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Received: 24 December 2020 Revised: 4 August 2021 Accepted: 9 August 2021
DOI: 10.1002/jtr.2489

RESEARCH ARTICLE

Marketing and social influences, hospital branding, and medical

tourists' behavioural intention: Before- and after-service
consumption perspective

Tat-Huei Cham1 | Yet-Mee Lim1 | Marianna Sigala2

1
UCSI Graduate Business School, UCSI
University, Kuala Lumpur, Malaysia
2
UniSA Business, University of South Australia,
Adelaide, Australia
Correspondence
Yet-Mee Lim, UCSI Graduate Business School,
UCSI University, Kuala Lumpur, Malaysia.
Email: limym@ucsiuniversity.edu.my
Abstract
The international growth of medical tourism requires hospital operators to adopt
effective marketing practices to ensure survival and competitiveness. Although there
is a burgeoning research on medical tourism, there is still limited knowledge about
the roles of brand image and brand trust on medical tourists within the healthcare
service context. This study investigates the influence of advertisements and social
media communication on the hospital brand image and brand trust formation before
consumption stage, and their impacts on medical tourists' perceptions and attitudes
at the post-consumption stage in relation to service quality, satisfaction, and behav-
ioural intention. Data was collected from 294 Chinese medical tourists and a struc-
tural equation modelling technique was used for testing the hypotheses. The findings
revealed that advertisements and social media communication positively influence
medical tourists' perception of hospital brand image, which influences their trust
towards the hospital's brand. It was also found that medical tourists' perceived value
and trust towards the medical staff mediates the relationship between their per-
ceived service quality and satisfaction. Overall, the study contributes to the literature
by providing evidence and understanding on hospital branding formation and its
influence on the perceptions and attitudes of medical tourists before and after the
consumption of the healthcare service.

KEYWORDS
advertisement, behavioural intention, brand image, patient satisfaction, perceived trust,
perceived value, service quality, social media, word-of-mouth

1 | I N T RO DU CT I O N trend, known as medical tourism, is usually referred to as a ‘set of

Wellness-based service offerings have become an important part of
the healthcare industry, which is growing rapidly at a global scale
(Patientsbeyondborders.com, 2019). In the early days, patients from
less developed countries often visited developed countries to receive
advanced medical services. Since the early 1990s, this trend began to
reverse. Nowadays, more and more patients from developed nations
travel to developing countries to get medical treatments, while simul-
taneously engaging in other tourism activities (Cham et al., 2014). This
activities in which a person travels often long distances or across the
border, to avail medical services with direct or indirect engagement in
leisure, business or other purposes’ (Jagyasi, 2008, p. 9). Medical tour-
ism has now become an important and growing industry internation-
ally (de la Hoz-Correa et al., 2018) with a projected growth rate of
25% annually and an estimated revenue of about 3 USD trillion by
2025 (medicaltourismindex.com, 2018).
Medical tourism is an earmarked industry with great potential
(Connell, 2013; Ganguli & Ebrahim, 2017). As many developing

140 © 2021 John Wiley & Sons Ltd. wileyonlinelibrary.com/journal/jtr Int J Tourism Res. 2022;24:140–157.

CHAM ET AL.
countries in the Asian region have taken the opportunity to attract
medical tourists from all over the world (Pan & Chen, 2014), the
industry competition has significantly intensified. Thailand, South
Korea, Singapore, India and Malaysia are some of the global players
that have generated considerable revenues from the medical tourism
sector (Patientsbeyondborders.com, 2017). Within the Asia region,
Malaysia represents a popular medical tourism destination with 1.2
million medical tourists and US$362 million income receipts during
2018 (Thomas, 2019). The Malaysia tourism industry possess several
competitive advantages, such as favourable exchange rate, trained
healthcare professionals, economic and political stability, a high rate
of literacy and cheaper medical costs (Cham et al., 2020).
Malaysia offers a wide range of general and specialised medical treat-
ments. These include health screening, pain management, fertility treat-
ment, cancer treatment, rehabilitative medicine, cosmetic surgery, dental
treatment, orthopaedics surgery and cardiothoracic surgery. There are
73 private hospitals participated in the medical tourism programs under
the initiatives of the Malaysian government (Malaysia Healthcare Travel
Council, 2020a), which are all accredited by the Malaysian Society for
Quality in Health (MSQH) to handle international medical tourists. Nine
of these hospitals are also recognised by the Joint Commission Interna-
tional (JCI), which is a US-based accreditation body for hospital healthcare
programs (Malaysia Healthcare Travel Council, 2020b). Malaysia attracts
medical tourists from various countries including Indonesia, India, China,
Japan, Australia, Vietnam, and some Middle Eastern countries such as
Saudi Arabia, Oman, and Qatar. Among all these markets, China is a
promising and growing market mainly because of the impetus of the
China's Belt and Road Initiative (BRI). Several other practices such as the
availability of e-visa (which is approved in less than 24 hours), the close
diplomatic collaboration between the two governments and the presence
of Malaysia Healthcare representative offices in China have successfully
attracted a huge number of Chinese medical tourists to Malaysia (The
Star, 2018).
Malaysia has always been regarded as one of the most preferred
medical tourism destinations among the Chinese nationals. This is evi-
dent by their high demand for fertility treatments in Malaysia since
2016, after the abolishment of the one-child policy by the Chinese
government (Aliman, 2018). The cultural proximity between the two
countries also plays a significant role in selecting Malaysia as the des-
tination choice for their medical treatments (Cham et al., 2021). In
Malaysia, almost a quarter of the total population are of Chinese ori-
gin. The ability of the Malaysian Chinese to communicate fluently in
Mandarin is a strength in attracting Chinese medical tourists to Malay-
sia. Nonetheless, it is highly challenging for Malaysia to maintain and
strengthen its competitive position in this hyper-competitive global
medical tourism industry. Malaysia is facing fierce competition from
her neighbouring countries of Singapore and Thailand, the other two
key players in the industry. Hence, the Malaysian players need to
strategise in attracting and serving the Chinese medical tourists. It has
been suggested that Chinese consumers are heavily influenced by
branding strategies (Cham et al., 2021); therefore, more research stud-
ies are warranted to examine the type of marketing and branding
strategies in attracting the Chinese medical tourists.
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141
Although there is an increased amount of research in the field of
medical tourism, not much has been studied on hospital brand forma-
tion and its impacts on patients' attitudes and behaviours in the con-
text of before and after consumption. Hospital branding may play a
significant role in patients' trust, perceived service quality, patient sat-
isfaction, behavioural intention and consumers' decision-making pro-
cess (Cham et al., 2016, 2020; Hyder et al., 2019). However, the
existing literature in medical services provides limited insight about
the formation of hospital branding before service consumption; and
how it may impact the perceptions and attitudes of the medical tour-
ists after service consumption. Generally, medical tourists need rich
information and/or testimonials from their counterparts (e.g., reviews,
comments and personal experiences) to decide on the destination
choice. They increasingly rely on technology to obtain such informa-
tion to support their decision-making (Cham et al., 2020). Messages
from advertisements and online social media may influence their cog-
nitive process in forming a certain image and trust of a particular ser-
vice provider. Moreover, pre-consumption expectations may have a
spill over effect on the post-service consumption stage.
As such, to what extent does hospital brand image influence the
perceptions and attitudes of medical tourists before and after service
consumption? It is especially important to address this research ques-
tion given the specific nature of medical services, which are highly
intangible, experiential, and of high personal risk (AlSaleh, 2019;
Han & Hyun, 2015). Hence, this study aims to examine: (1) the impact
of marketing and social factors on hospital brand image, which in turn,
may influence the perceived brand trust at the pre-consumption
stage; and (2) the relationships among perceived service quality,
patient satisfaction, trust in medical staff, perceived value, and behav-
ioural intention at the post-consumption stage. The marketing factors
included in this study are advertisements and company-generated
social media communication, and the social factors are user-generated
social media and word-of-mouth (WOM) communication. The signifi-
cance of the present study lies in the examination of the power of
social media communication in shaping consumers' perceptions, atti-
tudes, and intention in the medical tourism industry.
The remainder of this paper is organised as follows. The Section 2
reviews the related literature, which explains the development of the
study's hypotheses and research model. The following sections pre-
sent the research methodology and discussion of research results.
Finally, the paper concludes with the theoretical and practical implica-
tions of the research findings.
2 | LI T E RA T U R E RE V I E W A N D
HYPOTHESIS DEVELOPMENT
To address the hyper-competitive landscape, businesses need to craft
an effective branding strategy to differentiate themselves from the
competitors (Soltani et al., 2018). This is particularly true in the medi-
cal sector, whereby patients have limited evidence, cues and knowl-
edge to assess the quality of a treatment that may have a long-term
effect on their health. As an implicit indicator of quality, branding

142
would influence patients' decision-making process and behavioural
intention greatly, especially prior to their purchase or consumption of
the medical services.
Of the research in branding dimensions, brand image and brand
trust have been found to have the greatest impact on consumers' atti-
tude towards the service providers (Cham et al., 2016; Tran
et al., 2019). Hospital brand image plays a critical role in the minds of
the patients in visualising, evaluating and differentiating of the medi-
cal services (Cham et al., 2016; Wu, 2011). Brand trust also plays a
significant role in helping patients to mitigate risk and uncertainty in
their selection decision. Patients often rely on their perceived trust of
the hospital when selecting a provider for medical services (Han &
Hyun, 2015; Hyder et al., 2019). Although brand image formation and
perceived brand trust are dominant elements in the before-service
consumption stage, research studies in this area are still lacking (Cham
et al., 2016; Riezebos, 2003).
Patients often depend on the brand image when selecting a
healthcare provider in order to lower information search costs, to reduce
perceived risks and to simplify their decision-making (AlSaleh, 2019;
Kemp et al., 2014; Wu, 2011). Brand image signifies certain service char-
acteristics and hence, it plays an important role in influencing patients'
selection decision (AlSaleh, 2019; Hyder et al., 2019). According to Kim
et al. (2008) and (2018), branding has a spill over effect. That is, branding
influences not only customers' initial perception of the product or service
before consumption, but also their subsequent evaluation of the product
or service after consumption. Therefore, it is crucial to examine the ways
in which medical tourists construct the hospital brand image at the pre-
consumption stage; and how these perceptions may, in turn, influence
their service quality evaluation, satisfaction and behavioural intention at
the post-consumption stage. Understanding the antecedents and impacts
of hospital branding is particularly important for the first-time medical
tourists whom do not have any prior experience with a particular medical
destination or hospital.
It is well recognised that information sources influence consumers'
image formation considerably (Cham et al., 2020; Riezebos, 2003); but
the types of information sources used by consumers are very subjective,
contextualised and industry specific. Although hospitals' advertisements
and social media communication are among the major information
sources used by the medical tourists (Cham et al., 2020; Lee et al., 2018),
there is a lack of studies on the former's role in influencing medical tour-
ists' brand image formation and post-service perceptions. Furthermore,
WOM is a major part of social media communication and there is limited
knowledge about the role of WOM communication in the image-trust
relationship. To address these research gaps, this study examines the
impact of hospitals' advertisements and social media communication on
medical tourists' hospital brand image. This study also examines the
potential moderating effect of WOM communication on the relationship
between medical tourists' brand image and brand trust in the pre-
consumption stage.
It has been argued that perceptions developed during pre-
purchase stage would influence consumers' perceptions at the post-
purchase stage (Finn, 2012; Jiang et al., 2018; Tsiotsou &
Wirtz, 2015). Indeed, past research has indicated that customers'
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CHAM ET AL.
perception of branding at the earlier stage may potentially influence
their evaluation of service delivery and quality at the later stage (Jiang
et al., 2018; Tsiotsou & Wirtz, 2015). Customers who have developed
positive brand perceptions as a result of marketing and promotional
activities (pre-service consumption stage) may perceive service quality
favourably at the post-consumption stage (Finn, 2012; Tsiotsou &
Wirtz, 2015). Thus, it is important to understand the inter-relations of
customer perceptions before- and after-service consumption. The
present study examines how hospital branding perceptions of medical
tourists at the pre-consumption stage influence their post-
consumption perceptions in relation to quality, satisfaction, trust,
value and behavioural intention (recommendation and revisitation
intention).
With regards to the relationship between perceived service qual-
ity and customer satisfaction, some studies found a direct relationship
between the two (Chaniotakis & Lymperopoulos, 2009; Ladhari
et al., 2017). However, this relationship might not be as straightfor-
ward as it seems—it may be indirect and nonlinear (Ažman &
Gomišček, 2015; Finn, 2012). Trust in medical staff and value of ser-
vice may have a mediating effect on the relationship between service
quality and patient satisfaction (Kundu & Datta, 2015; Malik, 2012).
However, their mediating role is still under-examined in the service
research and healthcare literature. Their contributing role needs to be
addressed in view of the high-involvement decision and sacrifices
(time, effort and resources) associated with medical treatments
(AlSaleh, 2019; Han & Hyun, 2015).
The following sections present the development of the study's
hypotheses and the associated research model.
2.1 | Factors influencing brand image (pre-
consumption stage)
Brand image can be an important element for businesses due to its
enormous implications on firm's strategic planning and overall
organisational performance. It is a major part of a firm's brand
development strategy. Brand image is defined as ‘a set of percep-
tions about a brand, as reflected by brand associations in con-
sumer's memory’ (Keller, 1993, p. 3). It refers to the series of
recognition affiliated to a particular brand within the mind of the
consumers (Dobni & Zinkhan, 1990). Brand image plays a signifi-
cant role in consumers' purchasing decision making, especially in
selecting products and services among many competing brands
(Jalilvand & Samiei, 2012). According to the image forming theory,
consumers form a certain image about the product or service
through inductive inferences they make based on their exposure to
marketing communication and promotion techniques (Cham
et al., 2016; Riezebos, 2003; Robert & Patrick, 2009). Hence, brand
image formation does not solely depend on the functional aspect of
the product or service; it is greatly influenced by the firms' market-
ing strategies (Riezebos, 2003; Robert & Patrick, 2009). In this
study, the influencing roles of hospital advertisements and social
media on brand image formation were examined.

CHAM ET AL.
2.1.1 | Advertisements
Advertisement is any type of paid, non-personal presentation and promo-
tion of goods, services or ideas by an identified sponsor (Armstrong &
Kotler, 2007). This form of marketing communication tool includes print
media (e.g., magazines, brochures, and newspapers), outdoor media
(e.g., events and billboards), television, radio broadcast and the Internet.
Advertising is an effective marketing strategy to capture consumers'
attention and to motivate them to buy certain products and services
(Chen et al., 2016; Gong & Tung, 2017). Advertisements are effective in
creating product/service impression and in influencing customers' pur-
chase decision (Le et al., 2019).
Advertisements are found to have a positive relationship with brand
preferences and consumer buying behaviour (Liu & Mattila, 2017). Specif-
ically, advertisements can create some kind of image of an organisation
among the consumers, that is, formation of brand image (Ardestani
et al., 2014; Kim et al., 2016; Kim & Lee, 2020; Pike et al., 2021). The
study by Ardestani et al. (2014) found that advertisements play a signifi-
cant role in influencing customers' perception of brand image towards
Iranian insurance companies. Likewise, the study by Kim et al.'s (2016)
indicated that advertisements enhance customers' perception of brand
image of the coffee shops in South Korea. Thus, it can be postulated that
hospitals' advertisements can have a direct impact on how medical tour-
ists perceive the brand image of the hospital:
H1. Hospital advertisements have a positive effect on
hospital brand image.
2.1.2 | Social media communication
Social media is a group of Internet-based applications supporting the
creation and exchange of mass information (Kaplan & stated promises and functions (Chaudhuri & Holbrook, 2001). In other
Haenlein, 2010). Since its inception, social media has changed the way
businesses communicate with customers (Bruhn et al., 2012; Kaplan &
Haenlein, 2010). Social media allows mass communication in various
forms such as online discussions, reviews, chats, sharing opinions and
video conferencing. This function makes social media a new platform
for consumer socialisation and exchange of opinions freely. It has also
become an unconventional channel for marketing strategy develop-
ment and for shaping consumer perceptions and behaviours (Caber
et al., 2021). Social media plays a very important marketing role in the
medical tourism industry. It has become a main source of information
for medical tourists in selecting medical destination (country),
healthcare providers and medical treatments (Fletcher et al., 2017;
John et al., 2018; Lee et al., 2014; Lim et al., 2019; Sigala, 2012;
Sigala & Gretzel, 2017; Yeoh et al., 2013).
There are two major forms of social media communication:
(1) user-created social media established by the customers; and
(2) firm-created social media developed by the firms (Bruhn
et al., 2012). User-created social media allows consumers to engage in
multi-way social conversations and to play the role of broadcasters.
Consumers can now participate, create and assess the media content
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143
by sharing and discussing their opinions with one another. They no
longer simply listen to the marketers. Through this form of social
media, user-generated reviews and comments can potentially influ-
ence consumers' awareness of products and services and their subse-
quent brand image formation (Bruhn et al., 2012; Oliveira &
Panyik, 2015; Schivinski & Dabrowski, 2016).
On the other hand, firm-created social media is a contemporary web-
based application used as a marketing channel to target consumers online
(Schivinski & Dabrowski, 2016). Firm-created social media can enhance
the equity of the brand by influencing customers' evaluation process on a
particular brand. It helps consumers shorten the purchase decision pro-
cess and ultimately make a certain brand as their preferred choice (Bruhn
et al., 2012; Schivinski & Dabrowski, 2016). Bruhn et al. (2012) claimed
that firm-created social media (e.g., Facebook, YouTube, forum postings,
blogs, Twitter, and online magazines) has successfully created favourable
brand image in the pharmaceuticals and telecommunications industries.
Consequently, it is hypothesised that both firm-created social media and
user-created social media can have a direct positive influence on medical
tourists' perception of a hospital's brand image:
H2. User-generated social media has a positive effect on
hospital brand image.
H3. Hospital-created social media has a positive effect on
hospital brand image.
2.2 | Linking hospital brand image, brand trust, and
WOM communication (pre-consumption stage)
Brand trust in the present study is defined as the willingness of the
medical tourists to rely on the ability of the hospitals to perform their
words, brand trust refers to the trust a medical tourist has for a spe-
cific hospital. It is common for consumers to seek information and
evaluate a hospital before receiving medical treatments. Patients will
usually evaluate all the risks associated with every option available
when choosing a healthcare provider. They would form a trust
towards the brand of the hospital after the evaluation, and this trust is
taken into account in their decision making (Cham et al., 2016;
Hosseini & Behboudi, 2017). It is found that trusted service brands
are often patronised by repeat customers and are able to yield a
higher market share (Hosseini & Behboudi, 2017). This reflects the
importance of brand trust, whereby a certain level of trust should be
present before the medical tourists decide which hospital to go to
receive the needed medical treatments.
Brand trust is found to be associated with brand image. Numer-
ous studies have suggested that brand image is positively related to
brand trust (Han et al., 2020; Song et al., 2019). For example, in their
study on 425 airline customers, Han et al. (2020) found that passen-
gers' perception on the airline brand image is positively associated
with their trust towards the airline brand. Likewise, Song et al. (2019)
showed that the brand image of the coffee has a significant direct

144
impact on the trust of the coffee brand. Thus, a significant and posi-
tive relationship exists between brand image and brand trust. With
this, the following hypothesis is developed:
H4. Hospital brand image has a positive effect on hospital
brand trust.
WOM communication in the present study refers to an individual's
personal communication with family members, relatives, associates and
friends with regards to the medical services provided by the hospital
(Kotler, 2006). WOM is often regarded as a popular source of information
due to its reliability, trustworthiness and most importantly, its absence of
the profit motivation (Abubakar & Ilkan, 2016; Xu & Chan, 2010). Con-
sumers use WOM to minimise the risks and uncertainties associated with
a purchase decision (Abubakar & Ilkan, 2016). Medical tourists often rely
on WOM particularly when they have no prior experience with the desti-
nation and hospital they are about to visit (Lee et al., 2012; Martin, 2017).
The lack of medical knowledge and the complexity of the medical infor-
mation are also reasons for WOM to become a significant source of infor-
mation for patients (Hanefeld et al., 2015; Taheri et al., 2021).
WOM communication is a way to shape consumers' attitudes and
perceptions. It influences consumers' judgements on various aspects
of the brand (Ansary & Hashim, 2018; Ghosh, 2018) such as brand
trust (Kim et al., 2019), brand attitude (Ghosh, 2018), brand awareness
(Sürücü et al., 2019), and brand loyalty (Jun et al., 2017). WOM may
play a moderating role in influencing consumers' attitudes and percep-
tions on product/service branding (Ansary & Hashim, 2018; Lin &
Lu, 2010). Ansary and Hashim (2018) found that WOM communica-
tion moderates the relationship between consumers' perceived brand
image and their attitude towards the brand of the product of their
choice. Similarly, Lin and Lu (2010) argued that WOM moderates the
relationship between tourists' trust towards the online tour agencies
and their purchase intention of the tour packages.
This study examines the moderating effect of WOM in the per-
ceptual context of branding. Based on the abovementioned, it is hypo-
thesised that the medical tourists' engagement in WOM moderates
the relationship between brand image and brand trust:
H5. WOM communication engaged by medical tourists
moderates the relationship between hospital brand image
and brand trust.
2.3 | Linking hospital brand trust, perceived
service quality, patient satisfaction, and behavioural
intention (post-consumption stage)
2.3.1 | The influence of brand trust on perceived
service quality
Perceived service quality is defined as ‘a global judgment, or attitude,
relating to the superiority of the service’ (Parasuraman et al., 1988, p. 16).
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CHAM ET AL.
The concept of service quality has attracted the attention from various
parties—Managers, practitioners, and researchers. This concept has an
extensive effect on business profitability, customer satisfaction, opera-
tional costs, business performance and most importantly, customer loyalty
(Brady et al., 2001; Cham & Easvaralingam, 2012; Cheng et al., 2019;
Kocabulut & Albayrak, 2019). How customers perceive the quality of a
service depends on the trade-off between their expectations and service
performance (Brady et al., 2001; Parasuraman et al., 1988). Quality is
highly perceived if service performance exceeds a customer's expectation
and vice versa (Lai & Hitchcock, 2018).
Past studies indicate that the way consumers perceive the quality
of the service may be influenced by how much they trust the service
providers (brand trust) (Arfaeian & Chaipoopirutana, 2014;
Lassoued & Hobbs, 2015). Retail brand trust is able to promote the
consumers' confidence and service expectations towards the retail
store before any purchase is made (Jones & Kim, 2010). Similarly,
Tuan and Rajagopal (2017) found that the customers' trust towards
the brand positively influenced their perceived quality of the store.
Hence, consumers' trust can be a determinant of perceived service
quality (Lassoued & Hobbs, 2015; Tuan & Rajagopal, 2017). As dis-
cussed previously, it is expected that when medical tourists perceive
the brand of the hospital positively at the pre-consumption stage,
they will develop positive service quality perceptions of the hospital
at the post-consumption stage. Therefore, it is postulated that:
H6. Hospital brand trust has a positive effect on per-
ceived service quality.
2.3.2 | Perceived service quality and patient
satisfaction
Patient satisfaction refers to ‘the degree of congruency between a
patient's expectations of ideal care and his /her perception of the real
care him /her receives’ (Aragon & Gesell, 2003, p. 229). Patient satisfac-
tion is an outcome of the experience in receiving medical services; and
it plays a number of important roles in customer relationship (Pakdil &
Harwood, 2005). Its roles include assisting organisations in: (1) identify-
ing customers who are likely to disenroll if they are not satisfied with
the service (Aldaqal et al., 2012); (2) evaluating the quality of customer
care (Yeşilada & Direktouml, 2010); and (3) identifying the area of ser-
vice that can be improved. Patients are more likely to be satisfied if they
experience medical services of superior quality (Chaniotakis &
Lymperopoulos, 2009; Ladhari et al., 2017; Loureiro, 2017). Chaniotakis
and Lymperopoulos (2009) found that hospital's service quality has a
positive and direct influence on patients' satisfaction. Similarly, Ladhari
et al. (2017) found that the service quality of the clinics has a positive
impact on their patients' emotional satisfaction. Thus, it is hypo-
thesised that:
H7. Perceived service quality has a positive effect on
patient satisfaction.

CHAM ET AL.
2.3.3 | Patient satisfaction and behavioural
intention
Behavioural intention is defined as an individual's likelihood to engage
in a certain behaviour (Oliver, 1997). In general, customers' behav-
ioural intention can be either favourable or unfavourable
(Ladhari, 2009). Favourable behavioural intention will: (1) increase
customers' willingness to pay premium prices, (2) promote a better
relationship between the buyer and seller, (3) lead to a lower tendency
to switch brand among the customers, (4) enhance their willingness to
express positive WOM, and (5) increase future purchases from the
customers (Zeithaml & Bitner, 1996). Unfavourable intention usually
leads customers to: (1) spread negative WOM to their peers, (2) show
a sign of unwillingness to pay premium prices, (3) have a higher ten-
dency to switch brand, and (4) reduce their volume of purchase
(Zeithaml & Bitner, 1996). In general, behavioural intention of the cus-
tomers' is vital to the success and sustainability of any service firm
(Ladhari, 2009; Saiprasert, 2011).
Behavioural intention of the customers is directly affected by the
satisfaction level resulting from the service encounter (Dolnicar
et al., 2015). Satisfied customers tend to have a favourable behav-
ioural intention and stay loyal with the same service provider
(Kastenholz et al., 2018; Kim et al., 2008; Loureiro et al., 2019;
Loureiro & Kastenholz, 2011; Wu, 2011). Customer satisfaction not
only strengthens the relationship between the firm and its customers
but it also helps in retaining customers (Dolnicar et al., 2015). In this
study, behavioural intention refers to the tendency of medical tourists
to recommend and to revisit their hospitals (Saiprasert, 2011). Subse-
quently, the following hypothesis is formulated:
H8. Patient satisfaction has a positive direct effect on
patients' behavioural intention.
2.4 | The mediating role of perceived trust and
perceived value
2.4.1 | The mediating role of perceived trust
Trust in medical staff is defined as ‘the optimistic acceptance of a vul-
nerable situation in which the patient believes the medical staff will
take care of the patient's interests’ (Dugan et al., 2005, p. 64). Trust is
an important element in the healthcare industry due to the severe
consequences of bad medical services (Chang et al., 2013). Trust in
medical service involves two main issues of concern: (1) whether ‘the
medical institution and the physician are capable to make a diagnosis
and to provide treatment’, and (2) ‘will the medical institution and the
physician act accordingly in the best interest of the patient’ (Chang
et al., 2013, p. 3). Failing to understand patients' expectations can
result in mistrust and switching intention among the patients
(Alrubaiee & Alkaa'ida, 2011).
Past studies have found a direct and significant positive relation-
ship between perceived service quality and customer trust
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145
(Alrubaiee & Alkaa'ida, 2011; Saleem et al., 2017). Various aspects of
service quality such as tangible, assurance, staff responsiveness, staff
reliability, and staff empathy in the healthcare are vital in developing
patient trust (Alrubaiee & Alkaa'ida, 2011). Customers will evaluate
the explicit and implicit cues of the service providers before building
trusted relationships with them (Chiou et al., 2002). The experience
with the healthcare service providers is a critical factor in forming
trust among the patients. This is due to the lack of medical knowledge
among the patients and the highly complex and intangible nature of
the medical services (Alrubaiee & Alkaa'ida, 2011). In turn, patients'
perceived trust in medical staff may have a direct impact on their sat-
isfaction level with the service received. In general, customers are
more likely to be satisfied with the service provider if they trust the
entity in the first place (Chang, 2014; Chiou et al., 2002; Martínez &
Del Bosque, 2013).
Perceived trust is also found to have a mediating effect on the
relationship between service quality and customer satisfaction (Chiou
et al., 2002; Kundu & Datta, 2015; Ouyang, 2010). The study by
Chiou et al. (2002) found that customers' trust in the service provider
mediated the relationship between their perceived service quality and
satisfaction towards the company. Similarly, Kundu and Datta (2015)
indicated that customers' trust towards the bank mediated the rela-
tionship between service quality of the Internet banking and the
users' satisfaction of the system. Consequently, the following hypoth-
eses are developed:
H9. Perceived service quality has a positive effect on
medical tourists' trust in medical staff.
H10. Trust in medical staff has a positive effect on
patient satisfaction.
H11. Trust in medical staff mediates the relationship
between service quality and patient satisfaction.
2.4.2 | The mediating role of perceived value
Perceived value is defined as ‘the consumer's overall assessment
of the utility of product based on perceptions of what is received
and what is given’ (Zeithaml, 1988, p. 14). Firms need to under-
stand what the customers value so that they can compete
effectively and sustain in the marketplace (Choi et al., 2015).
Zeithaml (1988) argued that customers will only perceive a value
from the transaction if the benefits received at the post-purchase
stage exceed what they have to give up (sacrifices) before the pur-
chase. Benefits are largely the results of good quality service in
both the process and outcome domains. Benefits experienced by
the customers include value for money, stress-free services, less
waiting time and personal attention during service consumption.
Sacrifices can be in terms of (1) monetary costs, for example, the
price that paid by patients for the medical services engaged; and
(2) non-monetary costs, for example, mental and physical stress
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146 CHAM ET AL.

Perception of the hospital prior to service consumption Perception of the hospital after service consumption FIGURE 1 The research model

H11

Trust in
Word-of-Mouth Medical
Communication Staff
Hospital
Advertisements H1
H5 H9 H10

User-generated Hospital Hospital Perceived Patient Behavioural

H2
Social Media Brand Brand Trust Service Satisfaction Intention
Image H4 H6 Quality H7 H8

H12 H13
Hospital-created
Social Media H3
Perceived
value of
medical
trip
H14

experienced and the time spent in receiving the medical care
(Chahal & Kumari, 2011).
Past studies have indicated that perceived service quality is
positively related to customers' perceived value. A high level of
perceived value may be formed when customers perceive a high
level of service quality offered by the
et al., 2010; Malik, 2012). Malik (2012) found that service qual-
ity elements—tangible, reliability, responsiveness, assurance, and
empathy—are vital in forming customer value. Perceived value,
in turn, may have a positive effect on customer satisfaction.
Moliner (2009) found that the patients' level of satisfaction is
closely associated with the values that they perceive to receive
from the hospitals.
In other words, perceived value may have a mediating effect on
the relationship between service quality and customer satisfaction.
Findings from customers in various service sectors revealed that per-
ceived value partially mediates the relationship between perceived
service quality and customer satisfaction (Malik's, 2012; Yousef &
Dariyoush, 2018). Yousef and Dariyoush (2018) found that interna-
tional tourists' perceived value for their trip mediates the relationship
between their perceived quality and satisfaction towards Kuala
Lumpur, a capital city of Malaysia. Hence, the following hypotheses
are formulated:
H12. Perceived service quality has a positive effect on
medical tourists' perceived value on medical trip.
H13. Perceived value on medical trip has a positive effect
on patient satisfaction.
H14. Perceived value of medical service mediates the
relationship between service quality and
satisfaction.
Figure 1 depicts the research model of the study.
3 | RESEARCH METHODOLOGY
3.1 | Sampling procedure and data collection
The target respondents of this study are medical tourists who have
providers (Hu visited three major states of Malaysia—Penang, Selangor, and Kuala
Lumpur—to seek for medical services. These locations were included
due to the presence of a high number of healthcare providers involved
in medical tourism (Malaysia Healthcare Travel Council, 2020a,
2020b). The sample of this study was drawn from six major private
hospitals with two hospitals in each location. These hospitals are very
similar in terms of its operation size and types of medical treatments
provided. Two screening criteria were used for selecting medical tour-
ists from China to participate in the study: (1) the respondents came
to Malaysia for medical treatments, and (2) they had engaged in some
tourism activities during their medical trip. Examples of tourism activi-
ties were hotel lodging, sight-seeing, shopping, dining and engage-
ment of transportation of all modes. Survey questionnaires were used
to collect data from the target audience. The self-administered ques-
tionnaires were distributed to the Chinese medical tourists by the
enumerators at the hospitals' waiting areas, lobbies and cafeterias to
minimise the possibility of disturbance to the hospitals' business oper-
ations. These areas were selected because medical tourists are easily
accessible at these areas. A total of 300 questionnaires were distrib-
uted to the Chinese medical tourists across the six major hospitals
included in this study.
The questionnaire included items measuring the respondents'
perceptions about hospital brand and services at two stages of their
medical trip experience: before and after their service consumption.
The present researchers followed the approach by Kim et al. (2016)
and Tsai and Huang (2002) to simultaneously collect perceptual data
patient of pre- and post-service consumption. According to Kim et al. (2016)
and Tsai and Huang (2002), customers are able to recall their percep-
tions or opinions before visiting a service provider, even though the
questionnaire was distributed to them after their consumption of

CHAM ET AL.
the service. In general, customers are able to differentiate their per-
ceptions and emotions before and after their service experience.
To minimise the confounding effect between perceptions before
and after the consumption, the survey instrument included questions
structured in three separate sections. Section A seeks the respon-
dents' perceptions of the constructs in study prior to their visit. They
are user-generated social media, hospital-created social media, adver-
tisements, hospital brand image, WOM communication and hospital
brand trust. Section B consists of demographic questions. Section C
covers the respondents' perceptions of the constructs after their ser-
vice consumption. These constructs are perceived service quality,
patient satisfaction, trust in medical staff, perceived value of medical
trip, and behavioural intention. By incorporating a ‘time lag’ with
section B (seeking demographic information) between Section A
(before service consumption) and Section C (after the service con-
sumption), the design of the questionnaire allows the respondents to
psychologically separate their perceptions and emotions between the
two stages.
The questionnaire was prepared in two languages namely English
and Chinese, after the process of translation and back translation as
suggested by Brace (2008). To check the face validity of the research
instrument, the questionnaire was pre-tested with a panel of
11 experts consisted of tourism professionals, tourism researchers
and senior government officers involved in medical tourism. Based on
their feedback, two items of the questionnaire were rephrased to
improve language expression and understandability. The question-
naire was further pilot tested with 50 Chinese medical tourists who
visited Malaysia during the period of the study (March 2019–June
2019). The result of this pilot test indicated that all the questions were
clear, relevance, precise and well understood by the respondents.
Data were collected over a period of 4 months from July to
October 2019. After cleaning the data with missing data detection,
suspicious response patterns detection, normality test, outlier's detec-
tion and multicollinearity detection, six cases were found to be
unusable. Hence, the study's sample included 294 usable question-
naires for data analysis and hypothesis testing. According to Saunders
et al. (2012), a sample size of 300 is considered sufficient to represent
a large population. G*Power program was used to further check the
adequacy of the sample size. The results showed that the sample size
of 294 exceeds the required minimum sample size of 138, based on
the effect size of 0.15 at 95% power level (Faul et al., 2009). Thus, the
sample size of 294 in this study is considered adequate.
3.2 | Measurement scales
The measures of the constructs in study were adapted from existing
scales with some minor changes to accommodate the study's research
context. The construct of advertisements was operationalised based
on the scale developed by Cham et al. (2020), which address the per-
ceptions of the respondents towards the information, appeal, impor-
tance and content of the advertisements by the hospital. The
measurement scales of both user-generated and hospital-created
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147
social media were adapted from Bruhn et al. (2012), measuring the
respondents' evaluation on the online communication about the hos-
pital. Brand image was operationalised in terms of patients' experi-
ence, brand symbolic and practicability based on the scale by Hsieh
and Li (2008). Brand trust was measured using four items developed
by Zeithaml and Bitner (1996) that reflect the level of perceived trust,
honesty and safety towards the brand of the hospital. WOM commu-
nication was adapted from O'Cass and Grace (2004), measuring the
influence of family or friends on the respondents' evaluation, decision
making, ideas, attitude and understanding of the hospital brand.
The five-item scale of perceived service quality was adapted from
the studies by Suhartanto (2011) and Cham et al. (2020), which mea-
sures the assurance, responsiveness, reliability, empathy and tangible
aspects of the hospital's service. Based on the scale by Cham
et al. (2021), this study measured perceived value in terms of what
the medical tourists sacrifice or spend in return of the received medi-
cal services. To measure patient satisfaction, this study adapted the
scale by Panjakajornsak (2008), which measures patients' affective in
response to their service experience. Lastly, the construct of behav-
ioural intention was measured using three items adapted from Choi
et al. (2015), assessing the degree to which medical tourists (1) show
signs of repeat purchase; (2) provide positive recommendation to
others; and (3) have a positive attitude towards the hospital that they
have visited. All constructs were measured with a six-point Likert
scale ranging from 1 = strongly disagree to 6 = strongly agree.
4 | P RE S E N T A T I O N O F T H E F I N D I N G S
4.1 | Respondents' profile
Table 1 presents the profile of the respondents. The majority of the
respondents were females (54.40%) and married (77.80%). Most of
the respondents were in the age group of 36–55 years. One third
of them (30.50%) were Bachelor degree holders, followed by diploma
(26.3%) and high school certificate holders (22.5%). The commonly
sought medical services were orthopaedics treatments (23.3%), car-
diovascular surgery and care (17.9%) and comprehensive medical
check-up (16.3%). See Table 1 below for the common medical services
sought by the respondents.
4.2 | Measurement model analysis
Structural equation modelling was used to determine the fit of mea-
surement model using maximum likelihood estimation method.
According to Hair et al. (2010), a model is considered to have a good
fit if the normed chi-square (χ 2/df) is less than 3, Root mean square
error of approximation (RMSEA) is less than 0.08, goodness of fit
(GFI) is more than 0.90, comparative fit index (CFI) is greater than
0.90, and Tucker Lewis index (TLI) exceeds 0.90. The results of the
goodness-of-fit indices obtained in this study were normed chi-
square = 1.559, RMSEA = 0.044, GFI = 0.895, CFI = 0.934 and
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148 CHAM ET AL.

TABLE 1 Respondents' profile

Variable Classification Percentage (%)
Gender Male 45.6
Female 54.4
Marital Single 17.4
Married 77.8
Divorced 2.3
Widowed 2.2
Others 0.3
Age group 25 years old and below 4.4
26–35 years old 18.3
36–45 years old 27.0
46–55 years old 27.5
56–65 years old 18.1
Above 65 years old 4.7
Educational level High school or below 22.5
Certificate or diploma 26.3
Professional certificate 11.3
Bachelor's degree 30.5
Postgraduate education 9.4
Medical service seeking Orthopaedics (e.g., joint, spine) 23.3
Sight treatment/Lasik 9.6
Fertility care 5.7
Comprehensive medical check-up 16.3
Cosmetic/plastic/reconstructive surgery 5.5
Cardiovascular surgery and care 17.9
Oncology (cancer treatments) 9.8
Others 11.9

TLI = 0.928; which indicated that the measurement model was
considerably fit.
The convergent validity of the constructs in this study was
assessed based on three criteria: (1) standardised factor loadings,
(2) composite reliability, and (3) the average variance extracted (AVE)
as suggested by Hair et al. (2010). According to Hair et al. (2010), the
following conditions should be fulfilled for these three criteria: (1) all
the items should be significantly linked to their respective latent con-
structs with a loading of 0.60, (2) the composite reliability for each
construct is above 0.70, and (3) the AVE for all the constructs are
greater than 0.50. The results of the measurement model analysis
indicated that the loadings of some of the measurements items were
below the recommended value. Hence, an item from the construct of
advertisements was dropped from further analysis. After the removal
of the said item, Table 2 shows that the remaining items for all other
constructs satisfied the requirement with the values of factor loading
ranged from 0.639 to 0.941. Besides, Table 2 also shows that the
composite reliability for each of the constructs exceeds 0.70 with
AVE more than the threshold value of 0.50, suggesting that the con-
vergent validity of the data was established.
The discriminant validity of the measurement scales was exam-
ined based on Fornell and Larcker's (1981) suggestion. To address dis-
criminant validity, Fornell and Larcker (1981) suggested that (1) the
squared roots of AVE for the individual construct should be greater
than the correlation between any other two constructs, and (2) the
value of maximum-shared-squared-variance (MSV) for the construct
should be lower than its AVE value. Table 2 shows that the values of
squared roots of AVE (in bold) for all the constructs are greater than
the off-diagonal (in italics) components in the corresponding columns
and rows; and the values of MSV are lower than the AVE values for
the respective constructs. Hence, the discriminant validity was
deemed to be established for the present study.
In addition, the issue of common variance method (CMV) was
addressed based on the suggestion by Malhotra et al. (2006).
According to Malhotra et al. (2006), CMV is argued to be a problem
for a research study if all the item indicators for the constructs mod-
elled as a single factor is fit. The study's results showed that the model
is not fit; hence, it can be concluded that common method bias is not
a significant problem in this study. Having addressed the convergent
and discriminant validity of the measurement model, the following
 CHAM ET AL.

TABLE 2 Results of convergent and discriminant validity tests

Constructs F.L. C.R. AVE MSV 1 2 3 4 5 6 7 8 9 10 11

UGSM 0.639–0.842 0.850 0.655 0.222 0.809
VALUE 0.680–0.836 0.852 0.591 0.372 0.305 0.769
B.TRT 0.790–0.833 0.870 0.626 0.458 0.227 0.549 0.791
HCSM 0.876–0.941 0.931 0.818 0.069 0.263 0.108 0.100 0.904
B.IMG 0.775–0.868 0.863 0.678 0.250 0.382 0.274 0.391 0.233 0.823
ADS 0.656–0.818 0.862 0.558 0.458 0.271 0.465 0.677 0.082 0.350 0.747
PSQ 0.676–0.785 0.858 0.547 0.350 0.204 0.353 0.592 0.130 0.495 0.550 0.740
TMS 0.701–0.791 0.869 0.571 0.393 0.291 0.509 0.473 0.197 0.500 0.449 0.591 0.756
SATIS 0.764–0.825 0.871 0.629 0.596 0.227 0.516 0.508 0.084 0.463 0.482 0.537 0.627 0.793
INT 0.814–0.870 0.887 0.724 0.596 0.271 0.610 0.554 0.114 0.498 0.483 0.453 0.520 0.772 0.851
WOM 0.846–0.911 0.948 0.784 0.222 0.471 0.263 0.173 0.062 0.340 0.161 0.157 0.220 0.268 0.390 0.885

Note: The diagonal entries (in bold) represent the squared roots average variance. The off-diagonal entries (in italics) represent the variance shared (squared correlation) between construct.
Abbreviations: ADS, advertisements; AVE, average variance extracted; B.IMG, brand image; B.TRT, brand trust; C.R., composite reliability; F.L., factor loadings; HCSM, hospital-created social media; INT,
behavioural intention; MSV, maximum shared squared variance; PSQ, perceived service quality; SATIS, patient satisfaction; TMS, trust in medical staff; UGSM, user-generated social media; VALUE, perceived
value of medical trip; WOM, word-of-mouth communication.
149

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150 CHAM ET AL.

section presents the model fit of the structural model and the results that medical tourists' perceived service quality of the visited hospital
of hypothesis testing. has a significant positive impact on their satisfaction (β = 0.273,
p < 0.05), their trust in the medical staff (β = 0.640, p < 0.001) and
their perceived value from the medical trip (β = 0.484, p < 0.001).
4.3 | Path analysis and hypothesis testing Similarly, medical tourists' perceived trust in the medical staff

The structural model for the current study provides an adequate fit to
the data with Normed Chi-square = 1.720, RMSEA = 0.050,
GFI = 0.886, CFI = 0.922 and TLI = 0.922. An adequate structural
model allows further examination of the formulated hypotheses.
Table 3 below summarises the results of path coefficients for all the
hypothesised paths in the research model. The results showed that
hospital advertisements (β = 0.307, p < 0.001), user-generated social
media (β = 0.266, p < 0.05) and hospital-created social media
(β = 0.141, p < 0.05) were found to have a positive significant effect
on hospitals' brand image, which in turn, positively influenced medical
tourists' trust on the brand of the hospitals (β = 0.462, p < 0.001).
Next, the hospitals' brand trust was also found to be positively associ-
F I G U R E 2 The moderation effect of word-of-mouth
ated with medical tourists' perceived service quality for the hospital communication on the relationship between brand image and brand
that they visited (β = 0.668, p < 0.001). The findings also revealed trust [Colour figure can be viewed at wileyonlinelibrary.com]

TABLE 3 Hypotheses testing of structural research model

Hypothesised path Std. estimate Critical ratio Supported (yes/no)

H1: Advertisements à Brand image 0.307 4.679** Yes
H2: User-generated social media à Brand image 0.266 3.908* Yes
H3: Hospital-created social media à Brand image 0.141 2.311* Yes
H4: Brand image à Brand trust 0.462 6.786** Yes
H6: Brand trust à Perceived service quality 0.668 9.315** Yes
H7: Perceived service quality à Patient satisfaction 0.273 3.239* Yes
H8: Patient satisfaction à Behavioural intention 0.784 11.872** Yes
H9: Perceived service quality à Trust in medical 0.640 8.407** Yes
staff
H10: Trust in medical staff à Patient satisfaction 0.349 4.481** Yes
H12: Perceived service quality à Perceived value of 0.484 7.035** Yes
medical trip
H13: Perceived value of medical trip à Patient 0.239 3.820** Yes
satisfaction

**p value < 0.001. *p value < 0.05.

T A B L E 4 Testing moderating effect

C.I.
of word-of-mouth communication on the
Variable β SE t value L.L. U.L. relationship between brand image and
brand trust
Constant 4.525 0.033 134.526** 4.459 4.591
Brand Image 0.295 0.058 5.102** 0.181 0.409
WOM 0.028 0.035 0.817ns 0.398 0.096
Interaction (Brand Image X WOM) 0.081 0.038 2.125* 0.155 0.006

Note: Independent variable = brand trust.

Abbreviations: C.I., confidence intervals at 95%; L.L., lower limit; ns, not significant; U.L., upper limit;
WOM, word-of-mouth communication; β, coefficient beta.
**p value < 0.001. *p value < 0.05.

CHAM ET AL.
T A B L E 5 Testing indirect effect of
trust in medical staff and perceived value
of medical trip on the relationship Indirect paths
between perceived service quality and
H11: PSQ à TRUST à PS
patient satisfaction
H14: PSQ à VALUE à PS
Abbreviations: C.I., confidence intervals at 95%; PS, patient satisfaction; PSQ, perceived service quality;
TRUST, trust in medical staff; VALUE, perceived value of the medical trip.
(β = 0.349, p < 0.001) and perceived value of the medical trip
(β = 0.239, p < 0.001) were also found to be significantly related to
their satisfaction, which resulted in positive behavioural intention
(β = 0.784, p < 0.001) among the medical tourists. Hence, H1, H2,
H3, H4, H6, H7, H8, H9, H10, H12, H13 were found to be supported
by the data.
The moderating effect of WOM on the relationship between
brand image and brand trust of the hospital (H5) was addressed with
the use of SPSS PROCESS macro developed by Hayes (2013).
According to Hayes (2013), a moderation effect is assumed to exist if
the interaction term in the regression model is significant. As
highlighted in Table 4, the results of the regression test showed that
WOM (β = 0.081, p < 0.05) moderated the relationship between
brand image and brand trust. The moderating effect of WOM was
plotted in a graph shown in Figure 2. The graph shows that the inter-
polation line for the medical tourists who received high WOM from
their family and friends is steeper than that of those receiving low
WOM. Specifically, the results indicated that brand image is more
strongly associated with brand trust for the group of medical tourists
who received high influence of WOM from their family and friends as
compared to those with low WOM. Thus, H5 was supported in this
study.
Hypotheses 11 and 14 of the present study were assessed using
the bootstrap technique in AMOS. The results presented in Table 5
show that perceived service quality has an indirect effect on patient
satisfaction via trust in medical staff and perceived value of the medi-
cal trip. This result was obtained based on the bias-corrected boo-
tstrapping technique on 5000 bootstrap samples. It was found that
the 95% bias-corrected confidence interval for trust in medical staff
(lower level bound = 0.036; upper level bound = 0.189) and for per-
ceived value of the medical trip (lower level bound = 0.137; upper
level bound = 0.375) do not straddle a zero in between. Thus, H11
and H14 were supported in this study. Moreover, Table 5 also reveals
that the leading indirect decisive factor of patient satisfaction was
perceived value with an indirect effect of 0.237, followed by trust in
medical staff with an indirect effect of 0.097.
5 | D I S C U S S I O N A N D I M P L I C A T I O N S OF
R E S E A RC H F I N D I N G S
There are several key findings worth noting from the study. Firstly, it
was found that hospital branding prior to service consumption plays a
significant role in influencing the decision-making process of medical
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151
C.I. p value
Indirect Lower bound Upper bound
0.097 0.036 0.189 0.001
0.237 0.137 0.375 0.001
tourists. This finding is consistent with the past studies, such as Brodie
et al. (2009), San Martín et al. (2019) and Wu (2011). Customers often
make consumption decision based on the brand name or reputation of
the service provider, especially in the high-credence service industry
of medical care (Cham et al., 2016; San Martín et al., 2019;
Wu, 2011). Prior to their service experience, medical tourists are able
to form a brand image towards a hospital with the influence of com-
pany advertisements and social media. Positive hospital brand image
would result in positive decision outcome towards the hospital. Thus,
this brand image formation implies the importance of marketing com-
munication in the pre-service consumption stage (Cham et al., 2020;
Zhou et al., 2020). Advertisements with rich contents and persuasive
power can effectively deliver informative messages to potential cus-
tomers. Advertisement is an effective marketing tool to raise aware-
ness and to create brand image among the consumers especially for
new products and services (Kim & Lee, 2020). Similarly, firm-created
content allows hospitals to promote their services effectively while
user-generated content allows medical tourists to share their experi-
ence with their peers freely (John et al., 2018; Schivinski &
Dabrowski, 2016). As a content creation and distribution platform,
social media can appeal to a large pool of potential customers in an
influential, cost-effective manner (Bruhn et al., 2012).
Secondly, brand image was found to have a direct relationship
with perceived trust of the medical tourists towards the brand of the
hospital. This finding is consistent with the past studies whereby a
favourable brand image is able to enhance customers' level of confi-
dence towards the service provider and its brand (Mabkhot et al.,
2017; Song et al., 2019). The initial trust developed from the brand
(may reduce medical tourists' perceived risks associated with the med-
ical services) would lead to a significant impact on their perceived ser-
vice quality in the post-experience stage. It is also interesting to find
that the level of WOM communication moderates the relationship
between brand image and perceived trust. A high engagement of
WOM among the medical tourists is needed to enhance their level of
trust towards the hospital after a favourable formation of hospital
brand image. WOM is often viewed as a reliable, inclusive, objective
and a non-profit oriented source of information. It has been found to
have a strong and positive influence on customers' perceptions, inten-
tions and their actual behaviour on new product/service acquisition
(Stylidis et al., 2020).
At the post-consumption stage, the service quality experienced
by the medical tourists was significantly related to their level of satis-
faction, trust in medical staff, and their perceived value from the trip.
These findings are in line with the past research on service quality,

152
satisfaction, perceived value, and perceived trust (Aldaqal et al., 2012;
Ladhari et al., 2017). Service quality of the hospitals plays a substantial
role in retaining medical tourists. Superior service quality makes medi-
cal tourists feel satisfied and develop trust in the medical staff.
Medical tourists also believe that the expenses and effort they sacri-
fice for the medical trip are worthwhile when they receive quality ser-
vices from the hospital. All these elements are critical in creating a
lasting effect on the intention and future behaviour of medical tour-
ists. It is very likely that they engage in positive WOM to recommend
Malaysia as the destination choice, and that they have a high intention
to revisit Malaysia for medical purpose in the future.
Finally, it was found that perceived service quality has a direct as
well as an indirect relationship (mediated by perceived trust and per-
ceived value) with medical tourists' satisfaction. This finding shows
that service quality is not a sole predictor of satisfaction. Perceived
trust and value are equally important in influencing patient's satisfac-
tion (Kundu & Datta, 2015; Malik, 2012). Consequently, the research
model of this study provides a better understanding on how patient
satisfaction is generated.
5.1 | Theoretical implications
The research findings of this study provide several theoretical implica-
tions. Firstly, the present research adds to the current service market-
ing literature by acknowledging the importance of hospital branding.
Hospital branding plays an important role in influencing consumers'
perceptions and attitudes both at the pre- and post-service consump-
tion stage. This influential role is much needed in the credence-nature
of medical services in keeping patients satisfied. Consequently, these
patients become part of the hospital's promotion medium by spread-
ing positive WOM about the hospital. Secondly, this is one of the very
few studies that examines social media and advertising as the ante-
cedents of brand image. Both social media and advertisements are
perceived to be important brand formulation factors among the medi-
cal tourists. This finding implies that future marketing studies should
explore further on the roles of both online and traditional marketing
practices in corporate branding. Thirdly, the significant moderating
effect of WOM on the brand image-trust relationship provides a
deeper and better understanding about brand management. The inclu-
sion of WOM communication in this study highlights the need to
adopt a new marketing mindset and thinking. Marketing researchers
should consider the importance of this situational factor when exam-
ining the relationship between brand image and brand trust.
Lastly, the present study also expands the body of knowledge by
unravelling the complex interrelationships between service quality,
satisfaction, perceived trust and perceived value. Although the rela-
tionship between service quality and satisfaction has been profoundly
examined, there are limited studies investigating the mediating role of
trust and value on the service quality-satisfaction relation. This study
contributes to the field of marketing by incorporating the mediating
effects of both perceived trust and perceived value to better explain
the relationship between service quality and satisfaction.
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CHAM ET AL.
5.2 | Practical implications
The present study also provides several implications to guide and
inform the management practices of industry professionals. First, the
findings suggest that practitioners should invest sufficient resources
on advertisements and social media communication to enhance the
brand image of their hospitals at initial stage. Hospitals should fully
leverage on the benefits of both advertising and social media commu-
nication to frame a positive brand image by employing various adver-
tising and social media strategies. These include spicing up the
advertised contents, incorporating live chat features to make commu-
nication more interactive, making it more personal and persuasive,
sharing online professional opinions from doctors and other medical
professionals, promoting website addresses and web-links of the hos-
pital and other related professional bodies (information centres, gov-
ernment agencies, tourism board, and hotel associations) to enhance
the credibility of online information.
In fact, building relations with other medical professionals should
be a major part of the online hospital branding strategy, as seen by
the significant influential role of user-generated social media in this
study. To achieve these communication partnerships, it is suggested
that hospitals develop competent teams to manage their social media
profiles and online communication platforms. The social media experts
of the hospitals should possess a great deal of knowledge ranging
from general touristic to specific technical and medical information.
Assistance should be provided to the medical tourists to find the nec-
essary information and to communicate real time with the hospitals
and any other relevant parties when needed.
Secondly, since WOM critically influences how medical tourists
perceive the brand image of the service provider, hospitals should
think strategically and manage their WOM communication strategies.
A positive WOM can help to negate the effect of inferior impression
about the hospital brand. There are several ways for hospitals to cre-
ate positive WOM. These include provision of superior customer ser-
vices and personal touch, use of celebrities and key opinion leaders
and professionals for public relations, engagement in corporate social
responsibility activities (e.g., blood donation campaign and free medi-
cal check-up) and sharing of customer testimonials.
Thirdly, hospitals may consider collaborating with such agencies
as the Malaysia Healthcare Travel Council, Malaysia Tourism Promo-
tion Board and the Association of Private Hospitals of Malaysia to
build higher visibility and stronger presence in the international arena.
Forms of collaboration include joint advertising, organisation of medi-
cal forums and conferences, setting up tourism exhibitions and devel-
opment of co-branded campaigns. Partnerships with other members
of the tourism industry such as the airlines and travel agencies may be
instrumental to co-develop holistic medical tourism packages that pro-
vide a higher value to the medical tourists.
Fourthly, the study has examined the critical role of service qual-
ity in the post-consumption stage. Hospitals should strategise to con-
tinuously improve their service quality level to enhance medical
tourists' satisfaction, their perceived value and trust towards the med-
ical professionals. Medical professionals and doctors should possess

CHAM ET AL.
service quality and customer service skills, that is, they should be
customer-oriented. Customer-focus strategies are much needed in
these hospital organisations. Service-oriented organisational culture
can be cultivated and nurtured via such practices as (1) fulfilment
of hospital promises made to the patients, (2) being knowledgeable
in advising and providing medical treatments and products,
(3) observing and respecting professional codes of conducts in
serving patients, (4) being responsive in meeting the needs of the
patients, (5) addressing patients' problems and concerns promptly,
(6) providing services professionally with a personal touch, (7) build-
ing rapport with the patients, and (8) playing the role of counsellor
to show empathy towards the patients. Very often, the mindset
and professional standards of medical staff are not in sync with
the mentality of market-oriented service quality providers. Esta-
blishing medical professional standard operating procedures and
providing training on service culture and skills to all the medical
staff are supportive initiatives for customer-focus service delivery.
6 | L I M I T A TI O NS , S U G GE S T I O N S F O R
F U T U R E R E S E A R C H A N D CO N C L U S I O N
This study is subjected to a couple of limitations. Its first limitation is
the selection of sample, which consisted of medical tourists of Chi-
nese nationality only. Hence, the findings of the present study may
not generalise to medical tourists of other countries. The second limi-
tation is the use of survey questionnaire with close-ended questions
to collect data from the respondents. The absence of interviews and
open questions might have restricted some of the respondents to
express their opinions freely to provide more in-depth information.
Future research may consider to adopt a qualitative approach to gain
insights with regards to other factors which might have a significant
influence on the perceptions of medical tourists.
Nationality, culture, religion, health beliefs, experience with medi-
cal services and other contextual factors may significantly influence
medical tourists' perceptions. Hence, future research should refine
and re-test the study's model with a wider, more diversified global
sample of medical tourists. Multigroup comparisons among medical
tourists from different nationalities would contribute further to the
existing literature in the field of medical tourism. Furthermore, future
studies can also examine if Internet-based and non-Internet based
marketing practices have any differential impact on medical tourists'
perceptions towards a company brand.
In conclusion, brand image and service quality can be two unique
selling propositions for medical tourism hospitals. These two value-
creation concepts could enhance the competitive position of local
hospitals, which in turn, provide the country a competitive advantage
as the preferred choice for medical tourists. Various parties (govern-
mental agencies, hospitals, tourism boards and travel firms) play a role
in influencing brand image among the medical tourists; positive inter-
relations and long-term collaboration among these relevant parties in
the industry are much needed to make the country the top player
in the global market.
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153
OR CID
Tat-Huei Cham https://orcid.org/0000-0001-7636-5928
Marianna Sigala https://orcid.org/0000-0001-8997-2292
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AUTHOR BIOGRAPHIES
Tat-Huei Cham is an associate professor and
head of research at UCSI Graduate Business
School, UCSI University, Malaysia. His
research interests focus on medical tourism,
marketing, tourism and hospitality marketing,
advertising, consumer behaviour, service
industry strategy and operations, and e-com-
merce. His publications are seen in various international journals
that include Journal of Hospitality Marketing and Management,
Journal of Hopsitality and Tourism Research, Internet Research,
Asia Pacific Journal of Marketing and Logistics, Journal of China
Tourism Research, European Business Review, Industrial Manage-
ment & Data Systems, Australasian Marketing Journal, to name a
few. He is currently serving as Editor-in-Chief for the Journal of
Marketing Advances and Practices and editorial review board
member for several international journals. Dr Cham can be con-
tacted at: jaysoncham@gmail.com.
Yet-Mee Lim is an associate professor at
UCSI Graduate Business School, UCSI Uni-
versity, Malaysia. She holds a PhD from the
University of Alabama (USA), master's degree
(MBA) from the University of New Orleans
(USA) and Bachelor of Science (Business
Administration) from the University of
 15221970, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jtr.2489 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [13/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CHAM ET AL. 157

Southwestern Louisiana (USA). Her research interests focus on at the executive board of CAUTHE. She is the co-editor of the
organisational behaviour, knowledge management, user accep- Journal of Service Theory & Practice, and the Editor-In-Chief of
tance of technology, e-commerce trend, service industry strategy, the Journal of Hospitality & Tourism Management. In 2016,
human resource management and higher education. Dr Lim is the she has been awarded the prestigious EuroCHRIE Presidents'
corresponding author and she can be contacted at: limym@ Award for her lifetime contributions and achievements to tourism
ucsiuniversity.edu.my. and hospitality education. Since 2020, Professor Sigala is also
appointed as Research Fellow of CAUTHE. Professor Sigala can
Marianna Sigala is Professor at the University
be contacted at: marianna.sigala@unisa.edu.au.
of South Australia and Director of the Centre
for Tourism & Leisure Management. Her
interests include services and experience
management, Information and Communica-
How to cite this article: Cham, T.-H., Lim, Y.-M., & Sigala, M.
tion Technologies (ICT) in tourism and hospi-
(2022). Marketing and social influences, hospital branding, and
tality, as well as wine tourism. She is a widely
medical tourists' behavioural intention: Before- and
published and multi-awarded authority. She has a long record of
after-service consumption perspective. International Journal of
leadership and participation in international research projects
Tourism Research, 24(1), 140–157. https://doi.org/10.1002/
funded by various entities such as the E.U. and the Council of
jtr.2489
Europe. She is a past President of EuroCHRIE and a past member
of the executive board of ICHRIE and IFITT. She currently serves