title: The association between ethnicity and delay in seeking medical care for chest pain: a systematic review.
abstract: Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, and chest pain is one of the most common symptoms of ACSs. A rapid response to chest pain by patients and appropriate management by health professionals are vital to improve survival rates.People from different ethnic groups are likely to have different perceptions of chest pain, its severity and the need for urgent treatment. These differences in perception may contribute to differences in response to chests pain and precipitate unique coping strategies. Delay in seeking medical care for chest pain in the general population has been well documented; however, limited studies have focused on delay times within ethnic groups. There is little research to date as to whether ethnicity is associated with the time taken to seek medical care for chest pain. Consequently, addressing this gap in knowledge will play a crucial role in improving the health outcomes of culturally and linguistically diverse (CALD) patients suffering from chest pain and for developing appropriate clinical practice and public awareness for these populations.
  
  
  
  The current review aimed to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among CALD populations.
  
  
  
  Patients from different ethnic minority groups presenting to emergency departments (EDs) with chest pain.
  
  
  
  The current review will examine studies that evaluate the association between ethnicity and delay in seeking medical care for chest pain among CALD populations.
  
  
  
  The current review will consider quantitative studies including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies.
  
  
  
  The current review will consider studies that measure delay time as the main outcome. The time will be measured as the interval between the time of symptom onset and time to reach an ED.
  
  
  
  A comprehensive search was undertaken for relevant published and unpublished studies written in English with no date restriction. All searches were conducted in October 2014. We searched the following databases: MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, ProQuest (health databases only), Informit, Sociological Abstracts, Scopus and Web of Science. The search for unpublished studies included a wide range of 'gray literature' sources including national libraries, digital theses repositories and clinical trial registries. We also targeted specific health research, specialist cardiac, migrant health, and emergency medicine organizational websites and/or conferences. We also checked the reference lists of included studies and contacted authors when further details about reported data was required to make a decision about eligibility.
  
  
  
  Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to being included in the review. Validity was assessed using standardized critical appraisal instruments from the Joanna Briggs Institute. Adjudication was produced by the third reviewer.
  
  
  
  Data were extracted from included articles by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute.
  
  
  
  The extracted data were synthesized into a narrative summary. Meta-analysis could not be performed due to the heterogeneity of study protocols and methods used to measure outcomes.
  
  
  
  A total of 10 studies, with a total of 1,511,382 participants, investigating the association between ethnicity and delay met the inclusion criteria. Delay times varied across ethnic groups, including Black, Hispanic, Asian, South Asian, Southeast Asian and Chinese. Seven studies reported delay in hours and ranged from 1.90 to 3.10 h. Delay times were longer among CALD populations than the majority population. The other three studies reported delay time in categories of time (e.g. <1, <4 and <6 h) and found larger proportions of later presentations to the EDs among ethnic groups compared with the majority groups.
  
  
  
  There is evidence of an association between ethnicity and time taken in seeking medical care for chest pain, with patients from some ethnic minorities (e.g. Black, Asian, Hispanic and South Asian) taking longer than those of the majority population. Health promotions and health campaigns focusing on these populations are indicated.
authors.affiliation: 1School of Nursing and Midwifery, Flinders University, South Australia, Australia 2Centre for Evidence-based Practice South Australia: an Affiliate Centre of the Joanna Briggs Institute 3Paramedic Unit, School of Medicine, Flinders University, South Australia, Australia 4Flinders University Library, Flinders University, South Australia, Australia.
authors.forename: Kannikar
authors.initials: K
authors.lastname: Wechkunanukul
authors.forename: Hugh
authors.initials: H
authors.lastname: Grantham
authors.forename: Raechel
authors.initials: R
authors.lastname: Damarell
authors.forename: Robyn A
authors.initials: RA
authors.lastname: Clark
mesh_terms: D002637:Chest Pain / Q000208:ethnology / Q000628:therapy*; D003430:Cross-Sectional Studies; D005006:Ethnicity; D006293:Health Promotion; D006801:Humans; D010342:Patient Acceptance of Health Care; D011446:Prospective Studies; D012189:Retrospective Studies; D013997:Time Factors