Quantitative findings
Sociodemographic characteristics
The age of participants was not normally distributed and thus median age was calculated as 16 years with IQR 2. Female students constituted 66% and Janajati (49%) and Brahmin/Chhetri (31.5%) were the predominant ethnic groups. Majority of the participants fell into the upper lower (51.64%) class of socioeconomic status.
School nurse service utilization
Around 29% of participants visited the school nurse for various health or lifestyle concerns in past one year. Among those who visited (n = 80), grade 9 students were the most frequent visitors (47%). Most visits occurred one or two times, mainly within the last two to three months, with common cold or fever being the primary reasons. All visitors reported positive experiences. Among non-visitors, over 88% felt no need to see the nurse, while nearly 12% attempted but found her unavailable.
Factor associated with school nurse service utilization
Bivariate analysis of outcome variables with background and mediating variables
In the bivariate analysis, students below 16 years, females, those aware about available services in school nurse clinic, students friendly with nurse, those having motivation from parents, teachers or school nurse to utilize the service and students satisfied with school nurse clinic environment were associated with higher odds of utilizing the school nurse service. Interpretation of positive clinic perception should be considered carefully as the CI for the result was found very wide (1.30-374.75). Only variables found significant have been presented in the table (Table 1).
Multivariable logistic regression of eligible background and mediating variables
Multivariable logistic regression of outcome variable was performed with eligible background variables (Model 3) and eligible mediating variables (Model 4). Variables with p-value < 0.25 in Bi-variate Analysis and VIF < 2 were considered eligible for multivariable logistic regression analysis. After testing for multicollinearity, Age, Sex and Ethnicity were eligible from background variables and awareness about available services, student’s perception towards behavior of school nurse, motivator for service utilization, wish school nurse to be male, Student’s engagement in risk behaviors, learning difficulty and school nurse clinic environment were eligible from mediating variables for multivariable regression. Multivariable logistic regression revealed that students below 16 years, females, those aware about available services, having external motivation and those having a positive perception about school nurse clinic had higher odds of school nurse service utilization while students with learning difficulties had lower odds of utilizing the service. (Table 2)
Predictors of school nurse service utilization
Finally, multivariable logistic regression was performed between significant background variables from Model 3 and significant mediating variables from Model 4 with the outcome variable. Before running the final model, the multicollinearity test was done among significant variables from Model 3 and Model 4 and no issues of multicollinearity were found. The final model revealed that age, external motivation and learning difficulties were the independent predictors of school nurse service utilization among secondary students. Students below 16 years, those motivated by friends, teachers, or parents, and those without learning difficulties had higher odds of utilizing the services. Students under 16 years had 2.08 times higher odds of utilizing school nurse services compared to older students (p-value: 0.029, CI: 1.07–4.02). Similarly, students who reported having external motivation had 4.16 higher odds of service utilization (p-value: 0.019, CI: 1.26–13.64) than those without such motivation. Conversely, students with learning difficulties had 68% lower odds of visiting the school nurse (AOR: 0.316, CI: 0.134–0.744, p-value: 0.008) compared to those without such learning difficulties. (Table 3) The model fit the data (p-value less than 0.05) well and highlighted age, motivator for service utilization, and learning difficulty as significant predictors of school nurse service utilization.
Underlying factors influencing school nurse service utilization from qualitative study
To analyze qualitative data, we employed the SEM framework. Based on the framework, we classified codes into five themes namely Intrapersonal Factors, Interpersonal Factors, Organizational Factors, Community Factors and Policy level Factors.
External factors such as the influence of peers, teachers, parents, and relationships with student nurses have been recognized as promoting the use of school health nurse services among students. Nevertheless, issues like frequent turnover of school nurses, unavailability of nurse, and insufficient coordination among provincial, local, and school levels have impeded the utilization of these services.
The codes and subthemes generated in the study is presented below in Fig. 3:
Intrapersonal factors
Younger students, particularly those in lower grades, were more likely to visit the school nurse immediately when they had issues while older students, including those in secondary levels, were less likely to see unless they faced severe problems, reflecting higher hesitation levels among adolescents. A member of school health unit expressed,
“Younger children come to us immediately when they have issues, but secondary-level students are more hesitant and prefer to handle their problems independently rather than sharing. Students below grade six use our services more frequently than older students. The older students only seek help if they experience something severe during school hours. Otherwise, they seem reluctant to share their problems.” KII6.
Females, students aware about available healthcare services with nurse and those who trusted on ability of nurse were found to use the school nurse services more.
“The flow of boys from secondary level is comparatively low and they occasionally visit the school nurse” KII 1.
“If a nurse is available, any injuries or problems that occur, like a fight, will receive immediate care. Basic treatment can be provided on the school premises.” IDI 6.
Likewise, perceived importance of having a nurse available in school encouraged students to seek help.
“When you visit the school nurse, she is well-informed about issues. Why share it with anyone else? You might tell female teachers, but if a nurse is available, there’s no need to tell anyone else.” IDI 7.
‘’As girls, we face numerous challenges. She can assist us with menstrual problems. If there is a nurse clinic at school, it is much simpler to receive care if we become ill because we are distant from home and cannot travel to the hospital.’’ IDI 10.
Students’ attitude toward available services and fear of being stigmatized about sharing sensitive issues, such as sexual harassment or negative health behaviors, significantly influenced their behavior of utilizing school nurse services.
“If a student isn’t seeking help despite having an issue, it might be because they feel that sharing their problem won’t make any difference.” KII 4.
‘’If there are health services available in school, why would I go outside? I should use the facility made available for me.’’ IDI 7.
“If I experience sexual abuse or other sensitive incidents, it seems better to hide it not just from the nurse, but from everyone.” IDI 9.
Also, some students perceived they had difficulties regarding learning and they showed no differences in utilizing school nurse services compared to those without such difficulties. A 15-year female student shared,
“There is no problem in giving presentations, but I have difficulties with homework and studying. I visited the nurse for a menstrual issue in the past year.” IDI 8.
Interpersonal factors
Teachers, school nurses and some parents encouraged children to utilize the available school health nurse services in school. Teachers shared about available school nurse services in their regular classes and motivated students to visit nurse when they face any health issues. A female teacher from school health unit shared,
In the past, students with health problems or those requiring medication would drop their classes to find services outside the school. Eventually, we, as teachers, shared that such services were offered within the school and encouraged them to visit nurse. Now, when they have health issues, they go to the school nurse for support. KII3
“The teacher motivated me by assuring that there is no harm in consulting the school nurse when necessary and that I should not be afraid to share my concerns” IDI6.
Similarly, friends were identified as significant facilitators for students who were reluctant to share sensitive or other issues directly with the school nurse or other members of the school health unit. Communication among friends about the positive experiences with the school nurse and other authorities motivated hesitant students to seek help. When students learn from their friends that their problems are taken seriously and addressed, they become more willing to share their issues. A school health nurse shared,
“Sometimes, students who are too shy or uncomfortable to speak about their problems share their issues with friends. Close friends often come to me and explain the situation and ask ‘’Ma’am, what could be done for him/her?‘’ KII2.
Good relation and communication of nurse with students encouraged them to share their problems openly. Students appreciated the nurse’s friendly and supportive behavior. A female student stated,
“She would treat us like family and offer guidance and advice like our parents.” IDI 8.
Conversely, some students who experienced abuse or harassment opted not to inform it to the school nurse or staff due to threats from the abuser or restrictions imposed by their own family members.
“In situations of sexual harassment, families frequently discourage their children from voicing their experiences, worrying that it might bring disgrace to the family in the eyes of society. Consequently, the child perceives that disclosing such incidents would be a source of personal embarrassment.” KII6.
Organizational factors
A well-maintained school nurse clinic environment influenced the likelihood of students visiting. A female student in grade 9 shared,
“It feels private in the school nurse clinic. Since the nurse is alone in the room, it’s more comfortable to share anything.” IDI1.
Conversely, a female member of the school health unit from one school complained that their nurse clinic is cramped, and conversations inside can be overheard outside, causing students to hesitate to visit. She shared
“The school nurse clinic is small and crowded. Conversations inside can be heard from the other side and even seen from outside. These issues make students feel embarrassed and reluctant to openly discuss their problems.” KII5.
Support from teachers, the principal, and the school administration encouraged school nurses to provide services effectively, leading to increased utilization by students. Support from the school was generally positive across most study sites. A school health nurse state
“The school has created a friendly environment. Teachers actively contribute to coordination and crowd control. During campaigns, everyone collaborates and shares their ideas on enhancing effectiveness.“KII2.
Despite good support from the school community in most sites, a school nurse from one school complained about receiving less support and cooperation from teachers during a health camp she organized. This lack of support reduced the effectiveness of the program and hindered better utilization among students. A school health nurse shared,
“During the last camp I organized, I was on my own. Those from the hospital were there, but class teachers should have assisted with their classes. Managing everything alone isn’t feasible, especially with a large number of students. It’s the responsibility of class teachers to manage students and maintain order. More support from them would have made the process more systematic.“KII1.
In some schools, the nurse’s schedule did not align with morning classes for grades 11 and 12. A male student of grade 12 shared,
“The nurse is present, but not during our school hours. Our classes are in the morning, but the nurse doesn’t come then. I’ve heard she’s available when the younger students are in school during the day. I haven’t seen the nurse yet.” IDI3.
The difference in availability times between students and the nurse was identified to influence utilization of services. Key informants, including the school nurse, acknowledged this availability gap as a potential reason for the lower utilization of services among students in grades 11 and 12. A school nurse shared her opinion,
‘“I work from 10 am to 4 pm, but students in grades 11 and 12 have morning sessions and leave early. I can provide services to grades 9 and 10, who stay until noon. Due to timing conflicts, focusing on grades 11 and 12 is difficult.” KII2.
Community factors
There is a difference in how people from different communities express their concerns.
‘’In general, Tamangs and Janajatis tend to be more shy, often relying on their friends to share their problems on their behalf. In contrast, daughters from the Brahmin community are more likely to communicate their issues straightforwardly, often saying, “This happened to me” or “I am dealing with this problem.” – KII 3.
One aspect that often comes up is the influence of religious beliefs on healthcare decisions.
“For example, many students in this community follow Christianity, and during routine deworming initiatives, some show hesitation in taking the medication. They feel that their faith discourages certain medical treatments and believe that seeking divine prayer at church will adequately ensure their health. Such perspectives are commonly observed when distributing medication.” -KII6.
The gender of the school nurse significantly influenced female students’ comfort in seeking services. The majority of female students reported feeling at ease discussing menstrual and other reproductive issues with a female nurse. They also mentioned they would be reluctant to visit the nurse’s clinic if the nurse were male. A 15-year-old female student in grade 9 shared this sentiment.
“I wouldn’t go because I’d feel uncomfortable sharing with a male nurse. It’s much easier to talk about everything if the nurse is female.” IDI3.
Policy level factors
The ‘One School One Nurse Program Implementation Guideline’ states that schools can send their school nurse for relevant training. However, the unavailability of the school nurse in school during the training period was found to hinder service utilization among students. A member of the school health unit shared this observation.
“When Miss (the school nurse) attends conferences or training sessions, we’re not familiar with all the medications. Additionally, if we need to check blood pressure, we’re unsure how to do it. It becomes problematic when she’s not available.” KII3.
Likewise, the frequent turnover of school nurses and the extended gap until the next replacement were identified as significant issues that impeded service utilization among students. According to the ‘One School One Nurse Program Implementation Guideline,’ school nurses are appointed on a contract basis. However, since the nurses were not permanent fixtures in the school, they often left for better opportunities, resulting in high turnover rates. A member of the school health unit shared this concern.
‘’The province appointed a nurse, but she left for a better opportunity because she wasn’t a permanent staff member. Now, I have to manage my classes and student issues, which disrupts teaching. We lack the expertise of nurses. This program needs to be sustainable.’ KII6.
Effective coordination among school administration, the school nurse, and the municipality facilitated the timely release of budgets and management of medicines and supplies for the school nurse clinic resulting in better utilization of services among students. A school health nurse shared this observation.
“It depends on the municipality. In my case, the rural municipality sends the budget directly to the school’s account for health checkups and supplies. I purchase medicines from the pharmacy and submit the bill, while also obtaining free medicines from a nearby hospital. This ensures timely provision of supplies and services for students.” KII4.
At certain sites, school nurses expressed dissatisfaction with the coordination among the school, municipality, and province, which they believed hindered effective service delivery and subsequently reduced utilization among students.
“There’s confusion between the province, municipality, and school regarding program implementation. The province and municipality give conflicting instructions, leading to confusion over salary disbursement and program management. It would be easier if these matters were directly under school authority.”KII2.
In many study sites, school nurses were experiencing reduced motivation due to a lack of supervision from relevant authorities in their respective municipalities. A school nurse shared her experience.
“I’ve been here for four years now, and I sense there are management issues in the school health nurse program. Despite our best efforts, the lack of supervision is causing burnout. The absence of any supervision visits exacerbates the feeling of monotony and disengagement.” KII2.
School nurses identified a compromised program budget as a factor affecting service delivery and utilization.
“With just one room and bed in the clinic, maintaining privacy and accommodating multiple students, especially those with menstrual cramps, becomes challenging. Adding another room and bed would make a significant difference, but it depends on our limited budget.” KII1.
Mixed method finding (triangulation of quantitative and qualitative results)
Findings from quantitative survey were triangulated with those from qualitative study to cross- validate and find factors influencing school nurse service utilization among secondary students.
Age was found as a strong predictor of service utilization among students in quantitative survey. Students less than 16 years had higher odds of utilizing school nurse services compared to those who are older. A statement supporting this result was obtained in qualitative study that small kids don’t hesitate to visit for service but older or higher-grade students don’t visit for service utilization until there is something serious. Also, motivation by friends, teachers or parents was identified as a strong predictor for service utilization in quantitative survey while encouragement by friends and teachers was found to help some students seek care with the nurse in qualitative study.
The multivariable regression analysis revealed sex as an associated factor with school nurse service utilization while key informants shared that females visit nurse more compared to males. Likewise, students aware about services available in school nurse clinic had higher odds of visiting nurse compared to the ones not aware about that. Qualitative analysis also found awareness among students about services available with nurse to positively influence their utilization.
Contrastingly, quantitative survey found learning difficulties as a barrier for service utilization as students with learning difficulties had lower odds of using school nurse services compared to those without such difficulties while qualitative analysis showed no such differences between them.
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