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Abstract
Adolescent-friendly health services (AFHS) are considered key to addressing the sexual and reproductive health (SRH) of adolescents. Since 2009 Nepal has been integrating AFHS into its public health facilities. Despite much attention, and attempts to scale up AFHS, utilisation remains suboptimal. This thesis, therefore, aims to understand the factors contributing to adolescents’ utilisation of AFHS in Nepal.
Based on an interpretive research framework, a qualitative case study methodology was employed to understand the utilisation of AFHS. Health service utilisation was assessed through record review and via observations of health facilities, which results were compared with national standards criteria. A social constructionist lens and principles of grounded theory guided my understanding of adolescents’ experience and the factors associated with their accessing SRH services from AFHS; the meaning of AFHS for adolescents; health care providers’ attitudes towards adolescents seeking SRH services; and community perceptions and readiness to accept AFHS. A total of 16 interviews and six focus group discussions with adolescents (n=49), nine interviews with health care providers, and 13 interviews with key informants were conducted. Thematic analysis was applied in the data analysis.
The findings showed that both socio-cultural and health facility factors influence utilisation of SRH services. Many of these factors stem from the moral framework encapsulated in socio-cultural norms and values related to the sexual health of adolescents, and health care providers’ poor value clarification. For example, health care providers had taken on a policing role in prescribing adolescents’ conformity. In describing their ideal AFHS setting, adolescents spoke about maintaining privacy and confidentiality, and dignified SRH services. In stark comparison, the overriding community perception was to ascribe abstinence-only education from these health facilities.
This study provides an empirical understanding of the reasons and factors associated with SRH service utilisation, which goes much deeper than program provision of AFHS in Nepal. The recommendations offered can potentially strengthen policy, program and services to improve AFHS, together with creating an enabling and supportive environment for adolescents to access SRH services.