Community willingness towards a hypothetical new TB vaccine: a qualitative study to explore the enablers and barriers for vaccine acceptability in Nepal.

Introduction: Tuberculosis (TB) remains a leading cause of death in low- and middle-income countries, including Nepal. Although new TB vaccines are in clinical development, little is known about public willingness to accept them. This study explores the enablers and barriers for public acceptance of a hypothetical new TB vaccine among communities in three TB-affected districts in Nepal. Methods: We conducted an exploratory qualitative study in three TB-affected districts of Nepal- Morang, Banke and Mahottari. Six focus group discussions were conducted with 60 purposively selected participants with separate sessions for male and female participants from diverse sociodemographic backgrounds. Data were collected using a semi-structured guide adapted from the Capability, Opportunity and Motivation-Behaviour (COM-B) model, audio-recorded, transcribed, translated and analysed using semi-deductive reflexive thematic analysis aligned with the COM-B framework. Results: This study showed that the participants viewed a new TB vaccine positively, shaped by their experiences with COVID-19 vaccination and trust in government-led vaccination programmes. Key enablers included recognition of vaccines as preventive tools, positive vaccination experiences, mobilisation of healthcare workers and community figures in vaccine implementation and use of innovative communication strategies such as caller-back ringtone playing transparent vaccination message. Barriers included limited knowledge about TB vaccines, concerns about safety and efficacy, and exposure to misinformation. These factors interacted with other constraints to access vaccines, including lost wages and transportation costs, operational challenges at vaccination sites and geographic distance. Gender-specific challenges were identified, including limited mobility among caregivers and postpartum mothers and disproportionate TB-related stigma experienced by women. Conclusion: This study provides early community-level evidence indicating a favourable attitude towards a future TB vaccine. While the vaccine acceptance was shaped by institutional trust and prior vaccination experiences, inter-related barriers identified were knowledge gaps, safety concerns, indirect income loss and service-delivery constraints. Early equity-oriented planning can support the effective rollout of a new TB vaccine rollout.