Lay diagnosis and health-care-seeking behaviour for chest pain in south Asians and Europeans

Summary

Background

South Asian people in the UK experience greater delays than Europeans in obtaining appropriate specialist management for heart disease, but the causes are not known. We investigated whether south Asians and Europeans interpret and act upon anginal symptoms differently.

Methods

We randomly selected 2000 people from general practitioners' (family physicians) lists in London, UK, to receive a questionnaire that included a short fictional case history of an individual with possible anginal pain and asked how respondents would react to experiencing it. A second questionnaire seeking information on medical history, attitudes to health, and demography was sent later. The main outcome measure was the proportion who said they would seek immediate care (hospital emergency department or general practitioner) for the pain described in the case scenario.

Findings

The rate of response to both questionnaires was 60·2% (903 of 1500 who received both). 553 responders were of European origin, 124 were Hindu, and 235 were Sikh. There were no differences between the ethnic groups in the proportion identifying the pain as cardiac, but south Asians would be more anxious about the pain than would Europeans. Of the men, 55 (23%) Europeans, 20 (38%) Hindus, and 52 (47%) Sikhs said they would seek immediate care (p<0·0001 for heterogeneity); of women, 77 (24%), 25 (35%), and 58 (46%), respectively, would seek immediate care (p<0·0001). After adjustment for confounding variables the odds ratio for seeking immediate care in Hindus compared with Europeans was 2·67 (95% Cl 1·49–4·73) and that for Sikhs compared with Europeans was 3·18 (1·98–5·12).

Interpretation

Hindus and Sikhs reported a greater likelihood of seeking immediate care for anginal symptoms than Europeans; this finding indicates that barriers to cardiology services for south Asians are unrelated to difficulties in interpretations of symptoms or willingness to seek care. Improvement of awareness of heart disease may not decrease delays in obtaining care. Service-related explanations must be explored, such as general practitioners' difficulties in arriving at a diagnosis or differences in management because of ethnic origin.

Introduction

People of south Asian descent form one of the largest ethnic-minority groups in the UK, comprising 3% of the total population. Most south Asian people live in larger cities, such as London, where nearly a fifth of the population aged between 40 and 64 years is south Asian; this proportion is likely to increase with time.¹ South Asian people are especially prone to ischaemic heart disease; mortality and morbidity are about 1·5 times greater than those of the general population.2, 3

South Asian people must have equal access to interventions designed to ameliorate the burden of heart disease, such as medication, thrombolytic therapy, and revascularisation surgery, and, therefore, evidence of differences in access to effective cardiovascular health care for south Asians is of great concern. Studies on the management of chronic chest pain show that south Asian people in the UK are less likely to be referred for stress testing, despite being more likely to have a positive exercise test,⁴ wait twice as long as Europeans to be seen by a cardiologist,⁵ and wait longer for angiography⁶ after the onset of chest pain. In the acute phase after myocardial infarction, south Asians are less likely to receive thrombolytic therapy because of delays in presentation and misdiagnosis.7, 8 These studies were done in different geographical locations in the UK, and the similar findings are unlikely to be due to idiosyncratic barriers to health care. However, the studies could not show whether differential access was due to the influence of patient-related factors on the decision to seek care, such as reluctance to obtain medical advice and differences in patients' perceptions of symptoms, or to physician-related factors, such as doctors giving less weight to symptom reporting by south Asians, difficulties in reaching a diagnosis, and delays in seeking a specialist opinion.¹

Available information about health-care-seeking behaviour and use of health services by south Asians10, 11, 12, 13, 14, 15 led us to design a study to assess whether ethnic differences in health-care-seeking behaviour for heart disease could account for delays in obtaining care. Since most patients experiencing an acute myocardial infarction have a history of chronic angina,¹⁶ we decided to focus on the initial anginal symptoms of heart disease. We wished to find out whether south Asian people interpret severity and cause of symptoms of angina and act upon them differently from European people. We also wished to assess whether any differences between the ethnic groups could be accounted for by differences in demographic factors, health-related behaviours, first-hand experience of heart disease, and attitudes to health and to health-care providers.