Decisions about where and when to seek advice about illness are known to be complex and are often bound up with issues of risk, responsibility and legitimacy. They can be particularly difficult in situations where the meaning and severity of symptoms is unclear. In deciding whether or not to seek help, people must negotiate the tension between using health services in ways that are considered appropriate, while not taking risks with their health or that of the person they are caring for. This thesis explores how individuals account for a specific decision to call NHS 24 about symptoms in themselves or someone they were caring for and how that decision fits within their use of health services more generally. Building on what is already known about help-seeking behaviour, it seeks to understand how people interpret symptoms as needing or not needing attention and what is understood by appropriate help-seeking in the context of out-of-hours care. There have been significant changes to the way that out-of-hours health care is provided in Scotland. An increase in routes into care means that people must negotiate a complex health system when seeking help. At the same time, pressure on resources has created an imperative to ensure that health care is used in the most efficient way possible. NHS 24 is primarily an out-of hours triage service providing assessment and, where necessary, referral to other services. At its inception, NHS 24 was presented as being designed to simplify access to health care by acting as a ‘gateway’ to the NHS in Scotland. However, increasing demand has led to attempts to limit use of NHS 24, in the out-of-hours period, to situations where symptoms are considered to be too urgent to wait for a GP appointment. NHS 24 can now be understood as one of a number of different points of access to health care that people must choose between; this requires individuals to engage in a process of categorising their symptoms according to urgency as a way of ensuring that their call is considered appropriate. The thesis draws on data from 30 in-depth semi-structured interviews with people who had called NHS 24 in the out-of-hours period. The symptoms the participants had called about were generally, though not universally, what might be classed as minor symptoms. Most of the interviewees were given self-care advice rather than referral for a face-to-face consultation. The interviews focussed on a specific contact with NHS 24 but aimed to situate the call in the context of the interviewee’s understanding of NHS 24, as well as their illness behaviour and use of health services more generally. The analysis suggests that people’s understandings of NHS 24 are not straightforward and that this can cause some confusion and even anxiety for callers. Interviewees’ accounts emphasise uncertainty about the severity of symptoms, a sense of worry that symptoms may be indicative of a serious problem, and the inadequacy of their own knowledge in the face of potential risks. In talking about their reasons for calling NHS 24, they describe seeking, and obtaining, reassurance that they were ‘doing the right thing’. Although they generally construct themselves as healthy individuals, confident in their ability to self-care, and as responsible users of health services, people spoke frequently about their reliance on expert clinical knowledge in decision-making. The analysis suggests that when explored in the context of individual circumstances and the broader social context, calling NHS 24 about minor symptoms can be constructed as a rational and responsible act. While this thesis is primarily an exploration of the accounts of individuals who have called NHS 24, the accounts are situated within the broader social and structural context in which those individuals make their decisions about symptoms and help-seeking. A social constructionist perspective sees illness behaviour as shaped by the social structures and values of a society and by the health system operating in that society. Equally, the health system is shaped by individual actors, who define it by how they choose to use it and what they expect it to deliver. This thesis argues that understandings of risk and individual responsibility, as well as a policy emphasis on self-surveillance and self-care, shape the decisions made by individuals as well as the discourses available to them to account for those decisions. Drawing on theories of medicalisation and lay re-skilling, the thesis also aims to develop an understanding of the space that NHS 24 occupies in Kleinman’s (1980) model of the health system, and whether the service might best be conceptualised as ‘legitimation’ or ‘colonisation’ of the popular sector (Stevenson et al. 2003).

Syftet var att identifiera faktorer som påverkar föräldrars beslut att söka akutsjukvård för deras barn med icke akuta sjukdomstillstånd. Metod: Studien designades till en integrativ litteraturöversikt med systematisk ansats. Tre kvalitativa och tolv kvantitativa artiklar inkluderades och granskades utifrån Caldwells et al. (2011) granskningsmall. Analysen skedde i enlighet med Whittemore och Knafl (2005) som en integrativ analys utifrån en induktiv ansats. Resultat: Resultatet presenteras utifrån tre teman; Oro i samband med sjukdom, tillgänglighet samt individuella föräldrafaktorer. Dessa fördelades sedan in nio subtema; Rädsla för försämring, behov av information och trygghet, brist på kunskap, obegränsad tillgång, specialistvård, snabba svar, utbildningsnivå, åldersfaktorer samt överskattning av allvarlighetsgrad. Dessa faktorer spelade en väsentlig roll varför föräldrarna sökte akutmottagningen med deras icke-akut sjuka barn. Slutsats: Med hjälp av ökad insikt och förståelse av patientens helhetsbild kan sjuksköterskan möta föräldrars behov samt ge anpassad rådgivning och hänvisa till rätt vårdnivå, vilket ökar patientsäkerheten på en akutmottagning. / The aim was to identify factors that influence parents' decisions to seek emergency medical care for their children with non-acute medical conditions. Method: The study was designed as an integrative literature review with a systematic approach. Three qualitative and twelve quantitative articles were included and reviewed based on Caldwell's (2011) review template. The analysis took place in accordance with Whittemore and Knafl (2005) as an integrative analysis based on an inductive approach. Results: The results are presented based on three themes; Anxiety associated with illness, availability and individual parental factors. These were then divided into nine subthemes; Fear of deterioration, need for information and reassurance, lack of knowledge, unlimited access, specialist care, quick responses, level of education, age factors and overestimation of severity. These factors played a significant role in why the parents sought the emergency department with their non-acutely ill child. Conclusion: With the help of increased insight and understanding of the patient's overall picture, the nurse can meet parents' needs as well as provide tailored advice and refer to the right level of care, which increases patient safety in an emergency department.

During later years, the primary care services are experiencing a heavier strain in terms of increasing expenses and higher demand for medical services. An increased awareness about pharmaceutical adverse effects and the global concern of antibiotic resistance has given self-care and active surveillance a stronger position within the primary care services. The management strategy for minor illnesses is important because care-seekers tend to repeat successful strategies from past events, and past experience with self-care drives future self-care practices. The overall aim of this thesis was to explore people’s experiences and needs when practicing self-care and receiving self-care advice for minor illnesses. This was achieved by studying people’s experiences with and knowledge of minor illnesses, self-care interventions and channels of information used when providing self-care for minor illness. Needs for confidence in self-care were studied, as well as supporting and obstructing factors in the practice of self-care. Satisfaction with telephone nursing and people’s experiences of reassurance in relation to the decision-making process in self-care for minor illness was explored. The results showed that experience correlated with self-rated knowledge of the condition, and the least common conditions most often generated a health care services consultation. To confidently practice self-care people needed good knowledge and understanding about obtaining symptom relief. Younger persons more often reported the need of having family or friends to talk to. Easy access to care was most often reported as a support in self-care, and a lack of knowledge about illnesses was most often reported as obstructing self-care. Care-seekers receiving self-care advice were less satisfied with the telephone nursing than care-seekers referred to medical care, and feeling reassured after the call was the most important factor influencing satisfaction. Self-care advice had a constricting influence on healthcare utilization, with 66.1% of the cases resulting in a lower level of care than first intended. The course of action that persons in self-care decided on was found to relate to uncertainty and perception of risk. Reassurance had the potential to allay doubts and fears to confidence, thereby influencing self-care and consultation behavior. In conclusion, symptoms of minor illness can cause uncertainty and concern, and reassurance is an important factor influencing people’s course of action when afflicted with minor illness. The nurse constitutes a calming force, and the encounter between the nurse and the care-seeker holds a unique possibility of reassurance and confidence that minor illness is self-limiting to its nature and that effective interventions can provide relief and comfort. Just as health is more than the absence of disease, self-care is more than the absence of medical care.

Objetivo: desenvolver sistema de suporte à decisão clínica dos farmacêuticos no manejo de sintomas menores (SM) com medicamentos isentos de prescrição (MIPs). Métodos: Inicialmente, foi realizada uma revisão sistemática, entre janeiro 1980 a agosto de 2010, nas bases de dados Medline/Pubmed, Scopus, Lilacs e Embase. Posteriormente, uma amostra de conveniência de farmacêuticos comunitários (FC) participou de uma entrevista semiestruturada realizada nas farmácias comunitárias de duas grandes redes em Aracaju, no período de Junho a Agosto de 2012. Em seguida, a metodologia do paciente simulado (PS) foi aplicada a mesma amostra de FC com dois casos de SM (1 - mulher adulta com sinusite; 2 - mulher grávida com tosse seca e dor nas costelas). As simulações foram avaliadas de acordo com o instrumento desenvolvido pela Farmacopéia dos Estados Unidos (USP) chamado "Medication Counseling Behavior Guidelines" e validado para o português. No período de fevereiro de 2012 a janeiro de 2014, foi desenvolvido um software para auxiliar o farmacêutico no processo de manejo de SM do trato respiratório com MIPs. Para tanto, 7 farmacêuticos clínicos, juntamente com engenheiros de produção, determinaram o conteúdo dos algoritmos. Resultados: Apenas nove artigos preencheram todos os critérios de inclusão estabelecidos na revisão sistemática. Foi observado que quatro estudos relataram adesão do paciente a orientação do farmacêutico. Participaram da entrevista 40 FC e destes, 62,9% não cursaram na graduação disciplina sobre o manejo de SM. As respostas dos FC sobre sua atitude frente a automedicação, revelou que a depender do tempo da queixa eles indicam um tratamento ou encaminham o paciente ao médico. Foram realizadas 80 simulações que apresentaram um tempo total de atendimento farmacêutico de 91,31 segundos (DP ±68,63). A análise das simulações revelou que 83,3% e 72,5% dos FC recomendaram a visita ao médico para o PS1 e para o PS2, respectivamente. Foi observado que 45% e 17% dos FC revisaram a solicitação do paciente antes da orientação. No processo de desenvolvimento do software, os farmacêuticos especialistas apontaram que os algoritmos deveriam explorar as características dos SM (início, frequência, duração), os tratamentos farmacológicos e não- farmacológicos apropriados e os parâmetros de encaminhamento do paciente ao médico. A versão final do software proporciona a determinação de diagnóstico condizente com o conjunto de sinais e sintomas do paciente, retornando ao farmacêutico uma pequena lista das possíveis enfermidades. Conclusão: O software poderá melhorar as condições de trabalho dos farmacêuticos comunitários, adicionando-lhes maior evidência cientifica no manejo de SM com MIPs.