It is a quantitative analytical cross-sectional study conducted in the cardiology department of the Ignace Deen Hospital, Conakry.

New patients referred to cardiology during the study period (6 months).

Patients officially referred to cardiology and having given their informed consent.

Patients not officially referred or refusing to participate.

A consecutive sampling was used, including all newly referred patients. This method ensures a better representativeness of the observed cases.

The sample size was not calculated a priori because of the exploratory nature of the study. All patients meeting the inclusion criteria during the study period were consecutively recruited.

The primary endpoint, referral delay, was defined as the time elapsed between the first consultation in a peripheral service and arrival at the cardiology department of CHU Ignace Deen. The level of knowledge was measured using a standardized score based on ten questions; the aggravation of health status was assessed by the presence of cardiovascular complications reported at admission; and institutional barriers were identified through the absence of referral protocols or qualified personnel.

Variable operationalization concerned patients, with dependent variables including distance to the medical center (km), patient income (GNF), waiting time after referral (days/hours), and satisfaction (Likert 1 - 5), while independent variables covered socio-economic factors (income, education), accessibility (km traveled), medical staff availability (staff/patient ratio), and referral protocol (yes/no).

After the bivariate analysis, all variables with a significance threshold less than or equal to 20% were automatically included in the multivariate analysis, with adjusted estimates presented alongside their 95% confidence intervals.

dependent variables: reference delay, waiting time after reference, patient satisfaction.independent variables: socio-economic factors (income, level of education), accessibility to care (distance, transport), availability of medical staff, existence of reference protocols.

The home-to-hospital distance was categorized into ≤10 km and >10 km in order to assess the impact of geographical accessibility on referral delay. The 10 km threshold was chosen because distances beyond this limit are associated with transportation difficulties, travel costs, and traffic congestion in the urban context of Conakry.

The national average monthly income used as a reference corresponded to the minimum interprofessional guaranteed wage (SMIG), estimated at approximately 980,000 Guinean Francs (GNF) at the time of the study.

The data were collected using standardized questionnaires and semi-structured interviews with patients and healthcare staff.

Descriptive analysis: frequencies, percentages, means and standard deviations.Bivariate analysis: tests of Chi 2, Pearson correlation and ANOVA according to the nature of the variables.Multivariate analysis: logistic and linear regression to identify predictive factors of reference delay. A significance threshold of p < 0.05 was chosen.

Socio-demographic and economic characteristics (Table 1).

Table 1. Socio-demographic and economic situation of the patients.

Commentary:

Gender: The distribution is relatively balanced between the sexes, with a slight predominance of women (52.3% against 47.7% of men).Marital status: The majority of patients are married (62.2%), followed by widows/widowers (23.4%). Singles and divorcees represent a small proportion (11.7% and 2.7%).Level of education: More than a third of patients are out of school (35.1%), while the primary, secondary and university levels are fairly homogeneous (19.8%, 25.2% and 19.8%).Monthly income: The distribution is balanced: 27.9% have incomes below the national average, 36.9% equivalent, and 35.1% higher.Age range: Patients aged 45 and over are largely majority (74%), compared to 26% for the 15 - 45 years old.

Commentary: Each patient underwent an individual interview, including specific questions aimed at identifying the possible reasons for delayed consultation with a healthcare professional. Among the 111 patients interviewed, 59 (53%) reported lack of financial resources as the main reason for delaying consultation with healthcare personnel. In addition, 58 patients (52%) mentioned the absence of public awareness campaigns on cardiovascular diseases. Preference for traditional medicine and fear of the diagnosis were also identified as contributing factors, reported respectively by 30 patients (27%) and 23 patients (21%) (Figure 1 & Table 2).

Figure 1.Reasons for delaying a visit to the doctor.

Table 2. Level of knowledge of patients on cardiovascular diseases.

Commentary: 56% of the patients referred to the department have average knowledge about cardiovascular diseases.

Table 3. Multivariate analysis of associations between socio-economic, geographical and organizational factors.

Comments and interpretation

Level of education: Unschooled patients had a significantly higher risk of referral delay (OR = 2.10; 95% CI: 1.20 - 3.70; p = 0.008). Elementary school level showed a borderline effect (p = 0.095), while high school was not significant. This highlights the role of education in timely access to cardiology services.Monthly income: Patients with income below the national average were more likely to experience referral delays (OR = 2.40; 95% CI: 1.30 - 4.50; p = 0.006). Those with average income showed a nonsignificant trend (p = 0.180). Financial constraints remain a major barrier to specialized care.Distance home–center: Living more than 10 km from the hospital was strongly associated with referral delay and complications (OR = 3.20; 95% CI: 1.80 - 5.60; p < 0.001). Geographical accessibility is therefore a critical determinant of patient outcomes.Presence of medical staff: Insufficient availability of medical personnel significantly increased the risk of worsening health status (OR = 2.70; 95% CI: 1.40 - 5.10; p = 0.003). Adequate staffing appears protective against delays and complications.

The study showed that the majority of patients referred to cardiology were over 45 years old (74%), confirming that cardiovascular diseases mainly affect older adults. This finding is consistent with WHO data which indicates that the prevalence of cardiovascular conditions increases with age [9]. Furthermore, more than one third of patients were out of school (35%), which reflects an increased vulnerability to awareness and understanding of cardiovascular risks. This weak instruction can limit the recognition of symptoms and delay the decision to consult, as shown by Gesase et al. [5]. Finally, nearly 28% of patients had incomes below the national average, which constitutes a major obstacle to access to specialized care. These results confirm that socio-economic factors play a determining role in the first delay.

The main causes identified were lack of financial resources (53%) and insufficient awareness about cardiovascular diseases (52%). Fear of diagnosis (20%) and preference for traditional medicine (27%) also contributed to delayed consultation. These findings are consistent with those reported by Sory et al. [6], who emphasized that low awareness and cultural beliefs negatively influence medical decision-making. Similarly, Conboy et al. [7] showed that financial insecurity and limited access to healthcare services are major factors contributing to delays in seeking medical care in West Africa. Preference for traditional medicine reflects an important sociocultural dimension that should be considered in awareness and healthcare access strategies, as also recommended by Barry et al. [8]. Financial barriers therefore remain a major obstacle to early access to specialized healthcare services in low-resource settings.

More than half of the patients had average knowledge of cardiovascular diseases (56%), but 23% had low knowledge. This lack of knowledge directly contributes to the delay in referral, as patients do not recognize symptoms or measure their severity. This observation is similar to that of [2][3], which showed that health education is a key factor in the prevention and management of chronic diseases.

The multivariate analysis showed that unschooled patients had a significantly higher risk of referral delay (OR = 2.10; 95% CI: 1.20 - 3.70; p = 0.008). Low income and living more than 10 km from the hospital were also strongly associated with delays and complications. Insufficient medical staff availability increased the risk of worsening health status (OR = 2.70; 95% CI: 1.40 - 5.10; p = 0.003). These findings confirm that both socio-economic and organizational factors are critical determinants of timely cardiology referral.

Delays were statistically related to patients’ income and distance from the hospital. Cardiovascular complications were more frequent among patients living farther away. Although these associations are strong, the cross-sectional design does not allow causal inference, but highlights important patterns that warrant further investigation.

In addition, the absence of a priori sample size calculation represents another limitation of this study. The sample was based on the consecutive recruitment of all eligible patients over a six-month period, which may limit the statistical power and generalizability of the findings.

This study has several limitations that should be acknowledged. First, its monocentric design limits the generalizability of the findings to other contexts. The consecutive sampling method, although ensuring representativeness of observed cases, may introduce selection bias. The reasons for referral delay reported by patients relied on selfdeclarations, exposing the analysis to recall bias. In addition, the sample size was not formally calculated but was based on the inclusion of all eligible cases during the study period. Finally, the crosssectional nature of the study does not allow causal inference between referral delay and worsening health status, but only statistical associations. These limitations should be considered when interpreting the results and highlight the need for multicentric and longitudinal studies to confirm these observations.