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Utilisation of Sexual and Reproductive Health Services from Adolescent Friendly Health Services in Nepal

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Utilisation of Sexual and Reproductive Health Services from Adolescent Friendly Health Services in Nepal UTILISATION OF SEXUAL AND REPRODUCTIVE HEALTH SERVICES FROM ADOLESCENT FRIENDLY HEALTH SERVICES IN NEPAL Pushpa Lata Pandey B.Sc. Nursing, MPH A thesis in the fulfilment of the requirements for the degree of Doctor of Philosophy School of Public Health and Community Medicine Faculty of Medicine March 2019 Thesis/Dissertation Sheet Surname/Family Name : Pandey Given Name/s : Pushpa Lata Abbreviation for degree as give in the University calendar : PhD Faculty : Faculty of Medicine School : School of Public Health and Community Medicine Utilisation of sexual and reproductive health services from Thesis Title : adolescent friendly health services in Nepal Abstract 350 words maximum 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. i Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). ……………………………………… 15/03/2019 ……………………………………..……………… Signature Date Witness Signature The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. FOR OFFICE USE Date of completion of requirements for ONLY Award: ii ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’ Signed Date 15/03/2019 iii INCLUSION OF PUBLICATION STATEMENT UNSW is supportive of candidates publishing their research results during their candidature as detailed in the UNSW Thesis Examination Procedure. Publications can be used in their thesis in lieu of a Chapter if: • The student contributed greater than 50% of the content in the publication and is the “primary author”, ie. the student was responsible primarily for the planning, execution and preparation of the work for publication • The student has approval to include the publication in their thesis in lieu of a Chapter from their supervisor and Postgraduate Coordinator. • The publication is not subject to any obligations or contractual agreements with a third party that would constrain its inclusion in the thesis Please indicate whether this thesis contains published material or not. This thesis contains no publications, either published or submitted for publication ☒ Some of the work described in this thesis has been published and it has been ☐ documented in the relevant Chapters with acknowledgement This thesis has publications (either published or submitted for publication) ☐ incorporated into it in lieu of a chapter and the details are presented below CANDIDATE’S DECLARATION I declare that: • I have complied with the Thesis Examination Procedure • where I have used a publication in lieu of a Chapter, the listed publication(s) below meet(s) the requirements to be included in the thesis. Name Signature Date (dd/mm/yy) Pushpa Lata Pandey 15/03/2019 iv COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales and its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorize University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.’ Signed Date 15/03/2019 AUTHENTICITY STATEMENT ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.’ Signed Date 15/03/2019 v DEDICATION This thesis is dedicated to my mom Kamala Devi Shrestha Pandey and my dad Ram Chandra Pandey for making me who I am. You inspired me to be adventurous, never give up, and encouraged me to search for the unknown. Thank you so much for believing in me and letting me explore the world. vi ACKNOWLEDGMENTS This beautiful journey of accomplishing my PhD has been possible with the support and encouragement of many people. First of all, I would like to thank all the adolescents and young people of Nepal for whom I endeavour this journey. Thank you to my research participants for participating in this research and for giving me the opportunity to learn about your views and experiences. Thank you to the experts and programmers in government and development sectors who work in the field of adolescent health for sharing ideas and thoughts on what could be done to improve access to sexual reproductive health services for adolescents in Nepal. I hope that I have properly justified your thoughts in this research. I am grateful to my supervisors, Dr Holly Seale and Dr Husna Razee who taught me, guided me, supported me and clarified my doubts and confusions throughout the last three years to make this research possible. Words are never enough to express how extremely lucky I am to have had you both on my academic journey, you not only believed in my research but had faith that I could do this. Thank you so much, Holly, for your care, support, encouragement, constructive feedback, and always telling me that I am getting there. It meant a lot to me. Thank you so much Husna, I am indebted to the support you have given to my development as a researcher; you have done much more than be a supervisor. You were understanding, caring, supportive and inspiring at every step of my PhD. Your thorough, consistent and critical feedback to my qualitative research broadened my knowledge and capacity to see things differently. I want to thank Dr Suresh Mehata for supporting me and providing me guidance during my field work as a local national supervisor in Nepal. I want to thank my PhD review panel members, Dr Virginia Wiseman, Dr Sally Nathan and Dr James Wood for reviewing my progress and providing constructive feedback.
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