Individuals with immigrant backgrounds residing in the Asturias region (Northern Spain) were invited to participate in the study. The inclusion criteria were: being 18 years or older, possessing basic Spanish language skills, and having lived in Spain for a minimum of 3 months prior to the study.

The research team was supported by two non-governmental organisations (NGOs) in the region, Caritas and the Red Cross, for the recruitment of participants and the organisation of the sessions. These entities are strategic stakeholders within the region, providing a range of services that are designed to support the integration of the local immigrant population into society and participate fully in all aspects of life within the community. These services include, but are not limited to, Spanish language and culture courses, assistance with job searches, and guidance on administrative requirements. The sessions were organized in the facilities of strategic stakeholders in the community, which helped create a sense of familiarity with the participants.

Co-creation sessions: the methodology for the sessions is outlined in Table 1. Upon arrival, all participants were welcomed to the session facilities and reminded that their participation was voluntary. Each participant received a leaflet about the IDEAHL project and was advised to avoid using names during discussions to maintain anonymity. Two distinct participatory techniques were employed in each session to engage participants through diverse methods, enhancing the quality of feedback. This approach followed the IDEAHL methodology.

Each session was divided into two parts, allowing participants time to reflect on the ideas presented in the first part, enabling them to consolidate their responses in the second part.

The sessions were led by one coordinator and two facilitators. Two strategic stakeholder representatives, serving as co-facilitators, took notes to ensure cultural and target-group sensitivity in the data collection process. A participatory approach was followed. The choice of participatory techniques was made by the facilitators, in consultation with the strategic stakeholders, who offered recommendations based on their prior experience with the participants. In addition, the strategic stakeholders who understand the nuances of participants’ backgrounds, acted as cultural mediators and facilitated culturally sensitive communication, that is, they acted by clarifying expressions that could be confusing. The techniques employed included photovoice [18] and group interviews. A semi-structured interview guide developed in the IDEAHL project was used (Table 1).

Analysis of the information: field notes were collected using a standardized template developed in alignment with the IDEAHL methodology to ensure the quality of the data collected. Immediately following each session, facilitators and co-facilitators engaged in structured debriefings to reflect on the session dynamics, clarify observations, and validate interpretations. These discussions were incorporated into the analysis and contribute to ensuring data quality. Just after the sessions, the strategic stakeholders acting as co-facilitators, and the facilitators met together to revise and validate the information gathered. Three authors with experience in qualitative analysis participated in the analysis. The first author (IRH) analyzed the data in detail to discover saturation and recurrent patterns. This analysis involved rereading the notes several times to become familiar with the content. Themes and sub-themes were generated and indexed along with the written notes of all researchers. A detailed codebook was developed collaboratively prior to coding, outlining definitions and examples for each theme and sub-theme. This served as a reference to ensure consistency and reduce ambiguity during the coding process. To enhance inter-coder reliability, a subset of the data was independently coded by two researchers. Coding discrepancies were discussed and resolved through consensus, leading to refinement of the codebook. Two other authors (MPG and AFF) consolidated 100% of the total coding material to guarantee data quality, consistency, validity, and reliability of results. The reports were analysed using qualitative content analysis [19]. The subtlety of this analytical method helped identify patterns and key perspectives, providing a rich understanding of the barriers and needs related to DHL among immigrant populations. A qualitative data analysis software was used, - MAXQDA^® [20].

The study was approved by the Ethics Committee of Asturias (ref CEImPA 2023.004). All participants received an information sheet and signed an informed consent prior to the session. Anonymity was ensured throughout both the sessions and the data analysis process.

The characteristics of the participants are described in Table 2. 24 individuals from 12 countries participated in the study. The majority of participants were Spanish-speaking from the Americas (62.5%), while Africa and Europe accounted for 16.7% each and 4.2% from Asia. There were more female participants (75%). Additionally, 58.3% have been in Spain for less than or equal to 5 years.

Overall, all participants use their mobile devices to search for health information online. While they find this information helpful, they all consider advice from their doctor to be more reliable and essential. Many participants value the ability to seek health information online, particularly for disease prevention, as it allows them to access resources on healthy lifestyles. Several mentioned relying on more knowledgeable family members to assist in finding health information online. Participants also appreciate digital media for staying connected with loved ones, which positively impacts their mental health. They express deep gratitude for the support they receive from their community, recognizing that migration presents significant challenges. Overall, they reported having better access to digital resources and healthier habits in Spain compared to their home countries, and they view the Spanish healthcare system as high-quality, generally accessible, and free of charge.

A comparative analysis by sex reveals that women tend to use digital resources more frequently, particularly for topics such as nutrition, healthy lifestyles, emotional wellbeing (e.g., anxiety, stress), specific health conditions (e.g., cancer, migraines), and caregiving. In contrast, men focus more on targeted health concerns like smoking cessation and obesity, as well as practical uses such as fitness routines. Another key difference lies in how information is validated: women often cross-check sources or consult health professionals and family members with medical knowledge, while men are more likely to rely on personal judgment or general trust in the information they find online.

Three main themes, categories and codes were identified (Table 3): significance of DHL, socioeconomic and cultural factors hindering DHL and messages for new health policies.

This theme describes how useful it is for them to be able to search for health information on the internet, for what purpose they search for health information, what type of information they look for and which platforms they use most.

This theme describes the limitations the participants have found to search for health information using digital resources.

Although some barriers and challenges in using digital resources to look for health information were described earlier, some recurrent needs were identified to improve DHL among immigrant population.

Our study highlights the diverse dHL needs and challenges faced by immigrants. Participants view Digital technologies as a useful complement to information from healthcare professionals, mainly for consulting health issues, self-care, verifying information, and improving lifestyles. However, several barriers hinder its effectiveness, including language limitations, low health knowledge, and a lack of confidence in online information.

Participants stressed the importance of accessible, accurate, and practical health information that is free of charge and tailored to specific population groups. Health professionals play a key role in creating culturally sensitive, reliable online health content and recommending trustworthy sources. Strategic community stakeholders also need to be involved in developing health policies and interventions that improve DHL levels.

Advancing DHL is crucial to prevent inequalities from widening [5]. DHL is a powerful tool to improve health outcomes but much research is still needed on new policies and interventions to improve DHL [4]. This study is intended to provide insights from a qualitative perspective that can inform the development of health policies aimed at increasing DHL in Europe and contribute to the reduction of inequalities affecting immigrant populations.

Among the results of this study, it has been found that the participants perceive the positive value of DHL in taking a more active role in their own healthcare not only as a preventive measure, gaining knowledge on how to lead healthier lifestyles, but also to improve self-management of the disease and patient empowerment. These results align with previous research which shows that DHL reinforces selfcare and lead to better health outcomes [21, 22].

Language limitations and low levels of education and HL have been pointed out as building blocks for immigrants to better understand medical language and communicate with healthcare professionals, resulting in less patient involvement in healthcare decisions. This is further supported by existing literature which shows the importance of a good communication with clinicians and the positive effect on patients health [23]. Participants pointed to the need for easily understandable information, complemented by resources that enhance content and assist in overcoming linguistic constraints. Failure to use health services effectively or misunderstanding health information can hinder access to vital health information.

Participants called for easier access to and greater involvement of health professionals in the definition of health information available on the internet. Increased engagement of healthcare providers may have a significant impact on the establishment of medical relationships with cultural sensitivity and the effective management of health, aligning with research that also reflect the need for migrants to feel understood and supported by health professionals [24]. In addition, greater involvement of healthcare professionals would reduce mistrust and reluctance to use digital technologies to obtain health information.

A barrier generally identified in this study was the issue of cost when using certain apps. Even though some studies revealed that the use of digital interventions in healthcare was cost-effective in terms of costs and health outcomes [25], and the fact that all participants use basic digital resources (internet, mobile phones), the cost of healthcare resources still hinders access to health information among immigrants.

Additionally, the adaptation of health-related information to different types of population was required by participants in this study. Adapting health policies to meet the needs of immigrants is crucial for ensuring equitable healthcare access and improving overall public health. Immigrants often face unique challenges, such as language barriers, cultural differences, and limited access to resources, which can hinder their ability to navigate healthcare systems effectively. Policies and interventions should reflect cultural sensitivity and adapt to immigrants’ diversity [26]. It is recommended that strategic stakeholders in the community, providing assistance to immigrants in host countries, be involved in adapting health policies and interventions to help provide targeted-specific sensitivity and improve programme effectiveness. This statement is supported by existing literature that identifies the community stakeholders as strategic for the interventions with vulnerable populations [27–29].

There is an urgent need to strengthen country and region capacities to govern digital transformation in the healthcare sector and advance DHL (2). New policies should pave the way for enabling e-services and developing effective strategies to increase DHL among immigrants and contribute to reducing the digital health divide [5, 30]. Advocacy for person-centred, digitallyenabled health systems will drive DHL and inclusive approaches to digital transformation [31]. Immigrants should be engaged in participatory initiatives addressed to the definition of health policies and the design of health interventions to provide nuances on their specific needs which otherwise may be not perceived by researchers and policymakers, leading to more effective health policies [32].

Although the present study has recruited participants from different countries and periods of time living in Spain, this study could be extended with more participants from other regions of Spain. The limited sample size of 24 individuals and the focus on a single geographic area may constrain the broader applicability of the results. Including data on participants’ age, education and socioeconomic backgrounds and age could have provided additional context for interpretation. Furthermore, recruiting participants primarily through NGOs could have introduced selection bias, potentially influencing the diversity of perspectives captured. The use of field notes in place of full interview transcripts may have affected the depth and nuance of the qualitative data. Moreover, the lack of methodological triangulation—either through complementary qualitative or quantitative approaches—limits the robustness and validation of the findings.

This study sheds light on the real needs of immigrants to improve their dHL, emphasizing the importance of involving the target populations in the design of technologies, dHL policies and interventions. While barriers related to the inherent characteristics of the immigrant population exist, additional challenges stem from the lack of access to accurate, practical, and easily accessible health information, particularly information that is free of charge. Public authorities, health professionals, and strategic community stakeholders play a crucial role in promoting DHL and improving the health outcomes of immigrant populations. Primary healthcare professionals could play a central role in enhancing DHL among immigrants, as they are consulted more frequently than specialists. This is particularly relevant given the high representation of immigrants in elderly care—where primary care is often the first point of contact—and the reliance of immigrant families with children on these services. Cultural-competency training should be provided for healthcare professionals and digital health providers. Participants view digital health technologies as a powerful tool that empowers them to take a more proactive role in their healthcare, enhancing their ability to manage their health conditions and adopt healthier lifestyles. To enhance DHL among immigrant communities, developing tools with multilingual and interactive interfaces for widely used platforms like Google and YouTube could be highly beneficial. Ensuring these tools meet real needs requires co-design and collaborative strategies that actively involve immigrants in their development.

The findings of this study offer valuable insights for policy and practice, providing policymakers with evidence to develop inclusive strategies that promote dHL and refine health policies tailored to the specific needs of immigrants. However, ongoing monitoring and evaluation of digital health initiatives are essential to ensure their effectiveness, especially for vulnerable populations.