Exploring key factors of medical tourism and its relation with tourism attraction and re-visit intention

Figures & data

Figure 1. Research Framework and Hypothesis.

Note: Dashes mean no relevant reference is available.

Table 1. Experts’ information

Attribute	Position	Years of practice & Times of joining medical tour	Education
Practical	General Manager	3 Years	Master
Consumer		3 Times	Bachelor

Table 2. Final evaluation framework of medical tourism

Aspect	Criteria
Hospital information and facilities (A)	Hospital contact information (e.g., address, phone and email) (A1)
	Hospital introduction (e.g., mission or technique) (A2)
	Related information and service of Getting to the hospital (e.g., Entry visa assistance) (A3)
	On-site pharmacy and prescription assistance (A4)
	Source of obtaining the related information about medical tourism (e.g., internet or recommendation from others) (A5)
Admission and medical services (B)	Billing information (B1)
	Appointment booking (B2)
	Availability of medications (B3)
	Safety of medication quality (B4)
	Quality of medical treatment (B5)
	Service orientation of medical staff (B6)
	Waiting time for medical treatment from time to first contact to real treatment (B7)
	Required treatment available here (B8)
	Quality of required treatment (B9)
	Health evaluation (B10)
	High healthcare quality (e.g., ISO, NCQA, ESQA) (B11)
Interactive online services (C)	Interactive tools for online enquiries (C1)
	Pre-admission consultations at a distance (online or by phone) (C2)
	Medical records available via the Internet (C3)
External Activities (D)	Referral services for international physicians (via teleconference, online enquiries or phone) (D1)
	Links to relevant agencies/tourist attractions (D2)
Medical technique and level (E)	Number of hospital and clinic beds (E1)
	Accreditation by JCI (Joint Commission International) which is a gold standard in hospital certifications worldwide (E2)
	State-of-the-art medical equipment (E3)
	Accreditation of the medical facility (e.g., JCI, ISQUA) (E4)
	Reputation of the hospital/facility (E5)
	Diversified medical treatment (E6)
	Doctor’s expertise and reputation (E7)
	International certified doctors and staffs (E8)
	Advanced medical treatment (E9)
Commercial environment (F)	Good arrangement of the program and pick-up service (F1)
Marketing communication (G)	e-Commercial marketing (G1)
	Clear contents of medical tour pamphlets (G2)
	Multiple-language communication platform (such as websites) (G3)
Country environment (H)	Overall positive country image (H1)
	Safe to travel to country (H2)
	Stable economy (H3)
	Perception of safety and security as related to culture and political environment (H4)
Tourism destination (I)	Popular tourist destination (I1)
	Attractiveness of the country as a tourist destination (I2)

Table 3. Result of dependence

	A1	A2	A3	A4	A5	B1	B2	B3	B4	B5	B6	B7	B8	B9	B10	B11	C1	C2	C3
A1		⋆	⋆		⋆													⋆
A2	⋆																		⋆
A3	⋆				⋆		⋆										⋆	⋆
A4						⋆						⋆
A5	⋆
B1				⋆
B2	⋆
B3				⋆									⋆	⋆	⋆
B4				⋆				⋆		⋆			⋆	⋆	⋆
B5				⋆				⋆					⋆	⋆	⋆
B6										⋆						⋆
B7	⋆		⋆					⋆					⋆			⋆
B8								⋆
B9								⋆		⋆
B10								⋆	⋆
B11											⋆
C1																		⋆	⋆
C2	⋆
C3	⋆					⋆
D1	⋆																⋆
D2		⋆
E1		⋆
E2		⋆
E3		⋆
E4													⋆		⋆
E5		⋆						⋆
E6								⋆					⋆	⋆	⋆
E7								⋆	⋆				⋆		⋆
E8									⋆
E9										⋆			⋆			⋆
F1			⋆
G1	⋆	⋆
G2		⋆
G3	⋆
H1		⋆
H2		⋆
H3		⋆			⋆
H4		⋆
I1		⋆
I2		⋆

Table 3. (Continued)

	D1	D2	E1	E2	E3	E4	E5	E6	E7	E8	E9	F1	G1	G2	G3	H1	H2	H3	H4	I1	I2
A1		⋆											⋆	⋆	⋆
A2	⋆		⋆										⋆	⋆	⋆
A3		⋆
A4			⋆
A5														⋆
B1												⋆
B2							⋆
B3								⋆
B4				⋆				⋆
B5				⋆				⋆	⋆	⋆
B6											⋆
B7					⋆	⋆
B8					⋆	⋆
B9					⋆	⋆
B10										⋆
B11				⋆		⋆		⋆			⋆
C1		⋆										⋆	⋆		⋆
C2													⋆
C3	⋆	⋆
D1													⋆							⋆	⋆
D2	⋆												⋆							⋆	⋆
E1				⋆
E2						⋆
E3						⋆
E4					⋆		⋆
E5					⋆
E6				⋆
E7				⋆	⋆					⋆	⋆
E8				⋆					⋆
E9				⋆	⋆	⋆		⋆		⋆
F1													⋆
G1															⋆
G2													⋆
G3													⋆
H1																	⋆	⋆	⋆	⋆	⋆
H2																		⋆	⋆	⋆	⋆
H3																⋆	⋆		⋆	⋆	⋆
H4																				⋆	⋆
I1																⋆	⋆	⋆	⋆
I2																⋆	⋆	⋆	⋆	⋆

Note: ^⋆means the affecting scores are ≥85

Note: A1-Hospital contact information; A2-Hospital introduction; A3-Related information and service of Getting to the hospital; A4-On-site pharmacy and prescription assistance; A5-Source of obtaining the related information about medical tourism; B1-Billing information; B2-Appointment booking; B3-Availability of medications; B4-Safety of medication quality; B5-Quality of medical treatment; B6-Service orientation of medical staff; B7-Waiting time for medical treatment from time to first contact to real treatment; B8-Required treatment available here; B9-Quality of required treatment; B10-Health evaluation; B11-High healthcare quality; C1-Interactive tools for online enquiries; C2-Pre-admission consultations at a distance; C3-Medical records available via the Internet; D1-Referral services for international physicians; D2-Links to relevant agencies/tourist attractions; E1-Number of the hospital and clinic beds; E2-Accreditation by JCI which is a gold standard in hospital certifications worldwide; E3-State-of-the-art medical equipment; E4-Accreditation of the medical facility; E5-Reputation of the hospital/facility; E6-Diversified medical treatment; E7-Doctor’s expertise and reputation; E8-International certified doctors and staffs; E9-Advanced medical treatment; F1-Good arrangement of the program and pick-up service; G1-e-Commercial marketing; G2-Clear contents of medical tour pamphlets; G3-Multiple-language communication platform; H1-Overall positive country image; H2-Safe to travel to the country; H3-Stable economy; H4-Perception of safety and security as related to culture and political environment; I1-Popular tourist destination; I2-Attractiveness of the country as a tourist destination

Table 4. Weight and Ranking of Aspects

	Thailand (n = 22)		Singapore (n = 42)		Taiwan (n = 45)		Overall (n = 109)
	Average Weight	Ranking	Average Weight	Ranking	Average Weight	Ranking	Average Weight	Ranking
A	0.155	3	0.161	3	0.175	3	0.165	3
B	0.113	5	0.113	5	0.115	4	0.113	5
C	0.211	1	0.208	1	0.218	1	0.213	1
D	0.175	2	0.168	2	0.181	2	0.173	2
E	0.078	7	0.075	7	0.093	6	0.088	7
F	0.012	9	0.015	9	0.016	9	0.015	9
G	0.030	8	0.020	8	0.018	8	0.020	8
H	0.125	4	0.130	4	0.096	5	0.114	4
I	0.102	6	0.109	6	0.087	7	0.099	6

Note: Hospital Information and Facilities (A); Admission and Medical Services (B); Interactive Online Services (C); External Activities (D); Medical Technique and Level (E); Commercial Environment (F); Marketing Communication (G); Country Environment (H); Tourism Destination (I)

Table 5. Weight and Ranking of Criteria

	Thailand (n = 22)		Singapore (n = 42)		Taiwan (n = 45)		Overall (n = 109)
	Average Weight	Ranking	Average Weight	Ranking	Average Weight	Ranking	Average Weight	Ranking
A1	0.021	13	0.036	12	0.022	13	0.027	13
A2	0.006	22	0.011	21	0.007	21	0.009	20
A3	0.014	15	0.022	14	0.015	15	0.018	15
A4	0.062	9	0.051	10	0.057	10	0.055	10
A5	0.002	33	0.003	34	0.001	36	0.002	35
B1	0.018	14	0.021	16	0.020	14	0.020	14
B2	0.003	28	0.004	29	0.003	28	0.003	29
B3	0.053	10	0.059	9	0.064	8	0.059	8
B4	0.065	6	0.076	3	0.085	3	0.080	2
B5	0.076	5	0.062	6	0.081	5	0.075	5
B6	0.091	3	0.062	6	0.065	7	0.066	7
B7	0.050	11	0.038	11	0.043	11	0.042	11
B8	0.007	20	0.008	23	0.010	18	0.009	20
B9	0.025	12	0.023	13	0.032	12	0.029	12
B10	0.064	7	0.076	3	0.088	2	0.080	2
B11	0.098	2	0.068	5	0.072	6	0.073	6
C1	0.014	15	0.022	14	0.014	16	0.018	15
C2	0.001	37	0.004	29	0.002	30	0.003	29
C3	0.012	17	0.017	17	0.011	17	0.014	17
D1	0.011	18	0.017	17	0.009	20	0.013	18
D2	0.007	20	0.013	20	0.007	21	0.010	19
E1	0.001	37	0.001	39	0.002	30	0.001	38
E2	0.003	28	0.003	34	0.004	24	0.003	29
E3	0.003	28	0.002	37	0.003	28	0.002	35
E4	0.008	19	0.008	23	0.010	18	0.009	20
E5	0.003	28	0.004	29	0.004	24	0.004	27
E6	0.006	22	0.006	27	0.007	21	0.007	24
E7	0.101	1	0.088	1	0.099	1	0.094	1
E8	0.084	4	0.077	2	0.085	3	0.080	2
E9	0.064	7	0.061	8	0.060	9	0.060	8
F1	0.002	33	0.004	29	0.002	30	0.003	29
G1	0.004	26	0.005	28	0.002	30	0.003	29
G2	0.001	37	0.002	37	0.001	36	0.001	38
G3	0.002	33	0.003	34	0.001	36	0.002	35
H1	0.005	24	0.010	22	0.004	24	0.006	25
H2	0.004	26	0.008	23	0.001	36	0.004	27
H3	0.005	24	0.014	19	0.004	24	0.008	23
H4	0.000	40	0.001	39	0.000	40	0.001	38
I1	0.002	33	0.004	29	0.002	30	0.003	29
I2	0.003	28	0.008	23	0.002	30	0.005	26

Note: A1-Hospital contact information; A2-Hospital introduction; A3-Related information and service of Getting to the hospital; A4-On-site pharmacy and prescription assistance; A5-Source of obtaining the related information about medical tourism; B1-Billing information; B2-Appointment booking; B3-Availability of medications; B4-Safety of medication quality; B5-Quality of medical treatment; B6-Service orientation of medical staff; B7-Waiting time for medical treatment from time to first contact to real treatment; B8-Required treatment available here; B9-Quality of required treatment; B10-Health evaluation; B11-High healthcare quality; C1-Interactive tools for online enquiries; C2-Pre-admission consultations at a distance; C3-Medical records available via the Internet; D1-Referral services for international physicians; D2-Links to relevant agencies/tourist attractions; E1-Number of hospital and clinic beds; E2-Accreditation by JCI which is a gold standard in hospital certifications worldwide; E3-State-of-the-art medical equipment; E4-Accreditation of the medical facility; E5-Reputation of the hospital/facility; E6-Diversified medical treatment; E7-Doctor’s expertise and reputation; E8-International certified doctors and staffs; E9-Advanced medical treatment; F1-Good arrangement of the program and pick-up service; G1-e-Commercial marketing; G2-Clear contents of medical tour pamphlets; G3-Multiple-language communication platform; H1-Overall positive country image; H2-Safe to travel to the country; H3-Stable economy; H4-Perception of safety and security as related to culture and political environment; I1-Popular tourist destination; I2-Attractiveness of the country as a tourist destination

Figure 2. CFA of Medical Tourism, Tourism Attraction and Re-visit Intention (n = 109).

Note: †p < 0.1; *p < 0.05; ** p < 0.01; *** p < 0.001

Note: For easy reading, the observational variables and residual items are not listed here.

Table 6. Result of the Overall Samples’ Model Fit (n = 109)

Test Statistic		Standard	Result
Absolute Fit Indices	χ^2	The smaller, the better	108.855
	χ^2/df	1 ~ 5	1.76
	GFI	> 0.9/0.8	0.87
	AGFI	> 0.9/0.8	0.81
	RMR	< 0.08	0.08
	SRMR	< 0.08	0.07
	RMSEA	< 0.08	0.08
Incremental Fit Indices	NFI	> 0.9/0.8	0.80
	NNFI (= TLI)	> 0.9/0.8	0.87
	CFI	> 0.9/0.8	0.90
	RFI	> 0.9/0.8	0.75
	IFI	> 0.9/0.8	0.90
Parsimony Fit Indices	PNFI	> 0.5	0.64
	PGFI	> 0.5	0.59

Table

Aspect	Source	Criteria	Source
Hospital Information and Facilities	Moghavvemi et al. (2017)	Hospital contact information (e.g., address, phone and email)	Moghavvemi et al. (2017)
		Hospital statement of purpose (e.g., mission or vision)
		Photos or videos featuring the hospital facilities and technology
		Getting to the hospital: Ground transportation arrangements (e.g., pick-up from airports or home)
		Getting to the hospital: Travel arrangements/ bookings
		Getting to the hospital: Entry visa assistance
		Getting to the hospital: Partnerships with travel agents or hotels
		Patient privacy information
		Patient’s rights and obligations
		Patient feedback (e.g., testimonials and survey results)
		On-site language interpretation services
		Food arrangements specific to international patients
		On-site pharmacy and prescription assistance
		On-site facilities for patients’ companions (e.g., family lounge, accommodation within facility, etc.)
		Off-site accommodation arrangements for patients’ companions and outpatients
		Ratio of patients and medical staff	Singh (2013)
		Privatisation of facilities
		Availability of advanced or qualified medical instruments used for treatment	Woo & Schwartz (2014)
		Hospital facilities such as rooms and other spaces
		Recreation facilities for patient’s family
		Recreation facilities for patients in the hospital
		Recommendation from family and friends	Wongkit & McKercher (2016)
		Recommendation from others
		On newspaper and magazines	Lin et al. (2010)
		From experts
		On the internet
		On television
		From relatives and friends
		State-of-the-art medical equipment	Fetscherin & Stephano (2016)
		Accreditation of the medical facility (e.g., JCI, ISQUA)
		Reputation of the hospital/facility
Admission and Medical Services	Moghavvemi et al. (2017)	Billing information	Moghavvem i et al. (2017)
		Health insurance accepted (incl. affiliated insurers)
		Payment information and facilities (e.g., credit cards accepted)
		Foreign currency exchange information and facilities
		Inpatient accommodation
		Medical specialties/areas of excellence
		Medical staff descriptions
		Appointment booking
		Post-discharge arrangements
		Type of speciality services	Singh (2013)
		Fluency of medical staff in English
		Availability of medications
		Safety of medication quality
		Quality of medical treatment	Woo & Schwartz (2014)
		Availability of treatment if complication or side effects occurs
		Medical staff’s ability to communicate in patient’s own language
		Service orientation of medical staff
		Availability of translators in the hospital
		Waiting time for medical treatment from time to first contact to real treatment
		Required treatment available here	Wongkit & McKercher (2016)
		Quality of required treatment
		Availability of follow up service
		Availability of post-treatment service	Lin & Huang (2012)
		Premium medical equipment
		Advanced medical treatment
		Excellent medical care
		Short waiting time for treatment
		Health assessment
		Diversified medical treatment
		Doctor’s training	Fetscherin & Stephano (2016)
		Doctor’s expertise
		High healthcare quality indicators (e.g., low infection rate)
		Reputation of doctors
		High quality standards (e.g., ISO, NCQA, ESQA)
		High quality of care
		International certified doctors
		Internationally certified staff
		International educated doctors
		Friendliness of staff and doctors
Interactive Online Services	Moghavvemi et al. (2017)	Interactive tools for online enquiries	Moghavvemi et al. (2017)
		Pre-admission consultations at a distance (online or by phone)
		Medical records available via the Internet
		Links to online forums for patient feedback and
		social
		networking (e.g., Twitter and Facebook)
		Links to additional online venues for information generated by or about the hospital (e.g., YouTube and blogs)
External Activities		Healthcare joint ventures, international affiliations and overseas referral networks with other hospitals
		Referral services for international physicians (via teleconference, online enquiries or phone)
		Links to relevant agencies/tourist attractions
Technical Items		Site map present
		Site-wide search tool present
		Availability of alternative language options for the website (besides English)
		Website accessibility for people with sensorial disabilities
		Live (no broken) web links
Medical Technique and Level	Zhang & Gao (2016)	Number of hospitals and clinics	Zhang & Gao (2016)
		Number of hospital and clinic beds
		Number of doctors
		Medical training of staff	Singh (2013)
		Licensure of medical staff
		Doctor’s degree, certification and reputation	Woo & Schwartz (2014)
		Accreditation by JCI (Joint Commission International) which is a gold standard in hospital certifications worldwide
Medical Tourism Costs	Fetscherin & Stephano (2015)	Low cost of treatment	Fetscherin & Stephano (2016)
		Lower healthcare costs
		Low cost of accommodation
		Low costs to travel
		Affordability of airfares
Commercial Environment	Lin & Huang (2012)	Convenient transportation	Lin & Huang (2012)
		Reasonable cost
		Good catering service
		Good arrangement of the program and pick-up service
		Custom-made service
Marketing Communication		e-Commercial marketing
		Clear contents of medical tour pamphlets
		Multiple-language communication platform
Country Environment	Fetscherin & Stephano (2016)	Stable exchange rate	Fetscherin & Stephano (2016)
		Low corruption
		Cultural similarity
		Overall positive country image
		Language similarity
		Safe to travel to country
		Stable economy
		Image of Korea	Woo & Schwartz (2014)
		Perception of safety and security as related to culture and political environment
Tourism Destination		Popular tourist destination	Fetscherin & Stephano (2016)
		Exotic tourist destination
		Weather conditions
		Attractiveness of the country as a tourist destination
		Many cultural and natural attractions

Source: This study