The association between ethnicity (culturally and linguistically diverse migrants) and the time taken in seeking medical care for chest pain: a systematic review protocol

Review question/objective The objective of this review is to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among culturally and linguistically diverse (CALD) migrants. Background Approximately 5.5 million emergency department (ED) visits in the USA present with chest pain.1Six-and-a-half million Australians visit emergency departments nationwide each year.2South Australia Ambulance reported 9.9% of all emergency cases were related to cardiac causes.3In Australia, 34% of hospitalisations for cardiovascular disease in 2007 were related to coronary heart disease (CHD). In addition, CHD responsible for 17% of all deaths of which approximately 50% of all CHD deaths were attributed to acute myocardial infarction.4,5 Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, particularly among industrialized countries.6ACS is a spectrum of clinical manifestations of CHD ranging from unstable angina (UA), non-ST-segment elevation myocardial infraction (NSTEMI) and ST-segment elevation myocardial infraction (STEMI).7Chest pain is recognized as one of the most common symptoms of acute coronary syndrome.8, 9Classic or typical cardiac chest pain has been described as heaviness, pressure, aching, crushing, burning or squeezing and might be associated with sweating, breathlessness, abdominal pain, back pain, jaw pain and arm pain.7,10Although the presentation of chest pain is the central hallmark of ACS, chest pain is not always associated with cardiac conditions.11,12Patients presenting to emergency departments may be diagnosed with cardiovascular disease or other non-cardiac causes of chest pain including gastroesophageal reflux, peptic ulcer disease, pulmonary embolus, herpes zoster, neuropathic pain or panic attack.13 Dracup et.al defined the delay time as the interval from the onset of symptoms to the initiation of definitive medical care.14Alonzo has divided the time delay into the following three phases:15 1. The patient/bystander recognition and action phase is the interval from onset of symptoms to seeking medical help such as calling an ambulance. This phase also involves the response to chest pain from people around the patient, such as a spouse, or friends and family. This phase is considered as a decision time delay. 2. The pre-hospital action phase is the interval between accessing the emergency response system to the time of arrival at the hospital and is referred to as the home-to-hospital delay. Travelling time plays a crucial role in this stage. 3. The hospital action phase encompasses the interval time between arriving at the hospital and receiving definitive therapy. Rapid and accurate clinical decision-making and prompt operation of therapy are key factors in this phase. Definitive treatment for ACS should be started as soon as possible after onset of symptoms. According to the international guidelines for management of ACS, reperfusion therapy should be administered to all patients presenting with ACS within 12 hours.16-18Delay in responding to chest pain symptoms has been proven to be a substantial factor impacting on patients' outcomes. Boersma et al. found that 65 lives are saved for every 1000 treated patients when the initial treatment is administered within the first hour of symptom of onset.19The findings from international trials support the notion that mortality rates and survival rates within 30 days and one year of ACS symptoms are associated with the interval between symptom onset and treatment.20-22 Factors influencing delay from a number of studies have demonstrated three distinct domains; i) socio-demographic and clinical factors; ii) cognitive and emotional factors; and iii) social factors.23-36 Herlizt, Thuresson and Perkins-Porras et al. agree that socio-demographic and clinical factors are significant factors associated with pre-hospital delay.28,34Despite the socio-demographic characteristics, a number of other studies have concluded that the cognitive and emotional response of patients to ACS symptoms plays a crucial role in delay.24,33,37-39These factors include recognition of signs and symptoms, genders, education levels, income, and emotional and social factors. Early access to definitive care, usually by attending an emergency department, has a profound effect on survival from acute coronary syndrome; consequently, delay in seeking medical care for chest pain is an issue requiring a serious action and implementable policy.16-18,40 Ethnicity, often categorised or described by country of birth,41is one of the significant non-modifiable risk factors for cardiovascular disease.42,43Ethnicity has been found to be associated with delay in seeking medical care for chest pain and underutilisation of emergency services.44-46In addition to the effect of ethnicity on accessing medical care, previous studies stated that risks of CVD, mortality and morbidity rates vary among ethnic groups.5,47-49Interestingly, populations of Asian or African ancestry have higher risks of developing CVD than other racial groups.49-51Unfortunately, the majority of studies in delay to seek medical care for chest pain have focused on a general population who share the same culture, language, and beliefs in the same social and environmental context.24,28,32,52,53There are only a few studies which provide evidence in regard with the delay in responding to chest pain among differing ethnic groups, particularly culturally and linguistically diverse migrants.50,54 Multicultural societies have been acknowledged and accepted in many countries. International migrants living abroad worldwide have reached a total of 232 million people, accounting for 3.2% of the world's population.55Australia is one of the most pluralist societies in the world, ranking as the 9th country in terms of receiving international migrants.56Currently, the population of Australia has reached 23 million people and almost one-third of the population was born overseas, accounting for a total of 6.2 million people.57An international migrant is defined as any person who changes his or her country of usual residence. 58(p17)Their journeys inevitably end with a change of lifestyle, including food, activities, jobs, fashion, socialisation, and health care.59,60{Berry, 1997 #506;Frisbie, 2001 #508;Gilbert, 2008 #518} Nevertheless, they may keep their culture, beliefs, and attitudes in many aspects of their lives, such as language, ceremonies, traditional foods, traditional medicine, and social activities.61 Although public health promotion and national plans have been implemented in multicultural communities, the disparities in access to care and unequal care provision have still occurred to some extent and further action and policies are needed to close the gap.62-64For health care providers, not only does the system need to be developed and improved, but an understanding of immigrants from all aspects would be helpful in meeting their needs by including cultural care and cultural competence in health practice.65-68 Consequently, it is important to study the delay in seeking medical care in migrants to understand their delay and key factors that influence accessibility and equality in acute care services for cardiac conditions. These findings could provide further information to health providers, public health agencies and policy makers in order to establish health promotion programs, health campaigns and health policies that match the needs of ethnic groups.69 The aim of this review is to establish if there is an association between ethnicity and delay in seeking medical care for chest pain among migrants with different ethnic backgrounds. The findings of this study may provide further information supporting future research of cardiac care between general population and ethnicity, particularly migrants.