Factors influencing utilization of school health nurse program among secondary students of Lalitpur, Nepal: a mixed-method study

Abstract

Background

Acknowledging the unique health needs of school children, the Government of Nepal launched the “One School One Nurse” initiative, which was first implemented by the Provincial Government of Bagmati Province in 2018/2019. The program aims to improve health outcomes among school children by deploying a certified nurse in community schools who provides preventive healthcare, health education and first-aid services. Though the program is being scaled up over provinces, it is in its initial stage of development and there are scarce published literature available about the program. This limited availability of comprehensive resources evaluating the program’s usage and supportive and hindering factors demands further investigation on it. Thus, this study assessed the utilization of school nurse services among secondary students and identified the factors associated with service utilization quantitatively. Also, the study explored the underlying factors influencing school nurse service utilization qualitatively. Finally, the study did the triangulation to cross-validate the findings from both quantitative and qualitative studies.

Methods

A concurrent triangulation mixed-method study was conducted in six public schools randomly selected from each of six local levels of Lalitpur district implementing the ‘’One school one nurse’’ program. Quantitative data were collected from 280 students in grades 9–12 using a self-administered questionnaire. Qualitative data were gathered through in-depth interviews with ten students and key informant interviews with six school staff including school nurses and teachers. Data collection was done from November 2022 to January 2023. Quantitative data were analyzed using weighted multivariable logistic regression to determine predictors of school nurse service utilization. For the qualitative component, a deductive approach based on the socioecological framework was employed to explore factors influencing service utilization.

Results

The school nurse service utilization rate among secondary students was 28.69% in Lalitpur. The odds of utilizing the service were two times higher among students below 16 years (AOR: 2.08, 95% CI: 1.07–4.02) compared to older students. Additionally, those motivated by teachers, school nurses and parents had four times higher odds of utilization of the service (AOR: 4.16, 95% CI: 1.26–13.64) compared to those without such external encouragement. Conversely, students having learning difficulties had about 68% lower odds of utilizing the school nurse service (AOR: 0.316, CI:0.134–0.744) compared to the student without such difficulties. Triangulation of findings from both studies revealed factors like age, sex, External motivation, student awareness about services and learning difficulty influenced service utilization. Moreover, frequent turnover of school nurses, their absence in school during their training sessions or external programs and insufficient coordination between provincial, local, and school authorities significantly hindered students’ access to services. Ethical approval for the study was obtained by the Institutional Review Committee of Patan Academy of Health Sciences (Ref: PHP2209301678).

Conclusions

Around one third of secondary students utilized the school nurse services in past one year in Lalitpur district. Enhancing awareness and motivation among students, with a particular focus on older students, male students, and those with learning difficulties, could help increase service utilization rates. Additionally, implementing better staffing strategies and strengthening coordination among stakeholders would enhance program effectiveness, ultimately leading to improved service access. Further research is recommended to examine factors that positively or negatively impact the program at a broader level, incorporating insights from divisional and local level authorities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-21972-5.

Introduction

School nurses are licensed health care providers employed in schools responsible for providing different preventive, promotive as well as curative services like eye, ear, oral screening, anthropometric assessment, immunization against preventable diseases and treatment of communicable diseases, health education, counseling and also help students taking the health-related decisions. School nurses also plan and intervene for acute and chronic illness, obesity, substance use and abuse, injuries and emergencies, adolescent sexual and reproductive health issues, mental health and nutrition. They are the key source for addressing the major health problems experienced by children in school [1].

The World Health Organization (WHO) has consistently highlighted the health challenges faced by school-aged children and adolescents [2] in response to which WHO Global School Health Initiative, launched in 1995, laid the foundation of ‘Health promoting schools’ which aims to transform schools into healthy environments that foster not only educational attainment but physical, social, and emotional health of students, staff, and the broader school community [3].

Two key features of the ‘Health Promoting Schools’ initiative include linking schools with parents and the community and providing schools access to health services. School nurses not only provide health services to children and school staffs, they also play a catalyzer role in promoting healthy behavior from early childhood in children through the school setting, which benefits not only the children themselves but also their families, peers and wider communities [4].

Acknowledging the unique health needs of school children, the Government of Nepal launched the “One School One Nurse” initiative, which was first implemented by the Provincial Government of Bagmati Province in 2018/2019. By the fiscal year 2022/2023, the initiative has been rolled out in 1,011 schools throughout Nepal. The Nursing and Social Security Division (NSSD) within the Department of Health Services (DoHS) oversees the program and has facilitated 23% of the schools’ implementation, while the rest are managed by provincial authorities among the 1,011 schools. The National Health Policy 2019 has strongly advocated the placement of at least one health worker in every school, collaborating with the education sector under the Ministry of Education, Science, and Technology (MoEST). Following this, the School Health and Nursing Service Implementation Guideline was officially approved and developed in 2019 and School Health and Nursing Service Directive, 2024/2025 has been recently introduced [5–7]. This program aims to promote healthy lifestyles and improve overall health outcomes among school children by providing comprehensive health services including screenings, immunizations, and treatment of communicable diseases, health education, and counseling [1].

Studies conducted in Nepal have revealed that school going children suffer from different worm infestations, oral issues, mental health and behavioral issues, substance use and injury related problems [8–10]. Researchers have revealed that School nursing program is highly effective in improving children’s health through school and thus have recommended establishing it in many developing countries [11–14]. The program has also been effective reducing medical care costs and absenteeism among students [15]. Despite the beneficence, there is evidence that students hesitate to use available healthcare services in school due to various factors [16–18]. This underutilization prevents students from fully benefiting from the program.

Given that the program is new and is currently expanding across all provinces, there is a need to assess its utilization and associated factors, especially when published literature is scarce. This research sought to investigate the utilization of the “One School One Nurse” initiative in secondary schools in the Lalitpur district and to uncover the factors that affect its usage. Until July 2022, the program was expanded to 26 schools in Lalitpur. By addressing the limited published research on the ‘One School One Nurse’ program in Nepal, this study aims to provide evidence to provinces that are on the verge of developing sub-national guideline. The findings from this study serve as a reference for policymakers and local government to make evidence-based decisions on how secondary school students are utilizing the school nurse services and the factors that influence their engagement. Contextually, the results of our study inform local key stakeholders, nurses and academia of Lalitpur district, to emphasize on improving health service delivery and its uptake among school students and make this program impactful. Furthermore, the insights gained in the study guide future researchers who wish to explore similar topics.

Methodology

Study design

This study employed a concurrent triangulation mixed-method design with equal emphasis on quantitative and qualitative components (QUAN + QUAL). The design allows for direct comparison and contrast of quantitative statistical results with qualitative findings producing cross-validated and enriched information on the same topic [19].

Study setting

This study was conducted in six schools out of twenty-six public schools implementing the ‘One School One Nurse’ program in Lalitpur district. Schools were selected randomly from each of the six local levels of Lalitpur district, which comprises three Rural Municipalities (RM) and ten schools, two Municipalities and nine schools, and one Metropolitan city with seven schools. Only schools up to the 12th grade were included in this study.

Study participants

Adolescents constitute one-fifth of the total population in the country and 16% of the population in the Lalitpur district [20]. As adolescents undergo tremendous physical and mental growth and change, they are vulnerable to various physical and psychosocial problems. Since students in grades 9 to 12 largely fall within the adolescent group, we selected them as the study participants. For the quantitative component, information was collected from students in grades 9 to 12. Students who provided consent either themselves or through their parents were included, while those absent from school on the date of data collection or who did not provide consent were excluded. Students absent on the day of data collection were followed up for the next day and included in the study. For the qualitative component, ten In-depth interviews (IDIs) and six key Informant Interviews (KII) were carried out concurrently along with the quantitative survey in all schools. Two students from each school (one service utilizer and one non-utilizer) were interviewed after selecting via purposive sampling for IDI from those who participated in quantitative survey. For KII, school nurses were interviewed in three of the six selected schools and female teachers under the school health unit were interviewed in rest of the three schools. Though twelve in-depth interviews were taken, two interviews were disregarded based clarity and richness of information.

Sample size and sampling technique

The sample size of the study was calculated using the Cochrane Eq. (21) with a single proportion, taking into account the proportion of students utilizing services of school nurse program (p) = 90%, as observed in a pilot study [22]among 30 students in Kathmandu. Other parameters considered were the level of significance (α) as 5%, the margin of error (e) as 5%, the non-response rate (r) as 20%, and design effect (DE) as 2.

Adding Design Effect,

The total number of students of grade 9 to 12 of the selected schools (N) is 1787. Therefore, the minimum sample size with finite population correction was calculated using the following formula:

Making 20% non-response adjustment,

The calculated minimum sample size was 290. However, fifty-two participants were approached from each of the six selected schools for data collection, resulting in a final sample size of 312. Out of the 312 students approached, 280 gave consent to participate in the study.

The researcher obtained the list of public schools with ‘One School One Nurse’ program in Lalitpur district segregated by municipality/rural municipality from the provincial school nurse coordinator of Bagmati Province. There were twenty-six schools including 3,5,4,7,4 and 3 schools in Konjyosom Rural Municipality (RM), Godawari Municipality(M), Mahalaxmi (M), Lalitpur Metropolitan City, Bagmati (RM) and Mahankal (RM) respectively. To randomly select one school from each municipality or rural municipality, the researcher used the RAND BETWEEN function in Excel. For instance, in Konjyosom RM, the three schools were numbered sequentially (1st, 2nd, and 3rd), and the function RAND BETWEEN [1, 3] was applied to select a school randomly. One school under Mahankal (RM) was excluded as it did not have 11th and 12th grade students. Thus, one school from Mahankal RM was randomly selected from the remaining two schools.

From each school, 13 students from each grade (9,10,11and 12) were selected randomly using student’s attendance register. Students roll number was collected in each grade. Random roll numbers were generated using ‘’RANDBETWEEN’’ of 1 to last roll number in Excel. The sampling procedure is illustrated below in Fig. 1.

Fig. 1.

Sampling procedure of the study

For the qualitative component, ten in-depth interviews (IDIs) were conducted with students, comprising five service utilizers and five non-service utilizers, selected based on the researcher’s judgment. Additionally, six key-informant interviews (KIIs) were conducted. IDIs with students were stopped after thematic information saturation was achieved. (Fig. 3)

Fig. 3.

Socioecological model presenting codes and subthemes of qualitative findings

Data collection tools and techniques

Quantitative data collection involved a self-administered semi-structured questionnaire survey, conducted over two consecutive days in each school. The questionnaire was developed after an extensive literature review and expert consultation, and its face validity was ensured through pre-testing with 10 students from a non-sampled school.

Separate semi-structured open-ended guidelines for IDI and KII were developed for qualitative data collection in Nepali language. Also, both IDI and KII were conducted in the same language. Tools developed were finalized after qualitative research expert’s validation. After interviews, the audio recordings of qualitative interviews were transferred to a password protected researcher’s computer. The recordings were first transcribed into Nepali and then translated in English for analysis purposes.

Operational definition

School Nurse Service Utilization: It was defined as a student’s visit to school nurse for any health or other concern (e.g.: violence, harassment) or lifestyle related concerns (e.g.: food behavior, any addictive behavior: drug abuse, smoking, alcoholism, yoga) either by self-motivation or the recommendation by others (friends, school teacher, other school staff) in past one year.

Secondary Level Students: The students of Grades 9, 10, 11 and 12 were considered as secondary level students in the study [23].

Learning Difficulty: Learning difficulty in this study was defined as a condition where a student faces difficulty in following classes, doing homework, preparing for exam, reading, writing, calculation and giving oral presentation [24].

Aware about available services: A student in this study was considered as aware about available services if he/she had correctly answered all three right options in the questionnaire (Treatment of common health issues like common cold, diarrhea, vomiting, minor injuries and Consultation and counseling regarding behavioral issues like sexual engagement, smoking alcoholism, drug abuse and Counselling and consultation regarding menstrual health and other reproductive health issues).

Chronic Disease: Chronic Disease was defined as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both [25]. Socio-Economic Status (SES) of Family: Kuppuswamy scale was used to measure SES of family. The scale measures SES based on education and occupation of household head and family income per month. Each option of education, occupation and family income is given a score and SES is calculated by adding the total score. Depending on the total score obtained, socioeconomic status is categorized into five classes: Lower (less than 5), Upper-Lower [5–10], Lower-Middle [11–15], Upper-Middle [16–25], and Upper [26–29] [26]. Intrapersonal Factors: We classified students’ characteristics influencing school nurse service utilization like student awareness, attitude, fear of stigma in this category.

Interpersonal Factors: Factors relating to student’s social networks like peer influence, relation with nurse and parents were classified in this category.

Organizational Factors: Factors related to norms, culture or management of school like school nurse clinic environment, support of school community to nurse were classified under this group.

Community Factors: We classified social norms like religion, ethnic difference in community factors.

Policy related Factors: We classified anything policy statement flaws or programmatic issues like inadequate coordination among concerned authorities in this category.

Study variables

The quantitative and qualitative variables assessed in this study are demonstrated below in Fig. 2.

Fig. 2.

Conceptual framework depicting study variables used in the study

Data analysis

For the quantitative part, data were entered into Epi-Info version 7, cleaned in Microsoft Excel 2013, and analyzed using STATA version 13.0. Descriptive statistics included frequency, percentage, median, and interquartile range.

Five logistic regression models were developed, with Models 1 and 2 (Supplementary file S1) assessing bivariate relationships of background and mediating variables with the outcome variable respectively. Variables with a p-value < 0.25 and VIF < 2 in bivariate analysis were included in multivariable logistic regressions. Variables found significant in Models 1 and 2 (Supplementary file S1) were included in multivariable logistic regression with outcome variables forming Model 3 and 4 (Supplementary file S2) respectively. The final model integrated significant variables from Models 3 and 4 (Supplementary file S2) to assess their combined effect on the outcome variable. Significant association between dependent and independent variables determined by p-values < 0.05, were presented as odds ratios, confidence intervals, and p-values. Sampling design and non-response adjustment were considered during analysis to avoid biased estimates.

The recordings of qualitative interviews were transferred were first transcribed into Nepali and then translated in English for analysis purposes. The English translations of interviews were thematically analyzed. The researcher read and re-read the translations to get familiarized with the data and generated initial codes [27]. Two interdependent coders generated the initial codes of two KII and three IDI to get the intercoder agreement. Then the generated codes were re-evaluated for any corrections and then categorized deductively under five themes using a socio-ecological model (Fig. 3) [28] R-Package for Qualitative Data Analysis (RQDA) was used for qualitative data management [29].

Weight calculation

Sampling weights were determined by taking the inverse of the selection probability at each stage. The overall weight (W) was computed as:

W1 represents the ratio of the total number of schools to the number of selected schools.

W2 is the ratio of the total number of students in a grade to the number of selected students in that grade.

W3 is the response adjustment weight, calculated as the reciprocal of the response rate (1/response rate).

Validity and reliability

The questionnaire, developed through an extensive literature review, underwent content validation via discussions with the guide, co-guide, and faculty at the School of Public Health of Patan Academy of Health Sciences (PAHS). After pre-testing with 10 randomly selected students from non-sampling schools, necessary modifications were made. Forward and backward translation was done to ensure the reliability of the tool.

Iterative questioning was done during IDIs and KIIs to generate in-depth information. Two independent coders analyzed two KII and three IDI translations, which accounted for 30% of all the interview translations. They produced 35 codes, and the intercoder positive percent agreement was determined by dividing the number of matching codes by the total codes generated and then multiplying by 100. The code reliability agreement achieved was 77.14%.

Ethical consideration

Ethical approval

for this study was obtained from the Institutional Review Committee (IRC) – Patan Academy of Health Sciences (Ref: PHP2209301678). Additionally, approvals were obtained from all schools. All participants were briefed on the study’s objectives, and their voluntary participation was ensured. They were encouraged to ask questions about the study and were informed that they had the right to withdraw from the interview at any time without providing any explanation. Participants were explicitly informed that there were no direct benefits or harms associated with participating in this study. Written voluntary agreement (Consent or Assent) was taken prior to data collection for both qualitative and quantitative studies. For any selected student below 18 years old, the researcher collected the parent’s agreement form (Assent form) to involve that student in the study. Those who were denied to be involved in the study by their parents or themselves were not included in the study. Privacy was maintained while conducting each interview.

Results

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).

Table 1.

Bivariate analysis of background (model I) and mediating (model II) (weighted)

Variables	COR	95% CI	P value
Age
≥ 16 year	1
< 16 year	2.75	1.61–4.71	0.000**
Sex
Male	1
Female	2.30	1.26–4.20	0.007**
Awareness about available services
Not Aware	1
Aware	2.66	1.39–5.30	0.003**
Student’s perception towards behavior of school nurse
Unfriendly (not behaving like a friend, difficult to share personal matters)	1
Friendly (Like a friend)	2.40	1.13–5.10	0.022*
Motivator for service utilization
No	1
Yes	9.21	3.07–27.60	0.000**
School Nurse Clinic Environment
Uneasy to share personal matters, not maintained with every facility, gives feel that I don’t want to visit when necessary	1
Easy to share personal matters, maintained with every facility, gives feel that I want to visit when necessary	22.14	1.30-374.75	0.032*

*p < 0.05; **p < 0.01; Bold: Significant p value

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)

Table 2.

Multivariable logistic regression of eligible background (model 3) and mediating variables (model 4) (weighted)

Variables	Unadjusted OR [95% CI]	P value	Adjusted OR [95% CI]	P value
Eligible background variables
Age
≥ 16 year	1
< 16 year	2.75 [1.61–4.71]	0.00**	3.06 [1.73–5.39]	0.00**
Sex
Male	1
Female	2.30 [1.26–4.20]	0.007**	2.11 [1.12–3.97]	0.020*
Ethnicity		0.06
Dalit	1		1
Janajati	2.25 [0.95–5.30]	0.063	1.94 [0.80–4.72]	0.142
Madhesi	1.89 [0.23–15.4]	0.551	1.39 [0.15–12.67]	0.765
Muslim	1		1
Brahmin/Chhteri	1.10 [0.43–2.78]	0.839	0.93 [0.35–2.44]	0.884
Others	1		1
Eligible Mediating Variables
Awareness about available services
Not Aware	1
Aware	2.66 [1.39–5.30]	0.003*	2.43[1.15–5.15]	0.020*
Student’s perception towards behavior of school nurse
Unfriendly (not behaving like a friend, difficult to share personal matters)	1
Friendly(Like a friend)	2.40 [1.13–5.10]	0.022*	1.01[0.28–3.62]	0.981
Motivator for service utilization
No	1
Yes	9.21 [3.07–27.60]	0.000*	5.40[1.54–18.90]	0.008**
Wish school nurse to be male
No	1
Yes	0.662 [0.343-1.50]	0.245	1.034[0.32–3.33]	0.955
Student’s engagement in risk behaviors
No	1
Yes	0.19[0.33–1.32]	0.130	1.05[0.80-13.79]	0.969
Learning difficulty
No	1
Yes	0.552 [0.022–1.62]	0.079	0.307[0.128–0.736]	0.008**
Perceived School Nurse Clinic Environment
Uneasy to share personal matters, not maintained with every facility, gives feel that I don’t want to visit when necessary	1
Easy to share personal matters, maintained with every facility, gives feel that I want to visit when necessary	22.14 [1.30-374.75]	0.032*	20.69[1.05-407.12]	0.046*

*p < 0.05; **p < 0.01; Bold: Significant p value

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.

Table 3.

Multi-variate analysis of school nurse service utilization with significant background and mediating variables (weighted)

Variables	Adjusted OR [95% CI]	P value
Age
≥ 16 year	1
< 16 year	2.08[1.07–4.02]	0.029*
Sex
Male	1
Female	1.59[0.68–3.70]	0.282
Awareness about available services
Not Aware	1
Aware	2.01[0.94–4.32]	0.071
Motivator for service utilization
No	1
Yes	4.16[1.26–13.64]	0.019*
Learning difficulty
No	1
Yes	0.316[0.134–0.744]	0.008**
Perceived School Nurse Clinic Environment
Uneasy to share personal matters, not maintained with every facility, gives feel that I don’t want to visit when necessary	1
Easy to share personal matters, maintained with every facility, gives feel that I want to visit when necessary	17.50[0.995-308.025]	0.050

*p < 0.05; **p < 0.01; Bold: Significant p value

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.

Discussion

This study aimed to explore the utilization of “One School One Nurse” services and identify factors influencing student participation. The results suggest that a comprehensive, socio-ecological approach (Fig. 3) addressing individual, interpersonal, community, organizational, and policy-level factors is necessary to optimize the utilization of school nurse services and ensure that students, particularly adolescents, can fully benefit from the available healthcare resources.

School nurse service utilization rate among secondary-level students in this study was lower than that reported in previous studies from Chitwan [12] and Kathmandu [22] districts of Nepal, but higher than findings from Sunsari [30] district. These disparities in utilization rates may be attributed to variations in the operational definition of service utilization across studies. Given the paucity of literature specifically addressing school nurse services in Nepal, the current study’s findings have been contextualized by comparing and contrasting with studies reporting on related services, such as adolescent-friendly health services among secondary-level students. The observed low service utilization may be attributed to the relative novelty of the school health nurse program. Students may not yet have developed the habit of consulting school nurses for their health concerns, suggesting a need for enhanced motivation and awareness initiatives to increase utilization rates. This highlights the importance of targeted interventions to promote the acceptance and use of school nurse services among the student population.

The quantitative study revealed that younger students, particularly those under 16 years and females had higher odds of utilizing the school nurse services. The qualitative findings back this up, as older students and males were more hesitant to seek help unless there was anything serious. This aligns with existing literature [31–33] suggesting that younger age groups and females tend to be more proactive in seeking health services. The increased utilization among younger children may be attributed to their higher dependency for healthcare on others and lower ability to manage their own health. Additionally, the specific health concerns that females frequently encounter, such as menstrual problems and the comfort levels in discussing such issues with female nurses may have led them to seek assistance from the school nurse more often. Increasing awareness and motivation among older students and males through school nurse, teachers or peers should be a priority to ensure equitable access to school nurse services.

External motivators, such as friends, teachers, or parents significantly influenced students’ utilization of health services, emphasizing the need for a supportive environment that fosters open communication about health issues. Students motivated by friends, teachers, or parents showed higher odds of service utilization in the quantitative survey while qualitative study also revealed peer influence and teachers’ support greatly influences service seeking among students. The findings align with previous research emphasizing social support’s impact on adolescents’ health behaviors [34, 35]. but it contrasts with a mixed-method sequential study from Ethiopia, which found parents to be a barrier to adolescents accessing sexual and reproductive health services [18]. This emphasized that a supportive environment at home and school fosters open communication about health issues among children and promotes service utilization.

Student’s awareness of available school nurse services was a significant mediating factor in determining utilization, with informed students having higher odds of seeking help compared to the ones not aware about the services. Qualitative finding also revealed that students seek care with nurse because they know that they can have such services there. This finding is consistent with previous studies conducted in other regions, which have demonstrated that students’ knowledge about available health services is a critical determinant of service utilization [17, 30, 36]. Improving awareness through targeted outreach and information dissemination may be an effective strategy to increase utilization of these important health resources within the school setting.

Quantitative study finding revealed learning difficulty among students as a strong predictor of school nurse service utilization. It found that students with any kind of learning difficulties had lower odds of visiting school nurse for their problem compared to those without such issues. However, qualitative analysis found no such notable differences in service utilization. Additionally, this finding contrasted with the study from California [37] and Finland [24] both of which revealed that students with learning difficulties or disabilities were more likely to utilize the school-based health services or school nurse services.

The study highlights the significance of the school nurse’s behavior and clinic environment on service utilization. Students who viewed the nurse as approachable and the clinic atmosphere as welcoming were more inclined to seek care. This suggests the pivotal role of interpersonal skills and clinic ambiance in fostering student engagement with health services, aligning with prior research emphasizing healthcare providers’ interpersonal skills in promoting adolescents’ health service utilization [17, 23, 38].

The study revealed several barriers to service utilization. Frequent turnover of school nurses was identified as a major constraint of the program affecting its optimum utilization among students. This resembles with findings from a study in Georgia [39] where staff turnover at school-based health centers posed a major service barrier. Also, high turnover of school nurse has been notably highlighted in the provincial review of the program in Nepal in fiscal year 2078/79 B.S [6]. Our study revealed that school nurses are recruited on contract and thus they leave the job for better opportunities. Thus, ensuring job security and career growth opportunities like making the job of school nurse permanent rather than contractual and offering promotions, training may improve retention.

Organizational factors, such as nurse availability aligned with student schedules and clinic facility adequacy significantly influenced service utilization. Constraints like limited budgets and resources, such as having only one clinic bed, hindered effective care delivery. Previous research suggests the role of adequate resources and scheduling in optimizing school health services’ effectiveness [22, 39].

There were concerns about stigma and privacy among students. Approximately 16% of participants cited confidentiality issues, while stigma surrounding sensitive topics such as sexual health or substance use was a significant deterrent. Students feared negative perceptions from peers, family, and school staff if they sought help for these issues. This aligns with existing literature highlighting privacy concerns and stigma as primary obstacles to adolescents accessing healthcare [40, 41]. These findings emphasize the need for a safe and non-judgmental environment where students feel comfortable seeking help without fear of stigmatization.

While the use of a mixed-method design and random selection of clusters enhances the robustness and generalizability of the study findings to the district, the results may not be directly applicable to other regions or countries. Differences in school environments, nurse behaviors, and clinic conditions were not controlled, potentially affecting consistency across schools. The focus on grades 9 through 12 may limit insights into younger students or those in early childhood education with different health needs. The reliance on self-administered surveys could introduce inaccuracies due to misunderstanding, recall bias, or social desirability bias. Subjectivity may not have been completely avoided during qualitative data analysis and interpretation though measures like verification of the transcribed and translated scripts, inter-coder agreement, researcher’s reflexivity, and process documentation, were used to maintain the rigor of the study. Furthermore, the study had a limited range of study participants and could not cover the prospects managerial level authorities of the program.

The results of the study carry significant implications for enhancing the utilization of school nursing services among secondary students in Lalitpur. The lower participation rates among older students and males indicate to school authorities, the need for tailored strategies that address age and gender in order to boost their engagement. The beneficial effect of external motivation and student’s awareness of service usage informs that school authorities should cultivate a proactive and communicative environment that involves students and their parents. Additionally, systemic issues such as the frequent turnover of school nurses and their unavailability due to training or provincial programs highlighted the need for improved staffing strategies to ensure a consistent school nurse presence. Furthermore, the finding that insufficient coordination among provincial, local, and school authorities negatively impacts access to services calls for enhanced collaboration among all stakeholders to facilitate effective program implementation and improve service utilization.

Conclusion

This study highlights that the utilization of school nurse services among secondary students is low and is influenced by multiple factors. Encouraging students’ participation by involving teachers, peers and parents could enhance service utilization. Addressing programmatic challenges such as nurse turnover and fostering better collaboration among stakeholders could bolster the effectiveness of the program. Further investigation into the perspective of managerial stakeholders including subnational level authorities is necessary to understand the challenges of School Health Nurse Program.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted Odds Ratio

CI

Confidence Interval

DE

Design Effect

IDIs

In-depth Interviews

IRC

Institutional Review Committee

IQR

Inter Quartile Range

KIIs

Key Informant Interviews

PAHS

Patan Academy of Health Sciences

RM

Rural Municipality

RQDA

R-Package for Qualitative Data Analysis

SHN

School Health Nurse

WHO

World Health Organization

Author contributions

S.S. designed and conducted the research performed the statistical analysis, and produced the initial manuscript draft. A.M. provided critical revisions and summarized the results and overall manuscript. T.R.T. and S.B. assisted with methodology corrections, data analysis, and weight calculations. S.P. and S.B. supervised the entire study process, while Ms. P.T. reviewed the manuscript for important intellectual content. All authors gave their approval for the final version of the manuscript.

Funding

Financial support for this research was received from a Post Graduate grant provided by the Nepal Health Research Council (NHRC). However, the funding organization had no involvement in the study’s design, data collection and analysis, decision to publish, or manuscript preparation. These aspects were independently managed by the researchers.

Data availability

All relevant data that support the findings are included in our manuscript and supplementary file. However, the raw data of this study will be available on request from the corresponding author, SS. The data are not publicly available due to restrictions on identifiable information that could compromise the privacy of research participants.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Committee (IRC) – Patan Academy of Health Sciences (Ref: PHP2209301678). Additionally, approvals were obtained from all schools. All participants were briefed on the study’s objectives, and their voluntary participation was ensured. They were encouraged to ask questions about the study and were informed that they had the right to withdraw from the interview at any time without providing any explanation. Participants were explicitly informed that there were no direct benefits or harms associated with participating in this study. Written voluntary agreement (Consent or Assent) was taken prior to data collection for both qualitative and quantitative study. Privacy was maintained while taking each interview.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.