Journal of Retailing and Consumer Services 31 (2016) 207–216

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Journal of Retailing and Consumer Services

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Quality, Value? – Insights into Medical Tourists’ Attitudes and

Behaviors
Lyn Manassannan Prajitmutita c, Áron Perényi a, Catherine Prentice b,n
a
Faculty of Business & Law, Swinburne University of Technology, Hawthorn, Victoria, 3122, Australia
b
School of Business & Law, Edith Cowan University, Perth 6027, Australia
c
Sripatum International College, Sripatum University, Bangkok 10900, Thailand

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

Article history: The research investigates the factors influencing medical tourists’ attitudes and behaviors. The factors
Received 7 February 2016 examined include hospital service and customer perceived value. The study was undertaken in a major
Received in revised form hospital located in a South-East Asian country. The sample includes foreign patients who have received
7 April 2016
various medical treatments in the hospital. The findings indicate that medical tourists are value oriented
Accepted 8 April 2016
customers as their value perception has the strongest direct effect on their behaviors, followed by their
attitudes towards the hospital. Hospital service appears to have a substantial direct effect on perceived
Keywords: value and medical tourist satisfaction, and also exerts an indirect effect on medical tourist behaviors. The
Medical tourism research highlights the prominent role of perceived value, and pinpoints the most effective avenues for
Service marketing
healthcare providers in allocating resources to improve hospital performance from the perspective of
Customer value
medical tourists.
Service quality
& 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Due to the exorbitant cost of health services, citizens from
developed nations sought medical treatment abroad, particularly
in developing countries (Wongrukmit and Thawesaengskulthai,
2014). For example, about 46 million Americans, with various
reasons have no health insurance (Turner 2007). The majority of
these Americans would seek cheaper yet quality healthcare
somewhere else (Andersen et al., 2007). The Australian health care
system is also facing enhanced demand from an ageing popula-
tion, with increased consumer expectations, escalating cost of
healthcare, long waiting list, and need for health maintenance
(Mitchell and Thompson, 2001). These patients are shifting their
preferences towards more affordable services provided in devel-
oping nations (Wongrukmit and Thawesaengskulthai, 2014). These
countries, mostly located in Asia including Korea, Singapore, Ma-
laysia and Thailand, have become popular medical tourist desti-
nations with low cost and high performance advantages (Forgione
and Smith, 2007).
Along with the popularity, competition is intensifying among
these countries. For example, Malaysia is strengthening its posi-
tion as a premier medical tourism destination, albeit targeting
Muslim countries (Chee, 2007; Rad et al., 2010). Thai private
n
Corresponding author.
E-mail addresses: ms_lyn@hotmail.com (L.M. Prajitmutita),
aperenyi@swin.edu.au (Á. Perényi), cathyjournalarticles@gmail.com (C. Prentice).
hospitals compete with India and Malaysia on the low cost treat-
ment options and compete with Singapore and South Korea on the
high-end medical services (Teh, 2007). Fierce competition and
rising operational costs drive healthcare providers to focus on
designing appropriate strategies to achieve competitive advantage.
Similar to other service sectors, quality service provided by med-
ical operators becomes a key advantage in business sustainability
and growth (Chen, 2008; Mechinda et al., 2010; Wilson, 2011).
Research has shown that superior service quality is an important
factor of customer satisfaction and loyalty, and contributes to
competitive advantage of the healthcare providers (Laohasir-
ichaikul et al., 2011; Lee et al., 2010). Service quality has been
widely acknowledged to be a multidimensional construct. To op-
timize use of organizational resources and maximizing profit-
ability, it is important to understand what specific services con-
tribute to customers’ attitudes and behaviors. Previous research in
medical tourism field fails to address this issue.
On the other hand, quality of service per se is not adequate to
predict customer attitudes and behaviors. Customers interpret
value in different ways, including low cost, high quality, prestige
service, or equality perception. Patients’ value perception is com-
monly based on how satisfied they are with the services received.
The service patients receive may not match the value perceived
(Hu et al., 2009; Wu et al., 2008). Very few studies have examined
how value perception may influence medical customers’ attitudes
and behaviors.
Consistent with the foregoing discussion, this study develops

http://dx.doi.org/10.1016/j.jretconser.2016.04.005
0969-6989/& 2016 Elsevier Ltd. All rights reserved.
208 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216
an integrative model involving hospital service quality perceived
by medical tourists, value perception, patient attitudes and beha-
viors and examines respective effects on the criterion variables in
the healthcare sector (Choi, Lee, Kim, and Lee, 2005; Hu et al.,
2009). In this model, service quality is referred to as an outcome of
cognitive evaluation (Gill and White, 2009) whereas patient sa-
tisfaction is viewed as affective response (Owusu-Frimpong et al.,
2010; Spreng, Hui Shi, and Page, 2009). Patient perceived value is
wedged between the cognitive and affective perspectives (Sánchez
et al., 2006), and patient intention is a product of conative atti-
tudes (Etgar and Fuchs, 2009). Contrasting to uni-dimensional use
in previous research, (Chen, 2008; Kuo et al., 2009; Omar et al.,
2010; Shukla, 2010; Wu et al., 2008), this study operationalizes
service quality and customer value as multidimensional constructs
to examine their respective effects on the criterion variables.
The following section begins with reviewing the literature in
relation to the medical tourism industry, and continues by an
overview of the study variables. Hypotheses are formed on the
basis of literature review. The methodology is presented in the
next section, followed by empirical testing, and discussion of the
findings. Managerial implications and recommendations for future
research conclude the paper.
2. Literature review
2.1. Hospital service and medical tourist attitudes
Service quality is widely acknowledged as a multi-dimensional
construct and is often measured by both the delivery process
(technical quality) and outcomes (functional quality) (e.g. Para-
suraman et al., 1988; Prentice, 2013; 2014; Zhao and Di Benedetto,
2013). In healthcare services literature, some researchers argue
that technical quality is not appropriate to be included in mea-
suring service quality (Laohasirichaikul et al., 2011; Padma et al.,
2010) as patients are generally unable to evaluate the healthcare
treatment due to lack of knowledge about the medical processes
they received. However, other healthcare researchers such as
Dagger et al. (2007), Dagger and Sweeney (2007), and Gallan,
Jarvis, Brown, and Bitner (2013) include the technical quality in
assessing service quality. Technical quality refers to service pro-
viders’ expertise and outcome. Expertise is indicative of the
competence, knowledge and skills of hospital staff whereas out-
come refers to the evaluation of service process such as a better
feeling or a more positive attitude towards the results of medical
treatment. Kang (2004) examines the service quality model of
Grönroos’ to argue that functional and technical qualities are in-
separable aspects of service quality. In fact, these two facets of
quality are structurally integrated (Kang, 2006). Grönroos and
Gummerus (2014) further highlight the importance of functional
quality in a context where customer satisfaction is becoming an
organization wide responsibility. Their studies indicate that the
medical providers’ expertise constitutes a substantial part of ser-
vice technical quality, and patients are in fact capable of assessing
it. This study opts for this view and includes both aspects for
testing.
Satisfaction refers to a customer’s attitudes towards the pro-
duct or service in relation to the level of pleasure and fulfilment
felt (Hansen et al., 2013). Customer satisfaction can be con-
ceptualized by transaction-specific and cumulative evaluations.
While transaction-specific evaluation is used when assessing
particular events in service encounters, cumulative evaluation is
used to assess the overall impressions on a provider (Jones and
Suh, 2000). Healthcare researchers have commonly adopted a
combination of these approaches reflecting both transaction-spe-
cific and cumulative evaluations for measuring satisfaction (Wu
et al., 2008). This combined approach is deemed more suitable to
assess patient satisfaction, particularly for medical tourists, given
that their experience of the service provider is not necessarily
expected to be a repeated one.
González et al. (2007) asserted that service quality involves a
general impression of the superiority of service focusing on the
general attitudes towards services whereas satisfaction is based on
the affective state of individual transactions (Carlson and O’Cass,
2010). Positive attitudes anticipate positive affective state. Superior
service quality leads to higher levels of satisfaction and loyalty in
the healthcare industry (Alrubaiee and Alkaa'ida, 2011; Calisiret
al., 2014). Patients’ perception of service quality is a primary de-
terminant of a healthcare organization’s success. The higher the
patients’ perceptions of service quality, the more patients are sa-
tisfied, which in turn benefits respective service providers (Chang,
Chen, and Lan, 2013; Wu et al., 2008). On the basis of foregoing
discussion, the hypothesis is offered.
H1. Service quality by healthcare providers is positively related to
medical tourist satisfaction.
2.2. Patients perceived value
Value creation has been identified as a driver of the competi-
tiveness in the service industry (Grönroos and Gummerus, 2014),
where strategic commitment to customer retention (Fullerton,
2014) and customer participation in the value creation process
(Heinonen et al., 2013) impact on customer loyalty and corporate
reputation (Caruana and Ewing, 2010). This value is captured from
both the perspectives of the customer and the firm (Landroguez
et al., 2013).
Perceived value is generally defined as the balance of benefits
and sacrifices perceived by customers; Assessment of perceived
value is based on what is received and given, and can be inter-
preted either in a narrow or a broad perspective (Blocker, 2011;
Nasution and Mavondo, 2008). The narrow perspective of value is
focused on the single dimension of monetary value, encapsulated
by the trade-off between quality and price. Perceived value is
created when customers feel that the benefit (quality) received
exceeds the price paid.
Boksberger and Melsen (2011) argue that this interpretation is
insufficient for conceptualizing perceived value because it is not
just concerning price, but rather is a bundle of benefits and sa-
crifices reflecting multiple dimensions. Sheth, Newman and Gross
(1991) take this broad perspective on conceptualizing perceived
value by proposing five value dimensions: functional, conditional,
social, emotional and epistemic values. Based on this model,
Sweeney and Soutar (2001) introduce the PERVAL scale to assess
customers’ perception of value represented by four dimensions:
emotional, social, price/value for money, and performance/quality
value. Providing a more specific meaning and direction of per-
ceived value, Petrick (2002) has developed five dimensions of
perceived value named SERV-PERVAL specifically for service in-
dustry. It consists of behavioral price (such as time, effort, research
cost, and convenience), monetary price (actual money paid for the
service received), emotional experience (the feeling of receiving
the service such as a sense of joy, delight and happiness), quality
(customer judgement of overall quality performance received) and
reputation (the position of provider occupied in the customer’s
mind). SERV-PERVAL was empirically tested in the tourism sector
(Chen and Chen, 2010; Dumana and Mattila, 2005) and the use of
dimensions reflecting both monetary and non-monetary aspects of
perceived value were validated by the analysis.
Consequently, gaining insight into the attributes of value per-
ceived by customers is fundamental to succeeding in a competitive
marketplace (Ruiz et al., 2008). Value is judged subjectively by
 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216
customers in terms of what they get out of the service rather than
being determined objectively by providers in terms of what they
put into the service (Landroguez, Castro, and Cepeda-Carrión,
2013). When customers perceive a high value of product or ser-
vice, their satisfaction increases and this stimulates purchase in-
tention. Applying this concept into the healthcare industry, we
offer the following hypotheses:
H2. Service quality by healthcare providers is positively related to
medical tourist perceived value.
H3. Perceived value is positively related to medical tourist
satisfaction.
2.3. Service quality, perceived value, patient satisfaction and patient
behavioral intention
Patient behavioral intention is defined as the degree to which a
customer forms a plan to engage or not to engage in future be-
havior, referring to the extent of the efforts of carrying out parti-
cular behaviors (Jang and Namkung, 2009; Webb and Sheeran,
2006). From a firm’s performance perspective, behavioral inten-
tions are often used as indicators of customer loyalty and firm
success. Items related to the willingness to purchase, willingness
to recommend and providing positive word-of-mouth commu-
nication are commonly used as proxies of customer behavioral
intentions (Choi et al., 2004; Jang and Namkung, 2009).
Several scholars (e.g. Wu et al., 2008) have discussed the re-
lationships among service quality, customer value, satisfaction and
behavioral intentions in healthcare contexts. Models built around
these constructs in the literature follow the logic of the multi-at-
titudinal framework, where the cognitive component precedes
affective response, which in turn, determines conative attitude or
intention (Žabkar et al., 2010).
While service quality and patient perceived value are depicted
as an outcome of evaluation, patient satisfaction is a product of
affective response (Choi et al., 2004). Patient behavioral intentions
are a product of personal evaluation resulting in conative intention
(Lai et al., 2009). Service quality is identified as an antecedent of
patient perceived value (Hansen et al., 2013) and both service
quality and patient perceived value are antecedents of patient
satisfaction (Choi et al., 2004; Hansen et al., 2013) which in turn
leads to patient behavioral intentions (Liang et al., 2013; Rauyruen
and Miller, 2007). Researchers have found that perceived value is a
core antecedent of satisfaction, loyalty and more specifically, re-
purchase intention for medical tourists (Lai et al., 2009; Wu et al.,
2008; Wu et al., 2011). The hypotheses proposed in this study
correspond to the links within the multi-attitudinal framework.
Such reasoning informs the following hypotheses:
H4. Hospital service quality is positively related to medical tourist
behavioral intentions.
H5. Perceived value by medical tourists is positively related to
their behavioral intentions.
H6. Medical tourist satisfaction is positively related to their be-
havioral intentions.
Examples from services industries suggest that service quality
has an indirect influence on behavioral intentions through various
mediating variables including perceived value (Lai et al., 2009) and
satisfaction (Jen et al., 2011). Although some studies have tested
these relationships in the healthcare context (e.g. Omar et al.,
2010; Wu et al., 2008), the findings are inconsistent. Wu et al.
(2008) found that service quality, and other relevant constructs
have direct effects on medical tourist behavioral intentions;
whereas Omar et al. (2010) indicate that only an indirect effect on
209
SQ
(H4)
(H1)
(H6)
(H2)
PSAT PI
(H3)
(H5)
PPV
Fig. 1. Conceptual model. Note: SQ: Service Quality; PPV: Perceived Patient Value,
PSAT: Patient satisfaction; PI: Patient behavioral intentions.
the outcome variable is exerted by hospital service quality. To have
a better understanding of these relationships, we offer the fol-
lowing hypotheses:
H7a. Medical tourist perceived value mediates the relationship
between service quality and behavioral intentions.
H7b. Medical tourist satisfaction mediates the relationship be-
tween service quality and behavioral intentions.
The relationships among the study constructs are presented in
Fig. 1.
3. Method
3.1. Sample
The study was undertaken in the medical tourism industry in
Thailand. Reports show that the number of medical tourists has
increased by 10–20% annually in recent years (‘Healthcare Industry
Report: Thailand, 2012; Wibulpolprasert and Pachanee, 2008). The
income generated from the medical tourism industry has made
substantial contribution to the Thai economy (NaRanong and
NaRanong (2011)). In 2008, the medical tourism industry in
Thailand earned USD 850 million in hospital and clinic revenues,
and a total of USD 2 billion was contributed to the national
economy (Wibulpolprasert and Pachanee, 2008). Medical tourism
enhances economic growth in Thailand (Bookman and Bookman,
2007). Due to the lucrative nature of the industry, a significant
increase has occurred over the past years in the number of hos-
pital providers in Thailand. Almost half of the providers with more
than 100 beds are in Bangkok; 47 in Bangkok and 53 in regional
areas surrounding Bangkok (Bangkok Dusit Medical Services,
2011). Competition among medical tourism providers is in-
tensifying in Thailand as well as the adjacent countries including
Malaysia, Singapore and South Korea.
Of the two main players in the Thai private hospital sector,
Bumrungrad reported that 516,000 foreign patients from over 200
countries were treated in 2014 (Bumrungrad Hospital Public
Company Limited, 2015) and Bangkok Dusit Medical Services
commonly known as Bangkok Hospital that manages 28 private
hospitals, treated 659,070 foreign patients in 2008 (Bangkok Dusit
Medical Services, 2009). This highly concentrated and competitive
market scenario poses a challenge to healthcare providers in terms
of competition and managing patient perceptions and patient sa-
tisfaction for competitive purposes. The sample selection has im-
plication for increasing competitive advantage for the medical
tourist destinations.
The survey was conducted at one of the leading hospitals in
Thailand that cater for foreigners (the majority of their customers
210 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216
are foreign patients, referred to as medical tourists for the purpose
of this study) outside of Bangkok, located at Koh Samui in the
Southern part of Thailand. According to the Ministry of Tourism
and Sports (2012), the region attracted more than 690,000 foreign
visitors in 2011. The average number of the foreign patients vis-
iting the participating hospital in 2010 and 2011 was approxi-
mately 2,170 and 2,280 per month respectively. Foreigners ac-
counted for more than half of the hospital’s patients. This hospital
is one of the member institutions of Bangkok Hospital, and was
selected for sampling foreign patients. The choice of the sampling
frame allowed for effective management of the data collection
process (including consistency in terms of the random selection of
respondents).
3.2. Measures
Measures employed in the study are adopted from a wide range
of services marketing literature. Sturgeon (2014) argues that
healthcare services are considered to be similar to other consumer
services. All services have three common properties – search, ex-
perience and credence – by which their consumption can be
compared. Hospital services are more reliant on experience:
where the evaluation occurs during or after receiving the medical
care; and credence: where it is hard to evaluate the service even
after the consumption such as in case of a surgical procedure
(Martínez Caro and Martínez García, 2008). Therefore, perception
based measures adopted from other service sectors are presumed
to be applicable for healthcare as used in the present study. Si-
milarly to other perception based studies, a seven-point Likert-
type scale (1 ¼ strongly disagree; 2 ¼ disagree; 3 ¼ somewhat
disagree; 4¼ neutral; 5 ¼ somewhat agree; 6 ¼ agree; and 7 ¼
strongly agree) was used to measure the items.
Service quality Consistent with the above view, the five per-
ception-based dimensions of SERVQUAL which was originally de-
veloped by Parasuraman et al. (1988) including tangibles, relia-
bility, responsiveness, assurance and empathy was used to reflect
functional quality. SERVQUAL scale presents good reliability, con-
vergent and discriminant validity, and has been most cited in the
relevant literature (e.g. Marković et al., 2014; Papanikolaou and
Zygiaris, 2014). To capture the technical aspects of medical service
quality, the items adapted from Dagger et al. (2007) and Gallan
et al. (2013) are also used to assess medical service quality. These
items are indicative of technical quality of medical service, invol-
ving outcome and expertise dimensions. The reliability of this
scale is reported in the result section.
Patient perceived value was defined in terms of what patients
give up for a greater value of acquiring medical services from the
hospital and was conceptualized as a multi-dimensional construct
consisting of the five dimensions of the SERV-PERVAL scale de-
veloped by Petrick (2002). This scale reflects both monetary and
non-monetary aspects of value. The Cronbach’s alpha values for
each dimension are reported in subsequent section.
Patient satisfaction in this study was defined as a patient’s ful-
filment, based on an overall assessment of the service experiences
with the hospital provider (Oliver, 2010) in terms of experiences
specific to a particular service encounter (Jones and Suh, 2000). A
uni-dimensional construct of patient satisfaction measured by four
items was adopted (Choi et al., 2004; Wu et al., 2008), reflecting a
combination of transaction-specific and cumulative evaluation
approaches. The reliability of this scale was demonstrated by a
Cronbach’s alpha value of 0.94.
Behavioral intentions were measured using items that reflect
willingness to recommend, intention to repurchase and readiness
to articulate positive word-of-mouth communication. The mea-
sures were adopted from Zeithaml et al. (1996) and Bloemer,
Ruyter, and Wetzels (1999). The Cronbach’s alpha value for this
scale was 0.93.
3.3. Data collection
The targeted respondents include a random selection of in- and
out foreign patients of the hospital, discharged in the time period
of data collection. Prior to approaching the respondents, an au-
thorized medical professional determined whether the patient
was fit and suitable to participate in the data collection. Then the
patient was approached by the principal researcher to seek per-
mission to conduct the survey. Patients were advised to return the
completed questionnaire either to a secure locked box in the
cashier’s office or to pass the envelope containing the completed
questionnaire to designated nurses or medical professionals. The
envelope was provided along with the questionnaire, invitation
letter and consent form. While most of the out-patients were re-
cruited in the cashier’s waiting area, the majority of in-patients
were recruited during the discharge process, as suggested by
health professionals in the hospital.
As a result, 330 usable responses were generated. This sample
size was considered adequate for multivariate statistical analysis,
as the final model contained 35 individual indicators, adhering to
Hair et al.’s (2013) recommendations and providing a factor-in-
dicator ratio of almost 10. Among the respondents, 58.8% were
male, 60% aged between 26 and 35, 69.1% had full insurance cover,
77% were out-patients and 75.5% held a European passport. The
composition of respondents in medical tourism studies varies
depending on the availability of data and context of im-
plementation. Other studies of medical tourism in Thailand sug-
gest the distribution of respondents between expatriates and mi-
grants; medical tourists; and tourists as 40:26:32 (Wongkit and
McKercher, 2013) and 60:30:10 (NaRanong and NaRanong, 2011).
The distribution of respondents in this study was 30:14:56 (ex-
patriate and migrant: medical tourists: tourists), as Koh Samui is a
more popular place for overseas travelers.
The Pearson’s Chi square test was used to affirm homogeneity
of the sample in terms of demographic characteristics. The tests
revealed that responses did not significantly differ in terms of
(1) nationality and type of respondents (in- or out-patient)
(α ¼0.067); (2) nationality and type of treatment (surgery, cos-
metic, dental procedure, check-up or other kind) (α ¼0.566);
(3) nationality and gender (α ¼0.130) and (4) nationality and age
(α ¼0.384). This sample is indicative of a cohesive cohort.
4. Analysis and results
4.1. Factor analysis and validity testing
Prior to testing the hypotheses, confirmatory factor analysis
(CFA) was performed to validate the measures (Anderson and
Gerbing, 2004). The seven dimensions of service quality measure
were incorporated into the analyses. Preliminary results indicated
the lack of discriminant validity between the dimensions of ser-
vice quality (as expected). Based on the Fornell and Larcker’s
(1981) criterion, reliability, responsiveness, assurance, empathy
and expertise were found not to be distinct dimensions. Hence, the
measurement model was re- specified by merging these factors
into one, renamed as ‘expertise’, reflecting the scope of the re-
maining indicators after the removal of cross-loading items. This
approach is consistent with that in a number of studies (e.g.
Marković et al., 2014).
Ladhari (2008) contended that service quality can be a simple
and uni-dimensional construct in some contexts and a complex
and multidimensional in others, depending on the specific service
settings, cultural and value orientations of customers. Consistently,
 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216 211

a three-factor service quality model was adopted, consisting of Table 1

tangibles (TANG), outcome (OT) and expertise (EXP). The internal Scale items and reliability indices.
consistency, reliability, convergent validity and discriminant va-
Items FL α CR AVE
lidity for the revised measure were tested, showing acceptable
goodness-of-fit (GOF) statistics (χ2 (51) ¼113.95, CMIN/DF ¼2.23, Service quality
CFI ¼0.98, TLI ¼0.97, SRMR ¼ 0.04 and RMSEA ¼ 0.06). Although TANG The hospital has modern-looking equipment. .86 .82 .83 .63
the chi-square (χ2) is significant due to a relatively large sample The physical facilities in the hospital are visually .85
appealing.
size, other indices indicate a good model fit for further analyses Materials associated with the service (such as .65
(Bagozzi and Yi, 2012; Hair et al., 2013; Tabachnick and Fidell, pamphlets or statements) are visually appealing.
2013; Tam, 2004). The remaining GOF statistics demonstrate ac- EXP Staff in the hospital tell me exactly when services .56 .90 .92 .70
ceptable levels of convergent validity. will be performed.
Staff in the hospital are well trained and qualified. .87
Similar to service quality, patient perceived value was mea-
Staff in the hospital carry out their task .92
sured as a multi-dimensional construct consisting of five dimen- completely.
sions; quality judgement (QJ), monetary price (MP), reputation Staff in the hospital are highly skill at their jobs. .92
(REP), behavioral price (BP), and emotional experience (EP). Re- I feel good about the quality of care given me at .84
sults for testing internal consistency, convergent validity, dis- the hospital
OT I believe my future health will improve as a result .72 .90 .91 .72
criminant validity and GOF were satisfactory (χ2 (50) ¼383.814, p of having received medical attention at the
o0.001, CMIN/DF ¼2.40, CFI ¼0.97, TLI ¼0.97, SRMR ¼ 0.03 and hospital.
RMSEA ¼0.06). Details of the measures of a three-factor service I believe having treatment at this hospital has .87
quality, a five-factor patient perceived value, patient satisfaction been worthwhile.
I leave the hospital feeling encouraged about my .92
and patient behavioral intentions are provided in Table 1.
treatment
The standardized factor loadings (40.5), Cronbach’s Alpha I believe the results of my treatment will be the .88
values ( 40.7) and AVE values (40.5) demonstrate acceptable best they can be
levels of reliability and validity. The composite reliability (CR) va-
lues ranging from 0.81 to 0.97 were also satisfactory. As shown in Patient perceived value
Table 2, the correlations between latent constructs were below QJ Quality of service at the hospital is reliable. .93 .93 .93 .83
0.80 indicating neither redundancy nor violation of multi-colli- Quality of service at the hospital is dependable. .95
nearity requirements, demonstrating adequate convergent validity Quality of service at the hospital is consistent. .84
MP The price for medical care is fair. .91 .95 .95 .87
and internal consistency (Tabachnick and Fidell, 2013). The square
The price for medical care is reliable. .97
root of AVE (average variance extracted) values for each construct The price for medical care is consistent. .94
is added to the diagonal of Table 2. Discriminant validity of the Rep The hospital has good reputation. .93 .97 .97 .89
constructs is ascertained by the Fornell-Larcker criterion (Fornell The hospital is well respected. .97
The hospital is well thought of. .95
and Larcker, 1981).
The hospital is reputable. .92
BP Easy to access the hospital premise. .75 .81 .81 .60
4.2. Hypotheses testing Easy to acquire medical attention. .83
Easy to purchase the hospital’s services. .73
Structural equation modelling (SEM) was used to examine the EE Receiving medical treatment from this hospital .90 .97 .97 .89
gives me pleasure.
relationships among the constructs corresponding to the hy-
Receiving medical treatment from this hospital .97
potheses (Byrne, 2010; Hair et al., 2013). The SEM technique al- gives me a sense of joy.
lowed for the analysis of all relationships between the constructs Receiving medical treatment from this hospital .97
of the model, whilst controlling for the measurement errors in- makes me feel delighted.
Receiving medical treatment from this hospital .93
herently incorporated in the otherwise confirmed, valid and reli-
gives me happiness.
able psychometric scales (Hair et al., 2013) commonly employed in
consumer research (Bearden, Netemeyer and Haws, 2011). Further
advantage of applying the SEM approach was that it enabled Patient satisfaction
SAT I am satisfied with the treatment I received in the .74 .94 .94 .84
testing the proposed hypotheses simultaneously, as well as pro- hospital.
vided an avenue for integrated mediation testing, by allowing the I am satisfied with the health care services in this .76
separation of the direct and indirect components of total effects in hospital.
the model (Baron and Kenny, 1986). I am satisfied with the decision to use service from .90
this hospital.
Minor adjustments were made to the measure resulted in a
final model that demonstrated acceptable fit, as shown in Fig. 1.
The GOF statistics – including absolute and incremental fit indices Patient behavioral intentions
PI I will recommend this hospital to family and .95 .93 .94 .84
– were satisfactory (Cmin/df ¼2.11, RMR ¼0.07, SRMR ¼0.05,
friends.
RMSEA ¼0.06, CFI ¼0.95, TLI ¼ 0.95 and NFI ¼0.91.) The model I will recommend this hospital to anyone who .97
explained 78.6% of the variance in patient perceived value seeks my advice.
(R2 ¼.79), 64.5% in patient satisfaction (R2 ¼.64) and 59.4% in pa- If I need medical service in the future, I will con- .82
tient intentions (R2 ¼.59). sider this hospital as my first choice.

Patient satisfaction and patient perceived value have a direct
effect on patient intentions; however the effect of service quality
on patient intentions is not significant. Service quality exerts a
strong and significant influence on patient perceived value (0.89)
and a moderate effect on patient satisfaction (0.37). Patient per-
ceived value has a strong direct and significant influence on pa-
tient intentions (0.41), followed by patient satisfaction (0.37). Pa-
tient perceived value also has a strong, direct and significant in-
fluence on patient satisfaction (0.46) as shown in Fig. 2 and
Notes: TANG ¼ Tangible; EXP ¼ Expertise; OT ¼ Outcome; QJ ¼ Quality judge-
ment; MP ¼ Monetary price; REP ¼ Reputation; BP ¼ Behavioral price; EE ¼
Emotional experience; PSAT ¼ Patient satisfaction; PI ¼ Patient behavioral
intentions.
Table 3.
Further analyses were conducted to examine the direct and
indirect effects among the study variables (see Table 3). The bias
corrected bootstrapping p value is recommended for testing
212 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216

Table 2 perceived value and patient satisfaction on the relationship be-

Correlations among all latent variables. tween service quality and patient intentions (0.65, p r0.05) and
the mediation effect of patient satisfaction on the relationship
TANG EXP OT QJ MP REP BP EE PSAT PI
between patient perceived value and patient intentions (0.17,
TANG .79 p r0.05).
EXP .63 .83 Table 3 shows that the relationship between patient service
OT .52 .78 .85 quality and patient intentions is not significant at p ¼0.78 and the
QJ .58 .68 .61 .91
MP .34 .48 .49 .54 .93
standardized direct effect between these two constructs is not
REP .50 .59 .60 .66 .52 .94 significant according to the bias corrected bootstrapping p value
BP .40 .53 .56 .51 .48 .63 .77 (p 4 0.05). However, the standardized indirect effect (0.65) and
EE .34 .36 .42 .43 .49 .45 .34 .94 total effect (0.69) are significant (p r0.05 and p r 0.01 respec-
PSAT .51 .65 .71 .62 .58 .54 .64 .41 .92
tively). This indicates that patient perceived value and patient
PI .54 .55 .64 .58 .48 .56 .51 .43 .72 .92
satisfaction exert indirect and mediating effects on patient inten-
Notes: Service quality (SQ): TANG ¼ Tangible; EXP ¼ Expertise; OT ¼ Outcome. tions. Further analyses; partial model A and B, were conducted to
Patient perceived value (PPV): QJ ¼ Quality judgement; MP ¼ Monetary price; REP determine the mediation effects of patient perceived value and
¼ Reputation; BP ¼ Behavioral price; EE ¼ Emotional experience. PSAT ¼ Patient patient satisfaction.
satisfaction. PI ¼ Patient behavioral intentions. All correlation coefficients are
significant at the 0.001 level.
Models A (service quality, patient satisfaction and patient be-
havioral intentions) and B (service quality, patient perceived value
and patient behavioral intentions) are used to test mediating re-
lationships. While regression weights are used to test the statis-
tical significance of the model paths, the bias corrected boot-
SQ
0.04* (H4) strapping p values are used to indicate the significance of med-
0.37** iating effects. In model A (patient service quality, patient sa-
(H1) tisfaction and patient intentions), the paths between each pairs of
0.37***
0.89*** variables are significant (p o0.001, see Table 4) and the bias
PSAT (H6)
PI
(H2) corrected bootstrapping p is also significant (p o 0.05, see Table 4)
R2 = 0.64
R2 = 0.59
when patient satisfaction is included. A partial mediation is
0.46*** established.
(H3)
In model B (service quality, patient perceived value and patient
0.41** (H5) behavioral intentions), the paths between each pairs of variables
PPV
R2 = 0.79 are significant (p o0.001). The direct relationship between service
quality and patient behavioral intentions however is not sig-
Fig. 2. The main research structural model (standardised path estimates with re- nificant (p ¼ 0.28, see Table and the bias corrected bootstrapping p
gression weights). Notes: PPV ¼ Patient perceived value; SQ ¼ Service quality; is also not significant at p 4 0.05 (see Table 5)) when patient
PSAT ¼ Patient satisfaction; PI ¼ Patient behavioral intentions. Full model: χ2 perceived value is included. This finding indicates a full mediation
(481) ¼1016.06, CMIN/DF ¼ 2.11, CFI ¼ .95, TLI ¼ .95, NFI ¼0.91, SRMR ¼0.06, relationship between service quality, patient perceived value and
RMSEA ¼ .06, 90% CI ¼.05: 0.06;*** p r.001,** p o 0.01,* p 4 0.05.
patient intentions.
As a result, service quality has a direct effect on both patient
mediating effects (Bollen and Stine, 1990). Table 3 also displays the perceived value and patient satisfaction; and the latter two are
bias corrected bootstrapping p values, and the path coefficient significantly related with each other, confirming hypotheses H1,
estimates indicating the magnitude of the direct and indirect ef- H2 and H3. Since service quality does not have a significant direct
fects. For example, the significant bias corrected bootstrapping p relationship with patient intentions, H4 is not supported. Patient
value shown in Table 3 indicates the mediation effects of patient perceived value and patient satisfaction have a significant direct

Table 3
Relationships among service quality, patients; perceived value, patient satisfaction and behavioral intentions.

Path Estimates S.E. C.R. P

nnn
PPV o— SQ 1.29 .16 7.95
PSAT o— PPV .64 .20 3.24 .001
PSAT o— SQ .75 .29 2.57 .01
nnn
PI o— PSAT .46 .10 4.76
PI o— PPV .71 .26 2.80 .005
PI o— SQ .10 .35 0.28 .78

Construct PPV PSAT PI

Std. DE Std. IE Std. TE Std. DE Std. IE Std. TE Std. DE Std. IE Std. TE

nnn nnn nn n nnn n nn

SQ .89 .00 .89 .37 .41 .78 .04 .65 .69nnn
PPV .46n .00 .46nnn .41n .17nn .58nn
PSAT .37nn .00 .37nn

Notes: PPV ¼ Patient perceived value; SQ ¼ Service quality; PSAT ¼ Satisfaction; PI ¼ Patient behavioral intentions; Std. DE ¼ Standardized Direct Effect; Std. IE ¼
Standardized Indirect Effect; Std. TE ¼ Standardized Total Effect.
Model fit indices: χ2 (481) ¼ 1016.06; CMIN/DF ¼ 2.11; CFI ¼ .95; TLI ¼ .95; NFI ¼ 0.91; SRMR ¼ 0.06; RMSEA ¼ .06, 90%; CI ¼ .05: .06; nnn p o .001.
nnn
p r .01.
nn
¼ p r 0.05.
n
¼ p 4 0.05.
 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216 213

Table 4 Table 6
Relationships among service quality, patient satisfaction and patient behavioral Results for the relationships between service quality dimensions and the outcome
intention. variables.

Path Estimates S.E. C.R. P Variables β t p F df p Adj.R2

nnn
PSAT o— SQ 1.62 0.20 8.19 Patient Intentions 90.38 3,326 .000 .45
nnn
PI o— PSAT .58 .09 6.07 Tangibles .23 4.58 .000
nnn
PI o— SQ .85 .22 3.81 Expertise .15 2.29 .023
Outcome .40 6.84 .000
Construct PSAT PI
Patient Satisfaction 101.16 3,326 .000 .48
Tangibles .12 2.37 .018
Std. DE Std. IE Std. TE Std. DE Std. IE Std. TE
Expertise .31 4.97 .000
Outcome .36 6.27 .000
SQ .78nnn .00 .78nnn .33nn .36nn .69nnn
Patient Perceived value 130.70 3,326 .000 .54
PSAT .47nn .00 .47nn
Tangibles .22 4.59 .000
Expertise .28 4.83 .000
Notes: PPV ¼ Patient perceived value; SQ ¼ Service quality; PSAT ¼ Satisfaction;
Outcome .36 6.70 .000
PI ¼ Patient behavioral intentions; Std. DE ¼ Standardized Direct Effect; Std. IE ¼
Standardized Indirect Effect; Std. TE ¼ Standardized Total Effect.
n
¼ p 4 0.05.
Model fit indices: χ2 (481) ¼ 1016.06; CMIN/DF ¼ 2.11; CFI ¼ .95; TLI ¼ .95; NFI ¼ shows that all independent variables did predict patient inten-
0.91; SRMR ¼ 0.06; RMSEA ¼ .06; 90%; CI ¼ .05: .06; nnn p o .001.
nnn
tions; tangibles (Beta ¼.23, t(329) ¼4.57, p o0.00), expertise
p r .01.
nn (Beta ¼ .15, t(329) ¼2.29, p o 0.05) and outcome (Beta ¼.40, t
¼ p r 0.05.
(329) ¼6.84, p o0.00).
As shown in Table 6, tangibles, expertise, and outcome explain
significant variance in patient satisfaction (F (3,326) ¼101.16, p
Table 5 o0.00, R2 ¼.48, R2 adjusted ¼.48). The analysis shows that service
Relationships among service quality, patients’ perceived value and patient beha- quality dimensions, specifically, tangibles (Beta ¼.12, t(329) ¼ 2.37,
vioral intentions
p o0.05), expertise (Beta ¼.31, t(329) ¼4.97, p o0.00) and out-
Path Estimates S.E. C.R. P come (Beta ¼ .36, t(329) ¼6.27, p o0.00) did predict patient
satisfaction.
nnn
PPV o— SQ 1.27 0.16 8.01 Similarly, service quality explains a significant amount of the
nnn
PI o— PPV 1.02 .27 3.77
variance in patient perceived value (F (3,326) ¼ 130.70, p o0.00,
PI o— SQ .41 .38 1.09 .28
R2 ¼ .55, R2 adjusted ¼.54), with each dimension demonstrating
Construct PPV PI significant beta coefficients, specifically, for tangibles, Beta ¼ .22, t
Std. DE Std. IE Std. TE Std. DE Std. IE Std. TE
(329) ¼4.59, p o0.00, for expertise, Beta ¼.28, t(329) ¼4.84, p
o0.00, and for outcome, Beta ¼.36, t(329) ¼6.70, p o0.00. Result
nnn nnn n nn
SQ .89 .00 .89 .17 .52 .69nnn of the post-hoc analysis show that service quality (tangibles, ex-
PPV .59nn .00 .59nn pertise, and outcome) has direct and significant effects on the
dependent variables (patient intentions, patient satisfaction, and
Notes: PPV ¼ Patient perceived value; SQ ¼ Service quality; PSAT ¼ Satisfaction;
PI ¼ Patient behavioral intentions; Std. DE ¼ Standardized Direct Effect; Std. IE ¼ patient perceived value).
Standardized Indirect Effect; Std. TE ¼ Standardized Total Effect.
Model fit indices: χ2 (481) ¼ 1016.06; CMIN/DF ¼ 2.11; CFI ¼ .95; TLI ¼ .95; NFI ¼
0.91; SRMR ¼ 0.06; RMSEA ¼ .06, 90%; CI ¼ .05: .06; nnn p o .001.
5. Discussion
nnn
p r .01.
nn
¼ p r 0.05.
n
¼ p 4 0.05.
Drawing on the multi-attitudinal framework, this study ex-
amines the relationships among service quality, perceived value,
satisfaction and behavioral intentions of medical tourists. Service
relationship with patient intentions, supporting hypotheses H5 quality and perceived value are cognitive components that pre-
and H6. The findings also suggest that the relationship between cede satisfaction as affective response in the integrative model.
perceived service quality and patient behavioral intentions is en- These in turn determine the behavioral intentions of medical
hanced by the mediating effects of patient perceived value and tourists reflecting conative attitude. Service quality in this study is
patient satisfaction. Therefore, hypotheses H7a and H7b are formed by tangibles, expertise and outcome in relation to hospital
confirmed. services. The findings support the multi-attitudinal framework in
Further testing was performed to explore the mediating effects the healthcare sector. The results demonstrate that service quality,
in models A and B. Results indicate that the relationship between perceived value and satisfaction have different influence on
perceived service quality and patient intentions are no longer medical tourist behaviors. Specifically, service quality substantially
influences perceived value, which has a significant direct influence
significant when patient perceived value is included, indicating a
on medical tourist behavioral intentions. Both perceived value and
full mediation relationship. In contrast, the relationship between
satisfaction mediate the relationship between service quality and
perceived service quality and patient intention remains significant
medical tourist intentions, with the former fully mediating the
when including patient satisfaction which suggests a partial
relationship between service quality and medical tourist inten-
mediation.
tions. The following section discusses these findings.
Subsequently, all service quality dimensions were used in this
analysis with patient intentions, patient satisfaction, and patient 5.1. The relationships among service quality, perceived value and
perceived value, being the outcome variables respectively. The medical tourist satisfaction
results show that tangibles, expertise, and outcome explain a
significant amount of the variance in patient intentions (F Service quality and patient perceived value are conceptualized
(3,326) ¼ 90.38, p o 0.00, R2 ¼.45, R2 adjusted ¼.45). The analysis as multidimensional constructs. Patient perceived value in this
214 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216
Table 7
The effect of Service Quality and Perceived Value on Patient Satisfaction.
Pathn This Choi et al Wu et al. Omar et al.
study (2004) (2008) (2010)
PSAT o— PPV 0.82 0.25 0.38 0.37
PSAT o— SQ 0.46 0.82 0.55 0.50
n
Constructs labelled as per current study, namely satisfaction as PSAT, per-
ceived value as PPV and service quality as SQ.
study comprises of five dimensions, reflecting both monetary and
non-monetary aspects of value for medical tourists. Findings de-
monstrate that patient perceived value is a stronger (0.82) pre-
dictor of medical tourist satisfaction than service quality (0.46).
This finding is in contrast with that of other studies (e.g. Choi et al.,
2004; Omar et al., 2010; Wu et al., 2008) (see Table 7).
The findings imply that medical tourists are value-oriented
customers. Perception of value, contributes more to satisfaction
with the service provider, comparing to service quality they re-
ceived. Similar relationships between service quality, perceived
value and satisfaction have also been found in other tourism sec-
tors, such as airlines (Chen, 2008) and hotels (Hu et al., 2009).
5.2. The antecedents of medical tourists’ behavioral intentions
Medical tourists’ behavioral intentions are operationalized as a
proxy to customer loyalty in this study, referring to the willingness
to recommend to those who seek advice and consider the hospital
as the first choice when needing medical services in the future.
Among the three antecedents of patient intentions, patient per-
ceived value (0.41) has the strongest effect, followed by patient
satisfaction (0.37). This denotes that medical tourists are value-
oriented customers as their perceived value has a stronger effect
on their intentions than their satisfaction. This finding is con-
sistent with that of other healthcare sector studies (Wu et al.,
2008; Omar et al., 2010). However, in other studies (e.g. Choi et al.,
2004), satisfaction had a considerably stronger direct effect on
behavioral intentions. Similar findings are reported in studies by
Chen (2008), Chen and Chen (2010) and Lai and Chen (2011) in
other service sector studies.
This study shows that service quality has no direct effect on
behavioral intentions for foreign patients. However, consistent
with the result generated in other hospital settings (e.g. Wu, 2011).
In a similar study, Omar et al. (2010) found that there was no direct
effect between these two constructs but service quality was
mediated by perceived value and satisfaction in the Malaysian
healthcare context. A study from the Turkish hospital context by
Lonial et al. (2010) also indicated that service quality did not have
a direct effect on re-patronage intentions. The mediation effects
through perceived value and satisfaction in this study are also
echoed in other service sector studies, such as telecommunications
(Kuo et al., 2009), public transport (Lai and Chen, 2011) and
tourism (Chen and Chen, 2010).
5.3. The mediating effect of perceived value and satisfaction on
medical tourists’ behavioral intentions
This study examines the mediating effects of perceived value
and satisfaction on the relationships between service quality and
behavioral intentions of medical tourists. Two models variants,
model A (consisting of service quality, patient satisfaction and
patient intentions) and model B (consisting of service quality,
patient perceived value and patient intentions), are tested to ex-
amine the mediating effects.
The results of model A suggest that the effect of service quality
on behavioral intentions is partially mediated by satisfaction, in-
dicating that service quality plays a vital role in terms of both
direct and indirect effects on behavioral intentions of medical
tourists. The results of testing model B signify that perceived value
fully mediates of the relationship between service quality and
behavioral intentions of medical tourists. These findings suggest
that perceived value is a key factor to achieving medical tourist
loyalty.
6. Implications and future research
6.1. Theoretical implications
Though service quality, satisfaction, perceived value and be-
havioral intentions have been widely discussed in the relevant
literature, studies that encompass all these four constructs si-
multaneously in the medical tourism context are rare. This study
contributes to the body of knowledge by simultaneously testing
these relationships in the Thai medical industry. The findings of
the study demonstrate several theoretical contributions. Firstly,
this study includes both technical and functional quality aspects
that involve tangibles, expertise and outcome to measure service
quality in the healthcare sector. Validation of quality measures
encompassing both aspects of service quality in medical tourism is
a unique contribution of this study. The findings suggest the im-
portant role of the technical service quality in the medical tourism
setting. This study also indicates that only three service quality
dimensions are applicable in the healthcare context, which sug-
gests that researchers need to adapt service quality scale cau-
tiously. Cross-validation of the relevant scale is necessary to un-
derstand its impact on the study context.
Patient perceived value is tested as part of an integrative model,
as a multidimensional construct in this study, and is demonstrated
as a vital predictor of behavioral intentions, and presents as the
most dominant predictor. The interpretation of perceived value by
medical tourists has evolved beyond monetary aspects, and in-
cludes a non-monetary perspective. The multidimensional scale of
patient perceived value reflects a more holistic view and provides
a more comprehensive understanding of customer value percep-
tions for medical tourism researchers. This demonstrates the
variety of aspects medical tourists consider when assessing value
of healthcare services. The results confirm the applicability of a
multidimensional customer value conceptualization in the
healthcare context. The mediating role of patient perceived value
in the effect of service quality on patient satisfaction and on pa-
tient intentions confirms that medical tourists are value driven
consumers. Value as a mediator of the effect of service quality on
patient satisfaction in medical tourism augments the importance
of value for medical tourists, and implies the need to adjust the-
oretical approaches when investigating consumer behavior in the
sector.
6.2. Managerial implications
The medical tourism industry is profitable and the competition
is rather intense, especially in the internationalizing South East
Asian economies, as competition is not limited to local industry
participants. The findings of this study provide guidance to
healthcare providers on tailoring services to medical tourists in
order to enhance their satisfaction and loyalty. The study parti-
cularly highlights the prominent role of perceived value, and
pinpoints the most effective avenues for healthcare providers in
allocating resources to improve hospital performance from the
perspective of medical tourists.
Specifically, the study suggests that medical tourists perceive
 L.M. Prajitmutita et al. / Journal of Retailing and Consumer Services 31 (2016) 207–216
the quality of service through tangible aspects such as; (1) the
appearance of physical facilities and medical equipment; (2) the
expertise of staff and their performance on carrying out their task;
and (3) the outcome (success) of the medical treatment received.
These findings have practical implications for healthcare provi-
ders. Apart from the tangible aspects, this research shows that
expertise and outcome are both core technical aspects of health-
care services that hospital providers should attend to. Recruiting
renowned doctors and nurses with substantial experience is nee-
ded for healthcare providers to achieve competitive advantage.
This in turn will also contribute to the capability of the hospitals to
achieve successful outcomes, further enhancing medical tourists’
perception of service quality. Besides building credibility through
raising technical capabilities, advocating favorable outcomes also
affect medical tourists’ decisions.
The study also shows that the cost of treatment or medical bill
is not the primary factor that medical tourists consider in de-
termining the value they received. This finding suggests that the
service providers should reassess price-competition strategies.
Attention should be paid to external factors – such as risk and
developmental aspects in medical tourism. These factors may
serve as deterrents to potential medical tourists. Given that the
focus of the sample was actual patients, assertions made based on
their responses cannot approximate what deters other potential
patients who decide not to engage in medical tourism.
Further dimensions of value encompass: the reputation of the
hospital; the convenience of accessing hospital premises and ac-
quiring medical attention; and their emotional experience during
receiving medical services from the hospital. Hospital providers
are recommended to ensure that these aspects are attended to, in
order to improve perceived value, which converts into satisfaction
and loyalty, providing competitive advantage to the hospitals.
Finally, the findings suggest to hospital providers that beha-
vioral intentions of medical tourists can be directly enhanced
through perceived value and customer satisfaction, the former in
particular. Although showing indirect effect on behavioral inten-
tions, service quality is still an important factor in attracting cus-
tomers’ loyalty behaviors as suggested in the partial mediation
relationship.
6.3. Limitations and future research direction
Although this study underwent a rigorous process, several
limitations arise. The data were collected from a single hospital,
albeit from a cohort of medical tourists who came from various
countries, generalizability of the findings should be cautioned.
Future research should replicate the study and test the relation-
ships with a more representative sample, by increasing the num-
ber of hospitals or countries to cross-validate the results and
eliminate common method bias.
As the sample of this study primarily consists of medical
tourists from multiple countries and diverse cultural backgrounds,
cultural factors should be taken into consideration in the analysis
of the integrative model to avoid systematic evaluation biases and
response styles. This research applied a broad definition of medical
tourists, including all foreign patients. Although this definition has
been adopted in other studies (i.e. Heung et al., 2010; Horowitz
and Rosensweig, 2007), this option may neglect the group that
falls between the broad and narrow definitions (Brotman, 2010) of
medical tourists. Future study should attend to these specific sub-
groups to evaluate similarities and differences.
This study only tested behavioral intentions of medical tourists
to indicate their loyalty. To provide more insights into medical
tourists’ loyalty behaviors, future research should include both
behavioral and attitudinal dimensions of customer loyalty. The
dimensions capture different level of customer loyalty, as
215
suggested by numerous researchers (i.e. Prentice, 2013, 2014).
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