How Middle Eastern students in the USA use their social networks for medication information: a mixed methods study

Introduction

International students interact with online content, local students, fellow international students, and the local community to help solve their challenges while they are abroad in a new culture and unfamiliar surroundings. Facing illness in a new host country is particularly challenging. Generally, international students face greater information needs than the average student, as they struggle to navigate unfamiliar culture, policies, and infrastructure, but during times of illness the challenge is exacerbated. As the number of international students appears to be on the rise, data and information are needed to improve knowledge on the information seeking practices of subsets of international students (Melius, 2017).

International students turn to social networks to access health information and solve other problems they face in host countries (Sin and Kim, 2013). Social networks help bridge this gap, as they have the potential to provide relevant guidelines, material, and suggestions. Wasserman and Faust (1994) note that a social network encompasses the social structure, which includes the social factors (such as individuals or organisations), along with their connections or interactions. Through a social networking perspective, a number of methodologies for analysis of social aspects, in addition to diverse theories and patterns of behaviour, can be identified.

The literature to date includes a range of studies focusing on dimensions of seeking health information from the Internet and the role of social networks to access health information (e.g., Oh et al., 2013; Wing and Jeffery, 1999; Wicks, et al., 2010). However, few studies are investigating how people access medication information through social networks. Medication information includes facts about medications or drugs that would be used to make informed medical decisions. It may include things such as adverse effects, cost, or effectiveness (Kjos, 2009). Pharmacy studies also indicate that many people use interpersonal communication through social networks as a source of medication information (Schommer et al., 2009), such as cost and source, in addition to that which is more directly related to health issues.

Most current research has grouped a wide variety of nationalities into one sample population (Austin, 2013; Song, 2005; Yan et al., 2008). These broad categories are sometimes misleading and may overgeneralise as they fail to identify differences in barriers, health beliefs, behaviour, and needs of people representing specific cultures with different practices, systems, and traditions related to health. Therefore, the Middle Eastern population needs a separate study to analyse this kind of behaviour. Despite the potential importance of this issue, the goal of the research is to investigate how Middle Eastern international students utilise their social networks to seek medication information. To bridge this gap, this study addresses the following research questions:

RQ1. What are the sources of medication information in the personal networks of Middle Eastern international students?
RQ2. What medication-related topics do Middle Eastern international students discuss in their social networks?
RQ3. Why is social support from an individual’s network important for accessing relevant medication information?
RQ4. What do Middle Eastern international students consider to be the most important criteria for judging the trustworthiness and credibility of medication information?

Literature review

International students in the United States

The diversity of cultures in America is an invitation to enhance individual career prospects. This cultural experience and the huge number of universities and colleges are the key factors that make America the world's primary destination for international students from around the world (Ely and Thomas, 2001).The academic reputation of the United States, known for its quality of education and the comprehensive courses and degree programs available in its educational institutions, is appreciated by both graduate and undergraduate students. Based on the report from the National Association of Foreign Student Advisers (NAFSA), during the 2017-2018 academic year, 1,094,792 international students studying at U.S. colleges and universities contributed $39 billion in revenue and supported more than 455,000 jobs in the U.S. (NAFSA, 2019, p. 4).

According to NAFSA International Student Economic Value Tool (2019), in 2018, there were 6,064 international students enrolled in South Carolina. International students contributed $205.9 million in revenue and 2,017 jobs were supported in South Carolina. At the University of South Carolina-Columbia (USC) in particular, international students contributed $83.3 million in revenue and supported 1,044 jobs. Globalisation enables students from all over the world to seek education in any country of their choice. International students enrich the host country by bringing in diversity in culture and intellect. In addition, according to the demographic report provided on the University's Website (University of South Carolina..., 2017), in 2016-2017 the total enrolment of international students at the University of South Carolina included 1800 international students from 95 countries. During 2016-2017, there were 604 new international students in the USC. Notably, the number of international students increased by 9.6% when compared to 2015. At the University, students from China represent the largest population of international students. There were 502 Chinese international students enrolled in 2016, representing nearly 30% of the total international student enrolment. International students from India and South Korea have also demonstrated significant growth: 53.5% compared to Fall 2015 (from 56 to 86).

Many countries in the Middle East are investing heavily in scholarships for international studies. These countries have focused efforts on supporting their students by providing academic scholarships and considering these students to be the backbone of national development in various fields to prepare a globally competitive workforce (Melius, 2017). The number of international students from the Middle East increased by 17% in 2016. (University of South Carolina..., 2017). While the number of Middle East international students increased rapidly, information about this population is still limited. Therefore, this study was conducted to bridge the gap by focusing on this population.

Social networks and social support

Several researchers have conducted studies to address the positive effects of social networks (Cohen, 2001; Oh et al., 2013; Kim, 2013; Sin and Kim, 2013; Blieszner, 2014; La Greca et al., 1995; Ford and Kaphingst, 2009; Kim et al., 2015). These studies demonstrate that social networks have a positive impact on users ' health outcomes. Social networks are likely to be very important to international students. Kim's (2013) research paper is evidence for the tremendous need for social support while seeking health information. The study focusses on the case of Korean immigrants in the United States. Social support is seen to be of very great importance to immigrants, and they are likely to access social support in their social networks. Consistent with the findings, the study suggests that the perceived availability of assistance in any social network leads to improved health seeking behaviour. The importance of social networks cannot be understated in the case of immigrants. They need social networks and support to promote their health status. With a social network, immigrants can discuss healthy behaviour while living in the United States. Most often, they would fear to talk over their health issues with people who are not Koreans as they have some cultural reasons (Kim, 2013). Yoon and Kim (2014) stated that owing to language problems, the Korean graduate students in the USA chose Korean tools and the Internet was the primary source. They identified difficulties in finding relevant sources of health information and interpreting medical information. They often searched for online health information to solve the current health problems of them or their families, and consequently, like accuracy, personal relevance was considered an important criterion of evaluation.

In addition, Oh et al. (2013) explored the role of social support on social networking sites and the impact that it has on access to health-related information. In the study, respondents were asked to reply to various health topics, such as the specific diseases they suffered from, and the environmental dangers they face to measure online health information seeking. People with health concerns are likely to seek disease-specific information. Also, Song et al. (2016) investigated whether cultural variations exist in patterns of online health information seeking, particularly in perceptions of online sources of health information. Song found that Koreans and people from Hong Kong turn to social media and the Internet to share health information and perspectives. However, Americans showed a stronger preference for using expertise-based knowledge sources, which are more prepared and approved by physicians or healthcare professionals. (e.g., WebMD and Centers for Disease Control and Prevention).

Other studies focus on social networks as a source of medication information (La Greca et al., 1995; Austin, 2013; Manias, 2013; Schommer et al., 2009; Haghighi et al., 2016; Carpenter et al., 2015; Kjos, 2009; Shaghaghi et al., 2014). For instance, Kjos (2009) investigated use of social networks to obtain medication and health information. The study’s purpose was to determine the role of social networks in medication information seeking behaviour by describing the structure of social networks that provide information, as well as the content and the function of information. The study also examines the individual characteristics of people who use various types of social networks to obtain medication information. From the study, it was concluded that social networks, comprised of health professionals like pharmacists and physicians, provide information that is of great use to patients and other users. On the other hand, patients also provide information that is based on personal experiences in a bid to help others. The information obtained from the social network was used in making decisions on diagnosis, monitoring information environments, making recommendations, obtaining social support, staying informed, and invalidating the acquired or previous knowledge about a given issue.

To summarise, although a substantial amount of research has been conducted to investigate health and medication information behaviour, there have been no research studies that have examined how social support and social networks affect medication seeking behaviour among Middle Eastern international students. Moreover, there is no research on the ways that Middle Eastern international students use their social networks as sources of medication information.

Chatman's information poverty theory

This study is guided by Chatman's information poverty theory (1996). Information poverty can help to explain some of the personal factors that affect information-seeking behaviour in international students. Scholars have utilised this theory to understand information seekers who demonstrate protective behaviour, which limits their access to useful information. Also, information poverty theory can help to explain some of the personal factors that affect information-seeking behaviour in international students. This theory, then, could help us to understand how international students seek medication information to bridge the gaps of their knowledge to obtain the knowledge and understanding needed to improve their health status for medical conditions, which require medication.

Chatman considers the information behaviour of janitors, retired women and women looking for employment, drawing on the insider/outsider sociological concept and building on her previous work on economically poor groups and information (Chatman, 1991; 1992;). Related studies using information poverty for information behaviour research have also concentrated on particular groups and were conducted primarily in physical environments (Hasler et al., 2014).

The theory of information poverty has four key concepts: deception, risk-taking, secrecy, and situational relevance. Deception is a deliberate attempt 'to hide our true condition by giving false... information'. Risk-taking is an attribute that affects the acceptance or refusal of 'innovation'. Secrecy is viewed as having the purpose of protecting 'ourselves from unwanted intrusion'. Situational relevance is defined as consistent with utility, or that it addresses an expressed need (Chatman, 1996, p. 194).

Chatman predicts that people within a community tend to look within that community for information that they need, instead of outside their community. Culture also influences the meanings that people impart to their illness. In their own country, they may have a wealth of information and know how things work, but when they come to a new country, they will be in a state that may be characterised as information poverty. Information poverty is not to be equated with social poverty. It is not that international students are necessarily poor in the traditional economic sense, but that they do not have the skills or knowledge needed to overcome their difficulties. They do not have the information that promotes ease of seeking medication information in their host country. For this reason, it is understandable that students are likely to experience anxiety.

Research method

The mixed methods approach

The goal of this study is to examine the use of social networks in the study sample. A mixed methods approach, employing both social networks to retrieve medication information for the population and open-ended questions, was used to explore the role of social networks in information seeking on medications for the sample. Closed questions were employed to obtain specificity of response from the study participants; open-ended questions were used to obtain depth of response, to understand participants’ medication information seeking experiences in the social networks of Middle Eastern students while studying in the U.S.A.

A mixed methods approach was used to confirm predicted patterns and expose unpredicted patterns to answer the research questions for this study. This study used a convergent design. The researcher collected and analysed quantitative data through closed questions, and at the same time, collected and analysed qualitative data through open-ended questions. Data were merged to compare the results and determine explanations for behaviour and outcomes

The study population

The research was conducted at the University of South Carolina, Columbia campus, in the summer and fall of 2018. The target population was international students from Oman, Saudi Arabia, and Iraq who study at the University. This study examines information seeking relating to medications in the social context of these populations. This study focuses specifically on three nationalities from the Middle East who study at the University. This study occurs at a time when the University has the largest population of international students from Oman, Saudi Arabia, and Iraq that it has ever seen. According to the demographic report provided on its Website, in 2016-2017, the top sponsorships for international students at the University are the Oman Government, Saudi Arabia Government, and Higher Committee for Education Development in Iraq (University of Southern Carolina..., 2017).

Students from these three countries were chosen because a researcher needs to ensure that they can get a sufficient sample size for the study. Based on the International Student Enrollment Report (2017), there are some students who come from countries in the Middle East who are not from Oman, Saudi Arabia, and Iraq, but they do not have student associations, so it is difficult for a researcher to access them. Oman, Saudi Arabia, and Iraq have large populations at the University; therefore, these countries have club presidents who are easy to contact. In addition, these three countries have the same language, and similar cultural and traditional attitudes related to health and medicine.

Sampling method

After obtaining approval from the University's Institutional Review Board, the researcher contacted the club presidents of the Saudi, Omani, and Iraqi Student Associations. The researcher obtained membership lists from club presidents and contacted the students by phone to ask them to participate in the study.

Once a student agreed to participate, the survey link was sent to them immediately by e-mail, which also asked for their cooperation to help locate additional potential subjects. This e-mail detailed the goal of the research and stressed the importance of participation. Students who completed the questionnaire were able to check a box indicating that they had done so, thereby avoiding a reminder e-mail. Potential study participants were told that the survey was expected to take about 25 minutes or less to complete. If participants agree to participate, they were asked to click the online survey link in the e-mail message.

Considering the nature of the research, the purposive sampling method was selected as the most appropriate. Purposive sampling, also known as selective or subjective sampling, is a sampling technique in which the researcher relies on her own when choosing members of the population to participate in the study (Miles et al., 2013). The source of the data came from membership lists from club presidents. The estimated population of Middle Eastern students was 208. This is just the number of registered students. For a 95% confidence level, and a confidence interval of 5%, the minimum sample size was calculated to be 136 (power analysis). To ensure a fully sufficient sample, the researcher carried on enlisting until 187 students had agreed to participate. A sufficiently large sample ensures that the sample statistic will most closely correspond to the population statistic.

Data collection instrument

The questionnaire was developed to collect data on international students from the Middle East about medication information seeking behaviour. To enhance the validity of the results, the instrument used in this study was adapted from previous research to provide as much comparability as possible. This study did modify the language of previous surveys to reflect the focus on medication information instead of general health.

Part 1 of the questionnaire represents the demographic information of respondents. Part 2 and part 3 combines the data collection instruments of studies by Carpenter et al. (2015); Kim (2013); Yan (2008); and Kjos (2009) to establish the questions about social networks. The question regarding medication topics discussed most often was adopted by Carpenter et al. (2015). Participants were also asked to provide a narrative of their conversations with others about their medications; these questions were adopted from Kjos (2009). Participants were also asked to state and rate the criteria by which they judged the trustworthiness and credibility of obtaining medication information from their personal social networks. This question was adapted from Yan (2008). Finally, participants were asked about their reasons for using their social networks to seek medication information (Kim, 2013).

To re-validate the questionnaire following these modifications, each question was read and examined by an information science expert, six graduate students majoring in public health, and a statistician. The validators were subsequently asked to provide feedback and the questions that they considered ambiguous or improper were revised.

Based on their recommendations, all appropriate modifications were made. For example, through the process of pretesting the questionnaire, it was evident that the language in several sections was not clear. Descriptive text was consequently added to the beginning of each part to help participants completely understand the questions being asked so that the survey results would yield relevant answers. Also, based on the suggestion of my statistical consultant, changes were made to some Likert scale items to enhance data analysis

The survey was initially piloted with ten students from the Middle East. From this, issues of language clarity were identified and addressed. The final iteration of the survey was piloted with five international students from the Middle East. This time the language in all sections was found to be clear and the questions were determined to be meaningful and appropriate. No changes were made following the second pilot.

Data analysis

For the quantitative portion of data analysis, descriptive statistics (frequency and percentage distributions, mean, standard deviation, range, etc.) were used to describe the demographics and other characteristics of respondents in the collected sample. The statistical software IBM SPSS 24 was used for the statistical analyses.

For the qualitative portion of data analysis, the aim was to create descriptive data that provides deeper insight into student information seeking about medications in the social context. The open-ended questions were entered into the NVivo 10 qualitative data analysis software program. Through open coding, these data were evaluated and coded as recurrent regularities and patterns. These patterns became categories and themes that were coded and used as supporting evidence for the quantitative analysis.

Results

Characteristics of research participants

Of the 208 Omani, Saudi, and Iraqi students attending the University of South Carolina, Columbia campus, 187 (90%) students agreed to participate in the study and completed the questionnaire, beginning in August 2018 and ending in December 2018. The 187 participants provided stories regarding their experiences seeking medication information through their social networks. Among these stories, 153 (82%) were included in constant comparative analyses after excluding erroneous or irrelevant data.

RQ1: What are the sources of medication information in the personal networks of Middle Eastern international students?

Table 2 shows which sources of medication information in personal networks were preferred when students had a need for medication information. Students mainly sought medication information from their families (mode of 48.7% all the time; 41.2% often). Friends were used less (mode of 38.5% sometimes) although the frequency of use varied across the group. A similar pattern was shown for relatives (mode of 38.0% often), but only 6.4% used relatives all the time. Community clubs were rarely used (mode of 66.8% never used community clubs).

Including the data gathered from the NVivo analysis of qualitative research (analysis of open questions), supports quantitative research data shown in Table 2. These qualitative findings correspond with results from the Likert scale section that assessed sources of medication information in social networks. Five primary categories emerged from the qualitative portion: (1) family, (2) friend, (3) relatives, and (4) family members, relatives, or friends who are medical professionals.

A summary of the responses follows for the first qualitative question: 'Tell me about a time when you talked with someone about a medication. Who did you talk to and why do you choose to discuss things with these people?' Of the 187 students who proceeded to answer the qualitative section, 175 responded to this question. Twelve (7%) students stated that they only discuss health issues and medication information with specialised individuals.

A family member was the second most popular source in the quantitative data, after doctors. Sixty-seven of the 175 students stated that they use their family members’ network to seek medication information while they are studying abroad. The first primary category was Family, which includes mother, father, sister, husband, wife, and brother as major subcategories. The most used information sources were mother (n=27) and sister (n= 16) followed by brother (n=8). Other sources that were less commonly used and included wife (n=7), husband (n=6), and father (n=3). Representative responses included:

When I get sick, I talk with my mom. It makes me feel good to tell someone who is responsible for me and cares about me. I have a good talk and make at least some progress in my health. She always available in the ways that I need and deserve. I trust her. She listens, understands, encourages, believes, and cares. I can contact her any time even with the time difference between countries. She helps me feel I can solve my problems. Also, she helps me to manage my health issues while I am studying abroad (SAUDI 17).

I like to talk to my sister. She supports and encourages me to stay on track. She reminds me to take all of my pills and medications on a strict schedule. Also, I feel comfortable talking with her about my medication fears. Because some medication in the past made me feel dizzy and I could not drive, I feel nervous after taking new medication and she helps me to calm down. My sister and I share ideas when we have to make decisions. Whenever I am frustrated, I like to talk with her to help me calm down and think about a solution (OMANI 6).

The second primary category that emerged was friend (n=56). These are Middle Eastern friends not friends among other ethnic groups. The following are several examples of friend as a source of medication information that emerged from the data:

When I was sick my friend Fatimah expressed sympathy and wanted to make me feel better. She cares about me and is rooting for me. She was going to the grocery store and she was close to the pharmacy and picked up my prescription (SAUDI 19).

My friend loves to offer help when I am sick. He provides a ride to a doctor’s appointment without asking him to ensure that I get to my doctor's appointments. One night, my asthma symptoms kept getting worse. I had severe breathlessness even after I took medication as my doctor directed. Also, I did not find improvement after using a quick-acting inhaler, as the coughing would not stop. At that time, he came and took me to the emergency room (OMANI 22).

The third primary category that emerged as a type of social network source of medication information was “family member, relatives, or friends who are medical professionals (n=31).” This category of response emerged from the analysis of the qualitative findings, but was not included in the list of possible responses for the quantitative survey. Below are quotes from the subjects:

I discuss with my friend, because he is a doctor, about the kind of medicine either for me or for my family. He is one of my best sources of reliable information. I keep him updated with my health condition (SAUDI 15).

When I came to Columbia, I did not know how to use the health insurance. I did not understand healthcare systems very well. Also, I did not understand how to search for healthcare provider in networks. One day, I was very sick but I could not go to the hospital. I texted my sister because she is a doctor in KSA. Contacting my sister was the easiest and most convenient way for me at that time (SAUDI 25).

My brother knows more about the medications because he is a pharmacist. He helps me to stay on a budget. Because I am looking for expertise and availability, he is an ideal resource to answer all my questions and to help me find the best over-the-counter medications. He helped me evaluate whether I needed to see a doctor or if he could recommend a treatment (SAUDI 30).

The fourth primary category that emerged was relatives (n=15). A relative is considered to be anyone who is part of the subject’s family that is not a first degree relative. For example, cousin, aunt, grandmother, and uncle subcategories emerged. The following are several examples of relatives that emerged from the data that students relate in terms of obtaining medication information:

When I am sick, I like to talk with my uncle. Because he talks gently, affectionately and tries to understand me and feel that I am a positive person, and he makes me feel important (OMANI 3).

I feel my aunt would just be honest, even more than a doctor. Plus, I feel that doctors in general tend to make me exaggerated, they give a sense that you will die if you do not comply with their orders, advice and prescription so it is best to go to a doctor only in difficult situations (SAUDI 8).

RQ2: What medication-related topics do Middle Eastern international students discuss in their social networks?

As illustrated in Table 3, the respondents were asked to rate the frequency with which they discussed their medication information with their social networks on a 4-point scale (1 = Never; 4= All the time). Scores were calculated as mean ratings and standard deviations to report frequencies for each topic.

According to the questionnaire results, the side effects of medicine were the most-discussed topics for students within their social network (mode of 57.2% all the time; 28.3% often), followed by discussing prospective over-counter drugs (mode of 64.2% all the time), and alternative/holistic medicines or therapies were discussed even less (mode of 42.8% all the time), but only 6.4% discussed medicines in general Sometimes.

Including the data gathered from NVivo analysis of qualitative research (analysis of open questions), supports quantitative research data shown in Table 3. Of the 187 students that answered the qualitative section, 171 (91%) responded to the following: What things did you discuss? Was the medication something you took or were thinking about taking? Offer specific details. The goal of this question was to ensure that the data collection included any medication-related topics the students discussed in their social networks.

Sixteen students stated that they do not like to discuss medication with their family and friends. “Over-the-counter drugs” was the most-discussed category that students broached with their friends and family (n=60). Below are quotes from the subjects discussed in their social networks about medicines that are sold directly without a prescription from a doctor:

I could not sleep at night yesterday from acute sinusitis, nasal swelling, and pain. I contacted my brother, and we discussed prospective medications that could be available over the counter (SAUDI 30).

I have circular eczema all over my hand, and I text my sister to find over the counter lotions for Eczema. It has to be natural and gentle to help relieve dry and itchy skin associated with eczema. I want it to be moisturising without being heavy. I do a lot of lab experiments and I want cream without perfume (OMANI 6).

I have tooth pain and I was thinking of over the counter medicine to stop the pain until I saw the dentist, and my friend advised me to buy mouthwash and toothache paste from a specific brand he tried before and it really worked for me very well. Within a couple of days the pain would just completely disappear and I avoided another hospital visit (OMANI 22).

The next category related to medicinal side effects emerged from the data (n=36). Below are quotes from the subjects about the side effects of certain medications that were discussed in their social networks:

I discussed the use of a medication that helps with acne. I was thinking of taking Accutane to get rid of face acne. I still have not taken it, but I certainly will in the coming weeks. I asked my sister. She is pharmacist in my country about the side effects of Accutane. If it causes hair loss, dry lips, and so on. Also, she told me that it could cause depression, but I believe that having severe acne is much more likely to cause depression than Accutane. She gave me an idea of how medicine will work on me. What are the negativities and positives of using that medicine? (SAUDI 26).

I was discussing with my cousin whether or not to take vitamin D. She told that a high dosage of vitamin D will affect my body. She advised me to be exposed to sunlight because it is one of the most important sources of vitamin D and to eat foods that contain vitamin D naturally and drink milk. She told me that an increase in vitamin D may cause a problem to a body organ, and it can cause kidney failure if it is taken for a long time. Therefore, I need to follow the dosage prescribed by physician (IRAQI 49).

Effectiveness of the medication on treating the symptoms was the third most common theme that emerged (n = 25). Below are quotes from the subjects discussed with their social network regarding the effectiveness of medicine on relieving symptoms:

During the testing period, I did not have time to cook so I ate fast food and pizza, so I got heartburn frequently. Last night, I woke up with a sour stomach to painful heartburn. I had stomach pain and heartburn. I vomited and I felt full during a meal and was not able to finish eating. I talked with my mom and she advised me to take Tums antacid chewable. I told her I could not take anything right now but she said Tums taste good like candy and are very effective. I now keep a bag of them in my bag for when I eat out. The Tums took control and I feel much better (IRAQI 22).

I called my brother to ask him because I got cold and felt dizzy. He told me that dizziness may be caused by colds. He advised me to rest and take vitamin C with Panadol Cold and Flu and to inhale Vicks that I bought from my country. I like to bring some medications from my country especially some brands that I trust using because I know the effectiveness of these medications for me (OMANI 9).

Twenty-four of the students stated that they discussed the cost of medication as they have a limited budget. Some comments by participants are as follows:

After hours of sitting in front of my computer screen, my eyes feel terribly dry. My doctor recommended me to use eye drops. I contacted my brother to find me one with a good price. Medicines are expensive and talking to someone who has tried the medicine before helps me to make the right choice (IRAQI 54).

We were talking about how medical care is expensive in America. In the Kingdom of Saudi Arabia, healthcare is offered for free to Saudi citizens. Last month I was going to throw out garbage and I cut myself with a metal can. I called my friend and he took me to Doctors Care on Main Street. After the doctor's supervision, the nurse sterilised the wound and sewed it. At that time, I did not pay anything, and I thought that the insurance would cover it. A few days later, the bills started coming and I couldn't believe how much it cost (SAUDI 5).

I texted my brother to find less costly saline nasal sprays. I was using a specific brand but I could not write the name of it. When I ran out, I needed a new nasal spray. So, I asked him to look for another alternative brand that has the same effects. He turned me onto a generic brand available at CVS [a pharmacy chain]. After I texted him, he searched online and read drug facts for the saline nasal sprays. He bought me the medicine and shipped it to me within a day. He did that for me all the time and he did not accept any money. I used the new saline multiple times a day and it works just as well and costs much less (SAUDI 9).

Seventeen of the students stated that they discussed herbal medicine or home remedies. They like to depend on natural sources. Below are examples from participants:

In our culture, we believe in herbal remedies. Home remedies for bleeding gums are effective and after trying the remedy I got good results. Even though I will not get immediate results, by using this remedy I will keep my gums healthy and strong (SAUDI 15).

We believe that there is still much more to be learned from the past. I prefer using natural home remedies whenever possible with my family and it really does work. My grandmother has cultural knowledge about specific home remedies. As a student, I have a limited budget and the home remedies will save me a lot of money (SAUDI 4).

My mom and I believe in a natural remedy to manage asthma. Since she knows the effectiveness of home remedies, when I was a kid she treated me with these remedies that she knew from her grandmother, and I felt much better. Now, I feel closer to home when I use these remedies. Sharing natural home remedies techniques and what works for our family can help me feel better without using dangerous and toxic drugs. My mother always tried to heal us naturally as often as she could. Like my mom, I do not like to take aspirin when I feel a headache coming. I believe that when using aspirin makes me dependent on it (OMANI 52).

RQ3: Why is social support from an individual’s network important for accessing relevant medication information?

Participants were asked to rank each potential reason according to the Likert scale responses of 1 through 4. (1= strongly disagree to 4= strongly agree). A response of 1 indicated that this reason did not apply to them at all, while a ranking of 4 indicated that the reason is perceived as most substantial for the participant.

Among the survey respondents, shared experiences from others was the most common reason that made the students discuss medication information with their social network (mode of 63.1% strongly agree; 23.5% somewhat agree), followed by sense of belonging and personal comfort (mode of 53.5% strongly agree; 31.6% somewhat agree), and finally a shared belief in specific cultured based traditions about medication, health, and alternative health practices (mode of 46.0% strongly agree; 32.6% somewhat agree)

Including data gathered from NVivo analysis of qualitative research (analysis of open questions), supports the quantitative research data shown in Table 4. The third question in the qualitative portion asked: 'Why did you think it was important for you to discuss these things with someone?' Shared experiences (n=87) and feelings of belonging (n=32) were the most prevalent reasons. For example:

Moving to a new country may be a difficult experience for anyone, especially because I have children. Receiving support from friends around me help me because they are experiencing and the way they feel because they have often passed the same experience as well. I feel comfortable to talk with them about my kids’ health issues since they have the same culture and language. I like to listen to her stories about her kids’ experience. I want to be sure that my son follows the same pattern of development (IRAQI 51).

I believe in the well-known popular ideals in our communities "Ask an experimenter and do not ask a doctor". So, when I need information about medicines or medical advice, I feel it is better to ask those who preceded me in the experience, and in particular the experiences of older people (OMANI 12).

I prefer to take advantage of the experience of others because they provide many benefits, giving you skills and techniques to deal with illness, but the doctor gives one perspective and it could be different from other doctors. I believe that knowledge lies in experience and culture (SAUDI 59).

I like to share my medical information with my family. I like to stay connected with them, which makes me feel that I belong to my community and helps me feel less alone while I live in a different country. Studying abroad is an exciting adventure but it is also a major life transition. For me this is the first time I am away from home. Sharing this information with my family eases the tension that I feel about the many unknowns (IRAQI 29).

RQ4: What do Middle Eastern international students consider to be the most important criteria for judging the trustworthiness and credibility of medication information?

Participants were asked to rate each source with Likert scale responses of 1 through 3. A response of 1 corresponded to the least amount of trust while a response of 3 corresponded to the most. As seen in Table 5, respondents were asked to rate criteria.

Among the survey respondents, the information from a professional was the most important criteria for judging the trustworthiness of medication information, (72.2% indicate very important; 24.6% indicate somewhat important), followed by the information that is easy to understand (62.6% indicate very important; 29.4% indicate somewhat important), and finally the person who has links and sources of information (46.0% indicate very important; 40.1% indicate somewhat important). However, the person that is accredited with a reputable organisation was not considered a very important criteria for judging the trustworthiness for the students (35.8% indicate not important).

Including the data gathered from NVivo analysis of qualitative research (analysis of open questions), supports the quantitative research data shown in Table 5. To get a deeper understanding, students were asked to state and rate the criteria by which they judged the trustworthiness and credibility of obtaining medication information from their personal social networks. One hundred and seventy of the 187 participants responded to the qualitative questions at the end of the questionnaire. The last qualitative question was: 'What makes you think that the information you received is trustworthy?'

Fifty-eight students stated 'the medication information was from a professional' as being a very important trust criteria. Most of them have relatives or friends who are medical professionals in their countries. For example:

She is a pharmacist and she usually advises me to use WebMD's Drug Interaction Checker application to avoid harmful drug interaction. Now, I download this app on my phone so I can use it when I am taking medications. Even after picking up a prescription from my physician I like to check the information more just to be safe and read more about drugs facts (SAUDI 46).

My cousin is a pharmacist, so even after visiting my doctor I like to send him the prescriptions to look at it and give me valuable information about the prescriptions. I trust his educational opinions. I don’t ask any random person. The information will be accurate if it comes from people who work in the field like health care providers they are a source of trust (IRAQI 55).

Fifty-five students stated 'check reliable sources' after discussing the subject with their social networks as being a very important trust criterion. This category of response emerged from the analysis of the qualitative findings, but was not included in the list of possible responses for the quantitative survey. Below are quotes from the subjects:

I trust my mom, she prepared a cup of thyme when I was in my country. This drink helped relieve my symptoms of asthma. I was curious to know about the effectiveness of the thyme to relieve the symptoms therefore I searched online from reliable websites to learn more facts (OMANI 23).

My mom is one person that I always listen to. She takes care of my health since I was a child. Plus, I noticed a difference on the first day after taking TUMS. Also, I read about it on the Walmart website. Many people recommended them to relieve heartburn (IRAQI 22).

After getting the information from my friend, I read the safety warning on the label behind the bottle and the vitamins are made from natural and used organic ingredients. It is suitable for my son’s age too (IRAQI 45).

Following this, thirty-two of the students stated that they would trust the person who 'provided links and a source' of information.

Because my sister usually searches online about drug information from the National Library of Medicine website. She reads about side effects, dosage, special precautions, and more. I have found it helpful in getting reliable and accessible information about the medications to talk with some about who is really caring about my welfare (SAUDI 30).

I trust him because my friend is very knowledgeable and has read more about our health issues. Also, he usually sends me up-to-date articles and studies related to migraines (SAUDI 32).

Twenty-five of the students stated 'the information is easy to understand' as very important trust criterion for them. For example:

Moving to a new country may be a difficult experience for anyone, especially because I have children. I feel comfortable to talk with them about my kids’ health issues since they have the same culture and language (IRAQI 51).

My mom showed me how to cut the ginger in small pieces. Then I boiled them into a cup of water and after this cooled, I added one spoon of natural honey. Her information was provided in a clear and very understandable manner (SAUDI 50).

The information agrees with the emergency room doctor. Advil is a trusted brand of medicine that people use for pain. Since my son cannot take strong medicine Advil was the best choice for him (SAUDI 45).

Discussion

This investigation explored the role of social networks in medication information seeking behaviour for Middle Eastern international students. First, the role of social networks as important sources of medication information for Middle Eastern international students was examined through the first research question. The students tend to turn to family members when they have concerns and fears about their health. Some of the participants reported that they felt much better after talking to a family member about their fears, frustrations, worries, and any concerns about medications. This finding was consistent with previous studies, with reported students feeling that they wanted to talk with a family member who is responsible and cares about them, rather than a medical professional (Manias, 2013; Sin et al., 2013; Kjos, 2009). Also, the students seek medication information from family members until they are ready to seek help from a doctor or other medical professionals. Their families may assist them to identify symptoms and otherwise think through their health issues requiring medication, etc. Family support may be particularly important because the students have feelings of attachment with their family, who provided them with appraisal support while they were children. In addition, some participants stated that a family member could assist them to understand the terminology of the leaflets that come with the medicines. Nevertheless, the finding contrasts with Kim’s study (2013), that reported Korean immigrants do not tell the truth to family members, and lie or omit details sometimes to their family to keep them happy.

Additionally, the responses to the first research question revealed that another important source of medication information was friends. The findings found that students like to share with a friend their concerns as they talk together and give different ideas about health and medications in a comfortable way. Some participants stated that talking with friends about medication information will be kept confidential. This is consistent with other studies (Blieszner, 2014; La Greca et al., 1995; Kim, 2013). Kim’s study, specifically suggests that the most common sources of information are friends. One commonly reported reason for seeking medication information from friends is the prospect of tangible support, for example, asking for help with picking up prescriptions, or getting a ride to a doctor’s appointment.

Secondly, the findings resulting from the second research question revealed that the participants reported that they discussed the medication they were taking with someone. They always ask about the side effects of the medication to get an idea of whether what they were feeling is from the side effects or not. It may be because they forget to ask a doctor about such side effects, or because they do not want to go through the process of meeting with one.

Another important topic related to medication information was over-the-counter drugs. The findings reveal that students discuss over-the-counter drugs with their social networks when encountering illness, in case of emergency, or regarding diseases not considered serious enough to consult a doctor, such as a painkiller, or cold and flu medicines. In this last case, they access medications without the need of a doctor visit or missing school. The previous research addressed the fact that one of the main sources of information about over-the-counter self-medication was family (Haghighi et al., 2016). Haghighi’s study was undertaken to determine the frequency of over-the-counter self-medication among students in the Chamran University of Ahvaz, Iran in 2015. The study found that the prevalence rate of self-medication among selected university students was 81.6%. The most frequent medicines used by the students were adult cold therapies (69.05%) and analgesics (48.23%).

Interestingly, some participants reported that they like to use natural home remedies, which are better for common diseases because of the side effects of pharmaceutical medicines. The participants like to use natural home remedies strongly recommended by friends or family members who have tried them and seen great results. Middle Eastern international students used to take home remedies in their countries to get instant relief from illness. Discussing natural home remedies with their social networks helps students avoid taking chemicals all the time when they get sick. Many students reported that they start with home remedies first if the illness is in the beginning stages and then go to the doctor if they do not feel any improvement. There is a plethora of studies about this (e.g., Firenzuoli et al., 2007; Fürst et al., 2015).

Thirdly, the data from the third research question reveals the reasons for the importance of social networks for Middle Eastern international students. Some participants reported that they like to share similar medical experiences and medication consultations with their friends, relatives, or other people who have been exposed to the same issues. Taking advantage of others’ experiences is important as it provides many benefits, including enhancing the students’ skills and techniques to deal with their illness. Furthermore, one of the benefits of having social networks is that they can share similar experiences and children’s health issues since they have the same culture and language. In comparison, information related to health is usually kept by individuals in the Japanese culture (Yi et al., 2012). Japanese are afraid to talk loudly about the disease or share health information with others, while Koreans like to share information about the treatments of health problems with others (Kim, 2013).

Additionally, these findings also revealed that one reason for the importance of social networks for Middle Eastern international students was that they feel more comfortable talking with others who have similar cultural values, beliefs, and norms. They like to feel closer and more connected, regardless of the physical distance that separates them. The results show that during times of illness students feel homesick; therefore, they want to feel at home and contact family or friends, so that they might feel similar to the way they felt when treated at home. Effective medication information acquisition is important as it contributes to a sense of belonging. This finding supports previous studies that noted the use of social networks in relation to the sense of belonging for international students (Singh, 2018; Austin, 2013; Vincent, 2016; Kim, 2013). The results shed light on how social networks foster feelings of belonging and encourage information exchange.

Fourthly, based on the data from responses to the fourth research question, the most important criterion to Middle Eastern international students for judging the trustworthiness and credibility of obtaining medication information was getting medical information from a professional. Most of them are family member, relatives, or friends who are medical professionals in their countries. The participants reported sharing personal experiences, beliefs and attitudes, which they simply could not do with their USA health-care providers. This is consistent with (Kjos, 2009). The students believe that the information will be accurate if it comes from people who work in the field; like health care providers. This idea of utilising social networks, such as friends and family, who are knowledgeable about health and medication issues, is strongly associated with desired health behaviour because of their potential to provide not only information, but also the social support that is found in the literature (Redmond et al., 2010; Cohen, 2001; Ford and Kaphingst, 2009).

Furthermore, the information they received from a social network is easily understood, being perceived as simple and clear. Perhaps, because many participants described how they have faced some difficulties in understanding medication information from American doctors or friends, the barrier of culture, and not only language, comes into play. Therefore, information that is easy to understand is trustworthy and credible because the student participant is already familiar with it, so it confirms or verifies what they already know. It links in nicely and easily with the knowledge the students already have. This finding is consistent with Kim (2013) and Kjos (2009). The students need information they can understand and use to make the best decisions regarding their medication and health.

Finally, the results for this study compare with previous literature that has focused on the role of social contacts and medication information seeking behaviour. This study was consistent with the finding in the literature that participants are likely to go to their social networks as a source of medication information first (La Greca et al., 1995; Manias, 2013; Schommer et al., 2009; Haghighi et al., 2016; Carpenter et al., 2015; Kjos, 2009; Shaghaghi et al., 2014). One limitation of previous studies was that they only used one research method, a qualitative approach (e.g., Kim et al., 2015) which may have introduced response bias and resulted in missing items. However, this study used a mixed method. Close-ended questions were used to obtain specificity of response from the study participants; open-ended questions were used to obtain depth of response to understand participants’ medication information-seeking experiences.

The current study’s contribution to the literature focuses on the role of social networks among Middle Eastern international students in the U.S., specifically in regards to their medication seeking behaviour. Social networks play a vital role as a significant source of support and information exchange for these students. Another contribution of the current study is to add to the literature focusing on Chatman's information poverty theory (1996). The findings of this study are consistent with information poverty, in that students utilise their social networks and seek information from those who are close at hand (in this case not by location, but by long standing relation) as part of the process of information seeking that extends over time. This might be related to privacy concerns or may be attributable to Chatman’s information poverty because trust is something that is not easily achieved (as it needs to be earned) and thus health and medicine knowledgeable friends and family are more strongly used for health information on social networks owing to the interaction of knowledge and long-standing familial connection.

In relation to the four key concepts of information poverty theory (Chatman, 1996, p. 194), information about medication is involved in self-protective secrecy and deception behaviour to hide information needs from those who might be able to help. Students engaged in deception to maintain a sense of control about their health. Both secrecy and deception are mechanisms of self-protection owing to mistrust about other people's interest, or capacity to provide helpful information. Secrecy can be better maintained in a participant’s social network because a participant, to maintain secrecy, can more easily manipulate or control information flow in the relationship. Perceiving a lack of sources in their host country leads the students to their social networks as the most typical source of assistance. This shows that students take advantage of the dual nature of social networks as a source of medication information which provides both secrecy and access. It was also obvious that there was a lack of trust in the ability of potential sources to provide helpful medication information and not to risk exposure to their needs because of possible negative effects on their health. Finally, this research shows that social networks used as an extra source of assistance, or an intermediate step linked to the selective introduction of new knowledge, indicate the spectrum of information poverty and not an absolute situation at the same time.

Limitations

This study has a few research limitations. The study used a non-probability sampling method of an online survey. Because using an online survey creates participant time constraints and participants may experience a lack of understanding when answering questions, the data may be superficial, inaccurate, or biased. While the survey was anonymous and confidential, respondents may have been reluctant to disclose information, resulting in missing background information values. Thus, this study did not seek to generalise; the population of this study was specific to international students from the Middle East who study at the University of South Carolina, Columbia campus. Thus, the findings of this study may not accurately reflect the experiences of all Middle East international students living and studying in the United States. Despite these limitations, it is important that this study attempted to investigate the ways Middle Eastern international students use their social networks as sources of medication information. Because we now have access to this information, we can assist this population of students in their efforts to attain healthy bodies and minds.

Conclusions and implications

The current research examined how social networks affect medication seeking behaviour among Middle Eastern international students. The results show the ways that Middle Eastern international students use their social networks as sources of medication information. International students prefer to discuss medication information with their social networks to obtain more personalised information or reactions. This study found that:

• The student’s family members, relatives or friends who are medical professionals are important sources of medication information for the international students in their social networks.
• The most discussed topics for students in their social networks were the side effects of medicines, over-the-counter drugs, and herbal medicine or home remedies.
• Social networks are considered important to students as they shared experiences and felt a sense of belonging and personal comfort during periods of illness.
• Because the student is already familiar with their social networks, the medication information that is easy to understand is respected and trustworthy, so it supports or verifies what the student already knows in order make the best decisions regarding their medication.
• Students utilise the distance, privacy, and access to information that is offered by social networks to manipulate and control the flow of information. This finding is in line with Chatman’s concept of secrecy explicitly.

This study has important implications for understanding the information needs of Middle East international students, their medication information seeking experiences, and the sources used by students to obtain their medication. This study will also help pharmacists and other healthcare providers to provide culturally appropriate care and effective channels for distributing important medication information.

Future research can be carried out to investigate the same research questions based on different nationalities and compare the results among these nationalities to get more valuable insights. Cultural differences between the Middle East and other countries may exist; thus, researchers should cautiously interpret and use the research results. Also, future studies should approach the supportive functions of social networks from different perspectives.

About the author

Esra Abdoh is an Assistant Professor in the information science department, Taibah University, Janadah Bin Umayyah Road، Tayba, Medina 42353, Saudi Arabia. She can be contacted at Dr.eabdoh@gmail.com

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