Heart failure (HF) is a common condition contributing to significant morbidity and mortality in Western societies. It significantly impacts all aspects of quality of life, particularly impairing patients' mobility and performance of daily activities [1
]. Cultural differences exist among patients with HF in the interpretation of symptoms, hospital readmission rates, and functional status [2
]. The meaning that patients assign to symptoms and illness can have profound implications for their wellbeing. This meaning is influenced by culture, gender, experience, learning and beliefs, and all of these influence the individual's assessment of symptoms [3
]. Family systems, coping styles, health beliefs, behaviours and practices influence the individual response to chronic illness, often as a consequence of a chronic disease. Illness represents culturally shaped reactions to a certain discomfort which mirrors the way an individual perceives, experiences and copes with it [4
]. According to Helman, illness can be perceived as caused by external or internal factors, e.g., factors related to the individual, social relations, natural or supernatural forces [5
]. While illness reflects a personal and social experience of health status represented as symptoms, disease is the physiological disturbance with signs as its clinical hallmarks [6
]. Cultural differences exist also in explanations for the cause of disease and interpretation of symptoms. Such differences may lead to different responses to the illness, e.g., different self care measures or health care seeking behaviours.
Symptoms are sensations that signal a disturbance in normal body function to the individual. If these sensations cannot be recognised and management strategies are lacking, the individual's response may be inadequate or insufficient. Recognising the symptoms as a representation of unfamiliar sensations and responding adequately are behaviours which are related to the individual's cognitive, communicative or physical capabilities [3
]. Previous studies on symptoms in HF have reported up to 45 different symptoms [7
]. In a recent study, the majority of the patients with HF (58 %) sought emergency care due to symptoms and 70% of those who delayed seeking care for exacerbation of HF explained that they chose to "wait and see". This strategy may imply a failure to recognise symptoms of deterioration [9
] as medical attention is often sought only when acute or life-threatening symptoms occur [10
Appropriate health care seeking decisions are based on symptom recognition. Interpretation and evaluation of the experience requires sufficient knowledge about the disease, its treatment and recommended self care. This knowledge may also enable patients to develop their own management strategies. Several researchers have stated that the assessment and interpretation of sensations are influenced by gender, culture, beliefs, experience and learning [12
A review of the literature shows an under-representation of women, elderly, ethnic minorities and immigrants in clinical trials. The inclusion of these groups is imperative for determining appropriate treatments for these groups. However, studies involving HF patients have generally not focused on patient beliefs, perspectives and experiences of care and treatment, but rather on the pathophysiology of the condition, clinical factors or risk factors, epidemiology, readmissions and economical costs.
Immigrants in this study are defined as those who are born abroad, have another mother tongue than Swedish and are living in Sweden at present. This definition is in contrast to several other research designs which are built up on racial differences and classifies the participants as for example Asian, Black, White and Caucasian [15
]. This kind of classification is not distinct enough because people classified as belonging to a racial or ethnical group might not necessary be immigrants and they may well have be living in the county for many generations. The word race is not an adequate variable in study of differences between human populations since the lion's share of human gene variation falls within, not between populations. Therefore the term "race" remains a social construct with social meaning and influence on the health without having any biological or genetic basis [16
Due to an extensive global migration, Sweden has become a multicultural society with more than 120 different nationalities represented in the country. It is not known what patient perceptions or beliefs lead to beneficial decisions or response patterns in symptom interpretation among HF patients, especially immigrants. Moreover, knowledge about health care seeking patterns in immigrants is scarce.