Adolescent satisfaction with public health services and contraceptive use in Nepal - A sequential explanatory mixed methods study

This sequential explanatory mixed-methods study in Nepal reveals that while a majority of adolescents report satisfaction with public health services, underlying issues such as judgmental provider attitudes and privacy concerns significantly influence their contraceptive use, highlighting the critical need to strengthen health system factors like confidentiality and appointment accessibility.

The Gist

The Big Picture: A Tale of Two Surveys

Imagine you are trying to figure out why teenagers in Nepal aren't visiting the public health clinic to get birth control, even though the government says the clinics are open and friendly.

The researchers decided to investigate this using a "detective duo" approach (a mixed-methods study). First, they asked teenagers to fill out a quick survey right after leaving the clinic (the Quantitative part). Then, they sat down with groups of teenagers to chat openly about their real feelings and experiences (the Qualitative part).

The Surprise: The "Smiling Mask" vs. The Real Story

The Survey Results (The Mask):
When researchers asked the 154 teenagers who walked out of the clinic, "How was your visit?" about 82.5% of them said, "It was great!" They were satisfied. On paper, everything looked perfect. It was as if everyone walked out of a restaurant smiling and saying the food was delicious.

The Group Chat (The Real Story):
But when the researchers later sat down with these same teenagers in private groups, the story changed completely. The teenagers admitted that while the clinic might be okay for a fever or a cough, it felt like a nightmare when they wanted to ask for birth control or sensitive advice.

They described the experience as walking into a room where:

• The "Glass Walls" of Privacy: The waiting rooms were like fishbowls. Everyone could see who was coming and going. Teenagers were terrified that if they asked for a condom, their neighbors, parents, or the shopkeeper down the street would find out.
• The "Judgmental Gatekeepers": Some health workers acted like strict school principals. Instead of being helpful, they looked at unmarried girls with "bad eyes," asked embarrassing questions, or even chased them away, saying, "Go ask your parents."
• The "Missing Key": Getting an appointment was like trying to catch a bus that never arrives. If you couldn't get a quick, easy appointment, you just gave up.

The Main Characters: What Actually Matters?

The study found that whether a teenager liked the clinic didn't depend on who they were (their age, gender, religion, or how much money their family had). Instead, it depended entirely on how the clinic treated them.

Think of the health clinic as a smartphone app.

• The "Socio-Demographics" (Who you are): It doesn't matter if you have an iPhone or an Android, or if you are rich or poor.
• The "Health System Factors" (The App's Features): What matters is:
  1. Confidentiality (The "Incognito Mode"): If the app (clinic) doesn't keep your data private, you delete it. The study found that if teens felt their secrets were safe, they were 3.5 times more likely to be happy with the visit.
  2. Ease of Access (The "One-Click Buy"): If you have to jump through hoops to get an appointment, you won't use the app. Teens who could easily get an appointment were 6 times more likely to be satisfied.

The "Private Clinic" Competitor

Because the public clinics felt so risky (no privacy, judgmental staff), many teenagers started going to private clinics instead.

• The Analogy: Imagine a public library where the librarian reads your book title out loud to the whole room. You stop going there. Instead, you buy the book from a private bookstore where you can walk in, grab it, and leave without anyone asking questions.
• Teenagers said they preferred private clinics because they could get condoms quickly, without being asked personal questions, and without the fear of being seen.

The "Empty Shelf" Problem

The study also found that the clinics often ran out of stock (like a grocery store with empty shelves). If a teen went to get a condom and the box was empty, they just left. They didn't want to ask the staff for help because they were afraid of being judged.

The Bottom Line

The study concludes that you can't just count smiles to measure success.
The high "satisfaction" scores from the exit surveys were likely a social mask. Teenagers were too polite or too scared to say "no" to the person holding the clipboard.

The Real Lesson:
To get teenagers to use public health services, the government needs to stop focusing on just "having the medicine" and start focusing on how the medicine is delivered.

• They need to build soundproof walls (real privacy).
• They need to train staff to be friendly coaches, not strict judges.
• They need to make it easy to walk in and walk out without a hassle.

Until the public clinic feels as safe and private as a private doctor's office, teenagers will keep avoiding it, no matter how many "satisfied" surveys they fill out.

Technical Summary

Problem Statement
Adolescent pregnancy remains a critical public health challenge in Nepal, with approximately 17% of girls initiating childbearing by age 19. This contributes significantly to maternal mortality and limits educational and economic opportunities. While contraception is a proven strategy to prevent unintended pregnancies, utilization among adolescents remains low (14% among married adolescents), with a substantial unmet need. Although the Government of Nepal has established Adolescent Friendly Health Services (AFHS) and legal frameworks to support Sexual and Reproductive Health and Rights (SRHR), access and utilization remain constrained. Previous research has largely focused on structural and socio-cultural barriers, leaving a gap in understanding how adolescents' specific satisfaction with health services influences their decision-making and contraceptive use. This study addresses the need to explore the determinants of adolescents' satisfaction with public health services and how these factors relate to contraceptive service utilization.

Methodology
The study employed a sequential explanatory mixed-methods design across six districts in Nepal (Surkhet, Banke, Pyuthan, Nuwakot, Parsa, and Siraha) selected for their high and rising adolescent fertility rates. The research was guided by the Andersen Behavioral Model of Health Service Utilization.

• Quantitative Phase: Data were collected from April to June 2025 via client-exit interviews with 154 adolescents (aged 16–19) visiting 154 public health facilities. A structured questionnaire based on AFHS guidelines measured satisfaction levels and health system factors. Data were analyzed using SPSS version 26, employing binary and multivariate logistic regression to identify associations between satisfaction and socio-demographic or health-system variables.
• Qualitative Phase: Following the quantitative analysis, 12 Focus Group Discussions (FGDs) were conducted between November 2025 and February 2026 with 119 adolescents (60 girls, 59 boys). These sessions explored perceptions, experiences, and barriers regarding health service utilization, particularly contraceptive services. Data were analyzed using a deductive thematic approach based on the Braun and Clarke framework.
• Integration: Qualitative findings were used to explain, contextualize, and expand upon the quantitative results, specifically addressing discrepancies between reported satisfaction and lived experiences.

Key Results

• Quantitative Findings: Overall, 82.5% of adolescents reported satisfaction with the health services received on the day of their visit. Logistic regression analysis revealed that socio-demographic characteristics (age, gender, education, marital status, caste/ethnicity, and location) were not statistically significant predictors of satisfaction. However, specific health-system factors were significantly associated with satisfaction. In the multivariate model, confidentiality (AOR: 3.50; 95% CI: 1.19–10.37) and ease of obtaining appointments (AOR: 6.28; 95% CI: 2.18–18.08) were the strongest predictors of satisfaction. Perceived non-discrimination and availability of Information, Education, and Communication (IEC) materials were not significant in the adjusted model.
• Qualitative Findings: Despite high quantitative satisfaction scores, qualitative data revealed contrasting experiences. Adolescents reported significant barriers including:
  • Accessibility: Frequent stock-outs of contraceptives and medicines in public facilities drove adolescents to private clinics.
  • Confidentiality and Privacy: Fear of being recognized in community-based facilities, open waiting areas, and the risk of information leakage to family members were major deterrents.
  • Provider Behavior: Judgmental attitudes, intrusive questioning, and discriminatory practices, particularly toward unmarried girls, discouraged service seeking.
  • Communication: Language barriers and a lack of privacy during consultations were reported.
  • Participation: Adolescents reported minimal involvement in health facility governance (e.g., HFOMC), with engagement often limited to tokenism or relatives of committee members.
• Integration: The study identified a divergence between the high quantitative satisfaction scores and the nuanced qualitative dissatisfaction regarding sensitive SRH services. The authors suggest this discrepancy may be due to social desirability bias in exit interviews. The qualitative data confirmed that while general services might be rated highly, specific concerns regarding privacy, judgment, and access to contraceptives significantly impact actual service-seeking behavior.

Key Contributions and Significance
The paper claims that its primary contribution lies in the use of a mixed-methods approach to reveal the "hidden gaps" in adolescent satisfaction that quantitative metrics alone fail to capture. By integrating quantitative data with qualitative insights, the study demonstrates that reported satisfaction does not necessarily translate into actual service utilization, particularly for sensitive services like contraception.

The study highlights that health-system factors, specifically confidentiality and the ease of accessing providers, are more influential determinants of adolescent satisfaction and service use than socio-demographic characteristics. It underscores that the current structure of public health facilities in Nepal, while legally supportive of adolescent rights, often fails to meet the unique psychosocial needs of adolescents due to issues of privacy, provider attitudes, and lack of meaningful participation.

Significance for Policy and Practice
The authors argue that improving adolescent sexual and reproductive health outcomes in Nepal requires a shift from a service-availability approach to an adolescent-centered model of care. The study emphasizes that strengthening dimensions such as confidentiality, non-judgmental provider interactions, and accessible service delivery is essential. Furthermore, it calls for moving beyond tokenistic engagement to ensure meaningful adolescent participation in health system governance. The findings suggest that without addressing these specific health-system barriers, efforts to increase contraceptive uptake among adolescents will remain limited, regardless of the availability of services.