Phase 1: Quantitative phase.

To understand the extent of the problem, a quantitative survey was executed through the self-administered questionnaires developed and administrated using Google Forms. As the study was executed during the peak of the outbreak, the link to the electronic survey form was distributed to health professionals through social media platforms such as Facebook, LinkedIn, Twitter, and Email.

Sample size and sampling technique.

The sample size was determined using Cochran’s formula for estimation of a proportion (n = z²pq/d²). A web-based survey conducted during the early phase of the pandemic in Nepal reported 37.5% of the health professionals to have illustrated the symptoms of depression [27]. So, using this past prevalence at 5% allowable error and 95% CI, the initially estimated sample size was 363 health professionals, which was optimized to 400 after adjusting 10% non-response rate. Snowball sampling technique was adopted, where the health professionals were requested to share the Google Form with their contacts working in the Province. All health professionals working in Gandaki Province during the time of data collection were eligible to participate in this study regardless of their level of work, academic qualification, or nature of involvement in COVID-19 response and management. The online data collection was executed during the months of March to August 2021. A total of 418 complete responses were collected from nine districts of Gandaki Province, so the team decided to keep all the complete responses for the analysis. (Table 1).

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Table 1. Frequency distribution of response collected from each district.

https://doi.org/10.1371/journal.pone.0283948.t001

The online survey questionnaire was divided into five sections, where the first section included questions regarding participants’ demographic and academic profile. Second section consisted of questions regarding the change in social relations experienced by the participants at the time of COVID-19. Third section consisted of job satisfaction scale previously validated among the health professionals of Gandaki Province with a Cronbach’s alpha of 0.70 [34]. Fourth section consisted of two standard tools, COVID-19 fear scale [35] to assess the level of fear and Patient Health Questionnaire (PHQ-9) [36] to assess the level of depression among health professionals. The PHQ-9 has been translated and validated in Nepali language with a sensitivity of 0.94 and specificity of 0.80 to assess depression at the cut-off of ≥10 [37].

The questions to assess the social impact of COVID-19 pandemic were prepared by the authors in consultation with the experts from public health and social sciences to cover all the crucial aspects of social impact observed in the national context during the pandemic. The questions were converted to an online format using Google Forms and piloted among some health professionals of Bagmati Province. The health professionals provided their input on the length, and relevance of each item to assess the change that they experienced in their social relationships. Following their feedback, an agreement was reached on a final version of the questionnaire (S1 File). The Google Form with the complete set of questions was then pretested among another group of healthcare professionals of Bagmati Province and slightly rephrased based on their responses.

Quantitative data analysis.

The data acquired through the online survey was exported to Statistical Package for Social Sciences (SPSS) version 22 for analysis (S1 Data). Descriptive statistics were used to describe participants’ demographic and academic profile, social experience at the time of COVID-19 pandemic along with their job satisfaction and mental health status in the form of frequencies and percentages. Chi-square test and unadjusted odds ratio was calculated at 5% level of significance to identify the factors associated with depression. The factors found to have statistical significance (p<0.05) in chi-square test were subjected to the final model of multivariable logistic regressions along with the social impact-related variables. Before going into the multivariable analysis, the multi-collinearity among independent variables was tested using Variance Inflation Factor (VIF), where a VIF greater than five was taken as an indication of multi-collinearity between the independent variables. Hosmer and Lemeshow test was used to assess the goodness of fit of the model where p<0.05 represent that model is a poor fit.

Phase 2: Qualitative phase.

In context of qualitative survey, a total of 14 health professionals from different health organizations actively contributing for the management of COVID-19 crisis within the province were approached for in-depth interviews. The health professionals were selected purposively for the interviews based on their field of expertise, and range of characteristics such as age, ethnicity, gender, and professional roles as well as their acceptance for the face-to-face interviews. (Table 2). The number of interviewees were determined by data saturation; whereby subsequent interviews did not yield any new information.

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Table 2. Characteristics of participants involved in in-depth interview (n = 14).

https://doi.org/10.1371/journal.pone.0283948.t002

Qualitative data collection and analysis.

The consolidated criteria for reporting qualitative studies was followed (S1 Checklist). The interview guideline was developed by two authors (SP and AC) based on the findings from the quantitative phase and expert opinion from the last author (SBM). It was piloted among three healthcare professionals and was amended by SUP based on their feedback.

All fourteen interviews were conducted in-person with the interviewees at their residence by first four authors, following the COVID-19 precautions of distancing, and using sanitizer and mask. All the participants agreed to the face-to-face interview and provided their complete response to all the questions. The interviews were recorded after acquiring informed consent from the participants and field notes were also taken during the interviews. The average duration of the interview was one and half hours. The interview guideline used in the interview is attached as a (S2 File). All the interviewers (SP, SUP, DK, AC) are public health postgraduates with past experiences in both quantitative and qualitative data collection and analysis.

All in-depth interview audio were transcribed verbatim on paper by the researchers (SP, SUP, DK, and AC). The researchers cross-checked the transcripts for accuracy and language translation consistency from Nepali to English. Prolonged engagement of authors in every phase of the study and peer debriefing of translations of verbatim were done. The transcripts were not sent to the participants for their review. The interview transcripts and notes were read and analyzed several times to understand the emotions and experiences of participants and to become thoroughly familiar with the content. No software was used for the data analysis. Based on the information provided by the participants, the core concepts expressed by each of the participants were extracted by the authors. The inductive thematic analysis technique was used for which two of the authors (SP and SUP) independently generated the initial codes from the significant statements from the participants and searched for the themes within the transcripts. The concepts were clustered into themes based on their similarities to develop a comprehensive description of the participant’s expressions. The next two authors (DK and AC) reviewed the codes and collaboratively defined and named the themes. All authors collaboratively reviewed and finalized the themes.

Social impact experienced by health professionals due to COVID-19.

Theme 1: Change in social relationship. During our quantitative study, it was noted that more than half of the participants reported experiencing changes in their social relationships with family, friends, and community members during the pandemic. This observation was consistent with our qualitative findings, as many participants reported experiencing such changes in both positive and negative ways. Some of the health professionals expressed that they had been close to their community, providing health information and guidance at the time of infection, while others expressed being forced to be distanced from their community, relatives, and friends. Some of the participants even reported to have voluntarily distanced themselves from their family due to the fear of infecting their loved ones.

“Many relatives and friends contact me frequently for advice on home isolation, test procedure, days for quarantine and other COVID related information”

–IDI-1

“I am often contacted by my friends and neighbors to ask about COVID-19 test and things to do if they feel unwell even in case of negative RT-PCR reports.”

–IDI-4

“I live in a rented home near my office with limited space. Sometimes when I go home, I fear I might transfer infection to my family members. This makes me feel if I don’t have to go home or if I had bigger space where I could isolate myself.”

–IDI 2

The participants also reported to have experienced different forms of discrimination from the family as well as community people. During the interviews, some of the health professionals shared how they were maltreated by their landlords, community people and even local leaders during the time of COVID-19.

“My house owner said to me that I should either close my clinic or shift from his house because they feel insecure when I am there.”

–IDI 9

“Sometimes I feel like the shopkeepers behave differently around me. They seem to be more conscious when I go to their store to buy something. They always keep their eyes on me and keep a distance and use disinfectant more often than they do around other customers.”

–IDI 11

“I have been asked by my father-in-law to quit my job or take some time off until the rate of infection declines and everything come to normal.”

- IDI-5

Theme 2: Psychological distress during the pandemic. In the quantitative study, it was noted that a significant proportion of healthcare professionals screened positive for depression. Similarly, during the in-depth interviews, it was expressed by most of the professionals that the feeling of social isolation disturbed them emotionally and psychologically. They were disappointed for being assaulted and dishonored by the people while risking their life as frontline workers.

"The community people blame us if any life is lost. We don’t have enough equipment and resources but we are trying. Sometimes all of this lowers my self-esteem; Even though we feel demoralized, we continue to serve as it is the right thing to do.”

–IDI 4

"Due to my exposure, my family was also infected. We went through a lot of hardship, but what did we receive from it? We are the ones who get blamed."

–IDI 13

The health professionals were frustrated by inadequate resources at the time of crisis and pressure from the local leaders to direct scarce resources towards the elites of the community.

“During the time of vaccination, many of us were pressurized to hide vaccines for families of the local leaders and their people. We knew it wasn’t ethical but we had no choice other than to comply with their terms.”

–IDI 6

“We are risking our life to save people and continue to provide services without any rest. But still, we don’t have any support system. The leaders don’t care about us, nor about the health system. We haven’t even received our risk allowance. "

–IDI 11

Theme 3: Coping strategy adopted to handle social discrimination and maltreatment. During the quantitative survey, it was noted that a significant proportion of health professionals experienced changes in their social relationships. The quantitative findings also suggested that this social impact of the pandemic has a significant association with the mental health of health professionals. The coping mechanisms of the health professionals towards both the change in social relationships and the depressive symptoms resulting from the pandemic were explored during the qualitative phase of the study. While participants shared about their coping mechanisms to deal with changes in social relationships, there was limited information obtained on their coping strategies to manage mental distress. The qualitative analysis revealed that a common coping strategy among most professionals was ignorance, whereby they tried to overlook the maltreatment they experienced. Some of the health professionals also expressed that, sharing their awful experiences and distress with their loved ones helped them cope with such dissatisfaction, discrimination, and maltreatment.

"Yes, we are not treated right but what else can we do other than to serve? We choose this profession and it’s our responsibility regardless of any unpleasing events."

–IDI 2

"My family is really being my support system in these stressful days. COVID has made our interaction more frequent and sharing my day with them calms me and helps me to digest all the distressing events."

–IDI 9

“At the beginning, I wasn’t worried about the infection but later as the rate of infection increased exponentially and mortality raised each day, I was terrified. It was stressful but as a health worker we have to tackle this crisis so we shouldn’t care much about what people say or do, we should just aim to serve our best.”

–IDI 7

Theme 4: Expectations from government and leaders. During the interviews, considering COVID-19 as a national health emergency, the healthcare professionals were asked about the support they received from all three tiers of the government. They were also asked to provide recommendations to local and provincial governments to support the social and mental well-being of health professionals. The participants expressed dissatisfaction over the response of all three levels of government in the management of COVID-19 crisis, citing issues such as the lack of incentives for frontline workers, insufficient personal protective equipment, absence of insurance coverage, political pressure, and corruption.

“Incentives and other facilities are for the higher-level staffs who seat in the office even if they don’t work at the frontline but the main frontline workforce like us are still not getting any benefits. Neither are we getting any respect from the communities for our efforts.”

–IDI 8

Even in the case of privately owned health organizations, the health professionals were dissatisfied and demotivated by the overall COVID-19 management and response approach. During the interview, the participants notified that some of the organizations deducted the salary of their staff as they were bound to work from home whereas some of the organizations provided their staffs with the services of COVID-19 insurance which covered their basic remuneration. Staffs from some organizations also praised their management for the support during the pandemic. on the contrary, the staffs from some of the private hospitals notified that they did not receive any kind of training and in some cases proper PPE to protect themselves from infection.

“Our organization is very supportive during this time of pandemic. I feel very happy that the organization had provided the full salary along with some incentive, make the provision of work from home in the meantime, and also provide the different level of training to tackle the pandemic”

–IDI 3

The participants from both government and private organizations had a similar verdict that the government policies are well documented and could improve the level of satisfaction among health providers only if the policies are implemented properly. Proper and smooth implementation of the policies and acts, provision of sufficient medical supplies for diagnosis, and proper incentives for the health workforce were the key recommendations from almost all the participants for the government to tackle the COVID-19 crisis.

“Policy implementation must be enhanced to improve the healthcare system as many good policies and acts have been formulated but, in action, we sadly have to say there is almost zero implementation and commitment over those well-written documents.”

–IDI 14

The role of local government was also highlighted by some health professionals. It was stressed that the local government should focus on the health sector plan and program critically and should consider health as a priority program rather than just focusing on tangible developmental projects. The healthcare professionals also suggested that the Ministry of Health and Population at the Federal and Provincial levels should identify the grassroots problems of health professionals while implementing different programs by consulting with the local government.

“It is local government’s responsibility to regulate or monitor the private hospital and clinics in terms of COVID-19 testing and diagnosis for the effective regulation”

–IDI 4