Table 2.

General study characteristics, quality appraisal, and findings of fourteen studies addressing migrant sexual health help-seeking behavior in high income countries.

Title	Research Objective	Study Design	Conclusions/Recommendations
Adedimeji et al. (2015) [36] Increasing HIV testing among African immigrants in Ireland: Challenges and opportunities	To identify barriers for African migrants to access voluntary HIV testing, and to assess possible solutions to increase rates of HIV testing among this population.	Setting: Ireland Inclusion criteria/eligibility: Migrants from Africa, lived in Ireland more than 2 years and not previously diagnosed with HIV. Sample: 60 participants—focus groups (n = 56), interviews (n = 4). Mean of 4.7 years since migrating to Ireland. Age range: 18–64 years old Gender: Male and female Type of study: Qualitative; semi-structured interviews and focus groups Recruitment: Convenience and snowball sampling Ethical approval: Yes	Conclusions: Barriers to HIV testing in African migrants in Ireland were found, including fear of consequences of an HIV diagnosis (residency status and social relations) and test affordability. Recommendations: Involve stakeholders (immigrant group leaders, policy makers, health providers and religious leaders) in interventions to increase HIV testing to ensure cultural acceptability.
Agu et al. (2016) [27] Migrant sexual health help-seeking and experiences of stigmatization and discrimination in Perth, Western Australia: Exploring barriers and enablers	To explore barriers and enablers to sexual health help-seeking behaviors, and experiences of stigma and discrimination among migrants from sub-Saharan Africa and Southeast Asia living in Perth, Western Australia.	Setting: Australia Inclusion criteria/eligibility: Born in SEA or SSA, lived in Australia more than one year. Sample: 45 participants—21 from SSA, 19 SEA, 5 from other regions. 35 (76%) of participants had arrived in Australia less than 5 years. Age range: 18–50 years old Gender: Male and female Type of study: Qualitative; focus groups Recruitment: Purposive and snowball sampling techniques. Ethical approval: Yes	Conclusions: Barriers and enablers to sexual help-seeking behaviors included sociocultural and religious influence, financial constraints and knowledge dissemination to reduce stigma. Common experiences of stigma and discrimination (including in health care settings) and the social and self-isolation of people living with HIV. Recommendations: Address stigma and discrimination in health care settings. Provide culturally-appropriate sexual health knowledge that is group specific rather than targeted at migrants universally.
Akerman et al. (2017) [35] Healthcare-seeking behaviour in relation to sexual and reproductive health among Thai-born women in Sweden: a qualitative study	To explore sexual health help-seeking behaviors and views of HIV among Thai women living in Sweden.	Setting: Sweden Inclusion criteria/eligibility: Born in Thailand and living in Sweden less than five years Sample: 19 participants Age range: 24–50 years old Gender: Female Type of study: Qualitative; in-depth, semi-structured interviews Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Low sexual and reproductive health care use and low uptake of HIV testing. Women expressed low perception of risk to HIV. Barriers to healthcare included: language difficulties and low knowledge about the healthcare system. This resulted in a dependence on partners to access health services, or a preference to seek medical help in Thailand. Recommendations: Offer HIV testing as part of cervical cancer screening. Offer free health examinations to Thai migrants.
Drummond et al. (2011) [29] Barriers to accessing health care services for West African refugee women living in Western Australia	To examine barriers in accessing and utilizing health services of West African women refugees compared to Australian women.	Setting: Australia Inclusion criteria/eligibility: Refugee women from Liberia or Sierra Leone Sample: 51 women from Liberia or Sierra Leone and 100 Australian women (comparison). Women were newly arrived (less than 5 years) and had lived in refugee camps up to 10 years before resettlement. Age range: 20–67 years (West African), 18–90 years (Australian) Gender: Female Type of study: Quantitative; comparison study Recruitment: Snowball sampling Ethical approval: Yes	Conclusions: Barriers to accessing health care were negatively correlated with longer residence and higher education Emotional factors and service provider perceptions were major barriers to access healthcare services. Recommendation: Implement intensive health promotion campaigns through social networks and ethnic media.
Dune et al. (2017) [28] Culture Clash? Investigating constructions of sexual and reproductive health from the perspective of 1.5 generation migrants in Australia using Q methodology	To investigate the role of culture in constructions of sexual and reproductive health and health care seeking behavior from the perspective of 1.5 generation migrants	Setting: Australia Inclusion criteria/eligibility: Not described Sample: 42 participants with majority from SSA (43%) and SEA/EA (29%). Other regions included: Europe, Middle East and the Americans. 43% had arrived in the last 10 years. Age range: 18–39 years Gender: Male and female Type of study: Quantitative; Q methodology Recruitment: Purposive; flyers posted at relevant venues Ethical approval: Yes	Conclusions: Some migrants’ constructs of sexual and reproductive health changed when in a new culture; others had difficulty integrating new cultural values. Culture may be more easily adapted as many aspects of home (e.g., political, economically, etc.) do not exist in new country. Religion is portable, and may be the reason for an experience of ‘culture clash’ for some migrants.
Guionnet et al. (2014) [37] Immigrant women living with HIV in Spain: A qualitative approach to encourage medical follow-up	To examine the facilitators and barriers to medical follow-up among immigrant women living in Spain	Setting: Spain Inclusion criteria/eligibility: Women living with HIV; born in Spain, SSA or Latin America Sample: 26 participants—10 from SSA, 8 from Latin America, and 8 from Spain. Age range: 25–55 years old Gender: Female Type of study: Qualitative; semi-structured interviews Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Barriers for immigrant women living with HIV in continuing treatment included cultural, social, and gender roles, relationship with the healthcare system, and self-perception. Recommendations: Health professionals to work to identify and overcome barriers faced by patients in adhering to treatment
Korner (2007) [32] ‘If I Had My Residency I Wouldn’t Worry’: Negotiating Migration and HIV in Sydney, Australia	To describe the interrelationships between migration and resettlement, the Australian immigration system and living with HIV.	Setting: Australia Inclusion criteria/eligibility: People living with HIV, born in a non-English country, or speaking a language other than English at home Sample: 29 participants—16 (55%) in Asia, remainder from South America and Southern Europe; 11 (38%) were permanent residents, 12 (43%) had been in Australia longer than 10 years. Age range: 29 to 58 years Gender: Male and female Type of study: Qualitative; interviews Recruitment: Purposive sampling via a non-government organisation and a sexual health clinic Ethical approval: Yes	Conclusions: Main issue faced by migrants living with HIV was migration Uncertain immigration status can be a barrier to treatment, health care and support. Recommendations: Reduce barriers to accessing health services, including reviewing the practice of rejecting permanent residency applications of people living with HIV Address HIV-related stigma in migrant communities
Lindkvist et al. (2015) [40] Fogging the issue of HIV—Barriers for HIV testing in a migrated population from Ethiopia and Eritrea	To identify barriers faced by Eritrean and Ethiopian migrants in Stockholm, Sweden for HIV testing.	Setting: Sweden Inclusion criteria/eligibility: Born in Ethiopia or Eritrea Sample: 28 participants; focus groups (n = 21), interviews (n = 7). Arrival in Sweden ranged from 2 to 25 years. Age range: Age not reported Gender: Male and female Type of study: Qualitative; focus groups and interviews Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Main barrier was ‘fogging the issue of HIV’—categorised as hiding the truth, living in denial and seeking help outside the healthcare system. This was due to distrust of the healthcare system and fearing the consequences of living with HIV. Recommendation: Provide culturally appropriate information on HIV-related issues, in combination with offers of HIV testing early on arrival to Sweden.
Manirankunda et al. (2009) [38] “It’s better not to know”: Perceived barriers to HIV voluntary counselling and testing among sub-Saharan African migrants in Belgium	To examine the barriers, needs, and perceptions of HIV voluntary counselling and testing (VCT) among sub-Saharan African migrants in Belgium	Setting: Belgium Inclusion criteria/eligibility: Identified as SSA; English or French speaking. Sample: 70 participants. Mean duration of stay 8.5 years. Age range: 18–49 years Gender: Male and female Type of study: Qualitative; focus groups Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Multiple barriers to VCT identified including: fear of dying of AIDS, fear of stigma or discrimination and low perceived risk of acquisition. Recommendation: Implement VCT with pre- and post-test counselling, including via health services and via community outreach testing.
McMichael and Gifford (2009) [30] “It is Good to Know Now…Before it’s Too Late”: Promoting Sexual Health Literacy Amongst Resettled Young People With Refugee Backgrounds	To explore young refugees’ accessibility to health information	Setting: Australia Inclusion criteria/eligibility: From refugee background. Sample: 142 participants—interviews (n = 14), focus groups (n-128). Most participants were from Iraq, Afghanistan, Burma, Sudan, Liberia and the Horn of Africa. Age range: 16–25 years Gender: Male and female Type of study: Qualitative; focus group discussions and interviews Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Similar barriers were found to health service access as other young people Experiences of forced migration, displacement, and resettlement brings additional challenges. Recommendation: Improve accessibility of sexual health services to reduce poor sexual health outcomes and increase sexual health literacy.
Rogers and Earnest (2014) [31] A cross-generational study of contraception and reproductive health among Sudanese and Eritrean women in Brisbane, Australia	To assess knowledge and access to contraception and reproductive health of mothers and daughters from Sudanese and Eritrean backgrounds living in Brisbane	Setting: Australia Inclusion criteria/eligibility: Sudan or Eritrean women from refugee or migrant background Sample: 13 participants—8 aged between 35–55 years, 5 aged 18–30. Age range: 18–30 years, or 35–55 years Gender: Female Type of study: Qualitative; focus group discussions Recruitment: Purposive and snowball sampling Ethical approval: Yes	Conclusions: A range of barriers found to health service access and contraceptive use included: lack of cultural competency and ineffective communication by health care workers; poor knowledge of health care system and intergenerational culture clash in relation to sexual health education in the home. Recommendations: Provide sexual health information for new migrants during process of resettling Develop partnerships between health care professionals and CaLD communities Provide translated health information and access to interpreters Design culturally sensitive strategies for parents to communicate with their children about sexual health and enable parent-daughter transfer of health information.
Shangase and Egbe (2014) [33] Barriers to accessing HIV services for Black African communities in Cambridgeshire, the United Kingdom	To examine barriers faced by Black African communities to accessing HIV healthcare services.	Setting: United Kingdom Inclusion criteria/eligibility: From African communities. Sample: 30 participants; most aged in their twenties and thirties Age range: 21–65 years Gender: Male and female Type of study: Qualitative; focus group discussions Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: A range of barriers found including language, limited knowledge of HIV, preference for traditional medicines and lack of cultural diversity among health service workers. Recommendations: Plan health services considering cultural diversity, including use of traditional medicine Ensure HIV workforce undertakes cultural competency training, and is culturally diverse.
Thomas et al. (2010) [34] “If I cannot access services, then there is no reason for me to test”: the impacts of health service charges on HIV testing and treatment amongst migrants in England	To examine the influence of England’s government health policy on migrants’ health seeking and HIV testing.	Setting: United Kingdom Inclusion criteria/eligibility: Living in the UK as a migrant Sample: 70 participants from South Africa, Zimbabwe, and Zambia Age range: Above 18 years Gender: Male and female Type of study: Qualitative; focus group discussions Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Changes in policy resulted in difficulties in accessing healthcare services due to cost and difficultly registering. Recommendations: Reverse the policy changes made Provide clear information and guidelines to both migrants and health workers in regards to accessing free health services.
Yakubu et al. (2010) [39] Sexual health information and uptake of sexual health services by African women in Scotland: A pilot study	To identify sources of sexual health information sought by African women in Scotland.	Setting: Scotland Inclusion criteria/eligibility: Women from Africa Sample: 96 survey respondents; 47% had lived in the UK less than 5 years. Age range: 16–55 years old Gender: Female Type of study: Quantitative; cross-sectional survey Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Poor knowledge of STIs and HIV and low uptake of sexual health services and regular screening. Recommendation: Develop collaboration between African communities in Scotland with the sexual health services to develop better HIV prevention program.
Ussher et al. (2012) [26] Purity, privacy and procreation: Constructions and experiences of sexual and reproductive health in Assyrian and Karen women living in Australia	To assess experiences of Karen and Assyrian woman refugees in utilizing SRH services in Australia	Inclusion criteria/eligibility: Women from Karen and Assyrian communities who arrived as refugees Setting: Australia Sample: 42 participants—28 (67%) from Karen communities. Karen participants had arrived on average 3.5 years ago. Age range: 25–45 years Gender: Female Type of study: Qualitative; focus group discussions Recruitment: Purposive sampling Ethical approval: Yes	Conclusions: Constructions and experiences of sexual health were closely tied to cultural, religious and gendered family views. Recommendations: Further research to explore interaction of gender, culture and migration process in the construction of sexual health.