Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Journal of Destination Marketing & Management

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Research Paper

Impact of online WOM on destination trust and intention to travel: A

medical tourism perspective
Abubakar Mohammed Abubakar a,b,n, Mustafa Ilkan b
a
Faculty of Business and Economics, Eastern Mediterranean University, P.O. Box 95, Famagusta North Cyprus via Mersin 10, Turkey
b
School of Computing and Technology, Eastern Mediterranean University, P.O. Box 95, Famagusta North Cyprus via Mersin 10, Turkey

art ic l e i nf o a b s t r a c t

Article history: Electronic word-of-mouth (WOM), also known as eWOM, is one of the most influential sources of in-
Received 30 April 2015 formation on the web. The aim of this study is to examine the impact of online WOM on destination trust
Received in revised form and intention to travel in the medical tourism sector. In addition, the paper examines the moderating
7 December 2015
effect of income on the researched variables. Structural equation modeling is applied to examine the
Accepted 12 December 2015
interplay between the proposed variables, using a sample of 216 respondents. The empirical results
suggest that: online WOM positively influences destination trust and intention to travel; destination
Keywords: trust positively influences intention to travel; rising income strengthens the relationship between online
Online WOM WOM and intention to travel; and rising income weakens the relationship between destination trust and
eWOM
intention to travel. Implications and future research directions are discussed.
Medical tourism
& 2015 Elsevier Ltd. All rights reserved.
Destination trust
Travel intention

1. Introduction
Medical tourism (med-tour) is the act of seeking medical ser-
vices in a foreign country: it is a process by which medical tourists
(med-tourists) visit places for the purpose of healing and relaxa-
tion (Hunter, 2007). Med-tour is not a new phenomenon: mankind
has traveled to foreign lands to access treatment for many years
(Richard, Melisa, & Rupa, 2011). For years, med-tourists from de-
veloping countries have traveled to Europe and the USA to access
medical services. However, traveling from developed to develop-
ing countries to access medical services at a lower cost is a new
trend (Johnson, Youngquist, Garman, Hohmann, & Cieslak, 2015;
Misung, Heesup, & Tim, 2012). This has developed into a new
niche market, the med-tour market, offering an optimal oppor-
tunity for the tourism industry to diversify its services. Med-tour is
the process of combining products and services from the medical
industry and the tourism industry together, i.e. healthcare and
vacations (Lee, 2009; Misung et al., 2012).
Med-tour is developing rapidly in many countries such as
Turkey, India, Thailand, Singapore, Hong Kong and Taiwan (Tsoi,
2008). The fundamental factors that spark the growth of the med-
tour industry include the availability of well-qualified practitioners
in Asian countries, high costs of treatment in rich countries, long
n
Corresponding author at: Faculty of Business and Economics, Eastern Medi-
terranean University, P.O. Box 95, Famagusta North Cyprus via Mersin 10, Turkey.
E-mail addresses: mohammed.abubakar@cc.emu.edu.tr (A.M. Abubakar),
mustafa.ilkan@emu.edu.tr (M. Ilkan).
queues and waiting-lists in the source country and bargains in the
destination country (Keckley, 2008; Woodman, 2008). Further,
World Report (2010) reported that med-tour is growing fast in
emerging markets such as India, primarily due to a high level of
healthcare infrastructure, skilled medical personnel, and lower
prices compared to other med-tour destinations (Katz, 2015;
Mishra & Shailesh, 2012). India's med-tour sector is expected to
experience an annual growth rate of 30%, making it a $2 billion
industry by the end of 2015 (The Economic Times, 2015). Turkey is
viewed as the second-largest country in Eurasia in terms of med-
tour revenue and arrivals (Beladi, Chao, Shanee, & Hollas, 2015).
About half a million med-tourists visited Turkey in 2014 (Anadolu
Agency, 2015). According to the Ministry of Health (2012), the
country was ranked seventh in the world in 2009 with an esti-
mated revenue of $31.4 million in 2011 and about $1 billion in
2015 (Anadolu Agency, 2015). Private hospitals have been proac-
tive in creating and benefiting from the growth of this market. The
concept of med-tour has gained an audience in the present day
due to the prevalence of communication technology and the
consequent reduction of information barriers.
Sen and Lerman (2007) conceptualized word of mouth (WOM)
as a kind of real time conversation between consumers regarding a
product and/or service. The development of the Internet has ex-
tended the concept of WOM to an online context that embraces
wider audiences. Online WOM is a form of written memo on the
web, usually posted by experienced or previous consumers (Abu-
bakar & Ilkan, 2014a, 2014b). This written memo influences the
behavior of prospective customers (Abubakar & Ilkan, 2013). In

http://dx.doi.org/10.1016/j.jdmm.2015.12.005
2212-571X/& 2015 Elsevier Ltd. All rights reserved.

Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
2 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎
addition, the memo leads to information diffusion because it can
be accessed anytime, anywhere, and forwarded to other con-
sumers (Abubakar & Ilkan, 2013). For instance, Litvin, Goldsmith,
and Pan (2008) stated that the Internet has created a new type of
communication atmosphere that empowers both consumers and
providers: a platform that enables information flow along con-
sumer-to-consumer, consumer-to-business and business-to-con-
sumer channels. The improvement of hypermedia has led to an
increase in the number of people using the Internet to access in-
formation about a product and/or service (Litvin et al., 2008).
Online WOM is the most attested source of information for
consumers, and it is considered to be twice as inspiring as tradi-
tional advertisements (Hung & Li, 2007; Mayzlin, 2006). Further-
more, Casaló, Flavián, Guinalíu, and Ekinci (2015) stated that on-
line WOM has a strong influence in the tourism industry, primarily
due to the intangible nature of tourism services. TIA (2005) re-
ported that 67% of American travelers accessed the Internet to
retrieve information regarding their prospective travel destination.
Reports indicate that each year hundreds of millions of potential
visitors consult online reviews (Tripadvisor.com, 2011). Among
these potential visitors, 84% were influenced by reviews when
making travel decisions (Travelindustrywire.com, 2007). Potential
visitors consult online reviews because the tourism product and
service is not accessible until the moment of its consumption: thus
the risk and uncertainty associated with it is increased. For ex-
ample, a med-tour service like cosmetic surgery is accessible to
med-tourists only upon consumption (i.e. during the surgical op-
eration). Prospective tourists thus depend on referrals from their
friends, family members and social networks (Casaló et al., 2015).
According to Bickart and Schindler (2001), online WOM has the
potential to reduce the risk, uncertainty, and ambiguity associated
with a product or service. Interestingly, Jalilvand, Samiei, Dini, and
Manzari (2012) reported that online WOM has a significant impact
on tourists' destination image, attitude and travel intention in the
tourism industry. In this sense, it is argued in this paper that on-
line WOM has the potential to reduce the perception of the risk
and uncertainty associated with a med-tour destination. Although
the foregoing studies consider these information sources to be
factors that influence the perceived image of a tourism destina-
tion, there is a dearth of investigations regarding the effect on
destination trust, especially with regard to the med-tour industry
in which uncertainty and the potential for adverse effects is high.
2. Purpose of the study
Although research on the impact of online WOM on destination
image (e.g. Jalilvand et al., 2012; Mridula, 2009), destination choice
(e.g. Jalilvand & Samiei, 2012b; Zhu & Lai, 2009), and intention to
travel (e.g. Jani & Hwang, 2011; Papadimitriou & Gibson, 2008) is
not new, to our knowledge no research has investigated the im-
pact of online WOM on destination trust and intention to travel,
coupled with the moderating effect of income. Replicating similar
studies in the med-tour industry is therefore imperative for in-
creasing the generalizability of prior findings from other sectors of
the tourism industry.
3. Literature review
There are several reasons med-tourists travel over international
borders. These reasons tend to vary by country or region. For ex-
ample, in the USA, medical treatment is practically unaffordable
without health insurance (Beladi et al., 2015). In the UK, the Na-
tional Health Service waiting lists tend to be long and the cost for
private healthcare is very high, which often frustrates patients and
Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
forces them to travel outside the country in search of healthcare
services (Hanefeld, Lunt, Smith, & Horsfall, 2015). On the other
hand, African and Middle Eastern patients travel to India due to a
lack of medical expertise and unavailability of technology in their
own regions (World Report, 2010).
Awadzi and Panda (2005) noted that med-tourists are influ-
enced by both push and pull factors. The push factors are intrinsic
forces in humans, e.g. desires for personal privacy, confidence
enhancement and personal appearance (Ye, Yuen, Qiu, & Zhang,
2008). The pull factors are extrinsic forces related to a destination,
such as reputation, the known state of technology at the health-
care facilities, advertisement, price, doctors' experience and WOM
(Ye et al., 2008). According to Vincent, Deniz, and Haiyan (2011)
and Ben, Hanqin, and Peter (2011), Chinese med-tourists' moti-
vations to travel to Hong Kong are linked to factors such as pro-
motion, quality of medical services and personnel, expertise costs,
credibility and destination attributes.
The aforementioned factors in both studies are in line with
Awadzi and Panda's claims. Cheung and Wilson (2007) added that
for the purpose of reducing costs, the American medical insurance
scheme has advised policy holders to travel outside the USA to
access medical services in other nations. Thus, countries with
cheap but good-quality healthcare services have a competitive
advantage over those with higher costs; and this represents a
major advantage for promoting med-tour in developing countries
like Turkey. Although the quality of medical services and the im-
age of the destination country influences med-tourist decisions,
the main motivator is the economic benefit attached (Vincent
et al., 2011). The economic benefits can of course be the topic of
WOM and eWOM messages, along with any of the other afore-
mentioned motivating factors: logically, WOM is an inclusive
category.
Subsequently, a study by Ayoun, Ksouri, and Abdellatif (2015)
placed emphasis on the importance of WOM in the tourism in-
dustry. The study also showed that WOM is in fact the key factor
that shapes destination image construction and consequently
travel motivation. Given this, the present paper asserts that WOM
is a powerful element that influences travel decisions, and espe-
cially online WOM, due to its ability to travel farther and diffuse
faster. Online WOM communication refers to any positive or ne-
gative statements made by consumers and posted on the internet
for individuals and institutions in regard to products or services
(Hennig-Thurau, Gwinner, Walsh, & Gremler, 2004). Further, Yang
(2011) stated that the primary source of information for a tourist is
more likely to come from personal experience, WOM, and adver-
tisements from organizations. Empirical evidence has shown that
a WOM message has a considerable impact on the receiver's brand
attitudes (Laczniak, DeCarlo, & Ramaawani, 2001), attention
(Mikkelsen, VanDurme, & Carrie, 2003), intentions (Grewal, Cline,
& Davies, 2003), consideration (Grewal et al., 2003), and ex-
pectations (Webster, 1991).
3.1. Online WOM and intention to travel
Intention to visit a destination is defined as the willingness to
visit the destination (Chen, Shang, & Li, 2014); the decision to visit
a destination is interpreted as a rational calculation of the costs
and benefits of a set of alternative destinations, which were de-
rived from external information sources, including online WOM or
travelers' blogs (Chen et al., 2014). Online WOM has the power to
procure 30 times more consumers than the traditional channels
(Trusov, Bucklin, & Pauwells, 2009). This is because potential
visitors perceive online WOM to be up-to-date, enjoyable and
more reliable than information provided by travel firms. This study
posits that online WOM is essential for professional and ag-
gregating services, especially complicated ones like med-tour.
 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Research has shown that healthcare providers with a more posi-
tive WOM may have higher profits and an increase in the number
of patients (Campbell, 2012). In their influential studies, Lee, Han,
and Lockyer (2012) found that positive WOM enables South Kor-
ean healthcare providers to formulate a sustainable marketing
strategy and ensure their survival, while Ko and Kim (2011)
warned that healthcare providers should do anything within their
power to diminish negative WOM. This is because disparaging
WOM has a profound negative influence on the behavior of po-
tential visitors. Research in other sectors of the tourism industry
has revealed that favorable online reviews regarding a resort or
hotel increase the likelihood of booking and room sales (Duverger,
2013; Ogut & Tas, 2012; Vermeulen & Seegers, 2009). According to
this view, favorable online reviews may increase the number of
beds and patients from a med-tour perspective. Empirical evi-
dence has shown that online WOM has the potential to increase
the intention to travel (Arsal, Backman, & Baldwin, 2008; Filieri &
McLeay, 2014) and should be considered as the best advertising
tool that medical hub setups could take advantage of (Srivastava &
Mahajan, 2011). Given the extant literature, the following hy-
pothesis is proposed:
H1. Online WOM has a significant impact on the intention to
travel to a medical destination.
3.2. Online WOM and destination trust
An examination of the hospitality management literature re-
veals that little is known about the impact of online WOM on
destination trust. Online WOM is considered to be an important
information source influencing tourists' choice of destination (Ja-
lilvand & Samiei, 2012b). According to Morgan, Pritchard, and
Piggott (2003), disparaging WOM, in which dissatisfied tourists
share unpleasant and belittling comments regarding their ex-
periences, has an intense impact on destination image. Dennis,
Merrilees, Jayawardhena, and Wright (2009) added that a positive
attitude toward an e-retailer positively influenced e-consumers'
intention to make a transaction. Zhu and Lai (2009) studied how
online WOM influences tourism destination choice. The study
finds that the amount of information in WOM and consultations is
positively related to the actual tourist reception. The findings can
also be interpreted as a rational evaluation of WOM information
regarding attributes (i.e. reliability, integrity, competence, and
quality assurance) associated with a product, service, or destina-
tion. In the context of this study, the aforementioned attributes are
related to a destination. Trust is defined as 'one party's confidence
in an exchange partner's reliability and integrity’ (Morgan & Hunt,
1994, p. 23).
Destination trust refers to a visitor's willingness to rely on the
ability of a med-tour destination to perform its advertised func-
tions. In more practical terms, destination trust gives assurances to
med-tourists who choose to visit a particular destination, that
service provision will be transparent, reliable, risk, and hassle free
(Roodurmun & Juwaheer, 2010). Perhaps a destination that in-
culcates trust in tourists' minds can be more easily branded. Per-
sonal involvement is extreme in the med-tour industry, due to the
fact that the outcome is critical from the tourist's perspective.
Uncertainty and risk are perceived by med-tourists as high, given
the possibility of adverse medical effects. In order to reduce their
uncertainty and limit their risk, therefore, potential med-tourists
tend to seek information from previous customers, or trustworthy
and experienced individuals. Scholars have provided collateral
evidence that positive online WOM plays an important role in
reducing travelers' risk perceptions when booking accommodation
(Gretzel & Yoo, 2007; Sparks & Browning, 2011). Recently, a study
by Ladhari and Michaud (2015) noted that positive feedback
Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
3
increases the level of trust shown toward a destination. This paper
therefore argues that online WOM would reduce potential med-
tourists' risk and uncertainty perception associated with a med-
tour destination. Based on these theoretical and empirical argu-
ments, it is proposed that online WOM will have a significant
impact on med-tourist destination trust. Given the extant litera-
ture: the following hypothesis is proposed.
H2. Online WOM has a significant impact on the destination trust
for a medical destination.
3.3. Destination trust and intention to travel
Analysis of the literature identifies a gap in the research on
destination trust and the intention to travel. The ultimate goal of
destination marketing is to generate an intense bond between the
consumer and the brand, and the main ingredient of this bond is
trust (Hiscock, 2001). Trust is an effective means of minimizing the
perception of risk and uncertainty (Han & Hyun, 2013; Pavlou,
Liang, & Xue, 2007), and tourists are more likely to visit destina-
tions that they perceive as trustworthy and dependable (Roo-
durmun & Juwaheer, 2010). This trust premium is primarily in-
fluenced by issues of malpractice, quality, and adverse effects
(Han, 2013). Therefore, destination trust (i.e. reliability, integrity,
competence and quality assurance) may influence the willingness
to travel in the med-tour context. Turkey has about 32 hospitals
accredited by the Joint International Commission, which are
mostly located in Istanbul (Organization of Medical Tourism,
2015). Some hospitals have partnerships with top American hos-
pitals such as Harvard Medical Center and Johns Hopkins, and are
staffed by many highly-skilled, English-speaking, and Western-
trained doctors (Organization of Medical Tourism, 2015). Han and
Hyun (2015) confirmed that international med-tourists are more
likely to visit a destination they trust (e.g. clinic or country). Based
on these theoretical and empirical arguments, this paper proposes
that med-tourists are more likely to visit a trusted medical desti-
nation. Given the extant literature, the following hypothesis is
proposed:
H3. Destination trust has a significant impact on the intention to
travel to a medical destination.
3.4. Income as a moderator
Gross domestic product (GDP) as an aggregate measure of in-
dividual income is a predictor of the demand for tourism (Song,
Dwyer, Li, & Cao, 2012). Connell (2011) noted that high-income
nations such as Australia are prospective source countries for
visitors to med-tour destinations. According to the World Bank
(2015) income classification reports, Northern Cyprus is among the
high-income countries, with a per-capita GDP of $15,302. There-
fore, Northern Cyprus can also be viewed as a source country for
visitors to med-tour destinations. Income is one of the keys to
explicating the economic impacts of tourism, not only because of
its intimate relationship with the direct effects of a tourism
economy, but also its indirect and induced effects (Zhang, Ding, &
Bao, 2008). Travel activities are prone to constraints, which include
time and money (Chick & Dong, 2003; Kattiyapornpong & Miller,
2009). Subsequently, Johnston, Crooks, and Snyder (2012) added
that income is a significant motivational factor for Canadian med-
tourists to seek medical care overseas; and the level of financial
means is related to travel participation (Börjesson, Fosgerau, &
Algers, 2012). A substantial body of research in the tourism in-
dustry demonstrated that online WOM in particular affects tour-
ists' intention to travel (Filieri & McLeay, 2014). However, this re-
lationship is yet to be verified in the med-tour industry when
4 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Fig. 1. Conceptual model.
income is added in to the relationship. This paper proposes that
the impact of online WOM on intention to travel will be stronger
when income is higher. Given the extant literature, the following
hypothesis is proposed:
H4. A higher income will strengthen the relationship between
online WOM and the intention to travel to a medical destination.
Travel decisions are affected by preferences, income, and the
price of tourism (Cheng, 2012; Lee, 2012). The travel industry is an
excellent example of how risk and uncertainty about the quality of
service can affect consumer demand in a negative way (Ye, Law, &
Gu, 2009). Destination trust depletes anxiety, uncertainty, and
vulnerability related to med-tour transactions, especially in the
case of complex and experiential services (Hennig-Thurau et al.,
2004). For instance, 27% of tourists in the USA are willing to travel
abroad for medical services if they can be assured that the treat-
ment will be of comparable quality and save 50% by going abroad
(Deloitte, 2008). In short, once trust has been established, income
may exert some level of influence on med-tourists' intention to
travel (Zhang et al., 2008). This paper proposes that the impact of
destination trust on intention to travel will be stronger when in-
come is higher. Given the extant literature, the following hy-
pothesis is proposed:
H5. A higher income will strengthen the relationship between
destination trust and the intention to travel to a medical
destination.
The proposed model in this study investigates the relationship
between online WOM, destination trust, intention to travel, and
income in the med-tour industry. See Fig. 1.
4. Methodology
This section presents the research design adopted in this study,
the sampling technique, data gathering procedures and analysis.
The research is quantitative in nature: this approach was em-
ployed to better understand the phenomenon at hand and to
generate initial insights needed for future studies.
4.1. Sampling
To achieve the study goal, a survey was conducted with out-
bound med-tourists who have the potential to visit Turkey for
medical attention. The study employed a random sampling
Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
technique: a type of sampling technique that is not subject to
selection bias. The benefit of using this approach is that it is free of
classification error, and it is relatively easy to interpret data col-
lected in this manner.
4.2. Data collection
According to information obtained from the Ministry of Health,
Northern Cyprus has nine public hospitals with different specia-
lizations (Ministry of Health Northern Cyprus, 2015a), and 12
private hospitals (Star-Kibris, 2014), most of which are small in
size, expensive to run, and lacking in modern facilities. The
shortage of medical staff (Yeni-Duzen, 2014), problems of mal-
practice Özadam (2015), the high cost of private health insurance,
and the absence of full public health insurance (Ministry of Health
Northern Cyprus, 2015b) negatively affect the healthcare sector in
the country. These problems often force patients to seek medical
services abroad. Turkey was chosen as a focal destination due to its
reputation in med-tour (Beladi at al., 2015), proximity, socio-cul-
tural ties, and the absence of a language barrier (Hanefeld et al.,
2015). These factors have a profound influence on med-tourist
decisions, but WOM is the most important factor (Hanefeld et al.,
2015).
The questionnaires were distributed by the research team to
local patients (Northern Cyprus nationals) receiving medical care
in three public and three private hospitals in Northern Cyprus: the
hospitals were selected based on their size and the number of
patients. The respondents were being treated for cancer, diabetes,
heart, dental conditions, and kidney-related health issues, and
some were at the hospital for plastic surgery, cosmetic surgery,
hair transplants, and in-vitro fertilization treatment. These types
of diseases and procedures require professionalism and con-
tinuous attention. Thus, the propensity to seek medical attention
abroad is high, given the current state of medical services in
Northern Cyprus. The respondents were randomly approached,
such that all individuals had the same probability of being chosen,
and asked to complete the questionnaire in a self-administered
manner. The patients were contacted directly to improve the
ecological validity of the research, which also improves the ex-
ternal validity. Each questionnaire was accompanied by a cover
page stating that participation would be completely voluntary and
that the information provided would be kept confidential.
Common method variance (CMV) refers to variance that is at-
tributable to the measurement method rather than to the con-
struct of interest. Podsakoff, MacKenzie, Lee, and Podsakoff (2003)
suggested that assuring respondent anonymity will likely reduce
the potential for CMV. Social desirability is the tendency for re-
spondents to try to behave in a culturally acceptable and appro-
priate manner. Assuring confidentiality and anonymity should
reduce people's evaluation apprehension and make them less
likely to edit their responses to be more socially desirable
(MacKenzie & Podsakoff, 2012; Podsakoff et al., 2003). In addition,
proximal, and psychological approaches were used to make it
appear that the measurement of the predictor variable is not re-
lated to the measurement of the criterion variables (MacKenzie &
Podsakoff, 2012). We placed the predictor variable items on a se-
parate page, and criterion variables on another page. Additionally,
two filter questions were used to select the participants: (1) are
you a member of any online community? and (2) do you read or
post online reviews? Those who failed to meet the criteria were
excluded from the study. The survey consisted of four sections,
namely: (i) online WOM, (ii) destination trust, (iii) intention to
travel, and (iv) demographics.
 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 5

4.3. Measures Table 1

Respondents' profile (n¼216).
Online WOM was measured using six items adopted from
Frequency Percentage
studies of (Bambauer and Mangold (2011) and Jalilvand and Samiei
(2012a). Sample items included: “I often consult other medical Gender
tourists' online travel reviews to help me choose a good medical Male 100 46.3
destination” and “To make sure I choose the right medical destina- Female 116 53.7
Total 216 100.0
tion, I often read other medical tourists' online travel reviews”. Var-
ious articles and research papers have interchangeably used ‘des- Age
Below 20 3 1.4
tination’ and ‘brand’. For instance, ‘brand equity’ was translated to
21–30 90 41.7
‘destination equity’ (Papadopolous & Heslop, 2002), ‘brand per- 31–40 105 48.6
sonality’ was translated to ‘destination personality’ (Hosany, 41–50 17 7.9
Ekinci, & Uysal, 2006), and ‘brand image’ was translated to ‘des- Above 50 1 .5
tination image’ (Gallarza, Saurab, & Garcíab, 2002). Relying on this, Total 216 100.0

the paper proposed a definition for destination trust similar to

brand trust (Delgado-Ballester, 2004). The eight items were Marital status
adopted and modified for the operationalized destination trust Single 99 45.8
Married 117 54.2
context. Delgado-Ballester's studies consisted of relevant items Total 216 100.0
from consumer trust and organization trust, which were adopted
Income in TL
from empirical studies by Garbarino and Johnson (1999), Hess
Below 2000 3 1.4
(1995) and Morgan and Hunt (1994). Eight items were used to 2000–2999 40 18.5
measure destination trust. Sample items included: “I feel con- 3000–3999 100 46.3
fidence with Turkish hospitals” and “I could rely on Turkish hospitals Over 4000 73 33.8
to solve my medical problems”. Intention to travel consisted of three Total 216 100.0

items that were adopted from studies by (Kassem & Lee, 2004; Education
Kassem, Lee, Modeste, & Johnston, 2003; Jalilvand & Samiei, High school 8 3.7
Some college degree 29 13.4
2012b). The adopted items were modified to fit the oper-
Bachelor’s degree 86 39.8
ationalized medical travel intention context. A sample of items Higher degree 93 43.1
includes: “I would visit Turkey rather than any other medical desti- Total 216 100.0
nation” and “I predict I will visit Turkish hospitals in the future”. All
items were rated on a five-point scale ranging from 5 (strongly Notes: TL, Turkish Lira

agree) to 1 (strongly disagree). Demographic variables used in the

study included age, gender, marital status, education level, and
monthly income. The study constructs were written in English and
then translated into Turkish by linguistic experts. It was felt that
there was a need to have a Turkish version of the questionnaire
because the majority of the patients spoke and understood Turk-
ish. A pilot survey was conducted with seven respondents and
necessary changes were made to the questionnaire.
4.4. Data analysis
SPSS version 20.0 and AMOS version 20.0 were used for the
analysis, and confirmatory factor analysis was utilized in this
study. Four hundred questionnaires were distributed, 243 usable
samples were obtained, and those with missing data were elimi-
nated as recommended by Collier and Bienstock (2007). Only 216
were therefore used for data analysis, yielding a 61% response rate.
Before analyzing the interaction among the study variables, the
descriptive statistics and psychometric properties of the mea-
surement scale were examined. The proposed model was esti-
mated with AMOS, which is designed to estimate and test struc-
tural equation models (SEMs). Several goodness-of-fit indices were
evaluated, namely: chi-square statistic (χ2), goodness-of-fit indices
(GFI), the normed fit index (NFI), the comparative fit index (CFI);
root mean square error of approximation (RMSEA), root mean
square (RMR) and the χ2 re-estimate test (CMIN/DF) were used.
The goodness of fit for the model yielded the following results:
χ2 ¼123.5, df ¼62, po.001, GFI¼ .92, 1 ¼maximum fit, NFI ¼.70,
1 ¼maximum fit, CFI¼.80, 1 ¼maximum fit, RMSEA ¼.068,
values o .08 (indicating good fi), RMR¼.034, values o.045 in-
dicating good fit, CMIN/DF ¼1.99, values 4 1 and o3 were
accepted.
Next the demographic characteristics were evaluated. Out of
the 216 respondents, 54% (116) were female and the rest were
male. An overwhelming number of the respondents were in the
age range 31 to 40 (49%) and 21 to 30 (42%). Fifty-four percent of
the respondents were married and the rest single. Forty-three
percent of the respondents had higher degrees, 40% bachelor's
degrees, and 13% college degrees. The majority of the participants
(46%) had monthly income between 3000 and 3999 Turkish Lira,
and 33% had monthly income over 4000 Turkish Lira. The effects of
the non-response rate and missing data were evaluated by com-
paring the demographic characteristics of the subjects as sug-
gested by Armstrong and Overton (1977) and Collier and Bienstock
(2007). The comparison of the current research population's de-
mographics with those of the general population showed no sig-
nificant difference. In general, this increases the robustness of the
data: the sample seems to be a representative of the population of
interest. The descriptive data are presented in Table 1.
5. Results and discussion
The results show that the model fits are reasonable and ac-
ceptable as suggested (Bentler & Bonett, 1980; Bollen, 1989a,
1989b; Jöreskog & Sörbom, 1984; Tanaka & Huba, 1985; Wheaton,
Muthén, Alwin, & Summers, 1977). For scale reliability and validity,
internal consistency measures (i.e. Cronbach's alpha [α], compo-
site reliability [CR] and average variance extract [AVE]), convergent
validity (i.e. standardized loadings) and discriminant validity (i.e.
inter-factor correlations) were used. Cronbach's alphas were be-
tween .87 and .90, which is above the cutoff point of .60 (Hair,
Black, Babin, Anderson, & Tatham, 2006), CR values ranged from
.88 to .90, which is also above the cutoff point of .60 (Hair et al.,
2006), and AVE values ranged from .55 to .75, which is above the
cutoff level of .50 (Hair et al., 2006). In addition, the standardized
loadings were above the thresholds of .50 as suggested by Hair
et al. (2006). The results verify evidence of internal consistency
and convergent validity (see Table 2). Discriminant validity is

Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
6 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Table 2
Psychometric properties of the measures.

Scale items Loadings Mean S.D

Online WOM (α ¼.88; CR¼ .89; AVE ¼.61)

I often read other medical tourists' online travel reviews to know what destinations make good impressions on others .73 3.88 1.07
To make sure I choose the right medical destination, I often read other medical tourists' online travel reviews. .89 3.97 .96
I often consult other medical tourists' online travel reviews to help me choose a good medical destination. .77 3.99 .92
I frequently gather information from tourists' online travel reviews before I travel to a certain medical destination. .79 4.08 1.03
If I don't read tourists' online travel reviews when I travel to a medical destination, I worry about my decision. –a 4.04 1.08
When I travel to a medical destination, tourists' online travel reviews make me confident in traveling to the destination. .70 4.18 .91

Destination Trust (α ¼ .87; CR ¼.88; AVE ¼ .55)

Turkey as a medical destination meets my expectations. –a 3.96 .92
I feel confidence with Turkish hospitals. .61 4.06 .82
I will not be disappointed with Turkey's healthcare services. –a 4.01 .79
Turkish hospitals guarantee satisfaction. .82 4.13 .83
Turkish hospitals would be honest and sincere in addressing my concerns .82 4.17 .78
I could rely on Turkish hospitals to solve my medical problems. .82 4.01 .84
Turkish hospitals would make any effort to satisfy me. .68 4.03 .87
Turkish hospitals would compensate me in some way in case of injuries after service. .66 3.90 .95

Intention to travel (α¼ .90; CR ¼.90; AVE ¼ .75)

I predict I will visit Turkish hospitals in the future. .94 4.11 1.09
I would visit Turkey rather than any other medical destination. .81 3.86 1.02
If I need medical attention I think, I will visit Turkish hospitals in the future. .85 4.07 1.06

Notes: CR, construct reliability; AVE, average variance extracted; α, Cronbach's alpha. KMO Measure of Sampling Adequacy ¼.84; Bartletts' Test of Sphericity ¼ 2041.4, df¼91,
p o.001.
a
Dropped items during confirmatory factor analysis.

Table 3 Table 4
Means, standard deviations (SD), and correlations of study variables. Maximum likelihood estimates for the research model (n¼ 216).

Variables Mean SD 1 2 3 Exogenous Endogenous Coefficient Standard t- Statis- p

variables variables estimates error tics
1. Online WOM 4.02 .80 –
2. Destination Trust 4.05 .67 .429nn – Online WOM Destination .429 .051 6.187 nn

3. Intention to Travel 4.01 .97 .390nn .597nn – Trust

Online WOM Intention to .164 .071 2.740 .006nn
Note: Composite scores for each variable were computed by averaging respective Travel
nn
item scores. SD, standard deviation. Destination Trust Intention to .527 .086 8.803
nn
Correlations are significant at the.01 level. Travel

Interaction effect in the model

nn
established when the estimated correlations between the vari- Online WOM Intention to .454 .084 6.425
ables is below 0.85 (Kline, 2005). Table 3 presents the mean, Travel
n
(Online WOM Intention to .156 .056 2.210 .028n
standard deviation, and correlations of the respective study vari- Income) Travel
ables. Composite scores for each variable were computed by Destination Trust Intention to .498 .091 7.962 nn

averaging respective item scores. The inter-factor correlation Travel

analysis among the variables was below 0.85, so the results verify
evidence of discriminant validity. The table also shows that online
WOM had a significant impact on destination trust (r ¼ .43, po .01)
and intention to travel (r ¼ .39, p o.01). Likewise, destination trust
had a significant impact on intention to travel (r ¼.60, p o.01). This
provides preliminary support for the hypothesized relationships.
As a first step, SEM was used to test the hypotheses. The R2
value was used to assess the proportion of variance in the en-
dogenous variables that could be explained by the exogenous
variable. Approximately 57% of the variance for intention to travel
was explained by online WOM and destination trust, and 36% of
the variance in destination trust was explained by online WOM,
making the interpretation of the path coefficients meaningful and
resourceful. As shown in Table 4, the results provided con-
firmatory support for the hypothesized relationships. That is, on-
line WOM positively influences the intention to travel (β ¼ .16,
t¼2.74, po .05). This suggests that online WOM is an important
antecedent for med-tourists' intention to travel (H1 was sup-
ported). Secondly, online WOM positively influences destination
trust (β ¼ .43, t¼ 6.19, p ¼.000), which emphasizes that online
WOM can increase destination trust in the eyes of potential med-
tourists (H2 was supported). Finally, destination trust positively
(Destination Intention to  .052 .069  .862 .390
Trustn Income) Travel
n
Significant at the p o.05 level (two-tailed).
nn
Significant at the p o .01 level (two-tailed).
influences intention to travel (β ¼.53, t ¼8.80, p ¼.000). This sug-
gests that destination trust is an important antecedent for med-
tourists' intention to travel (H3 was supported).
As a next step, the moderating effect of income on the model
was examined. The direct impact of online WOM on the intention
to travel yielded the following results: R2 ¼ .152, F¼38.28**
p¼ .000. When the moderator ‘online WOM*Income’ was added to
the model, however, a significant change in the explained variance
was observed: the value of R2 increased, yielding R2 ¼.166,
F¼20.95** p ¼.000. In other words, the addition of income to the
model increased the explained variance in the relationship by 1.4%
(see Fig. 2). As such it can be concluded that rising income
strengthens the relationship (H4 was supported). Secondly, the
direct impact of destination trust on the intention to travel had the
following results: R2 ¼ .356, F¼118.35** p ¼.000. When the mod-
erator ‘destination trust*Income’ was added to the model,

Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 7

5 income. The direct effect of destination trust on intention to travel

was .762 before and .726 after moderation. In other words, for
4.5 each unit increase in the destination trust, the intention to travel
increases by 0.76 units before and 0.73 units after the moderating
4
effect of income. Lastly, the indirect effect of online WOM on in-
3.5
Moderator tention to travel through destination trust was .270 before and
Travel Intenon

.292 after moderation. Again, for each unit increase in online

3 Low Income WOM, intention to travel indirectly increases through destination
trust by .355 units before and .355 units after moderation. The
2.5 result signifies the importance of online WOM in the formation of
High Income
destination trust and in stimulating travel intention.
2 eWOM has become an important part of the online marketing
mix, and plays an essential role in the online shopping experience.
1.5
This study builds on previous research to explore the influence of
1 online WOM on intention to travel and on destination trust, and
Low Online WOM High Online WOM the induced effects of income were gauged. The effects of online
WOM on varieties of endogenous variables that are relevant in the
Fig. 2. Interaction term for Hypothesis 4.
med-tour industry are important to destination marketers. In this
study, it was shown that online WOM has a significant impact on
5
intention to travel and on destination trust. Rising income
4.5 strengthens the relationship between online WOM and intention
to travel, and rising income weakens the relationship between
4 destination trust and intention to travel – although previous re-
search concerning online WOM has documented a positive effect
Travel Intenon

3.5 Moderator
on tourists' intention to travel (Ayoun et al., 2015; Duverger, 2013;
3 Low Income Filieri & McLeay, 2014; Ko & Kim, 2011; Lee et al., 2012). There has
been no prior attention paid to destination trust, and the potential
2.5 mechanisms by which income may induce effects. The paper has
High Income
shown that online WOM has a significant impact on destination
2 trust and on intention to travel, and that destination trust has a
significant impact on intention to travel. Taken together the results
1.5
also suggest that online WOM has an indirect impact on intention
1 to travel through destination trust. Further, the indirect effect was
Low Desnaon Trust High Desnaon Trust higher when the income variable was included in the model.
In sum, the findings show how online WOM influences desti-
Fig. 3. Interaction term for Hypothesis 5.
nation trust and travel intention. Prior studies have established
similar results with online sales (Chevalier & Mayzlin, 2006),
however, the explained variance decreased: the value of R2 dete-
brand image (Jalilvand & Samiei, 2012a), destination image (Ja-
riorated, yielding R2 ¼ .347, F¼ 31.11** p¼ .000. Thus, the addition of
lilvand et al., 2012), and destination choice and travel intention
income to the model decreased the explained variance in the re-
(Jalilvand & Samiei, 2012b). The studies asserted that online WOM
lationship by 0.9% (see Fig. 3). As a result, it can be concluded that has a significant effect on consumers' and travelers' decisions. For
rising income weakens the relationship (H5 was rejected). This example, the Jalilvand et al.'s (2012) study indicates that online
shows that wealthier med-tourists are less reliant on destination WOM has a significant effect on destination image, travel inten-
trust to make travel decisions. tions and tourists' attitudes. This paper has extended the model
Finally, to examine the interplay among the study variables using destination trust and intention to travel to suggest a more
they were analyzed according to the total, direct and indirect ef- enriched and dynamic relationship with income. The moderating
fects (see Table 5). The direct effect of online WOM on destination effect of income between travel motivation (e.g. online WOM) and
trust was .355 both before and after the moderating effect of the intention to travel relationship has been emphasized by pre-
vious scholars (Kattiyapornpong & Miller, 2009). This study has
Table 5 shown that income strengthens the relationship, such that when
Break down of total effect of the research model (n ¼216). income is higher, the impact of online WOM on intention to travel
is higher. Furthermore, increasing income dampens the relation-
Exogenous Endogenous Total Direct Indirect Confidence
ship between destination trust and intention to travel, instead of
variables variables effect effect effect interval (%)
strengthening the relationship as predicted. This suggests that
Online WOM Destination .355 .355 .000 99 rising income plays a marginal role in the relationship between
Trust destination trust and intention to travel. This might be because
Online WOM Intention to .466 .196 .270 99 wealthy med-tourists rely heavily on online WOM and are less
Travel
Destination Intention to .762 .762 .000 99
reliant on destination trust to make travel decisions. Second,
Trust Travel wealthy med-tourists have better healthcare, and thus have less
experience with health-related consequences, which in turn af-
Interaction effect in the model (income)
Online WOM Destination .355 .355 .000 99 fects their risk perceptions. Third, those with high income may
Trust have a number of alternatives and are more likely to take impulse
Online WOM Intention to .542 .250 .292 95 decisions. In other words, more wealthy med-tourist travel deci-
Travel sions are more likely to be influenced by online reviews, rather
Destination Intention to .726 .726 .000 99
Trust Travel
than destination trust. These findings are ground breaking, and at
the same time call for more investigation, considering the claims

Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
8 A.M. Abubakar, M. Ilkan / Journal of Destination Marketing & Management ∎ (∎∎∎∎) ∎∎∎–∎∎∎
made by prior studies (Cheng, 2012; Lee, 2012; Ye et al., 2008).
This establishes the need for additional research.
Practitioners in the med-tour industry should do anything
within their power to increase positive online WOM in order to
increase destination trust and intention to travel. In their study,
Ladhari and Michaud (2015) noted that information from an ac-
quaintance is less likely to be rejected, especially in a context in
which consumers are becoming more vigilant and demanding.
Thus, destination marketers should do more in order to diminish
negative online WOM. Providing a top-notch service experience
might increase the steady stream of positive online WOM. Online
WOM is of course important but it is not the only factor that
shapes tourists′ destination trust and travel intention.
6. Conclusions
This study provides evidence of the relationship between on-
line WOM, destination trust and intention to travel, as well as the
moderating effect of income. The results suggest that online WOM
has a significant impact on destination trust and intention to tra-
vel. The findings from a structural modeling revealed that income
strengthens the relationship between online WOM and intention
to travel by increasing the likelihood of travel. Additionally, des-
tination trust has a significant impact on intention to travel, and
income weakens the relationship by decreasing the likelihood of
travel. The role of destination trust in med-tour marketing is very
important, because destination trust is believed to be a funda-
mental component of building successful business relationships,
since it has the ability to influence perceptions of confidence, re-
liability, and integrity among exchange partners. More generally,
the enormous pressure on destination marketers to increase the
attractiveness of their destination suggests that it is both ethical
and practical to increase positive online WOM. Favorable online
WOM plays an important role in creating favorable destination
trust and in intensifying the intention to travel.
As a recommendation, destination marketers should organize
and create point-of-service activities (e.g. instant photo sharing
during beautification or cosmetic procedures) in the form of ser-
vice trials, with the aim of motivating online WOM communica-
tion. These activities could provide a medium by which potential
med-tourists may form their own impressions, as previous and
present med-tourists share their experiences online and these are
made available to millions of potential med-tourists. Finally, med-
tour destination marketers should take advantage of this compe-
titive tool to boost their destination attractiveness and also in-
crease profits. This can be achieved by monitoring and observing
different kinds of online reviews posted on sites like luxury-
traveladvisor.com, tripadvisor.com and other social media plat-
forms. In contrast to ‘normal’ WOM, online WOM is more man-
ageable and cost-effective, since it is information that is posted
online and which can be accessed easily by practitioners.
6.1. Limitations, strengths and future research direction
While this paper has shed some light on online WOM, it has
some limitations. The findings should be considered with caution
given the sample size and data collection method employed.
Sampling and research design was one of the limitations identified
in this study. The cross-sectional design limits the extent to which
cause–effect relations can be inferred from the research findings.
Future research that adopts a longitudinal design would be better
suited to addressing the causal status of the variables examined in
this research. The impact of travel distance was not considered on
the model, as such researchers are encouraged to investigate this
in future work. Examining the effect of online reviews on
Please cite this article as: Abubakar, A. M., & Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical
tourism perspective. Journal of Destination Marketing & Management (2016), http://dx.doi.org/10.1016/j.jdmm.2015.12.005i
destination trust, destination choice, and destination image si-
multaneously may provide additional insights for med-tour prac-
titioners. As this research utilized a sample with a single-country
focus, future research should examine the generalizability of these
findings through cross-cultural or multi-country studies. In terms
of strengths, due to the representativeness of the sample obtained
through the random sampling technique, generalizations can be
made from the results of the sample to the general population.
Acknowledgment
The authors wish to thank the anonymous reviewers for their
detailed and useful comments on the earlier draft of this
manuscript.
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Abubakar Mohammed Abubakar is affiliated with Eastern Mediterranean Uni-
versity. His research areas include e-Learning, Internet and social media marketing,
Macro/micro organization behavior, Creativity and cognitive individual differences
in internet searching.
Mustafa Ilkan is affiliated with Eastern Mediterranean University. His research
areas include IT project management, Risk management and security, Business
solutions, eWOM, Knowledge management and IT and Tourism management.