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Should I stay or should I go?

:
Motivators, decision factors, and
information sources influencing
those predisposed to medical
tourism
Jennifer N. Henson, Bonnie S. Guy and Michael J. Dotson

Correspondence to:
Jennifer N. Henson,
Appalachian State
University, Raley Hall,
Boone, NC 28608, USA
nevinsjl@appstate.edu

Appalachian State University, Raley Hall, Boone,


NC, USA

Abstract
This exploratory study, employing a national
sampling of persons in the USA, focused on a
group of respondents who self-identified as willing
to consider seeking medical care abroad, otherwise
known as medical tourism. To learn more about
how such individuals approach the decision of
whether to engage in medical tourism, they were
surveyed regarding their motivations to do so, the
decision factors they would consider important,
and the information sources they would consult.
In addition, the study sought to determine if these
responses differed across several variables, such as:
(a) the nature of the medical condition for which
treatment is sought (life threatening, serious but
not life threatening, medically optional or life
enhancing), (b) prior international travel experience
and prior receipt of care abroad, (c) confidence that
their health insurance was sufficient to cover current
and future medical needs, (d) risk aversion, and (e) a
number of basic demographic variables. The results
contribute to limited empirical research on the consumer decision-making process of those considering
medical tourism. Findings provide tentative guidance to countries and healthcare providers marketing their services to medical tourists, as well as to
domestic healthcare providers either competing
against or referring patients to medical tourism
options.
Keywords: Medical tourism, Medical decision
making, Sources of medical tourism information

Purpose and review of the literature


As documented in numerous prior articles, medical
tourism, defined as travel with the express purpose

W. S. Maney & Son Ltd 2015


DOI: 10.1179/2047971914Y.0000000083

of obtaining health services abroad, is a phenomenon and industry which is rapidly expanding and
undergoing dynamic change. However, many note
the lack of original and replicated empirical research
on who considers medical tourism as an option to
obtain needed or desired healthcare services,13
what conditions motivate them to do so,4 what
factors drive their decision making,3,5 and what
sources they consult to obtain information important to them.3,6,7
A much clearer understanding is needed about
how potential and/or actual medical tourists go
through the decision-making process about
(a) whether to participate in medical tourism,
(b) what destinations to consider and select, and
(c) what healthcare facilities and providers to consider and select. Concern has been expressed that
there are insufficient health communication efforts
to adequately inform potential medical tourists
about the options, benefits, and risks,8,9 and suggestions that patients should obtain information from
multiple sources including the internet, others
with similar experiences, family members, primary
care physicians, and foreign provider facilities. In
addition, a limited space in promotional materials
necessitates valid knowledge of the motivations
and considerations people find important.5
There have been some conceptual pieces outlining
proposed decision models for medical tourists.
Smith and Forgione10 present a two-stage model,
proposing that those who decide to become
medical tourists first determine a country or location
for their care, after which they make decisions about
what facility and doctors they will choose. This
model does not address what goes into the original
decision to seek or reject the option of receiving care
outside ones domestic borders. Other conceptual

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Henson et al. Motivators, decision factors, and information sources influencing medical tourism

Motivations, decision factors, and information sources


This article focuses on ones decision to engage in
medical tourism or not, rather than specifically
what location, facility, or healthcare provider to
select. It assesses the motivations, decision factors,
and information sources considered important by
respondents self-identified as likely to consider
medical tourism for various treatment conditions.
Furthermore, its purpose is to determine if these
variables differ among respondents based on
characteristics of medical condition for which treatment would be sought, prior international travel
and/or medical care received abroad, sufficiency
of healthcare coverage, level of risk aversion, and
basic demographic classifiers.
A common set of motivations to seek medical care
abroad have been identified by numerous sources,
though not widely empirically verified. These
motivations include (a) significant cost savings to
obtain desired treatment, frequently associated
with a lack of insurance coverage, (b) reduction of
wait times to receive care, (c) ability to access treatments not available at home, (d) desire for confidentiality/privacy, (e) obtaining advanced technologies
or expertise, and (f ) receipt of organ
donation,1,2,6,7,10,1214 among others.
Conceptually, it has been posited that medical
tourists consider the following decision factors relevant to medical tourism: quality of care, training
and credentials of foreign doctors, accreditation of
foreign healthcare facilities, medical safety and confidence, availability of treatment options, affordability and insurance coverage, distance from home,
destination country conditions (economic, political,
regulatory, crime and safety, esthetics, and vacation
aspects), and cultural dimensions such as a common
language and common religious protocols; there is
some limited empirical support for each of these
variables as well.5,7,8,10,12,13,15

One article7 grouped many of these variables into


three factors procedure-based, travel-based, and
cost-based. Another5 examined informational and
promotional materials provided at a medical
tourism exhibition and found a surprising lack of
messages related to costs or cost savings. Instead,
the main themes included advanced technology/
facility services and specialties, credibility of providers, accreditation, and credentials, and compassionate staff. It was hypothesized that cost was
downplayed as it may run counter to peoples
ideas of safety and quality of care.
Information sources thought to be utilized by those
investigating medical tourism are the internet web
searches (including commercial websites, foreign
provider and government websites, medical
tourism agency websites, blogs, discussion forums,
advertisements, etc.), primary care providers,
foreign healthcare providers, insurance companies
and employers, medical tourism agents/facilitators,
travel agencies, previous medical tourists, family,
and friends.46,12,1618
Among previous medical tourists from China,
India, Jordan, and the UAE, 45% had consulted
family and friends, 35% had sought information
from internet-based sources, only 13% had
requested referrals from their primary care physicians, and a mere 3% had consulted with insurance
providers.4 Family and friends are unlikely to have
extensive expertise in the area of medical tourism;
their high importance is likely due to a persons
need for support and validation from those with
whom they associate closely. Internet sources are
plentiful and attractive to independent, self-directed
healthcare consumers, but concerns remain about
the accuracy, ethical standards, and information
overload associated with internet sources.
Healthcare decisions and delivery are so complex
that patients have most often deferred decision
making to their physicians, although medical
tourism does not require referrals from primaries
nor do foreign health providers (FHPs) typically
communicate with domestic health providers
(DHPs) prior to or after foreign provided treatment.19 Primary care providers may have both negative and positive influences on those considering
medical tourism. Traditionally, DHPs have seen
FHPs as competition for their services as well as
unknown commodities, and have dissuaded their
patients from seeking care abroad. Increasingly,
however, domestic providers are outsourcing some
types of treatment to foreign providers through strategic partnerships and hospital networks.17
Medical tourism brokers and agencies vary in the
scope of services provided, which may include

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models have been based on supply and demand


factors6 and on the Theory of Planned Behavior,11
but provide no empirical support.
Finally, Levary12 presents a complex analytic hierarchy process, which incorporates input from multiple decision makers and includes tangible and
intangible criteria. Its purpose is to rank destinations
based on individual inputs and priorities, and using
pairwise comparisons. Using a software program,
the potential for this process was tested in an
applied case analysis. Further replications of this
process would go a long way towards understanding how people make decisions about medical
tourism under a variety of individual and situational conditions.

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phone consults, advice on country, facility, and


doctor selection, arrangement of travel logistics,
tourism within country, among other provisions.
Some consider themselves patient advocates or the
patients physician one step removed, though this
may cause tension between business interests and
patient advocacy. In interviews with 12 facilitators,
no clear consensus on roles was established.18
Travel facilitators deal with lodging and transportation logistics but generally have little or nothing
to do with the medical aspects. Insurance companies
and employers are increasingly consulted as more
health insurance plans seek to reduce medical
costs by obtaining medical care from internationally
accredited foreign providers.
Differentiating characteristics
Medical condition
It seems plausible that motivations, decision factors,
and information sources used would differ with the
type of medical treatment needed or desired.
Theoretically, the nature and severity of the
medical condition should influence an assessment
of the benefits/risks tradeoff of seeking care from
foreign sources.8 It is hypothesized that persons
needing major surgery would take more time at
each step of the decision process and gather more
information, while the issues for those seeking wellness or discretionary care would be fewer, simpler,
and focused more on geographic location and ancillary tourism considerations.

Risk aversion
Perceived risk is the function of uncertainty and
potential consequences inherent in the product,
in the pace and mode of purchase, within the subjectivity of tourists themselves it is individual and
situational, shaped by past experiences, lifestyle,
demos, culture.20 It seems likely that a higher importance on various decision factors would be found
among those who are more risk averse than
among those who are more risk tolerant.
Demographics
Various studies provide conflicting results regarding differences in medical tourism motives and
decision making based on age, gender, education,
marital status, children, income, etc. Therefore, this
study seeks further clarification on how demographics correlate with medical tourism motivations,
decision
factors
considered,
and
information sources utilized.

Methods

Healthcare coverage
In one study, 83% of respondents reported having
no domestic health coverage for medical treatments
sought.13 Those who are not insured or who have
inadequate insurance coverage should be more

Surveyed respondents were grouped by one of the


three hypothetical medical conditions: a life-threatening condition (e.g. organ transplant, open heart
surgery); a serious but not life-threatening condition
(e.g. hip replacement or gastric bypass); or a condition for which medical treatment is considered
to be medically optional (e.g. cosmetic surgery,
dental procedures, plastic surgery), and instructed
to answer all questions assuming they were faced
with that medical condition. Then respondents
were queried regarding their likelihood of seeking
medical treatment abroad under varying conditions,
the importance of various decision factors, and the
information sources likely to be consulted to make
medical tourism decisions. The survey also posed
additional questions including number of healthcare
visits per year, prior international travel, health
insurance coverage, confidence in future ability to
cover necessary medical expenses, and general risk
aversion, followed by demographic questions, in
order to determine if and how these differentiating
characteristics would correspond to differences in
these decision-making variables.
A market research agency was contracted to distribute an online survey via SurveyMonkey to a
nationwide US sample, and 207 completed surveys
were obtained for analysis. Respondents were split

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Prior international experience/medical


tourism
Prior experience with international travel in general
or in specific locations are likely to increase the
comfort level of potential medical tourists,1
however this would also be dependent on the
nature of and satisfaction with those past experiences. Given positive experiences overall, those considering medical tourism should feel more confident
about making travel arrangements, traveling in and
interacting with people from foreign cultures, differences in food, language, and differing levels of
development. Generally speaking, the same
relationship should hold true with those who have
previously received services from foreign healthcare
providers, perhaps more so, again assuming positive interactions and outcomes.

motivated to consider medical tourism than those


who have excellent health insurance coverage.
Healthcare coverage may also be related to the relative importance of decision criteria and information
sources utilized.

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Table 1: Total sample profile

Demographics
Gender
Male
Female
Age
2129
3039
4049
5059
60+
Education
High school or less
Some college
Associate/Bachelor degree
Graduate degree
Health insurance coverage
Yes
No

Frequency

Percent

98
96

50.5
49.5

2
31
41
59
61

1.0
16.0
21.1
30.4
31.4

20
45
62
67

10.3
23.2
32.0
34.5

180
15

92.3
7.7

nearly evenly between males (49.5%) and females


(50.5%). The majority were well educated with
66.5% having a college or post-college graduate
degree. Table 1 presents a profile of the overall
sample.

Results
Medical tourists and non-tourists
Data were initially pooled across all three medical
treatment conditions to distinguish those likely to
consider healthcare treatment abroad from those
not likely to do so. The data were coded for segmentation using K-means cluster analysis, predicated on
responses to the question, I would consider seeking
medical treatment outside the U.S. if and included
eight different items assessing different motivations
for considering traveling abroad for medical services. Responses were measured on a 5-point

Likert scale (1 = strongly disagree/5 = strongly


agree). A two-cluster (willing/unwilling) solution
appeared most appropriate and results provided
good separation between the two groups based on
the clustering variables, allowing understandable
and consistent interpretation. Cluster 1 (n = 68;
32.8%) consisted of respondents generally unwilling
to consider traveling abroad for medical treatment.
Cluster 2 (n = 139; 67.2%) included respondents
who indicated they would be willing to consider
medical treatment outside the USA. Resulting clusters are presented in Table 2, showing final centroids
for the two groups.
Respondents in Cluster 2 (labeled Medical
Tourists) indicated greater willingness to consider
medical treatment outside the USA for various
reasons. In contrast, for Cluster 1 (non-tourists) all
factor means were below the 3.0 midpoint, indicating an unwillingness to consider medical treatment
abroad, regardless of motivation type.
Because the objective is to better understand
motivations and decision-making aspects of potential medical tourists, subsequent analyses are performed only on the Medical Tourists cluster. No
significant differences were found between the two
clusters on any demographic variables, healthcare
coverage, international travel, or risk aversion. The
main distinction between the medical tourists and
non-tourists is their inherent un/willingness to consider travel abroad for healthcare. Table 3 presents a
demographic profile of these Medical Tourists.
Motivations for considering medical tourism
An open-ended question was used to elicit motivations for considering medical tourism. The most
frequently cited reasons were to take advantage of
cost differentials (n = 71, 51.1%) and to obtain

Table 2: Results of cluster analysis of willingness to consider medical treatment outside USA

I would consider medical treatment OUTSIDE the USA:


(1=Strongly disagree to 5=Strongly agree)
If the most highly regarded doctors or specialists for this condition
were located outside the USA
If the cost was beyond my financial means in the USA but
affordable to me outside the USA
If there was a significantly shorter waiting period abroad
To receive treatment options that are not approved or available in
the USA
If I were seeking a procedure or treatment for which I desired a
high level of privacy, discretion, or confidentiality
For a better standard of overall care/follow-up
If my insurance would cover treatments outside the USA
To combine obtaining care with the opportunity to explore/tour/
enjoy a desirable foreign location

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Cluster 1:
Non-tourists
Item mean

Cluster 2: Medical
tourists
Item mean

2.62

4.25

2.49

4.39

1.85
2.07

3.93
3.82

1.62

3.14

1.57
2.56
1.79

3.18
4.19
3.15

Henson et al. Motivators, decision factors, and information sources influencing medical tourism

Table 3: Characteristics of medical tourists

Medical tourists
Cluster
Demographics
Gender
Male
Female
Age
2129
3039
4049
5059
60+
Marital status
Married
Unmarried
Children
Yes
No
Education
High school or less
Some college
Associate/Bachelor degree
Graduate degree
Income
<$40 000
$40 000$70 000
$70 001$100 000
$100 001$150 000
>$150 000

Frequency

Percent

74
56

53.2
40.3

2
16
31
40
41

1.4
11.5
22.3
28.8
29.5

91
39

65.5
28.1

91
40

65.5
28.8

10
29
44
48

7.2
20.9
31.7
34.5

25
40
22
30
13

18.0
28.8
15.8
21.6
9.4

access to treatment not available in the USA (n = 33,


23.7%). Other reasons mentioned include quality of
care, proven track records of success in treating a
specific condition, privacy, length of wait for treatment, and combination with a vacation package.
Medical condition
There were few significant differences in the motivating factors across treatment conditions. However,
there was a statistically significant difference
between groups as determined by one-way analysis
of variance (ANOVA) in the opportunity to combine
treatment with leisure travel (F2,136) = 3.94, P =
0.022). A Tukeys post hoc test revealed that those
seeking medically optional treatment were more
likely to consider this as an option than were those
with life-threatening conditions (meanoptional =
3.5 vs. 2.86life-threat, P = 0.019). There was no statistically significant mean difference between those with
serious conditions and either of the other medical
conditions.

USA (e.g. living, studying, or working abroad)


were more motivated to travel abroad to take
advantage of shorter waiting periods than were
those with less international travel experience
(meanexperienced = 4.2 vs. meaninexperienced = 3.8, P =
0.036). However, prior receipt of medical care
abroad did not provide any significant differences
across the motivating factors.
Healthcare coverage
Given the importance attributed to cost or financial
motives, there was interest to see whether relative
(in)ability to pay for domestic healthcare would
provide greater incentive to seek treatment abroad.
As nearly all medical tourist respondents had
some form of health insurance (n = 131, 94.2%),
this variable did not provide any insight of this
type. However, respondents were also asked to indicate their level of confidence that their health insurance coverage would be adequate for all their major
health needs, currently and in the foreseeable future
(5-point scale: 1 = not at all confident, 5 = very
confident). Responses were coded as either low confidence (n = 49, 39.5%) or high confidence.
Independent samples t-tests revealed that those
with low confidence would be more motivated to
consider medical tourism by a lack of trust in the
US healthcare system as compared to those with
higher confidence in their insurance coverage
meanhigh conf = 1.77,
P=
(meanlow conf = 2.29,
0.008). Those less confident in their health insurance
coverage would also be more likely to consider
medical tourism options if they thought that their
insurance would pay for such treatment
(meanlow conf = 4.41, meanhigh conf = 4.12, P = 0.035).
Risk aversion
Risk tolerance was also considered relevant to
medical tourism decisions, as such treatment often
requires patients to face many unfamiliar situations.
Risk tolerance was measured using a 5-item scale
( = 0.64). A median split was used to identify
those more risk tolerant from those more averse to
risk. Independent sample t-tests revealed that risk
averse patients rated desire for privacy and
confidentiality more highly than did those who
were more risk tolerant (meanrisk averse = 3.3 vs.
meanrisk tolerant = 2.9, P = 0.024).

Prior international experience/medical


tourism
Respondents who identified themselves as having
spent a significant amount of time outside the

Demographics
There were no significant demographic differences
in motivations to consider medical tourism treatment options in terms of education, gender, or
marital status. Only age provided a statistically significant difference in that 30- to 44-year olds
(mean3044 = 4.5) are more likely than other groups

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to participate in medical tourism if doing so meant


they could obtain care from the best specialist in
the field F(2,127) = 3.45 P = 0.035 (mean4560 = 4.0;
mean>60 = 4.2).

cultural similarities/differences ( = 0.85), and the


provider countrys level of economic development
and safety concerns ( = 0.78). The items and loadings are presented in Table 4.

Decision-making factors
Survey respondents were presented with a list of
factors they might consider when making such a
decision and were asked to rate each one on a 5point Likert scale as 1 = Very Unimportant to 5 =
Very Important. Principal components analysis
yielded four components with eigenvalues >1,
explaining 68.5% of the variation. Varimax rotation
revealed components that correspond to considerations regarding travel/logistics (Cronbachs =
0.90), medical confidence considerations ( = 0.86),

Medical condition
To understand whether the nature of the medical
condition influences the decision criteria employed,
univariate ANOVAs and post hoc analyses were run
for each of the decision-related factors (travel, cultural, medical confidence, and development/safety).
Medical condition was found to influence the
importance placed on cultural-related decision
making factors (F(2,131) = 3.3, P = 0.039). Specifically, medical tourists seeking elective treatments
rated the importance of cultural criteria (e.g. food,

Table 4: Component loadings

Components
Variable

Travel Culture

Positive patient referrals or testimonials from former


patients
Hospital or doctor credentials/accreditation
Success rates/reputation in treating the condition
Level of economic development/wealth of provider
country
Safety of the provider country
Perceived attitudes towards Americans held by the
countrys citizens
Political philosophies of the provider country
Beauty/Attractiveness of the physical location
Availability of cultural, entertainment, tourist
attractions of the provider country
How similar or different the countrys culture is
from my own
How similar or different the countrys language is to
my own
How similar or different the countrys food is to my
own
Whether the professionals treating me could speak
0.676
my language or not
Availability of quality accommodations for family/
0.551
friends accompanying me
Costs of travel to and from the provider country
0.710
Length of time I would have to be out of country and 0.761
away from home
The amount of difference in costs for treatment
0.804
between provider country and the USA
If there is professional assistance in making all
0.797
necessary travel and treatment arrangements
Availability of quality aftercare upon returning to
0.755
the USA
Eigenvalues
7.73
% of variance explained
40.7
Cumulative % of variance explained
40.7
Cronbachs
0.90

Medical
confidence

Development and
Safety

0.762
0.835
0.798
0.554
0.547
0.713
0.751
0.811
0.834
0.755
0.631
0.708

2.80
14.7
55.4
0.85

1.37
7.2
62.6
0.86

1.11
5.9
68.5
0.78

Principal component analysis after varimax rotation. Only loadings >0.5 are included. Eigenvalues are from unrotated
solutions.

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attractions) more highly (meanoptional = 3.1) than did


those with life-threatening conditions (meanlifethreat = 2.6, P = 0.030), although such considerations
were not rated extremely highly for either groups.
Differences between those with serious medical conditions were not statistically significantly from the
optional or life-threatening conditions (meanserious = 2.8).
Item-level analysis revealed which cultural criteria differ between those with medically discretionary conditions and those with life-threatening
conditions. The beauty/attractiveness of the provider country location were rated as more important
by those seeking medically optional treatment
(mean = 3.2) than by those with life-threatening or
serious conditions (mean = 2.5/2.5 respectively)
(P = 0.002). Relatedly, the availability of entertainment and tourist attractions was much more
important (mean = 3.0) as compared to those with
life-threatening or serious conditions (mean = 2.4/2.5)
(P = 0.011). In comparison, those with life-threatening medical conditions were more discerning
about the level of economic development of the
provider country (mean = 3.8) than were patients
with serious (mean = 3.6) or medically optional
conditions (mean = 3.3) (F(2,131) = 3.19, P = 0.044).
It tentatively appears that those seeking life-saving
procedures are more likely to use economic development as an indicator of the likely quality of the
medical sector in a potential provider country.

10

have never received healthcare services abroad


(meanno prior = 2.9, meanprior = 2.4, P = 0.016). Those
who have received prior medical care abroad may
have found that cultural differences do not necessarily
impede quality of care. Consumers lacking prior
treatment abroad also seem to perceive more potential difficulties with the travel logistics and thus rate
these items as more critical to their decision-making
process than those prior treatment experience
(meanno prior = 4.0 vs. meanprior = 3.5, P = 0.004). It
may be that those with prior experience may perceive that the costs/difficulties of travel are not
that high, or that the benefits outweigh the costs/
difficulties involved. In addition, a level of economic
development and safety issues become less important for those who have already experienced
foreign medical care (meanprior = 3.4 vs. meanno prior
= 4.0, P = 0.000). Prior receipt of medical care
abroad had no effect on the importance of medical
confidence considerations. Both consumers with
and without prior experience rated this as an important consideration (meanno prior = 4.4, meanprior =
4.2, P = 0.214). Table 5 summarizes the findings.
Healthcare coverage
There was no difference in decision-making criteria
based on respondents level of confidence that
their healthcare coverage could meet foreseeable
healthcare needs.
Risk aversion
Risk tolerance/risk aversion had a strong influence
on the importance of decision criteria. Item-level
analysis reveals significant difference between the
risk profiles on all four factors related to medical confidence, safety of the provider country, cultural and
logistical issues. Risk averse respondents were generally likely to rate the range of criteria as more important to their decision making than were the risk
tolerant respondents. Table 5 summarizes the results.

Prior international experience/medical


tourism
Respondents who lacked significant international
exposure placed significantly greater importance on
decisions regarding travel logistics (meanexperienced
3.5 vs. meaninexperienced = 4.0, P = 0.023), cultural
differences (meanexperienced 2.6 vs. meaninexperienced =
2.9, P = 0.042), and economic development/safety
factors (meanexperienced 3.5 vs. meaninexperienced = 4.0,
P = 0.021). There was no difference between those
with and without significant international experience
in the importance of medical confidence in the provider country and facilities (meanexperienced 4.3 vs.
meaninexperienced = 4.4, P = 0.433). Item-level analysis
shows multiple areas where prior international
experience seems to alleviate concern about country
and cultural differences that may be daunting to
those with little international exposure. A summary
of the significant mean differences across items are
shown in Table 5.
Prior receipt of medical care abroad also has a significant impact on the importance of travel logistics,
cultural and development/safety concerns. Cultural
differences are more important for those who

Demographics
We found few criteria that differed across demographics, with the exception of the availability of
quality aftercare upon returning home among
older patients, females, and unmarried persons.
Seniors show greater concern with the availability
of quality aftercare than do younger patients
vs.
mean3044 years = 3.8,
(mean>60 years = 4.4,
(F2,127 = 3.1,
P = 0.049).
mean4560 years = 4.05)
Females and unmarried persons also place greater
importance on quality aftercare than males and
married persons (meanFemale = 4.34, meanMale =
3.93; P = 0.016) (meanUnmarried = 4.36, meanMarried =
4.00; P = 0.050). Marital status influenced the
decision criteria to some degree. Unmarried persons

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Table 5: Mean scores on the importance of key decision-making criteria

Prior receipt
of foreign
healthcare

Significant
international
experience

No

Risk

Item

Yes

No

Yes

Averse

Tolerant

Medical confidence factors ( = 0.86)


Positive patient referrals or testimonials from
former patients
Hospital or doctor credentials/accreditation
Success rates/reputation in treating the
condition
Development/safety factors ( = 0.78)
Level of economic development/wealth of
provider country
Safety of the provider country
Perceived attitudes towards Americans held by
the countrys citizens
Political philosophies of the provider country
Cultural factors ( = 0.85)
Beauty/attractiveness of the physical location
Availability of cultural, entertainment, tourist
attractions of the provider country
How similar or different the countrys culture is
from my own
How similar or different the countrys language
is to my own
How similar or different the countrys food is to
my own
Whether the professionals treating me could
speak my language or not
Travel logistics factors ( = 0.90)
Availability of quality accommodations for
family/friends accompanying me
Costs of travel to and from the provider country
Length of time I would have to be out of
country and away from home
The amount of difference in costs for treatment
between provider country and the USA
If there is professional assistance in making all
necessary travel and treatment arrangements
Availability of quality aftercare upon returning
to the USA

4.28
4.14

4.44
4.26

4.19
4.00

4.45
4.28

4.50
4.26

4.29
4.18

4.28
4.41

4.48
4.57

4.22
4.35

4.49
4.58

4.58
4.65

4.28*
4.42

3.51
3.38

4.00*
3.70

3.37
3.26

4.00***
3.71*

4.02
3.66

3.73*
3.55

4.14
3.55

4.46
4.22*

4.09
3.26

4.45
4.25***

4.55
4.22

4.20*
3.91

2.96
2.55
2.48
2.52

3.63**
2.90*
2.82
2.66

2.87
2.45
2.39
2.48

3.62*
2.91*
2.82
2.66

3.66
2.90
2.72
2.54

3.26*
2.69
2.69
2.65

2.48

2.91*

2.44

2.90*

2.99

2.58*

2.79

3.34*

2.70

3.33*

3.42

2.97

2.48

2.80

2.26

2.82*

2.85

2.54

3.86

4.13

3.70

4.15*

4.25

3.86

3.53
3.03

4.02*
3.61*

3.47
2.83

4.01**
3.62

4.17
3.77

3.66***
3.15***

3.69
3.21

4.21+
3.92**

3.61
3.22

4.20+
3.88*

4.43
4.03

3.75***
3.49**

3.93

4.33*

3.91

4.31

4.48

4.03

3.24

3.73*

3.35

3.68

3.91

3.35**

3.76

4.22+

3.70

4.21+

4.31

3.95*

***P 0.001; **P 0.01; *P 0.05; +P 0.10.

placed more importance on success rates for treating


the specified condition (meanUnmarried = 4.74,
meanMarried = 4.45; P = 0.03) and the importance of
economic development levels (meanUnmarried =
3.92, meanMarried = 3.49; P = 0.01), likely as indicators of treatment effectiveness, although it is
unclear why this would differ from married
persons.

consult, 5 = very likely to consult) and were provided a list of potential information sources.
Univariate ANOVAs and independent sample ttests were performed to determine significant
differences.

Information sources about medical tourism


Potential medical tourists were asked how likely
they would be to consult various sources for guidance about receiving healthcare treatment in the
USA versus treatment abroad (1 = very unlikely to

Medical condition
The severity of medical condition had only a marginal significance on the information sources consulted. Those with life-threatening conditions rated
personal physician input more highly as an information source (meanlife-threat = 4.6) than those with
medically optional conditions (meanoptional = 4.2),
P = 0.063.

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Henson et al. Motivators, decision factors, and information sources influencing medical tourism

Figure 1: Information sources used in medical tourism decision making. Percentage of respondents who indicated the
source as Likely or Very Likely to be consulted.

Prior international experience/medical


tourism
People with significant international travel experience would rely less heavily on friends and family
as information sources than those with little international experience. (meanexperienced = 3.6 vs.
meaninexperienced = 4.1, P = 0.036). Inexperienced
travelers would be more likely to consult with
travel or tour operators than experienced travelers
(meanexperienced = 2.1 vs. meaninexperienced = 2.6, P =
0.023), although neither group indicated general
travel/tourism operators as highly likely sources of
information.
Respondents who have previously received
medical care in a foreign location showed a slight,
but significantly lower, difference in their reliance
on their personal physician for information about
healthcare treatments abroad (meanprior = 3.9 vs.
meannoprior = 4.5, P = 0.006). Their prior medical
care may make these patients more likely to directly
consult FHPs about treatment options.

Conclusion

Risk aversion
Those who are more risk averse are more likely
to consult with friends and family than those
who are more risk tolerant (meanrisk averse = 4.2,
meanrisk tolerant = 3.8, P = 0.025). While both groups
rate personal physicians as being important information sources, risk averse patients rate their
personal physician much more highly than do
risk
tolerant
patients
(meanrisk averse = 4.6,
meanrisk tolerant = 4.2, P = 0.006)

Results of this study offer preliminary conclusions


about how potential medical tourists approach
decisions about whether to seek healthcare abroad
or not. Both commonalities and differences in
motives, decision factors, and information sources
were found across differentiating characteristics.
The most common motives cited among all
respondents were to obtain lower cost treatment
and treatment options not available at home.
However, results also supported quality of care/
proven success, privacy, reduced wait times, and
combining vacation with treatment as valid and significant motives to become medical tourists.
Key decision factors grouped along the four dimensions of medical confidence, development and safety,
culture, and travel logistics. So far, medical confidence
factors were the most important to everyone, development/safety factors and travel logistics factors were
moderately important, and cultural factors were of
moderate-to-low importance, with the exception of
the doctor speaking the patients language, which
was of moderate-to-high importance.

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Healthcare coverage
Those who had low confidence that their insurance
coverage would meet current and future medical
needs were more likely to consult medical tourism
facilitators than were those with high confidence
in their insurance coverage (meanlow conf = 3.6,
meanhigh conf = 3.1, P = 0.03).

12

Demographics
Only age and gender showed any statistically significant influence in the use of information
sources. Older patients (>60) were less likely to
consult medical tourism agencies or facilitators
than were younger age segments (mean>60 = 2.9,
mean3044 = 3.5, mean4560 = 3.4; F(2,127) = 3.24, P =
0.042). Females were more likely to consult with
friends/family than were males (meanFemale = 4.3,
meanMale = 3.8, P = 0.008). There were no significant
differences between married/unmarried patients in
terms of the information sources consulted.
Figure 1 shows the likelihood that potential
medical tourists would use the identified resources
in their decision-making process.

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Respondents were likely/highly likely to consult


several information sources when researching
medical tourism options, which reflect an expected
high level of involvement for something of this
nature. Almost all indicated they would likely
consult another medical tourist who sought treatment for the same condition (91.8%) and their personal physician (88.8%). In a second tier of
probable information, sources were patient support
groups for same condition (80.6%), friends/family
(79.9%), foreign healthcare provider (78.4%), any
prior medical tourist (78.4%), and health insurance
providers (77.6%). Slightly fewer would consult
the internet (69.4%) and medical tourism agencies
(48.5%), and very few would consult regular
travel/tour operators.
Prior research17 has identified four trends challenging the medical tourism industry: (1) with more
confidence and awareness, consumers will increasingly bypass intermediaries and go straight to providers; (2) as more insurance companies cover
procedures abroad, patients will look to insurers
for assistance and direction; (3) there are increasing
pressures for DHPs to partner with FHPs, increasing
the reliance on primary providers for referrals; (4)
FHPs are increasing the direct marketing they do
to attract patients. These trends suggest a declining
role for medical tourism facilitators. While average
inquiries to MTFs rose significantly and consistently
from 2007 through 20082009,13 our data also
suggest that potential patients do not value these
organizations very highly in their decision-making
processes. As such, MTFs may need to more
clearly define the role their role and their range of
services when promoting themselves to potential
clients. In particular, given the greatest concerns
indicated by our sample, MTFs could enhance
their services that streamline the logistics associated
with medical travel and engage in more information
and education provision to alleviate patient concern
about provider country development and safety.

physicians when making decisions about medical


tourism.
Prior international experience or medical tourism
Those who had spent more time abroad were most
likely to consider medical tourism as a means to
reduce wait times for care. Both those with more
international travel experience and those who previously obtained care abroad place less significance
on travel logistics, cultural aspects, and development and safety factors than those with little experience. The more experienced rely less on family/
friends and travel/tour operators as information
sources. Previous medical tourists are slightly less
inclined to consult personal physicians. These
results no doubt reflect the greater knowledge and
confidence acquired through personal experiences
abroad.
Confidence in healthcare coverage
Those with lower confidence in the ability of their
healthcare coverage to meet current and future
medical needs are more motivated to engage in
medical tourism due to lack of trust in domestic
systems, and even more so if their insurance providers are willing to pay for care abroad. Decision
factors are evaluated similarly, regardless on the
level of confidence in coverage, however, those
low in confidence are more likely than others to
consult medical tourism agencies and facilitators.
Risk aversion
Those who exhibit higher levels of risk aversion are
most likely to be motivated towards medical
tourism by privacy and confidentiality concerns.
The risk averse view hospital/doctor credentials
and accreditations, safety, political philosophies,
cultural similarity, and travel factors as far more
critical determinants than those who are risk tolerant. They also place much more importance on
inputs from family/friends and their personal
physicians.

Medical condition
As for motives, those seeking a medically optional
treatment are more motivated to go abroad to
combine treatment with leisure and vacation activities. As such, they place much more importance on
cultural elements such as food, beauty, entertainment, and attractions when making decisions.
Those with life-threatening conditions are significantly more concerned with the economic development of a provider country, perhaps equating
advanced development with advanced technologies, quality of care, or safety. They are also far
more likely than others to consult their personal

Demographics
A few demographic differences exist in medical
tourism decision making. Those in the 3045 age
group are more likely to travel abroad for care
than respondents in other age ranges. Those who
are older, single, and female are most concerned
with availability of quality aftercare, and married
respondents place higher importance on medical
confidence, success rates, and economic development of the destination country. Older respondents
are less likely to utilize medical tourism agencies
and females are more likely to solicit inputs from

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Henson et al. Motivators, decision factors, and information sources influencing medical tourism

family and friends. These findings may help medical


tourism marketers develop more targeted messages to
address the concerns of specific groups of consumers.
Our results contribute to limited empirical
research on the consumer decision-making process
of potential medical tourists. Understanding the
motivations and other decision criteria of such consumers provides healthcare marketers a means of
segmenting the marketplace and identifying the
most appropriate channels of communication. Our
findings provide tentative guidance to countries
and healthcare providers to market their services
to medical tourists, as well as to domestic healthcare
providers either competing against or referring
patients to medical tourism options.

Disclaimer statements

6.
7.

8.
9.
10.
11.
12.

Contributors All authors contributed to the


research, analysis, and writing of this manuscript.

13.

Funding None.
Conflicts of interest None.

14.

Ethics approval There were no ethical issues associated with this paper. The study survey was
reviewed by the Institutional Review Board at
Appalachian State University at determined to be
exempt from further IRB approvals.

15.

16.

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