School nurse service utilization among secondary level students and associated factors in selected public schools of Lalitpur district: A mixed method study.

Thesis Report.

SUMMARY;

Background: Many countries in the world have shown that despite of existence of health
service providers in schools, there is gap in utilization of school health services among
students and there are various factors associated with it. Concept school nurse also
initiated in Nepal in the year 2075/76 B.S. and is in expansion phase. Since this program
is new and is expanding every year, it is necessary to assess its utilization and factors
associated with the utilization of this service.

Aim: The aim of the study was to assess school nurse service utilization and identify and
explore factors associated with school nurse service utilization among secondary level
students.
Design: Concurrent triangulation mixed method design

Method: This was a cross sectional study conducted among 280 secondary level students
using two stage cluster random sampling. One school implementing 'one school one
nurse' program from each of six municipality/rural municipality was selected. Data was
collected using pre- tested questionnaire, entered in Epi-Info version 7.2.4 and analyzed
using STATA version 13. Multivariate logistic regression was used to identify the
predictors of school nurse service utilization using odds ratio with 95% confidence
interval.
Qualitative study included 10 in-depth interviews with selected students already involved
in quantitative survey and six key informant interviews (3 school nurses and 3 female
members of school health unit. The participants for interviews were selected purposively.
In-depth interview guideline and Key informant interview guideline was used to collect
the data. All interviews were audio-recorded and transcribed and translated in MS-Word version 2013. Factors associated with school nurse service utilization were explored using
socioecological model.

Results: The period prevalence (weighted) of school nurse service utilization over the
period of nine months was found to be 28.69%. Age [AOR: 2.08, CI: 1.07-4.02] existence of
motivator [AOR: 4.16, CI: 1.26-13.64] and learning difficulties [AOR:0.316, CI: 0.134-0.744]
were found to be significantly associated with school nurse service utilization. The
qualitative study revealed individual factors like student's attitude, fear of stigma,
awareness of service and trust for school nurse were associated with school nurse service
utilization among secondary level students. Likewise interpersonal factors like student
nurse closeness, teachers and friends' support, institutional factors like school timing,
environment of school nurse clinic, societal factors like religion and policy factors like
budget, supervision from higher authority, school nurse turnover were associated with
school nurse service utilization.
The mixed method analysis explored age and existence of motivator and engagement in
risk behavior under areas for convergence, sex, ethnicity, awareness about service,
learning difficulty , gender of school nurse, confidentiality concern, school nurse clinic
environment under areas of divergence and religion, school timing, friend's role and
school nurse turnover under area of expansion.

Conclusion: The period prevalence of school nurse service utilization over the period of nine
months among secondary level of students in Lalitpur district was low. The most common
problems students reported for visiting school nurse was common cold, reproductive
health problems and injury related problems. Secondary level students are recommended
to at least try to make a move and share their problems with school nurse or other
members of school health unit. Teachers and school nurses are recommended to
continue motivating students to utilize the available services and also to pay more
attention for students with learning difficulties and conduct regular assessment and one
to one counselling targeting students with learning difficulties. Parents are recommended to support their children even in case of sensitive health problems and take support from
concerned authorities in school.Schools are recommended to increase meetings with
parents and inform them about existing health services, manage the timing of grade
eleven and twelve students' classes and school nurse availability in school with internal
co-ordination, manage the school nurse clinic in a more spacious and separate room as
far as possible. Program/Policy level authorities are recommended to strengthen the
supervision from municipal authorities and health office to school regularly and develop
strategy to immediately fulfil vacant positions of school nurses in school.

Keywords: Factors, School Nurse, Secondary level, Service utilization, Students