Health-seeking behaviours of immigrants, asylum seekers and refugees in Europe: a systematic review of peer-reviewed articles

Purpose – Immigrants,asylumseekersandrefugeeslivinginEuropefaceanumberofchallengesinaccessing or using health information and healthcare services available in their host countries. To resolve these issues and deliver the necessary services, providers must take a comprehensive approach to better understand the types of health information and healthcare services that these individuals need, seek and use. Therefore, the purpose of this paper is to develop that comprehensive approach. Design/methodology/approach – Inthispaper,asystematicliteraturereviewofpeer-reviewedpublications was performed, with 3.013 articles collected from various databases. A total of 57 qualifying papers on studies conducted in Europe were included in the review after applying the predefined inclusion and exclusion requirements, screening processes and eliminating duplicates. The information seeking and communication model (ISCM) was used in the analysis. Findings – Thefindingsrevealedthatwhilemanyhealthinformationandhealthcareservicesareaccessiblein Europefor immigrants, asylumseekersand refugees, many ofthese individuals are unaware of theirexistence or how to access them. While our findings do not specify what health-related information these groups need, use or seek, they do suggest the importance and value of providing mental health, sexual health and HIV, as well as pregnancy and childbirth information and services. Furthermore, according to our results, health information services should be fact-based, easy to understand and raise awareness about healthcare structure and services available in Europe for this vulnerable population. Practicalimplications – Thisstudyhasarangeofpracticalimplications,including(1)highlightingtheneed formentalhealthandbehaviouralhealthservicesand(2)stressingthevalueofaddressingculturalcontextand religious values while investigating (health) information seeking of people with foreign background. Originality/value – This is one of the first studies to systematically review and examine the behaviour of immigrants, asylum seekers and refugees in relation to health information and healthcare services in the European context.


Introduction
Europe has historically faced several internal migrations and also migrations from other continents. There has been a significant increase in the number of people migrating to Europe in recent years. For example, the number of asylum seekers in Europe grew from 200,000 in 2008 to 1,400,000 in 2015 (Eurostat, 2020) and this figure is continuously rising. This has led to remarkable changes in the cultural, social, political, economic and healthcare structures of the European countries that are open to migration (Sansus et al., 2020, p. 59). People move to Europe for different reasons such as immigration, family ties, work, in search of refuge, or seeking for asylum due to political situations in their countries of origin (Van Mol and De Valk, 2016).
The provision of healthcare services to these individuals living in Europe is one of the most highly investigated problems. The importance of studying this demographic, especially their seeking behaviour for health information and healthcare services, is increasing as the number of residents with a foreign background in Europe continues to rise. Understanding what sort of health information and healthcare services this group of people needs, as well as how they pursue those information and services, is the first step towards addressing the challenges they may face.
In this study, we looked for scientific research on health information-seeking behaviour (HISB) and health-seeking behaviour. According to Lalazaryan and Zare-Farashbandi (2014), HISB refers to a range of possible situations, from an accidental exposure to health information, to the need for such information, as well as finding, selecting, using and even ignoring information. The HISB has been extensively researched among immigrants in the USA (e.g. Chen et al., 2010;Galeshi et al., 2018;Lee, 2018;Shin and Maupome, 2017;Yoon and Huang, 2017;Woodall et al., 2009). However, we found very few studies in Europe that focused on these groups. As a result, it was considered necessary and timely to concentrate on this demographic, extend the spectrum from health information-seeking behaviour to a broader viewpoint and examine the population's health-seeking behaviour. In this approach, we hope to look at research from the perspectives of both health-seeking behaviour and health communication.
The existing studies that have focused on immigrants, asylum seekers and refugees in Europe have used common categories regarding the population's health-seeking behaviours. These studies have focused on topics such as healthcare needs, healthcare seeking, selection of healthcare sources, healthcare assessment and use, evaluation of health-seeking outcomes, health-seeking strategies and future healthcare seeking intentions; all from the patients' perspectives (Biswas et al., 2011;Gondek and Kirkbride, 2018;Onyigbuo et al., 2018).
In light of these categories, this research employs Robson and Robinson's (2015) information seeking and communication model to cover all specific aspects of the healthseeking process from the perspectives of both users and healthcare providers. In this paper, "users" refers to immigrants, asylum seekers and refugees residing in Europe, while "healthcare providers" refers to, e.g. healthcare professionals and medical staff. Moreover, in the European context, this study examines the experiences of healthcare professionals in terms of health information needs, information sharing with patients, evaluation and utilisation of health information and healthcare services by these individuals (Degni et al., 2012;Delilovic et al., 2018;Koehn, 2006;Misra et al., 2006b;Sundvall et al., 2018). By using the information seeking and communication model as a categorisation method, we hope to gain a holistic view of the phenomenon. We used this model to conduct a literature review of healthcare providers' perspectives on health communication needs, communication methods and communication barriers between healthcare professionals and their patients. To the best of our knowledge, there is a dearth of studies on the health information-seeking behaviours of immigrants, asylum seekers and refugees in Europe. Of the handful existing studies, few have been conducted on the behavioural aspects of health information-seeking (Devillanova, 2008;Ekblad et al., 2012;Garnweidner et al., 2013;Lecerof et al., 2011). Furthermore, a comprehensive analysis of the literature on the health information and healthcare service needs of immigrants, asylum seekers and refugees, as well as the type of information sought and used by them, and how they interpret the information received, is missing. As a result, this review paper seeks to fill this void by presenting new perspectives and highlighting areas that need more study. We hope to have answers to the following research questions in particular. RQ2. From the healthcare providers' perspective, what type of health information and healthcare services are used, and how do they evaluate the health-seeking behaviour of immigrants, asylum seekers and refugees residing in Europe?

Methods
To pursue the aim of this study, a literature search was conducted in October 2019, using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (Shamseer et al., 2015). The primary goal of this study was to focus on the health informationseeking behavior of immigrants, asylum seekers and refugees living in Europe, as there have been few studies on this subject (see, e.g. Ekblad et al., 2012;Lecerof et al., 2011). In this study "health information-seeking behaviour" refers to individuals' use of specific actions and/or strategies to acquire health information (Lambert and Loiselle, 2007, p. 1,008). This approach includes HISB processes related to how individuals cope with health-threatening situations (Davison et al., 2002;Garvin et al., 2003;Hoskins and Haber, 2000;Ransom et al., 2005;Rees and Bath, 2000). In addition, we also focused on studies of health-seeking behaviours as problem-focused coping strategies adopted by patients and healthcare providers as responses to threatening situations (Rees and Bath, 2000). We argue that this approach will provide a better understanding of which health information and healthcare services are needed, sought and used by this target group. In order to be as comprehensive as possible and include all relevant information, we considered qualitative, quantitative and mixed-methods studies as well as the case reports provided that they were original studies and published in peer-reviewed journals or conference proceedings. To be included in the review, studies had to (1) be published in English or English along with another language, (2) focus on human health-related issues, (3) focus on immigrants, asylum seekers and/or refugees residing in Europe and (4) be original studies, not a brief review of an original study published in a conference paper or editorial note. Since our focus was on specific target groups in Europe, other minorities such as indigenous ethnic minorities or subcultures (e.g. S ami-speaking minorities in Finland, Sweden or Norway) were excluded. Furthermore, studies were also excluded if they focused primarily on the legal or political aspects of healthcare service provision for refugees and/or asylum seekers, rather than focusing their health-seeking behaviour.

Search terms
The search consisted of free terms related to the main objectives of the study, and truncation (*) as well as research subject terms and keywords were used. The search terms were combined by using the Boolean operators "AND" and "OR." In addition, the terms "asylum seeker," "refugee" and "immigrant" along with all their synonyms and related terms were combined with proximity operators with a distance space of 10 (adj 10) to retrieve more results. The formulated search statement of this study was as follows: ((health information OR health seek* OR health help* OR care seek* OR health behavi* OR health commun* OR information practice* OR information literacy) AND (emigra* OR immigra* OR refuge* OR asylum seek* OR foreign* OR migra*)).

Study model
The information seeking and communication model (ISCM) was used to categorise the articles (Robson and Robinson, 2015). This model was developed to track information sharing JD 78,7 and communication between users and providers (see Robson and Robinson, 2015, p. 1,045). In our study, as mentioned earlier, users were immigrants, asylum seekers or refugees residing in Europe, and providers were healthcare providers in Europe. Moreover, this model also covers all factors relevant to health information-seeking behaviour such as information needs, information seeking, selection of information sources and information assessment, use or dismissal. The ISCM is a relatively new and a more comprehensive model compared to previous models of information seeking and communication, such as those developed by Wilson (1981) and Ellis (1989). Moreover, the ISCM was developed building on previous models from the fields of library and information science (LIS) and communication studies (e.g. Dervin, 2005;Ellis, 1989;Ingwersen and J€ arvelin, 2005;Johnson, 1997;Thackeray and Neiger, 2009;Wilson, 1981).
We categorised our selected articles according to the information seeking and communication model aiming at analysing and interpreting the findings from healthseeking behaviour research and to explore factors influencing this process in the studied groups of people. We reinterpreted the model from information seeking behaviour to healthcare seeking in order to explore the topic and shed light on different aspects of the phenomenon from both providers and users' points of view. We did not consider any labelling for the last step of the ISCM, which refers to the user needs' satisfaction from the healthseeking process. The satisfaction, if mentioned in the selected studies, is described in relevant sections either in the summary of findings or when answering the research questions. The following categories were created based on the original model: (1) User: needs/wants/goals/perception.

Selection of studies
Studies were selected based on the research model in three phases: reviewing titles, abstracts, keywords and full-text records. All databases were searched simultaneously, and records were extracted either directly or through Publish or Perish Version 7.11 [1]. We used Rayyan [2] website and mobile application for conducting the systematic review. This tool is designed to help researchers in screening and selecting records based on the PRISMA guidelines. In the review phase, the first author screened all records and excluded those that did not fit to any of the categories created based on the ISCM (Robson and Robinson, 2015). We tried different strategies for selecting records conducted in Europe. In order to be sure that the studies are conducted in a European country, we read abstracts and methods of the articles. Table 1 shows the keywords used in the screening process.
In the second phase, abstracts of the selected articles were double-checked by all authors. Finally, full texts were screened for relevance by the first author and checked for accuracy by the co-authors.

Full text review: data extraction and search results
A code was developed for data extraction. The code captured general information of the studies (author, publisher, publication type and year), characteristics of the population studied (sample size, sample group background, place of recruitment and countries where the studies were conducted), methodological components (study design, methodological characteristics and means of data gathering), themes, objects and study results. A total of 3,013 records were retrieved from 12 databases. In addition to excluding the duplicated records, we removed the records if they were not available in English, within the relevant research domain, available in full text or did not match the criterion about the publication type. As such, we ended up with 947 articles. After title and abstract screening and removal of irrelevant records, 57 articles remained as the final sample (see Appendix 1). Figure 1 presents a complete overview of the whole screening and selection process.

Characteristics of the included studies
The final list (57 articles) addressed a wide variety of themes, including information about different health issues (e.g. cardiovascular disease, diabetes, diet and nutrition, mental health, oral health, perinatal health, pregnancy and childbirth, sexual health and HIV) and issues experienced by healthcare providers (e.g. communication and cultural issues, attitudes and perceptions as well as the research methods (see Table 2).
Keywords Title ((health information OR health seek* OR health help* OR care seek* OR health behavi* OR health commun* OR information practice* OR information literacy) and (emigra* OR immigra* OR refuge* OR asylum seek* OR foreign* OR migra*)) Inclusive European countries Exclusive Sub-culture, systematic review, literature review, editorial notes, human rights, health law, role of the employer, ambulatory care, safety science, mediators, education and debate, health information systems, health promotion, health policy and practice, faith-based community action, medicine and medical science and public health In studies on health-seeking behaviours, a qualitative approach (50%) was the most widely used methodology, and more than half of the studies focused on specific health-related issues (61.40%). In addition, the largest share of studies on mental health adopted a qualitative approach (47.36%), while 22 out of 57 selected studies did not focus on any particular health related theme as specified in Table 2. Some studies objectively focused on topics such as informing, educating or helping patients to decide on their health issues (e.g. Knipscheer and Kleber, 2001;Knipscheer and Kleber, 2005;Leavey et al., 2007;Lecerof et al., 2011;Straiton et al., 2018), and others objectively focused on understanding the healthcare provider's perceptions, attitudes and challenges in health services provision (e.g., Delilovic et al., 2018). Appendix 1 and Appendix 2 provide additional information on the articles such as categories, participants (place of recruitment) and means of data gathering, a descriptive  Table 2.
Key findings on healthseeking behaviours of immigrants, asylum seekers and refugees in Europe JD 78,7 summary of the selected studies including the country, participants (sample size, ethnic background of sample group). The largest share of studies was conducted in the United Kingdom, Sweden, The Netherlands and Germany (75.44%), while the rest were conducted in seven other European countries. Interviews and semi-structured interviews were the most common means of data gathering for qualitative studies (36.84%), whereas questionnaires were most commonly used in quantitative studies (15.79%). A mixed-methods approach was adopted in 14.03% of the studies. More than half of the studies had small sample sizes (1-100); the majority of participants were of African or Middle East background (59.65 and 50.88%, respectively). Participants were mainly recruited through hospitals, clinics, health centres (33.33%), voluntary groups, cultural communities (28.07%) or refugee camps or refugee reception centres (17.54%) (see Appendix 1 and 2).

Summary of findings based on the research categories
The results showed that most of the studies focused on users' points of view and covered issues related to needs (24.56%), use (28.07%) and communication medium and process (8.77%).
Health communication medium and process (8.77%), healthcare needs (7.02%) and healthcare use (1.75%) were also discussed from healthcare providers' points of view. We also found discussions on other issues such as information seeking (26.32%), source selection (8.77%), outcomes (8.77%) and further information seeking (1.75%). The largest number of studies on using health services had participants with either African or the Middle East ethnic backgrounds (81.25 and 56.25%, respectively). These studies highlighted issues related to the provision of access to medical services for asylum seekers, refugees and immigrants in Europe (see Appendix 1). Next, we present findings based on our model of study. User: needs/wants/goals/perception. In total, fourteen articles discussed and covered the various types of health services that asylum seekers need, using either qualitative or quantitative approaches (see Appendix 1). These studies emphasised that mental health services were highly needed (e.g. Bartolomei et al., 2016;Djuretic et al., 2007;Gondek and Kirkbride, 2018;Kleinert et al., 2019;Laban et al., 2008;Maier and Straub, 2011;Misra et al., 2006a;Palmer, 2007;Papadopoulos et al., 2003). However, healthcare services related to respiratory diseases, infections, musculoskeletal or connective tissue problems, gastrointestinal issues, injuries, perinatal health, pregnancy and childbirth, as well as diet and nutrition were also found to be needed (Garnweidner et al., 2013;Gewalt et al., 2018;Goodman et al., 2018;Emtell Iwarsson et al., 2019). Misra et al. (2006a) argued that providing health services for asylum seekers and refugees, due to their complex needs, must be broad-based and include social service and advocacy groups, as well as primary care and specialised mental health services.
User: assess/use/ignore communication. Sixteen articles covered issues related to assessing or using healthcare services. More than half of the studies were conducted in non-English speaking countries (e.g. Denmark, Finland, Germany, The Netherlands and Portugal), mostly with participants with either African or Middle Eastern backgrounds. These studies reported challenges with accessing or using psychiatric and psychotherapeutic treatments, sexual health and HIV treatments, pregnancy and childbirth services or with obtaining dental check-up appointments (Dias et al., 2020;Erdsiek et al., 2017;Jayaweera and Quigley, 2010;Kleber, 2001, 2005;Mattila et al., 2016;McMunn et al., 1998;Nikendei et al., 2019;Toar et al., 2009).
Moreover, participants reported differences in access to or the use of health services based on their ethnic backgrounds (Gerritsen et al., 2006). In addition, the participants (asylum seekers, refugees and immigrants) mentioned that factors such as migration status, length of residency, educational background and cultural norms and values have a significant influence on their choice and use of health services (Erdsiek et al., 2017;Hansen et al., 2008;Knipscheer and Kleber, 2001).

Health information and healthcare services
Participants in the studies conducted in the United Kingdom and Ireland had different attitudes towards assessing, using or dismissing health communication (e.g., Kang et al., 2019). They also indicated some challenges and difficulties in relation to navigating health communication or negotiating primary care services (Kang et al., 2019, p. 541). Such challenges rooted in the language barriers, inadequate interpretation services, lack of awareness of the structure and function of the national health system, difficulties meeting the costs of dental care, prescriptions, transportation and perceptions of discrimination in terms of race, religion and immigration status (Kang et al., 2019, p. 537). The main reasons for using health services in studies conducted in the United Kingdom were related to psychiatric, musculoskeletal and dermatological treatments (Carruthers and Oakeshott, 2019).
Regarding factors influencing the use of health services, local and transnational social networks, ethnicity, birthplace and length of residency in the host country were found to impact migrants' health decision-making processes (Jayaweera and Quigley, 2010;Thomas, 2010). In a comparative study on self-reported health and healthcare utilisation, Toar et al. (2009) found that asylum seekers and refugees living in Western countries need healthcare services related to mental health issues, especially about posttraumatic stress disorder (PTSD). In addititon, a strong need for health information related to HIV/AIDS prevention was found in two studies on Sub-Saharan African and African migrant communities (respectively, in Portugal and the UK) (Dias et al., 2020;McMunn et al., 1998). For example, Dias et al. (2020) argued that current HIVprevention interventions, especially HIV testing, are not reaching the target groups, and most likely prevention opportunities are being missed. This result indicated that Sub-Saharan African migrants probably are not aware of available sexual health services, for instance, sexual/reproductive health consultations. Therefore, the rate of using health services among these immigrants in Portugal is very low. Similarly, Mediterranean migrants with lower education in The Netherlands reported a more negative attitude towards consulting mental health services, mostly due to being less familiar with the services (Knipscheer and Kleber, 2005). Finally, a study on migrants from the former Yugoslavia living in the UK disclosed difficulties and challenges in adapting to a new healthcare system. The results highlighted a reflection of cultural appropriateness of mainstream services that led to constrains in service use (Djuretic et al., 2007). Furthermore, a quantitative study with participants with Asian and African ethnic backgrounds suggested that "in order to conduct a study on health and healthcare utilisation among asylum seekers and refugees, it is important to adopt a crosscultural adaptation of the chosen measurement instruments, translation and back translation only is not sufficient" (Gerritsen et al., 2004, p. 9).
User: communication medium/process. Five articles focused on health communication media and processes. On the one hand, from a user point of view, trust is a key to facilitate health communication between healthcare providers and users who are refugees or residents with different ethnic backgrounds (Feldmann et al., 2007;Garnweidner et al., 2013). For instance, midwifes were mentioned as trustworthy sources of nutrition-related information during antenatal care of pregnant women with different ethnic backgrounds residing in Norway (Garnweidner et al., 2013). On the other hand, findings from studies on undocumented immigrants and refugees emphasised the significant role of social information networks and transnational health networks as health communication media (Devillanova, 2008;Thomas, 2010). Finally, a study on vulnerable groups of Arabic-and Somali-speaking asylum seekers in Sweden reported that "providing health information in a host country through official channels needs to be based on fact-based information, and patients need to be treated with concern and respect" (Ekblad et al., 2012, p. 21).
Provider: needs/wants/goals/perception. Four studies covered issues related to healthcare providers' needs and goals in healthcare settings. The main topics of these studies were related to mental health services. Interviews were the most common form of data collection in studies conducted on immigrants, asylum seekers, refugees and healthcare providers in Sweden and the UK (Delilovic et al., 2018;Misra et al., 2006b;Palmer, 2007). In addition, healthcare providers in a study conducted on asylum seekers originating in Asia, the Middle East and the Indian subcontinent mentioned their difficulties in decoding languages of distress, and understanding trauma and subjective meanings of suicide, challenges of combining patients and their perspectives and a sense of shared powerlessness (Sundvall et al., 2018). Moreover, healthcare professionals in a study investigating the experiences of professionals who treat asylum seekers and refugees argued that "it is hard to explore health problems such as depression or somatisation as they felt that the interpreter may not be accurately translating the words, or there may not be a word for depression in the language being used" (Misra et al., 2006b).
Still, in a study exploring healthcare provider perspectives on health examinations for asylum seekers in Sweden, healthcare professionals encountered challenges including intercultural competence, guidelines and tools on how to appropriately assess mental health and individuals' willingness to disclose personal experiences (Delilovic et al., 2018). A study on asylum seekers and refugees living in the UK provides some practical solutions to cover health service providers' needs while providing services for this vulnerable patient group. Health service providers need to be aware of the cultural, social and political context within which individuals operate and are judged. Furthermore, healthcare providers need to have education and training programmes to incorporate the understandings and allow for considered and sensitive exploration of the belief systems operating in asylum seekers and refugees' communities (Misra et al., 2006b). Finally, healthcare providers need to develop their treatment programmes for this group of patients as a flexible, preventative approach based on different, complex, individual requirements, allowing for inclusion of traditional and alternative treatment options and longevity of treatment programmes (Misra et al., 2006b).
Provider: assess/use/dis-/misinformation. Among the studies selected for the review, we found an interesting comment related to the healthcare provider assessment and dis-/ misinformation. In a study conducted on female suicidal asylum seekers living in the UK, mental healthcare providers reported challenges related to understanding unfamiliar expressions; particularly, cultural idioms of distress (Sundvall et al., 2018).
Provider: communication medium/process. On the providers' side, the communication medium and process were pointed out by five articles covering topics including mental health, perinatal health, pregnancy and childbirth. Two studies mentioned that healthcare providers and patients' problems were grounded in the communication (including linguistic difficulties), cultural traditions and religious beliefs (Degni et al., 2012;Reynolds and White, 2010). In another study, healthcare providers were recommended to implement an approach that considered asylum seekers' cultural beliefs and traditional health practices in order for their patients to adhere to treatment recommendations (Koehn, 2006). Moreover, in a qualitative study conducted in Sweden focusing on the communication challenges between healthcare providers and patients, Sundvall et al. (2018) revealed that such communication is often affected by, e.g. the unbearable realities of the women, difficulties for clinicians in decoding languages of distress and understanding trauma and subjective meanings of suicide, as well as challenges with combining patients' and clinicians' perspectives, and a sense of shared powerlessness. In accordance with this result, asylum seekers in another Swedish study argued that due to poor communication, inadequate information and lack of clarity regarding the aim of health examinations, they felt that they received insufficient information both ahead of and during the health examination (Delilovic et al., 2018).
Health or information seeking activity/feelings/thoughts. This section covers studies on healthcare seeking and activities, and feelings or thoughts during this process, rather than health information-seeking which was rarely mentioned in the findings. The findings can, however, reveal possible activities, feelings or thoughts related to the information-seeking behaviour of the studied groups. The activity of seeking health services and expressing feelings and thoughts about the health services were discussed in 15 studies. First, in terms of Health information and healthcare services activities and thoughts, the importance of cultural values and religion within health seeking were highlighted in ten studies on mostly African migrants, whereas one study focused on immigrants with multi-ethnic backgrounds (Garnweidner et al., 2013;Gilgen et al., 2005;Hjelm and Apelqvist, 2016;Jensen et al., 2014;Knipscheer and Kleber, 2001;Onyigbuo et al., 2016;Onyigbuo et al., 2018;Palmer, 2007;Straiton et al., 2018;Teunissen et al., 2014). For instance, religion was pointed out to have impact on health-related lifestyle behaviour of firstgeneration Polish immigrants living in Germany (Morawa and Erim, 2018). Second, feelings and thoughts related to health seeking were found to be influenced by the education and the awareness of treatment opportunities, and by whether general medical care was perceived to be designed to meet patients' needs and expectations (Dorn et al., 2011;Garnweidner et al., 2013;Gilgen et al., 2005;Hjelm and Apelqvist, 2016;Onyigbuo et al., 2016;Straiton et al., 2018). Participants pointed out mental health services as the most sought-for health services, especially among immigrants from Africa, Asia, the Indian subcontinent and the Middle East (Teunissen et al., 2014;Leavey et al., 2007;Palmer, 2007;Straiton et al., 2018). Finally, acculturation, coping style, beliefs about healthcare and illness and their impact on self-care and care-seeking, recognition of symptoms, as well as cultural care were mentioned as factors influencing health seeking behaviour (Hedemalm et al., 2008;Hjelm and Apelqvist, 2016;Onyigbuo et al., 2016Onyigbuo et al., , 2018. Source selection: credibility/utility. Five studies pointed out some factors affecting selection and utility of healthcare services. On the one hand, studies on female asylum seekers revealed significant influence of behavioural factors, language and culture on accessing perinatal services, resources and information (Barkensj€ o et al., 2018;Reynolds and White, 2010). For instance, a study on perinatal health services found that when healthcare providers express empathic concern and have a listening behavioural approach towards their patients, patients feel empowered, acknowledged and encouraged, leading them to trust clinicians and diminishing fear relating to seeking healthcare services (Barkensj€ o et al., 2018). Another study conducted in the UK showed that the working environment of healthcare staff affects the services that they could provide to asylum-seeking women who were pregnant or had young babies (Reynolds and White, 2010). On the other hand, a study on Ethiopian refugees showed that the state of being a refugee has had impact on their health beliefs and practices (Papadopoulos et al., 2003). Furthermore, a study on undocumented migrants in Germany revealed that migration status has significant impact on the ignoring of health problems until they reach an acute and potentially life-threatening stage (Huschke, 2014).
Finally, a study about providing online information in primary care services for refugees and asylum-seekers showed that even though the majority of local statutory organisations, which are responsible for improving public health provide good information regarding coordination of services and evidence of a thorough health needs assessment; there is, however, a need for considerable work if the requirements for access to high quality information about services of the public and government are to be met (Kralj and Barriball, 2004).
Outcomes: actions/decisions/knowledge. This section covers five studies exploring factors influencing health outcomes. First, health literacy and educational level were reported to be the most important factors influencing health information-seeking outcomes for asylum seekers, refugees and immigrants (Lecerof et al., 2011;W angdahl et al., 2018). Health literacy refers to accessing, understanding, appraising and using health information (Sørensen et al., 2012(Sørensen et al., ). W angdahl et al. (2018 argued that "the outcome of healthcare-seeking is associated with comprehensive health literacy (CHL) and found that a considerable proportion of the refugees in Sweden have limited CHL, and report less than good health and impaired wellbeing, or that they have refrained from seeking healthcare" (p. 410). Lecerof et al. (2011) andW angdahl et al. (2018) argued that the asylum seekers, refugees and immigrants' health literacy level have impact on their health outcomes. Moreover, educational background and lack of health information were reported to have significant effects on the studied groups' JD 78,7 health decision-making processes (Lecerof et al., 2011). Second, factors including untreated mental conditions and patients ethnocultural background were mentioned in studies on health outcomes among asylum seekers in Finland and Germany Koehn, 2006). In addition, access to medical attention for routine check-ups, lack of awareness of primary medical care's surgery hours, perception of symptoms of illness, the role of nurses in asylum seekers' healthcare seeking, language translation services in primary care and the role of specialists' help in medical settings were all mentioned as more general factors influencing health outcomes of asylum seekers living in the UK (O'Donnell et al., 2007).
Future information seeking. Future information seeking was not mentioned in the selected studies in this systematic review; however, findings from a study on undocumented immigrants living in Denmark showed that future health-seeking strategies included selfmedication, contacting doctors in the home countries and borrowing health insurance cards from Danish citizens (Biswas et al., 2011). The main reason behind seeking alternative health services has rooted in having restricted access to healthcare; in particular, limited medical services rights, healthcare professionals' arbitrary attitudes, fear of being reported to the police, poor language skills, lack of local social networks, lack of knowledge about the healthcare system and lack of knowledge about informal networks of healthcare professionals, were the most important ones (Biswas et al., 2011).

Answering the research questions
Two main broad research questions were formulated in this study. The first question asks, "from the perspective of immigrants, asylum seekers, and refugees residing in Europe, what are their health information and healthcare service needs, what type of health information and healthcare services are sought and used, and how do they evaluate such services?" Many asylum seekers and refugees expressed a strong need for mental health services as a consequence of the stress entailed by immigration and asylum-seeking processes (Bartolomei et al., 2016;Djuretic et al., 2007;Gondek and Kirkbride, 2018;Kleinert et al., 2019;Kleber, 2001, 2005;Laban et al., 2008;Leavey et al., 2007;Maier and Straub, 2011;Misra et al., 2006a;Nikendei et al., 2019;Palmer, 2007;Papadopoulos et al., 2003;Straiton et al., 2018;Teunissen et al., 2014;Toar et al., 2009). Asylum seekers and refugees in other studies expressed they need health service related to respiratory problems, infections, muscular and skeletal issues, and injuries (Goodman et al., 2018).
The majority of studies highlighted the influence of culture and religion on the healthseeking behaviour of asylum seekers, refugees and immigrants in Europe (Hjelm and Apelqvist, 2016;Morawa and Erim, 2018;Onyigbuo et al., 2016;Onyigbuo et al., 2018;Papadopoulos et al., 2003;Straiton et al., Teunissen et al., 2014). For example, undocumented immigrants in The Netherlands reported that they seek healthcare advice first through their friends, religious leaders and religious communities, and lastly, through physicians (Teunissen et al., 2014). Moreover, Nigerian clergy and healthcare professionals living in the United Kingdom also mentioned using religious and cultural care along with formal healthcare methods in their health information-seeking processes (Onyigbuo et al., 2016).
Even though our findings are not directly describing what health-related information is needed, used, our sought by immigrants, asylum seekers and refugees residing in Europe, the findings of this review study highlight the importance of providing health-related information about mental health, sexual health and HIV, pregnancy and child birth for them (e.g., Barkensj€ o et al., 2018;Dias et al., 2020;Kleinert et al., 2019;Straiton et al., 2018). Also, health information should be fact-based, easy to understand and raise awareness about healthcare structures and health services which are available for this vulnerable group of residents in Europe (e.g. Ekblad et al., 2012;Hjelm and Apelqvist, 2016;Kang et al., 2019;Onyigbuo et al., 2016;Straiton et al., 2018).

Health information and healthcare services
The second research question asks, "from the healthcare providers' perspective, what type of health information and healthcare services are used, and how do they evaluate the healthseeking behaviour of immigrants, asylum seekers, and refugees residing in Europe?" Not surprisingly, healthcare providers mentioned challenges related to communication with the patients while they are providing health services related to mental health, perinatal health, pregnancy and childbirth (Delilovic et al., 2018;Degni et al., 2012;Koehn, 2006;Reynolds and White, 2010;Sundvall et al., 2018). Apart from difficulties related to assessing the patients' health, linguistic barriers and religious or cultural differences, many healthcare providers experience difficulties in decoding language of distress and unfamiliar expressions, as well as cultural idioms of distress (Degni et al., 2012;Delilovic et al., 2018;Reynolds and White, 2010;Sundvall et al., 2018). In addition, physicians added that there is a lack of appropriate training programmes, which could help them to deal with asylum seekers and refugees in need of mental health services (Misra et al., 2006a). Healthcare providers reported that their evaluation of the health seeking of immigrants, asylum seekers and refugees residing in Europe depends on factors such as quality of communication and communication style between patients and healthcare providers, quality of interpreting services, whether the perspectives of patients and physicians are combined in healthcare services and a mutual understanding of cultural similarities and differences between healthcare professionals and users (Degni et al., 2012;Koehn, 2006;Sundvall et al., 2018). These findings, from an information point of view, can shed light on topics such as the importance of providing guidelines, tools and information related to providing special health-related services for the patients (Delilovic et al., 2018).

Discussion and conclusion
The results of this systematic review study show the health-seeking behaviours of immigrants, asylum seekers, and refugees in Europe have been analysed in a number of disciplines, ranging from medical science to health communication science. Findings from a systematic review of 57 articles revealed that this subject has been studied using qualitative, quantitative and mixed methods approaches. The articles included in the review looked at both the viewpoints of healthcare providers and patients, but the majority of them concentrated on only one.
We reinterpreted the information seeking and communication model (ISCM) to categorise, label and interpret the findings. Using the ISCM helped us to track health-seeking behaviour and health information sharing and communication between users (our target population) and healthcare providers. The advantage of the ISCM is that it allows to observe information sharing between patients and healthcare providers from the starting point to the evaluation of the acquired health information (Robson and Robinson, 2015). Applying this method also helped us to capture and interpret health-seeking behaviours of asylum seekers, refugees and immigrants while considering contextual and environmental influential factors.
The findings of the reviewed articles emphasise the significant role played by religion, beliefs and cultural norms in the healthcare-seeking behaviour of the studied groups (e.g. Hjelm and Apelqvist, 2016;Morawa and Erim, 2018;Onyigbuo et al., 2016;Onyigbuo et al., 2018;Papadopoulos et al., 2003;Straiton et al., 2018;Teunissen et al., 2014). The findings show that there are limited number of studies on information-seeking behaviours of the studied groups, and the majority of studies have focused on healthcare services provision, limitations, and facilitators. Therefore, this systematic review cannot provide clear answers to all questions related to health information needs, uses and the efficiency of the processes for both healthcare providers and users. However, the results showed the importance of providing health-related information on topics related to mental health, sexual health and HIV and pregnancy and childbirth for immigrants, asylum seekers and refugees living in Europe JD 78,7 (e.g. Barkensj€ o et al., 2018;Dias et al., 2020;Kleinert et al., 2019;Straiton et al., 2018). Moreover, the results highlight the role of friendship and individual networks, and religious communities as first-hand health information sources for the studied populations (Devillanova, 2008;Ekblad et al., 2012;Thomas, 2010).
Common barriers in using and assessing health information or services are the difficulties to navigate or negotiate health related issues, to get an appointment for treatment, to assess the quality of the received treatment, to access the required healthcare services and to know one's medical services rights (Erdsiek et al., 2017;Kang et al., 2019;Mattila et al., 2016;Nikendei et al., 2019). The findings also show alternative health-seeking strategies such as using transnational health networks to cope with the aforementioned barriers (Thomas, 2010). Researchers also report that health literacy and educational level play a significant role in adapting to health-seeking approaches and strategies (Lecerof et al., 2011;W angdahl et al., 2018).
The studies highlighted the importance of adopting a cross-cultural approach in providing health services and health information, specifically regarding the adaptation of measurement tools in terms of translation, cultural norms and values (Gerritsen et al., 2004). For example, mental health problems are a taboo topic in the African and Asian cultures. Lack of knowledge or lack of trust in physicians as well as general barriers to accessing healthcare services are also considered important factors influencing the health-seeking behaviour of immigrants living in Europe (Teunissen et al., 2014).
This research adds to the body of knowledge by revealing new details about the health (information) seeking behaviours of asylum seekers, refugees and immigrants in Europe, as well as new insights into this phenomenon from the perspective of healthcare providers. Findings of the reviewed studies were arranged into nine broad themes (see Table 2). Half of the studies included in the review covered particular health issues; however, mental health and parental health were the most common among the studied subjects. Furthermore, almost half of the articles did not focus on any particular health issue and mainly discussed the health-seeking behaviour of this particular population on a more general level. Among the studies focusing on a specific health issue, the majority investigated topics related to mental health, possibly due to the prevalence of stress experienced during the process of becoming an immigrant, an asylum seeker or a refugee. Therefore, it can be argued that the provision of information related to psychological health is highly needed by ethnic minorities living in Europe. More attention should be paid to healthcare providers and users' search, use and assessment of healthcare information and services. One major result of this review study was not only revealing the overall lack of studies focusing the health information behaviour of the studied population but also showing the lack of findings related to information in the studies we reviewed. In contrast to similar studies in the USA (e.g. Chen et al., 2010;Galeshi et al., 2018;Lee, 2018;Shin and Maupome, 2017;Yoon and Huang, 2017;Woodall et al., 2009), this topic is surprisingly neglected and our review points to an urgent need for additional studies in the European context.

Implications
Immigrants, asylum seekers and refugees experience numerous health service needs. This systematic review highlighted the importance of addressing these issues. The results of this study have some implications for healthcare providers, health policymakers and relevant authorities. First, the review results identified health services commonly sought by the studied population, including those related to mental health, perinatal health, pregnancy and childbirth, oral health, diabetes, diet health, cardiovascular health and sexual health and HIV. Our findings identified an area of concern related to mental health services and relevant health information for these groups. As such, it is suggested that healthcare providers pay more attention to these Health information and healthcare services concerns. Second, this review identified the role of healthcare providers' attitudes and of users' trust in them in relation to health services selection. These behavioural factors must be taken into consideration when providing health services for these groups. The results also highlighted the need for culturally specific and accurate health information targeted towards immigrants, asylum seekers and refugees in Europe. Health services providers and health professionals should develop services and information materials that are culturally specific for these population groups. The health services and health information should be pilot tested in these groups to ensure that they meet the occurring health (information) needs. The results also shed light on the need for cultural competence among healthcare providers, so that they can better address the needs of these users. Finally, the findings underline the importance of developing a patient-provider communication approach aiming at the improvement of encounters and communication between healthcare providers and immigrants in Europe. Additional studies should be conducted to explore how culturally specific health information can be delivered to this population.

Limitations
The search strategy of this review initially focused on the health information-seeking behaviours of immigrants, asylum seekers and refugees in Europe. However, we decided to broaden the search from health information-seeking behaviours to health-seeking behaviours, in order to include more relevant studies. We are aware that there may be relevant references concerning other minorities in Europe. However, we focused on the healthcare needs of asylum seekers, refugees and immigrants, without including those of other local minorities. We also acknowledge that this systematic review may not represent all relevant fields, as the scientific databases used in this review did not necessarily contain references to all the key publications. However, we are confident that the articles examined and evaluated in this review provide an overall overview of the body of academic publications within this multidisciplinary area of research.
Notes 1. A software package for retrieving and analyzing academic citations from different scientific and open access databases.