Determinants of patient delay in seeking care for worsening heart failure symptoms in out-of-hospital settings: protocol for a systematic review and meta-analysis.

introductionWorsening heart failure (HF) is common and associated with rehospitalisation, premature death, poor quality of life and high healthcare costs. Patients frequently delay seeking medical care for hours or days after symptom escalation, and longer delays are linked to more severe clinical status at presentation and worse outcomes. Existing quantitative and qualitative studies have explored multiple potential determinants of patient delay, but findings remain fragmented and inconsistent, partly due to differing sets of candidate predictors and variation in populations and healthcare settings. To date, no HF-specific, theory-driven systematic review has synthesised determinants of patient delay for worsening HF within Andersen's Behavioural Model of Health Services Use or quantified their associations with delay. METHODS AND ANALYSIS: This protocol describes a systematic review and meta-analysis that will synthesise determinants of patient delay in seeking care for worsening HF symptoms arising in out-of-hospital settings among adults (≥18 years). We will include observational analytical studies (cohort, case-control and analytical cross-sectional designs) that report quantitative measures of patient delay, defined as the time from first awareness or onset of worsening HF symptoms to the decision to seek care or first contact with a healthcare facility. Based on Andersen's model, candidate determinants will be grouped as predisposing, enabling and need factors. We will search PubMed, EMBASE, Web of Science Core Collection, CINAHL, Cochrane Library, CNKI, WanFang Data and SinoMed from inception to 25 November 2025, include full-text articles in English or Chinese and perform duplicate screening and data extraction. Risk of bias will be assessed using the Newcastle-Ottawa Scale for cohort and case-control studies and the JBI critical appraisal tool for analytical cross-sectional studies and where appropriate we will conduct random-effects meta-analyses to pool effect estimates for the same determinant and delay definition with prespecified subgroup and sensitivity analyses to explore heterogeneity. The certainty of evidence for key determinant-delay relationships will be graded using the Grading of Recommendations Assessment, Development and Evaluation approach, and where meta-analysis is not feasible, we will provide structured narrative synthesis. ETHICS AND DISSEMINATION: As this study involves secondary analysis of published, anonymised data, formal ethical approval and informed consent are not required. Findings will be disseminated through peer-reviewed journals, academic conferences and knowledge translation to inform clinical practice and patient education. PROSPERO REGISTRATION NUMBER: CRD420251242808.