum Institute in India with no liability clause stemming from a tug of vaccine-diplomatic relations between India and China. This contributed to the halting of the vaccine delivery after the surge of the Delta variant in India during April-May 2021, resulting in a delay in receiving second dose of a dosing schedule. The government, therefore, made diplomatic efforts through utilizing existing diplomatic relations with China, Russia, United States of America to receive vaccine dosage in a bid to curb the vaccine shortage in Bangladesh and the delayed dosing schedules in between the dosage regimen. The COVID-19 vaccination campaign eventually resumed in July 2021, resulting in delayed dosing schedules of more than 2 months after receiving the first dosage risking the efficacy of COVID-19 vaccination in preventing SARS-COV-2 infection in Bangladesh. Furthermore, many of these agreements also resulted in receiving vaccine COVID-19 vaccines global access facilities as late as August 2021. Therefore, many of these recipients were given the second dose with other sources of vaccination like Sinopharm linked with limited evidence of similar efficacy resulting in potential vaccine cocktailing risking in the development of potential vaccine-related COVID-19 side effects. The delayed action on procuring vaccines employing global diplomatic relations can be clearly linked to the anticipated erosion of trust in delivering COVID-19 vaccination by the government even in the availability of strong immunization backbone in the country due to succinct and relevant contingency planning in availing COVID-19 vaccination campaign without major disruptions.

To evaluate the micro-level impact of the COVID-19 pandemic in Bangladesh, particularly their health, economic and lifestyle changes, this study conducted an online survey. Additionally, the level of trust in the government's immunization performance given the recent changes was investigated. The objective is to assess the disruption in micro-level lifestyle in Bangladesh due to the pandemic and its subsequent impact on people's trust in the government to fully inoculate the public.

2 THEORETICAL FRAMEWORK

Trust is a vital factor for good governance.²⁵ Trust, in the context of this research, refers to an efficient means required in building any social, economic, and political relationship,²⁶ which underpins the interaction between human and political institutions where the individual holds a favourable perception towards the government and its activities.²⁷ Trust in the government allows and drives the citizens to adhere to the stringent measures taken by the government in times of crisis. Trust in political institutions is often cultural and deeply rooted as an extension of interpersonal trust.^{28, 29} However, as per institutional theories, the level of trust varies with the performance of the institutions.^{30, 31} During crisis and post-crisis scenarios in developing countries, both social trust and political trust play key roles, as higher dissection with political elites or representors can lead to deleterious consequences for policymakers and worsen the ramifications.²⁵

Most theories underpin political trust with financial crisis,^{32, 33}which places the public health crisis in a new paradigm. Certainly, in the complex global political order, a non-financial international crisis has hardly ever been experienced in recent decades let alone a public health mayhem. This paper engages itself in explaining the propensity of causing disruption to life by a global public health crisis, the COVID-19 pandemic in this context, and trust in the government. As trust in the government, even within the context of public health, is a vast discourse, this study focused on the aspect of immunisation performance as vaccination is commonly regarded as the best-known answer to any infectious disease pandemic.

3 METHODOLOGY

4 RESULTS

5 DISCUSSION

The objective of this study was to assess the scenario of disruption to the public's lives in Bangladesh due to the COVID-19 pandemic and the public's level of trust in the government in conducting a successful immunisation campaign. Almost half of the sampled respondents reportedly faced disputations in their daily lives during the pandemic, and most of them were hampered financially (nearly 90%). Trust in the government was very low at the time of the survey as only one in 10 could rely on the government to successfully run the mass vaccination campaign. The sample was heavily skewed to the urban privileged class. This shows the manifestation of the immediate adversity due to the pandemic in Bangladesh even among the affluent section of the society. Although the income earners and those with self-judged more knowledge on COVID-19 claimed to have their lives more disputed than the others, they also kept higher faith in the government.

Arguably, the ongoing pandemic has disrupted the lives of every living being. However, inadequate tests, lack of contextual contingency planning, and ambiguities involved in decision making including imposing lockdowns with limited testing capabilities in metropolitan areas have kept the numbers for Bangladesh low.³⁵ Despite that, over 40% of the sample have reported having known someone who died related to COVID-19 causes (immediate family members, relatives, or neighbours). Furthermore, 8% of the respondents reported having tested positive before the survey. These issues lead to severe underreporting in this region.³⁶ An overwhelming number of respondents (89.4%) reported that they suffered financially due to the pandemic. While financial damage is expected to some extent,³⁷ the interesting finding here is that it has affected earners or non-earners, students or non-students, and residents in urban or rural areas indiscriminately. Thus, one could argue that the large-scale impact of COVID-19 includes both economy and health, not limited to any financial or working cohort, which challenges policymakers of small economies to find damage-mitigating interventions.

While two-thirds of the study sample was from urban residents, almost half of them were observed to have their life disrupted compared to one-third of the rural residents. There are two possible explanations. One, rural areas are less densely populated than the urban cities, such as Dhaka or Chattogram, where there is a lesser scope for the spread of viral infection.³⁸ Moreover, livelihood in rural areas allow social distancing as most of the rural population, unlike metropolitans.³⁹ Thus, life continued relatively smoothly without major deterrents in rural areas, and they reportedly did not experience a major outbreak or deaths. The explanation exercises more caution in interpretation of lower prevalence of life disruption the sense that there has not been adequate testing in rural areas to feasibly conclude if viral infection was ever present at large in rural areas. Biswas et al., 2020⁴⁰ provided instances where testing was limited to major towns and no testing capacity in peripheral districts. Also, regional lockdowns in Bangladesh were strictly implemented in major cities such as Dhaka, which attempted to cut off infection spread from cities to the suburban areas and villages, which might have helped in barring massive spread in outer regions.⁴¹ However, instead of considering them individually, a combination of these hypotheses perhaps explains the greater impact of pandemic on urban residents.

The proportion of Muslims in the sample matches national distribution and they reportedly had life more disrupted than people belonging to the other religions or those who are non-religious. Expectedly, earning members of the household experienced greater damage from the pandemic than those who are not financially active. There exists an extensive literature on how viral transmission and subsequent control measures lead to economic slowdown, resulting in loss of jobs, business closures and income stagnation.⁴² In the case of Bangladesh, studies have reported that 14.75% of the people were pushed into poverty due to the pandemic alongside existing 20.5% who are already in poverty⁴³ and some research hypothesised how it would take years for Bangladesh to recover from the damage despite ongoing growth.⁴⁴ However, the current study has found that even the relatively privileged cohort in urban areas has suffered during the pandemic and the earning members of society were the worst victims at the micro-level which is likely to trickle down and affect those who are dependent on the earning family members.

This study did not assess respondents' COVID-19 knowledge, rather they reported their self-assessed knowledge level. Those who claimed to be more knowledgeable were found to experience greater life disruption but had higher trust in the government's immunisation performance. There are a few hypotheses for this. They could be aware of global disruptions and relate to that with their lifestyle. They could be more aware of the success of the Bangladesh government's previous immunisation campaigns, praised worldwide, which could have given them a greater faith in future vaccination programs (at the time of the survey no vaccination was conducted).⁴⁵ However, it is certainly a contradictory finding that graduate or more educated respondents had less faith in the government's immunisation performance, which makes the insights from the variable ‘self-assessed knowledge on COVID-19’ questionable.

Participants who lived in group housings and were earning members of the family were found to be less trusting on the government's immunisation capability. Many of these responses can be potentially linked to the series of disruptions happened during the pandemic in Bangladesh. Although the survey was conducted prior to start of vaccination campaign in Bangladesh, the government faced with several setbacks including shortage of vaccine, over-reliance on one source and no local reliable production capacity.⁴⁶ Group housing refers to university hostels or private boarding houses which provides a cheaper housing for students, unemployed or temporary residents as well as single unmarried job holders. Given the current housing crisis in metropolitan Bangladesh,⁴⁷ the residents in such housing are hardly happy with the government's progress on this issue. Such discontent among this cohort could explain their lack of faith on the government's campaigns. The respondents who are financially active, on the other hand, would be on the receiving end of the government's failure on job protection, business venture bailouts and inefficient planning prior to viral containment measures such as lockdowns.⁴⁰ With the ongoing fragile state of democracy and healthcare infrastructure in Bangladesh,⁴⁸ there is a lack of citizen trust in public health campaigns run by the government.

The highly educated (graduates and postgraduates) were less trusting of the government's immunisation capability than those who completed high school level education or less. Bangladesh's health system has hardly ever lived up to its expectations. With 72% of the health expenditure coming from out-of-pocket spending, leading to financial impoverishment of 3.4% as of 2015 amounting to 5.3 million people for meeting their health needs, such unfavourable conditions would render the public to put very little faith in the system.⁴⁹ The educated guess from many would be that the immunisation campaign might be another failure compounded by the growing misconceptions regarding vaccines, the limited availability of vaccination involving the adult population at a mass scale and the perennial hesitancy to accept vaccines.

While this study was one of the first ones to assess opinion on COVID-19 pandemic life disruption and people's faith in the government immunization performance in Bangladesh, there were a few limitations. First, this study used a snowball sampling procedure based on internet survey tools and it was thus not completely randomized. The study was skewed towards the urban privileged class, particularly those with access to the internet. Due to public health constraints, face-to-face data collection was not applicable which limited the sampling frame. Second, due to online data collection, responses were self-reported and cannot be verified. Moreover, some variables such as ‘Financial contribution to family’ can be subjective and require a mixed methods (quantitative and qualitative) approach. While these could not be done during the pandemic, future studies can utilize qualitative measurement for a validated measure of personal finance and trust in government services. Third, there were no established scales for ‘life disruption’ or ‘trust in the government’ were used in this study, which could compromise study reproducibility to some extent. Even though, in the event of limited vaccine availability and global vaccine diplomacy, efficient procurement from multiple sources in maintaining the immunization continuum are expected to be a challenge. However, the incorporation of vaccine availability from multiple resource will potentially garner an ambiguous response which was difficult to incorporate with the developed structured questionnaire with simpler terminologies. Hence, we also recommend future studies specifically measuring vaccine procurement should provide a heightened focus on vaccine purchasing and co-financing arrangements. Finally, the study is cross-sectional, so there was no baseline to compare life disruption from a pre-pandemic period.

6 CONCLUSION

The study revealed that half of the respondents reportedly had their lives disrupted by the pandemic, largely in the financial aspect and only one in 10 had faith in the government's mass immunisation capability. The impact of the pandemic seemed to be quite high despite the on-paper continued economic development in the form of gross domestic product growth. The lack of trust in the government might, stemming from both the erosion of democratic system as well as poor pandemic governance could jeopardise the government's attempt at probable upcoming and ongoing public health interventions such as mass vaccination and imposition of health guidelines. Effective risk communication and timely display of data-driven decision-making efforts seem to be the most reliable strategies in regaining the public trust before the ever-required consolidated plans for public health interventions such as lockdowns with economic compensations are employed. These are key factors in ensuring greater cooperation from the public and getting traction in extensive campaigns aimed at making people believe that a successful immunisation operation can be run in Bangladesh.

AUTHOR CONTRIBUTIONS

Raaj Kishore Biswas: Conceptualisation; investigation; methodology; project administration; and writing – original draft preparation. Awan Afiaz: Investigation; methodology and software; and writing – review & editing. Samin Huq: Investigation; resources; validation and writing – review & editing. Maysha Farzana: Data curation and writing – review & editing. Enamul Kabir: Supervision and writing – review & editing.

CONFLICT OF INTEREST STATEMENT

There was no conflict of interest among the authors. All authors read the final manuscript and approved it.

ETHICS STATEMENT

All procedures performed in studies involving human participants were in accordance with international ethical standards. Ethical approval was taken from The UniSQ Human Research Ethics Committee (H17REA157). The participation to the study was voluntary and informed consent was obtained from all patients for being included in the study.