Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare – systematic review

Introduction Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents’ decision making when seeking unscheduled healthcare for their children. The systematic review question was “What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?” Method Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data. Results Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent’s perception that the child’s condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP. Conclusion Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients’ behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.


Background
Unscheduled healthcare is healthcare which is typically provided in under 24 h' notice [1]. Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), emergency medicine physicians in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. From 1996 to 2010, 47.7% of hospital-associated healthcare was delivered in emergency departments in the USA [2] and attendances at emergency departments have been rising steadily at an international level [3]. Children are some of the heaviest users of unscheduled healthcare [1] and young children make up a large proportion of ED attendances that may have been treatable at primary care [4]. Moreover, in England, unplanned paediatric hospital admissions are also rising, particularly from EDs, and evidence has shown that these are typically short stays for minor conditions that, while often necessary for younger children, may be treatable in the community [5]. There are multiple complex factors and circumstances that can influence parents' decision making regarding where, when and why they seek unscheduled healthcare for their children. At present, there is incomplete understanding of how parents and families make decisions when accessing unscheduled healthcare and the present review seeks to clarify this gap in the literature.

Factors that influence care-seeking
As users of a health system, practical concerns, prior knowledge and experience of healthcare structures tend to feature heavily when patients are deciding where to attend unscheduled healthcare services, regardless of the urgency of the condition [6]. Such practicalities include availability of primary care appointments out-of-hours, advantages of the facilities available in the ED and the need for reassurance regarding their complaint [6]. Issues around access to and confidence in primary care are frequently cited as reasons for increased attendances at the ED, with the perceived urgency of the condition also noted [7][8][9]. Other pragmatic concerns that influence patients can be costs associated with certain services within the health systems and availability of transport to and from healthcare services [7]. Individual patient factors such as socioeconomic status (SES) can also dictate where care is sought with low SES typically associated with higher use of the ED [10][11][12], however, this is mediated by many complex interacting factors that require further exploration.

Understanding the unscheduled healthcare system
Health systems must be adaptive to the needs of the populations they serve [13], and responding to evolving child health needs requires a systems approach to improve child health and access to health services in this population [14]. Access to healthcare is a complex interaction between the individual and the health system [15][16][17] and encapsulates the identification of healthcare needs through to the fulfilment of those needs by the health system [17]. The application of systems thinking can provide a pathway to addressing challenges within a health system [13], and evidence of the whole system is required in order to understand demand for its individual components and the complexities that govern how patients utilise them [7].

A system of unscheduled healthcare
Much of the research in this area to date has focused on the use of primary care, ED and out-of-hours care as individual components within the health system or has focused on the use of scheduled or specialist health services. The variety of services that offer unscheduled healthcare has given rise to the argument that they should be studied as one system rather than as individual components within a health system [1,18]. There is little evidence regarding the utilisation of unscheduled healthcare as a single system with multiple options that offer unplanned healthcare when needed, and critically, how patients make decisions about care seeking within that system. Many potential factors that influence where patients choose to seek care exist and accessibility and convenience also shape their care-seeking behaviour. This may result in a blurring of the boundaries between the types of unscheduled care on offer, which can be confusing for patients as they try to navigate this complex system and seek the most appropriate care [19].
When making such decisions, patients draw on existing knowledge about their health and the health system within a specific context [19]. Unpacking this process is critical to respond appropriately to healthcare needs. The aim of the current systematic review will seek to identify the factors that influence parents' and families' decision making when seeking unscheduled paediatric healthcare.

Review question
What are the factors that influence decision making of parents and families seeking unscheduled paediatric healthcare?

Protocol and registration
The protocol for this systematic review was published on HRB Open Research [20] and was also registered on PROSPERO (ref: CRD42019129343).

Search term identification
A preliminary search of PubMed and CINAHL using a limited number of key words was carried out to identify primary keywords used in the titles and abstracts of articles that will emerge in the search engines. These were used to formulate the search terms that were used in the systematic review.

Inclusion criteria
Only studies published in English were considered for inclusion Empirical studies Studies that directly sought to establish factors that influence the decision making for the access of paediatric unscheduled healthcare (only factors that were explicitly reported from primary sources were included e.g., factors pertaining to socioeconomic status were not inferred from the data provided but had to be explicitly stated by authors)

Exclusion criteria
Studies that elicited factors that influence decision making for accessing adult healthcare or combined child/adult data Studies related to scheduled or specialist healthcare services Expert opinion or editorials Studies that used secondary data as the only data source (e.g., hospital administrative data)

Databases
The 5 databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) were selected to capture a wide range of specialities and disciplines. A full electronic search of PubMed with limiters is provided in Supplementary  Table 1.

Grey literature
The search strategy described above was used to search ProQuest Dissertations and Theses, while modified search strategies were used to search Lenus, OpenGrey and Google Scholar. The results of the first 10 pages in Google Scholar were screened for inclusion in the study.

Types of study to be included
All study types were included in the review provided they met the inclusion and exclusion criteria.

Screening
Two authors independently screened the title and abstracts of search records retrieved against eligibility criteria. Full-text publications of all potentially relevant articles, selected by either author, were then retrieved and examined for eligibility. The search strategy and study selection is documented in the PRISMA flow diagram ( Fig. 1) [21]. The reference list of each included article was also searched to identify additional relevant papers, and this yielded a further 9 articles for screening.

Data management
The review management website Covidence™ [22] was used to remove duplicates and sort exclusions and inclusions using the create group function. Table 2 outlines the data that was extracted from the included studies. Three categories of data that were initially planned to be collected were covered by other fields (i.e., Research Question) or were not reported in the studies (e.g. details on health system, reasons for  ). The data extracted includes general information related to the study, country of origin, and the aims and rationale of the research. Some variables (i.e., socioeconomic factors) were not consistently reported across the studies and any factors that were recorded were extracted (e.g., level of education, occupation etc.). With regards to the paediatric population in question, the relationship to the child (e.g., mother, father, caregiver), age, any disease groups or conditions was noted and the reason for attendance at unscheduled care, if reported. One reviewer extracted the data from the included studies and approximately 10% (n = 5) were checked for consistency by a second reviewer. There was 90% agreement rate between the two reviewers. Any discrepancies typically arose from a lack of clarity in the reporting of the papers and were discussed and agreed between the two reviewers. A narrative approach was used to synthesise the extracted data.

Data extraction
Data availability and dealing with missing data All data underlying the results were available as part of the article and no additional source data were required. There was no missing data in any of the included studies. The full text of 11 papers could not be accessed despite attempts to contact study authors for full texts using a maximum of three e-mails. After 3 weeks, if there was no response the review proceeded without these papers. Of the excluded papers, 7 were dissertations and 9 were from the USA with 1 from both the UK and Italy.

Quality assessment
The Mixed-Methods Appraisal Tool (MMAT) [23] was used to assess the methodological quality of included studies. Papers selected for data extraction were evaluated by one reviewer (EN), prior to inclusion in the review. A second reviewer (TMcD) reviewed 25% of the studies to check for consistency. There was 93% agreement between the two reviewers with any disagreements resolved through discussion or consultation with a third reviewer (EM). The results of the quality assessment can be found in Supplementary Table 2. Given the large number of studies that emerged in the searches, those with a quality score of 25% or less were excluded from the review. Evidence from the literature has found that the exclusion of inadequately reported studies is unlikely to affect the overall findings of a review [24].

Overview of included studies
A total of 56 published studies were included in the systematic review. Countries of origin included USA (n = 29), Australia (n = 10), Canada (n = 4), the UK (n = 5), Belgium (n = 1), The Netherlands (n = 2), Sweden (n = 1), Singapore (n = 1), Denmark (n = 1), Brazil (n = 1) and Lithuania (n = 1), which represented a broad array of health systems in the review. Few studies provided details on the health system where the research took place, however, the range of countries from which the included studies originated suggests a broad array of different health systems. A range of methodologies emerged in the review with some utilising quantitative techniques such as surveys and questionnaires (n = 32), qualitative inquiry such as interviews and focus groups (n = 19), mixed-methods (n = 2), and discrete choice experiments (n = 3).
For studies that employed quantitative methods, the most common means of analysing data was through descriptive and other statistical analyses (odds ratios, modelling) (n = 31). The majority of qualitative studies used thematic analysis to analyse the data or generated common themes (n = 11), however, content analysis (n = 3), an iterative thematic approach (n = 1) and grounded theory (n = 4) were also used.
Regarding the ranges of ages represented in the paediatric samples in each particular study, they ranged from a minimum of 0-28 days, while the older cut-off ranged from 17 (the most common cut-off for a paediatric sample) to 18 in 3 studies [25][26][27]. Thirty-nine studies did not report the age of the paediatric sample. Table 3 outlines the demographics of the participants in each included study.
Pre-disposing factors for use of unscheduled healthcare A number of the studies included in the review identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as having an influence in the care-seeking behaviour of parents. SES was typically reported using measures such as income, education, and deprivation level of the area where participants were living. The relationship between SES and child health is well documented [79], however, given the multi-faceted   nature of SES, we only extracted data where SES measures were explicitly stated by the authors to be a factor that influenced attendance or care-seeking at unscheduled healthcare. SES interacts with factors such as race and ethnicity, which can also incorporate language and level of acculturation into the main culture [79]. These findings need to be balanced against the health system in which they occur with regards to local and structural issues and therefore, the countries in which such findings emerged are stated in Table 4. Immigrant and minority populations were found to be more likely to use the ED as a source of first-contact care [40,73] with lower levels of acculturation related to even greater use of the ED in Latin American populations in the USA [73], and low abilities in the native language also associated with higher ED use in Sweden [40]. Health literacy, which has been defined as the "skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health" [81], was also a relevant factor [56] with lower levels of health literacy associated with greater ED use [57]. Other factors included lower income [34] and use of public health insurance programmes based on income such as Medicaid in the USA [27,51,61] or a lack of any health insurance [64]. In one study from Brazil, parents often utilised private healthcare as a substitute for public health services when they were unavailable,  Children whose mothers reported that they had (1) asthma diagnosed by a physician, (2) day or night asthma symptoms, including wheezing, shortness of breath, and/or a cough at least once a week during the past 2 weeks, and/or (3) at least 1 visit for asthma to the ED in the previous 6 months or 1 overnight hospitalization for asthma in the previous year.
Mothers who reported the highest tertile of depressive symptoms also reported the most frequent use of the ED (Mantel-Haenszel test, 2 = 6.33, P = .01).        although the public health services occasionally met important needs such as paediatric-specific emergency departments not provided within the private health system [35]. While the clinical reason for attendance was not a primary focus of the current review, which sought to collate non-clinical factors, it is difficult to completely isolate the non-clinical factors from the clinical reason for attendance. Indeed, as a common childhood condition, asthma was central to a number of the included studies (n = 4). With regards to children with asthma, minority children were more likely to utilise urgent care compared to non-minority children in the USA when other relevant factors were controlled for including income, gender, source of usual asthma care [42] and frequency of night-time symptoms [69]. Moreover, among a predominantly Latino population in an American hospital, perception of acute need was the main reason parents sought the ED for their children with asthma, however, those who use the ED do so due to barriers using primary care for unscheduled appointments [54].
Parental-specific factors were also identified in the review as influencing where first-contact care was sought. For instance, mothers who reported as being in the highest tertile of depression were more likely to bring their child to the ED rather than the GP [30] and younger parental age which was associated with a greater likelihood to seek care at the ED [34]. In a study exploring care seeking in lone parents in the UK with a partner on active duty abroad, a lack of support at home increased the likelihood that they would seek care when their child was unwell [32]. This latter finding is analogous to other studies which found that being a single-parent was a risk factor for higher ED use for non-urgent conditions [61,76], such that parents with limited social support were more frequent ED attenders [37] and living in low income areas made the ED a more convenient choice for stressed families [38].
Pre-disposing factors are multi-faceted, inter-related and can be difficult to isolate from systems factors that also affect healthcare-seeking behaviour at unscheduled services. However, given their influence in care-seeking behaviour, it is important to report them in the present review.
Factors that influence decision to attend and choice of unscheduled healthcare The following factors emerged from the data as directly influencing parental choice of attendance at ED, primary care and out of hour's services. Table 4 outlines these results from the review.

The need for reassurance
The need for reassurance featured heavily as a common reason parents seek healthcare at the ED. Specifically, parents wanted reassurance that their child's illness is not serious or will not become more urgent, while also seeking guidance on how to manage the condition [25,37,41,56,60,82]. Reassurance and seeking guidance on how to manage specific conditions such as respiratory tract infections (RTI) [49,71] and for general illnesses [66] also factored into the decision of parents choosing to attend their GP. Parental self-efficacy and ability to cope tended to increase with more parental experience due to having other children, and this in turn influenced the decision to consult healthcare for RTIs [49,50]. Moreover, while social pressures to seek care for their children in order to be seen to be 'doing the right thing' as a parent [66] was also related to care seeking, fear of wasting the doctor's time for a minor illness was perceived as a barrier to seeking primary care [49].
Shorter waiting time and after-hours access to the ED compared to primary care A number of the included studies (n = 9) concluded that shorter waiting times, availability and accessibility of the ED after hours was a significant factor in parents' decision to attend the ED [25-27, 31, 33, 45, 64, 70, 75]. In a further qualitative study, parents stated that they wanted to avoid double waiting if they were sent to the ED by the GP [46].

Timely access to the GP (both during normal working times and after hours)
The unavailability of a timely appointment with the GP also increased the likelihood that parents would seek care in the ED [28,41]. Moreover, one study that explored return visits to the ED stated that a lack of availability of GP appointments led to return visits to the ED [29]. Another common issue regarding ED attendance was an inability to contact the GP by phone prior to ED attendance, with between half and threequarters of parents attempting to contact the GP prior to presenting at the ED [26,43,47,48,59,60,74,83]. There were no differences in SES for parents who attempted to make contact with the GP prior to attending ED [48]. Parents were more likely to attend the ED without referral from the GP during evening and weekends [36].

Satisfaction with GP
A positive relationship with the GP, overall clinic environment and friendly staff were associated with choosing primary care as the first contact for care [51]. Problems with primary care include poor communication and general dissatisfaction with their GP [27,33], however, one study did not find that problems with primary care was a clear motivator for parents to choose the ED over the GP for non-urgent conditions [38]. While the problems with primary care contributed to greater ED attendance rates, on balance, two studies found that convenience and satisfaction with primary care increased the likelihood that parents would seek care from their GP [51,66].

Convenience
While only a small number of papers explored the reasons that parents choose their GP or primary care provider as the first contact for care, many of the reasons for choosing primary care were similar to those for choosing ED. For instance, in a study comparing parents who chose the paediatric ED with those who would choose primary care [59], it was found that parents chose primary care because it was more convenient [53], they would be seen quicker and they could get in touch more easily. Indeed, convenience and appointment availability [51] and travel time and same day appointments [77,78] were also identified as important factors.
Five studies found that proximity or location of the ED was a factor in parents' decision to utilise this service [25,31,39,67] with city-dwellers from lower socioeconomic areas more likely to use the ED [83] as they live closer to the hospital. With regards to primary care, a discrete choice experiment (DCE) of preferences for enhanced access to a primary care (in the medical home model) found that parents were willing to spend an additional 14 min traveling for a same day visit [77].

Perception of higher quality care in the ED
One of the most commonly occurring reasons for parents to choose the ED as a source of unscheduled healthcare for their children was the perception that higher quality care is available in EDs [25,33,39,53,58,64,72,75,84]. This finding also relates to the diagnostic and other equipment typically available in a hospital setting but not in a GP practice. Parents stated that they preferred the ED as diagnostics such as blood tests and X-rays can be carried out immediately, and they believed their child would get a more thorough examination by doctors in a paediatric ED [25,28,33]. Parental trust in ED doctors was also an important factor when seeking care for injuries [44]. On balance, dissatisfaction with the ED, including disappointment with medical staff, care and information, increased the likelihood of a return visit to the ED in one study [29].

Perceived urgency or severity of illness
Parents' perception of the urgency or severity of their child's illness also played an important role in parents' decision to consult the ED [45,52,53,56,60,68,74,75,82,84]. An increased perception of an illness as being urgent was also found to be associated with differing levels of health literacy as parentsthose with low health literacy were more likely to seek care immediately [56]. The perceived severity of a child's condition decreased with the age of the child, as parents' perceived children less than 1 year old to have conditions requiring more urgent care than older children [60].

ED compared with out-of-hours services
Four studies explored parents' decision making when choosing to attend out-of-hours' healthcare, with a particular focus on use of these services in comparison to the ED. For instance, two studies [62,63] explored the factors that influenced preferences for out-of-hours' care and found that waiting times and receiving an adequate explanation or reassurance about their child's illness were two of the most important factors when choosing where to seek care after hours. However, experience was also a key factor and parents who had used a GP cooperative previously were more likely to do so again [63]. Waiting times and convenience were also key factors in the use of out-of-hours' services, and patients with knowledge of the system were more likely to utilise it [55]. Nevertheless, while ED care was still the preferred location of care for parents, whether the doctor seemed to listen was the most important attribute when evaluating different models of out-of-hours care [65].

Discussion
The present systematic review sought to examine the non-medical factors that influence parents' decision making when seeking unscheduled healthcare for their child. From a patient perspective, the boundaries between unscheduled health services are less pronounced than they may seem from the perspective of health providers [19]. The current review adopted this approach by extracting data related to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) and synthesising them as one system of healthcare. Strengthening first contact care is a key focus for paediatric healthcare in Europe [14] and it is important to examine how factors influencing utilisation of these services relate to and interact with one another, and the contexts in which certain behaviours occur.
Initiating help-seeking behaviour: perception of urgency and the need for reassurance A parents' decision regarding "when" to seek healthcare for their child can be influenced by the perception that their child's condition or illness was urgent and the need for reassurance or an explanation from a healthcare professional. This initial decision to seek care is rarely a straightforward one for parents and anxiety can be heightened when making decisions for others, such as young children who may struggle to communicate their symptoms [85]. A common focus of the studies included in the review was the use of the ED for low-acuity or non-urgent conditions, however, it is difficult to synthesise these findings as there was considerable heterogeneity in how non-urgent or low-acuity conditions were defined by researchers. This is reflected in the literature where there is a lack of agreement among ED physicians on how to define an "inappropriate" visit to the ED [85], and while they recognise that certain illnesses and conditions can be treated elsewhere, they do not always consider such visits to be problematic [86]. In the present review, parents did take the appropriateness of an ED visit into account [49] and indeed, it was clear that parents do make attempts to contact a GP ahead of attending the ED [40,43]. Navigating "appropriate" use of the unscheduled healthcare system can be challenging for patients [19] and a more nuanced understanding of how parents make sense of illness and urgency of care seeking is required.
Health literacy was found to influence a parents' perception of urgency and in turn, their choice of service. Interventions to improve parental health literacy can reduce presentations to the emergency department [87] as parents' understanding of health and management of illness may reduce their need to seek care elsewhere. Moreover, chronic conditions such as asthma or disability place greater caring demands on parents which further disadvantages those with lower health literacy [87]. Experiences such as being a lone parent increased care seeking [32] and non-urgent use of the ED [61]. Once a parent has decided to seek healthcare for their child, they will access care in the quickest and most convenient place at any given time. In order to enhance access and facilitate patient contact with the health service in a way that will result in the best health outcomes, we need to understand the decision making process regarding "where" care is sought, and therefore inform the design of accessible first contact services for unscheduled care.
The choice of unscheduled health service: practical considerations and the relationship with your GP The review identified a number a pre-disposing factors that can influence where parents choose to seek unscheduled healthcare for their child. For instance, socioeconomically disadvantaged and immigrant parents were typically more likely to seek healthcare in the ED, with this effect observed in Australia, Brazil, and the USA in the articles in the current review [34,35,51,61,64,69,73]. However, at the core of access and availability to unscheduled healthcare are practical issues and concerns that families must consider when seeking healthcare, and it is important to recognise that constraints within a health system can limit the options for some parents regarding where to initiate contact with the health service. For instance, the unavailability of appointments with the GP within a reasonable timeframe (e.g., within 24 h) causes parents to seek healthcare in the ED [26], and the times of available appointments can also be restrictive as they are typically during standard working hours. Parents also perceive access to diagnostic tests and the specialist equipment available in a hospital as important [25], or may go straight to the ED to avoid having to "wait twice" if they think they will be sent on to the ED by their GP anyway [46]. Due to the temporal structure of primary care and the limited diagnostic tests available, attendances at EDs for non-urgent conditions are often inevitable, therefore, strategies for reducing "inappropriate" visits to the ED could instead focus on investment in primary care to take the pressure of EDs and provide greater care in the community.
While these pragmatic concerns can impact where parents seek unscheduled healthcare, the relationship between a GP and a parent or family was also found to be an important factor when parents were considering the option of attending primary care or the ED. Socioeconomic vulnerabilities can be further exacerbated by differing experiences of primary care and other healthcare services. For example, in a study from Hong Kong, which has a primary care system dominated by private healthcare, patients with higher incomes and private health insurance reported favourable experiences in primary care [88]. In the present review, an unsatisfactory relationship with your GP was related to higher use of the ED [33] and evidence suggests that families with high income and education were more likely to report a positive relationship with their child's GP, and reported greater involvement in decision making around their child's health [89]. Moreover, another study in the review reported that parents with greater health literacy placed a high value on a close relationship with their GP and were willing to wait longer for an appointment [56].

Recommendations for future research and implications for policy
The studies included in the systematic review each focused on a specific health service or services that fell within the scope of unscheduled healthcare, however, none of the studies examined parent's utilisation or preferences for first-contact healthcare as a single service with multiple shared characteristics and entry points. It is clear from the current findings that while parents may utilise different health services as a source of unscheduled healthcare, they are using these different services for similar reasons and also operating within constraints that exist in their health system. Furthermore, the persistent framing of non-urgent, low-acuity or 'unnecessary' visits to the ED as problematic behaviour on the part of parents may be shifting focus away from the challenges in the system of unscheduled healthcare that result in this behaviour. While targeted interventions that improve health literacy can reduce presentations to the ED [87] and educate parents on management of minor childhood illnesses, understanding parents' behaviour as part of a system of unscheduled healthcare should be an important priority for future research. Such research can inform policy and practice in this area by identifying opportunities for intervention that are responsive to parents' behaviour and needs. Finally, the impact of the COVID-19 pandemic on paediatric attendance to EDs has been noted [80,90], and it is likely that this has impacted parental decision-making when seeking unscheduled care more broadly, however, further research is needed to understand decision-making during the pandemic [91].

Limitations
The review sought to include sources of unscheduled healthcare where patients are required to attend in person, however, other forms of unscheduled support and advice are available in some jurisdictions. For instance, pharmacists often provide advice to patients, however, the evidence around the effectiveness of this advice requires further study [92]. Some health systems provide telephone advice services where patients can speak with healthcare professionals for advice on whether to attend the ED or to receive guidance on how to manage a condition, although the evidence around these service is unclear [1]. On a related note, much of the literature made reference to parents phoning their GP for advice ahead of attending the ED, however, the outcomes of the calls were not consistently reported and it is difficult to ascertain the impact this had on attendance. Chronic conditions such as asthma will increase attendance at unscheduled services, however, this attendance is still heavily influenced by the issues brought up in the review. Further limitations of the study were the lack of focus on the clinical reason for a visit as we sought to examine the non-clinical reasons for attendance at unscheduled healthcare and the exclusion of non-English articles.

Conclusion
The present review and narrative synthesis identified a number of factors that can influence parental preferences and decision making when seeking unscheduled paediatric healthcare. Parental decisions on when and where to seek unscheduled healthcare for their children are not made in a vacuum as parents weigh up the options in front of them, utilise prior experiences and make the most appropriate decision in any given context. While a strong system of primary care has been associated with more positive population health outcomes [93], access issues that are faced by subsections of the population and the practical considerations of parents are substantial limitations that need to be addressed. Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points [19,85]. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy [87] or reducing emergency hospital admissions through preventative primary care [9] requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.