39 In another review, women and men were shown to have different ways of relating to pain. Women experience pain throughout life as a result of non-pathological processes including menstruation and childbirth.40 As a result of differing relationships between pain, gender and pathology, women relate pain to the monitoring of health as well as of injury. Men on the other hand do not experience the specific types Erlotinib OSI-744 of non-pathological pain as women do, and therefore view pain more

as diagnostic symptom of injury.40 Over 400 publications examine help-seeking and cardiovascular disease.18 They are predominately quantitative studies and are exclusively based on emergency cardiac events (heart attacks). A few studies have undertaken comparative analysis between men and women. In the studies that look at the differences between men and women (sex differences), there is no consensus on whether women delayed longer than men or the reasons behind any delayed help-seeking.16 17 19 41–43 The wider body of evidence in the area of gender and CVD—like the comparative studies—is weak and conflicting. Most of the studies used ‘response to symptoms’ instruments. The validity of these instruments to accurately measure cardiac symptoms is questioned because they are based on men and male symptoms rather than being developed and tested with women.27

The qualitative literature appears to be more decisive and suggests women experience cardiac symptoms differently to men, making symptoms difficult to interpret, which in turn affects help-seeking decisions.1 27 44 Symptom recognition in women is also a challenge for health professionals. Professionals may fail to diagnose cardiac symptoms correctly, resulting in women being undertreated.2

19 A review of 60 qualitative studies concluded that the perception that heart disease is a male problem was likely to account for a delay in help-seeking in women. It also noted the lack of comparative analysis between men and women, and called for further research in the area.2 This overall weak evidence, together with limited qualitative gender comparative research,2 and no enquiry into the help-seeking decisions of Entinostat patients with stable angina accessing chest pain clinics, demonstrates a clear gap in the literature and therefore justifies further exploration. A recent review of the literature in 2013 called for further exploration of gender and help-seeking for cardiac symptoms.45 Understanding what influences these help-seeking decisions—enablers or barriers—could have a significant public health and health promotion benefit, as it is known that early presentation and treatment of cardiac symptoms is associated with better clinical outcomes.3 45 Methods and study design The study design has two phases and is a mixed methods project. The first phase will be qualitative with semistructured interviews analysed using a thematic approach.