CHAPTER 1

INTRODUCTION

1.0 Introduction

This chapter first describes the background of the study, followed by the problem

statements, research objectives, and research questions. Subsequently, the significance

of the study, delimitation, and definition of terms would be outlined, followed by the

organisation of the thesis.

1.1 Background of the study

Medical tourism is a multi-billion dollar industry (Fetscherin & Stephano, 2016). It is

frequently used as a means of economic development (Yu et al., 2011; Smith, 2012).

Thus, many countries are taking part in this industry by promoting medical tourism

and improving medical services (Crozier & Baylis, 2010; Heung et al., 2011). The

Asian financial crisis in 1997 and the global financial crisis in 2008 have encouraged

many nations to introduce and develop the medical tourism industry (Beladi et al.,

2017). In some countries, for instance, Greece started to see the potential benefits of

medical tourism as a way to overcome the economic crisis (Sarantopoulos, Vicky, &

Geitona, 2014). It was reported that high-class hotels are ready to invest in medical

tourism since they have the relevant infrastructure (Sarantopoulos et al., 2014).

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Medical tourism has been regularly labelled as ‘First World treatment at Third World

prices’ because it often takes place in low medical expense countries (Smith &

Puczko, 2009). Medical tourism is not a new term in the olden days, it appeared

during the Greek times when Greek pilgrims travelled from different places

throughout the Mediterranean to Epidauria (Gahlinger, 2008). Epidauria was

previously identified as the home of healing and was the first medical tourism

destination in the olden day (Gahlinger, 2008).

Crossing the border for healthcare is not new for many Europeans, during the 18th

and 19th centuries travelled to isolated places to look for a spa treatment (Condrea,

Constandache & Stanciu, 2014). Cuba appears to be one of the first nations to

participate in and promote medical tourism (Smith, 2012). There are many types of

medical tourists who travel abroad for medical cures. Table 1.1 summarises some

common medical procedures in medical tourism.

Table 1.1 Common procedures patients pursue medical tourism

Category Type of treatment

1. Cosmetic surgery Breast augmentation/mastopexy/breast reduction
Facelift/blepharoplasty
Liposuction/body contouring
2. Dentistry Cosmetic dentistry
Dental reconstruction/prosthodontics
3. Cardiology and Coronary artery bypass
cardiac surgery Cardiac valve replacement/reconstruction
Percutaneous coronary angioplasty/stenting
Stem cell therapy for heart failure
4. Orthapaedic surgery Hip replacement/resurfacing
and spine surgery Knee replacement
Arthroscopy/joint reconstruction

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 Laminectomy/spinal decompression
Disk space reconstruction/disk replacement
5. Bariatric surgery Gastric bypass
Laparoscopic adjustable gastric banding (Lap-Band;
Inamed/Allergan, Inc.; Irvine, California)
Body contouring subsequent to massive weight loss
6. Reproductive system In vitro fertilization
Hysterectomy
Prostatectomy/transurethral resection
Gender reassignment procedures
7. Organ and tissue Solid organ transplantation (Renal & Hepatic)
transplantation Bone marrow transplantation
Stem cell therapy – (Heart failure & Neurologic diseases)

8. Other services LASIK eye surgery General medical evaluation/check-up Wide

range of diagnostic studies
Source: Adapted from Horowitz and Rosensweig (2007)

Malaysia is among the world’s most favoured medical tourism destinations (Dahlui &

Aziz, 2011). The number of healthcare travellers is increasing significantly. Table 1.2

shows the number of healthcare travellers from 2015 to 2019. In 2019, more than 1.22

million medical tourists in Malaysia (Malaysia Healthcare Travel Council, 2021).

Table 1.2 Number of healthcare travellers and revenue from 2015 - 2019
Year Number of Healthcare Revenue (RM)
Traveller
2019 1,220.000 1,700,000,000
2018 1,200.000 1,500,000,000
2017 1,050,000 1,300,000,000
2016 921,000 1,123,000,000
2015 859,000 914,000,000
Source: Malaysia Healthcare Travel Council (2019).

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Figure 1.1 reported the Malaysian Medical Tourism Revenue and Healthcare

Travellers 2011 – 2020. In 2014, medical tourism contributed RM730 million

(US$191 million) in revenue (Puvaneswary, 2015) and RM1.2 billion in 2016 (The

Star, 2017).

Figure 1.1 Malaysian Medical Tourism Revenue and Healthcare Travellers 2011
- 2020
Source: Malaysia Healthcare Travel Council & Cardas Research (2017)

However, the healthcare travel industry was reported to contribute RM1.5 billion to

the nation’s economy (The Star, 2017; New Straits Times, 2017). The arrival of 1.2

million medical tourists is expected to contribute RM2.8 billion in revenue (Yusof,

2017). The revenue generated by this industry appears to be promising, where it was

forecasted to reach RM1.3 billion in 2017 (Malaysia Healthcare Travel Council,

2017). It was also stressed that the overall expenditure of medical tourists was higher

and almost double compared to ordinary tourists. In general, foreign medical

travellers spent not less than RM1, 000.00 per visit. In some states such as Penang,

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medical tourism contributed significant revenue to the state’s economy, where each

medical tourist spent an average of RM4, 247.00 per visit (Penang Institute, 2016).

The nature of the medical tourism industry is largely regional, where the majority of

the medical patients are from neighbouring countries such as Indonesia. Over half

(57%) of the medical tourists come from Indonesia while the remaining were from

other countries. As Malaysia is part of a member of the Organization of Islamic

Conference (OIC), getting medical tourists from OIC and Gulf Cooperation Countries

(GCC) is not a big issue due to the same Muslim culture (Malaysia Health Travel

Council, 2014). Figure 1.2 presents the distribution of health tourists' arrival to

Malaysia in 2014.

Figure 1.2 Health Tourist Arrivals to Malaysia, 2014

Source: Malaysia Healthcare Tourism Council (2015)

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However, the trend of the movement of medical travel is changing, from less

developed to more developed economies (Wongkit & McKercher, 2013).

Traditionally, wealthy people from developing countries travel to developed countries

for medical treatment but now, people are moving in both directions, mostly patients

from developed countries travel to developing countries to get medical treatment

(Veerasoontorn, Beise-Zee, & Sivayathorn, 2011; Manaf et al., 2015).

A large number of patients had crossed borders to other medical destinations in Asia

and South America in search of medical treatment which is always been said to be

costly, inadequate or unavailable at home. For example, the United States was once

famous for medical tourism and people from developing countries travel to United

State for medical treatment (Agbeh & Jurkowski, 2015). However, the trend is

shifting where Alleman et al. (2011) studied the availability of medical tourism

services in United State and why residents travel overseas for medical services. Some

of the reverse trends are caused by several reasons such as cost, access, quality of

service and so forth.

1.2 Problem statement

Medical tourism generates significant economic to the country as well as service

providers, at the same time medical patients receive medical treatment. All these

benefits prove that medical tourism is worth exploring. The Malaysian government

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aims to diversify the tourism sector into dissimilar sectors. Medical tourism is

identified as one of the sectors that can contribute significant revenue to the nation’s

economy. Thus, the Malaysian government has made medical tourism one of the

alternative engines for economic growth (Ormond et al., 2014). Yet, research in

medical tourism receives limited research attention (Ulaş & Anadol, 2016),

particularly in Malaysia, and thus it opens room for investigation.

As medical tourism is viewed as an income generator that has contributed huge

revenue to developing countries, it is vital to understand the behaviour of medical

tourists. Previous literature largely studied the subject based on the supplier side.

However, the demand side is always being ignored. Thus, there is a need to

understand the demand side which is from the tourist’s angle. As Connell (2013, p.11)

argues ‘medical mobility in developing countries is even more poorly understood.

Much more needs to be known about cross-border’. Though previous literature has

widely examined the tourist motivation factors and behaviours (i.e., Mathijsen, 2019;

Musa et al, 2012), very few researchers have examined customers in this emerging

industry. Furthermore, limited research has examined how motivational factors

influence medical tourists’ decision-making process. Accordingly, there is a lack of a

theoretical model to describe medical tourist behaviour. For the preceding reasons, the

objective of this study is to extend medical tourism research and fill the research gap

by using medical tourists as a unit of analysis to study the motivational factors and

how customers decide to engage in medical tourism.

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To date, there has been also a paucity study on the specific question of consumer

behaviour, in this case, medical tourist behaviour. For instance, the motivation and

decision making to pursue medical services abroad are lacking (Adams, Snyder,

Crooks, & Johnston, 2015). Similarly, Global Healthcare Resources (2019) published

the first Medical Tourism Index in 2015 to assist helping medical tourism

stakeholders to have an assessment of medical tourism destinations. The medical

tourism index covered 41 destinations from the five regions, however, Malaysia as a

popular medical tourism destination has been excluded from the survey. It is still

unknown why Malaysia is excluded from the study.

Adding to this, Yuhanis, Zaiton, Khairil Wahidin, and Zulhamri (2015) developed a

medical tourism index for Malaysia based on a service perspective only. It has been

suggested by Fetscherin and Stephano (2016) that future research should test the scale

cross-culturally and adopt the medical tourism index in other types of destinations

such as cities, regions or states. However, not many countries have a medical tourism

index such as Malaysia. The medical tourism index is an important point of reference

for tourists who are seeking medical treatment abroad. Therefore, this study is timely

to develop an index for a region, namely Klang Valley (i.e. Selangor, Kuala Lumpur,

Putrajaya) and Malacca. Klang Valley and Malacca was chosen as this two region

has the highest medical tourists from neigbouring countries, particularly medical

tourists from Indonesia.

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1.3 Research objectives

In corresponding with the subjects debated above, the objectives of this study can be

stated as below:

1. To explore the characteristics of medical tourists travelled to Klang Valley and

Malacca

2. To examine the factors influencing medical tourists’ to seek medical treatment

in Klang Valley and Malacca

3. To develop a medical tourism index for Klang Valley and Malacca

1.4 Research questions

1. What are the characteristics of medical tourists travelling to Klang Valley and

Malacca?

2. What are the factors influencing medical tourists’ to seek medical treatment in

Klang Valley and Malacca?

3. What are the attributes of the medical tourism index for Klang Valley and

Malacca?

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1.5 Significance of the study

The main contribution of this study is the medical tourism index, which serves as

a benchmark for medical tourism performance. In this study, the researcher

used Malacca and Klang Valley as the study sites. Then, the performance of

medical tourism were compared based on few dimensions.

The outcome of this study is believed will contribute to the development of the

medical tourism industry in terms of theoretical and practical knowledge. Based on

the review of previous literature (Lee, Jim, & Kim, 2020; Chaulagain, Pizam, &

Wang, 2021), there is a fairly limited study about the motivation influencing medical

tourists, perceptions and behaviour towards medical tourism destinations.

The review of previous literature indicates there is a fairly limited study about the

motivation influencing medical tourists, perceptions and behaviour towards medical

tourism destinations. The findings of the study will enhance the motivation,

perception and behaviour theory applicable to medical tourism literature and apply it

to the interdisciplinary field of research.

Apart from that, this research highlights the practical contributions of the interested

parties in the healthcare industry by proposing appropriate and effective marketing

approaches. From a practical standpoint, research in medical tourism is very

important to help hospitals that are actively involved in medical tourism in developing

competitive and sustainable marketing strategies. By understanding the medical

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tourists’ motivation to visit, this study will assist the marketing managers of

Malaysia’s hospitals to develop appropriate competitive strategies in the medical

tourism industry.

This study is also expected to contribute to the marketing literature from both

practical and academic perspectives. From an academic perspective, this study will be

expected to contribute to the literature on medical tourism in various aspects. In a

nutshell, this study allows one to better understand the medical tourism industry in

Malaysia.

1.6 Limitations

In research, limitation assists researchers in arranging what is most relevant and

creating clarity (Creswell, 2012). This section summarises the limitation of this thesis

as follows:

1. The study is limited to the international tourists who visited Malaysia (particularly

Klang Valley and Malacca) for medical purposes and at the same time engaged in

tourism activities.

2. The study drew on medical tourists samples from private hospitals in Klang Valley

only.

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3. This study was conducted during the COVID-19 time when only limited access to

the medical tourists.

1.7 Definition of terms

Medical tourists: Patients who travel internationally for non-urgent medical

treatments like organ transplants, stem cell treatments, reproductive services, cosmetic

surgery, and dental care (Chuang et al., 2014, p.49).

Medical tourism: All the activities related to travel and hosting a tourist who stays at

least one night at the destination region, to maintain, improve or restore health

through medical intervention (Musa, Doshi, Wong, & Thirumoorthy, 2012, p630).

Push factors: Originated from intangible or intrinsic desires of human beings,

including the desire for escape, novelty-seeking, adventure-seeking, dream fulfilment,

self-exploration, rest, health and fitness, prestige, and socialization.

Pull factors: The tangible and intangible external forces emerging from the attribute

that attracts the individual to a specific destination and establish the actual specific

destination choice.

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Medical Tourism Index: An index covers how consumers perceived certain

criteria across three primary dimensions (i.e., Destination Attractiveness, Safety,

and Quality of Care).

1.8 Organisation of the thesis

The study aims to understand the medical tourist profile and develop a Medical

Tourism Index. Chapter 1 delivers the background of the research and overview of

medical tourism both in the International and Malaysian context. Then, this study

showed the research problems for the current study based on the research gaps

identified from the existing research. Finally, the research objectives and questions

are presented. In Chapter 2, the definition of medical tourism and its attributes.. In

addition, a theory underlying this study was broadly discussed, and an overview of

concepts in medical tourism, factors influencing medical tourism and the medical

tourism index are reviewed and presented.

In Chapter 3, the research methodology used for this study will be addressed. This

chapter outlines the research design, operationalization of variables, data collection,

survey questionnaire development, sampling strategy, and procedures for data

analyses. Finally, the study ended with ethical considerations. Chapter 4 summarises

the research findings that addressed the research question one to three. The last

chapter discusses the findings and provides implications of the study, followed by

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research limitations and suggestions for future research. Chapter 5 discusses the

findings, and highlight the limitations and suggestions for future research.

CHAPTER 2

LITERATURE REVIEW

2.0 Introduction

This chapter first describes the theory embedded in this study followed by medical

tourism and medical tourists. Then, the thesis details the factors influencing

motivations to receive medical tourism abroad. Subsequently, medical tourism in

Malaysia will then be outlined. Finally, the chapter presented the medical tourism

index followed by the conclusion.

2.1 Medical tourism

Medical tourism is not a new term in this era, where it originated in the ancient period

(Smith & Puczkó, 2008). Figure 2.1 shows the evolution of medical tourism from

ancient times to the current period. Medical tourism has become a significant niche of
14
the tourism industry. Many tourists choose to have medical treatments abroad

(Rodrigues, 2017). Medical tourism is a cross-discipline between the medical and

tourism business (Kanittinsuttitong, 2015). Figure 2.2 outlines the subjects

contributing to the development of travel medicine with examples of the themes they

research.

Figure 2.1 The evolution of medical tourism

Source: Menvielle and Menvielle (2010)

Medical tourism is not a single sector, it is a mixture of medical and healthcare

services, tourism and travel services, and support services for the other service aspects

(Eman, 2011). Meanwhile, Yu, Lee, and Noh (2011) agreed that it is a combination of

medicine and tourism and is always viewed as a subset of healthcare tourism or health

tourism (Carrera & Bridges, 2006; Lunt & Carrera, 2010; Pocock & Phua, 2011, p.2).

Figure 2.3 presents the medical tourism equation as proposed by Eman (2011).

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 Figure 2.2 Subjects contributing to the development of travel medicine with
examples of the themes they research

Source: Adapted from Page (2009)

Figure 2.3 Medical tourism equation

Source: Adapted from Eman (2011)

Healthcare tourism is a ‘‘commercial phenomenon of industrial society which

involves a person travelling away from his or her normal home environment for the

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express benefit of maintaining or improving health and the supply and promotion of

facilities and destinations which seek to provide such benefits’’(Hall, 2003, p. 274).

Meanwhile, Altin et al. (2012, p. 1004) defined health tourism as “the travel of

individuals from their residences to other places to receive treatment”. Figure 2.4

presents the classification of health tourism.

Similar to health tourism, there is no consensus reached on the term and scope of

medical tourism (Connell, 2013; Bolton & Skountridaki, 2017) because different

countries and researchers defined the term differently (Helble, 2011). Thus, the notion

of what is medical tourism is always receiving debate. Youngman (2009; see also

Pollard, 2010) argued that ‘By definition almost every official figure is flawed. They

are often badly collected, imperfectly collated and spun to infinity. Some hospitals

inflate figures by counting the number of patient visits rather than the number of

patients. In other words, it is very difficult to identify who are the medical tourists as

well. Yu and Ko (2012, p. 81) claim “medical tourism involves not only going

overseas for medical treatment but also the search for destinations that have the most

technical proficiency and which provide it at the most competitive prices [ … ]

combination of medical services and the tourism industry.”

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 Figure 2.4. Classification of health tourism

Source: Adapted from Chen et al. (2012)

According to Medical Tourism Association (2018), medical tourism is ‘where people

who live in one country travel to another country to receive medical, dental and

surgical care while at the same time receiving equal to or greater care than they would

have in their own country, and are travelling for medical care because of affordability,

better access to care or a higher level of quality of care’. Connell (2006) explained

that humans have been travelling beyond the boundary to seek health care. On the

other hand, Carrera and Bridges (2006, p.447) defined tourism as ‘the organized

travel outside one’s local environment for the maintenance, enhancement or

restoration of an individual’s wellbeing in mind and body’. Connell (2013, p.2) noted

that medical tourism is ‘where improved health is a key component of travel overseas,

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and involves invasive procedures (and also medical check-ups), rather than the more

passive processes of health and wellness tourism’. Similarly, Whittaker (2008, p.272)

sees ‘medical tourism as a misnomer, carrying connotations of pleasure not always

associated with this travel, and blurs distinctions between desperately ill people [and]

more discretionary travel’.] The definition of medical tourism is summarised in Tale

2.1.

This study defined medical tourism as all the activities related to travel and hosting a

tourist who stays at least one night in the destination region, to maintain, improve or

restore health through medical intervention.

Medical tourism destinations offer not just surgery but also embedded tourism

elements into it (Crooks et al., 2010). In conclusion, medical tourism can be simply

put as travelling across international borders to get medical treatment, at the same

time participating in recreational activities.

Table 2.1 Summary of the definition of medical tourism

Author Definition
Johnston et al. (2010,p1) ‘patients leaving their country of residence outside of
established cross-border care arrangements made with
the intent of accessing medical care, often surgery,
abroad’
Edelheit (2008, p.10). ‘patients travelling to another country for more
affordable care, or care that is higher quality or more

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 accessible’
Pollard (2010) ‘someone whose specific reason for travelling to another
country is medical treatment’
Lunt and Carrera (2010, ‘patients who are mobile through their own volition’
p.27)
Jagyasi (2008, p.10) ‘the set of activities in which a person travels often long
distance or across the border, to avail medical services
with direct or indirect engagement in leisure, business or
other purposes’
Heung et al., (2010, ‘a vacation that involves travelling across international
p.236) borders to obtain a broad range of medical services. It
usually includes leisure, fun and relaxation activities, as
well as wellness and health-care service’
Jenner (2008, p.236) ‘the blending of tourism and medical treatment for both
elective and necessary surgical and medical procedures
as well as for dental procedures’
Hopkins et al. (2010, ‘cross-border health care motivated by lower cost,
p.185) avoidance of long wait times, or services not available in
one’s own country. Such care is increasingly linked with
tourist activities to ease foreign patients into a new
cultural environment and to occupy them during the pre-
and post- operative periods’
Wongkit & McKercher, ‘the travel of people to a specific destination to seek
(2013, p. 5) medical help that forms the primary purpose of their
trip’
de la Hoz-Correa et al., ‘travel across international borders with the intention of
(2018, p.200) receiving medical care ’
Crooks et al. (2010, p.1) ‘travel abroad with the intention of obtaining non-
emergency
medical services’
Musa, Doshi, Wong, & ‘all the activities related to travel and hosting a tourist
Thirumoorthy (2012, who stays at least one night at the destination region, for
p630). the purpose of maintaining, improving or restoring
health through medical intervention’
Smith (2012) ‘the movement of individuals abroad primarily to seek
biomedical services’
Manaf et al. (2015, p.2) ‘medical services and treatment specifically received in
another country either with or without tourism activities
such as sightseeing’
Carrera (2006, p.1453) ‘organized travel outside of someone’s health care
jurisdiction to enhance or restore health’
Voigt et al. (2011, p.8) ‘the process of patients travelling abroad for medical
care and procedures as a result of unavailability or
unaffordability of certain medical procedures in their
respective countries.
Sarantopoulos et al. ‘an industry where people from all around the world are
(2014, p.371) travelling to other countries to obtain medical, dental
and surgical care while at the same time touring,
vacationing and fully experiencing the attractions of the
countries that they are visiting’

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Source: Compile by author
There is also an argument about whether medical tourism is a form of tourism. As

Lovelock and Lovelock (2018, p.145) noted, ‘the suspicion is, that many, if not most,

people who travel overseas for medical services are primarily motivated by their need

for treatment, rather than a desire to have a holiday’. This is because most of the time

spent by the medical tourists is for treatment but not a participation in tourism

activities. This is supported by Chen et al. (2012) that travel for medical service is the

main purpose. Similarly, Nahai (2009, p. 106) also agree with the notion that ‘while

we appreciate the involvement of the travel and hotel industries we must never lose

sight of the fact that travelling abroad for a medical procedure is not a vacation, it is

surgery’.

Nonetheless, Uchida (2015) contends that the term medical tourism is inappropriate

because people who travel overseas are patients, not tourists looking for shopping and

relaxing vacations. Uchida (2015) then proposed “medical examination and treatment

abroad” over medical tourism. Similarly, Chow, Pires, and Rosenberger (2015) prefer

to term ‘international medical travel’. It can be concluded that the main intention of

medical tourists is travelling for medical treatment while participating in the tourism

activities may be optional. It appears rational to conclude that “medical tourism is

conceptually full of nuances, contradictions and contrasts” (Yu & Ko, 2012, p. 82).

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Medical tourism is a worldwide industry that has involved many different

stakeholders with commercial interests. The stakeholders comprised of the following:

1. Brokers who mediate global healthcare arrangements for medical tourists (Penney,

Snyder, Crooks, & Johnston, 2011)

2. Insurance that covers travel expenses and medical complications (Turner, 2011)

3. Providers who include clinics and healthcare providers, as well as tourist operators

(Lunt & Carrera, 2011)

4. Travel, accommodation, and concierge service providers who, since medical

tourism is a holistic business, expect that tourists also seek leisure activities while

recovering from medical interventions (Johnston et al., 2015)

5. Conference and media medical tourism-related services that include conferences

and media coverage (Lunt et al., 2011)

6. Financial products that include insurance and financial advice to cover expenses

(Lunt & Carrera, 2011)

7. Websites that provide platforms for gaining access to healthcare information and

advertisement (Lunt & Carrera, 2011)

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Figure 2.5. outlines the medical tourism industry.

Brokers

Websites Insurance

Medical
tourism

Financial
Providers
products

Travel
Conference and
accommodation
media
, concierge

Figure 2.5. Medical tourism industry

Source: Adapted from Lunt et al. (2011)

Chuang et al. (2014) classified the current medical tourism themes into three different

development paths. Table 2.2 summarises the medical tourism themes.

Table 2.2 Medical tourism themes

Path A Path B Path C
1. MT has demonstrated 1. The unregulated MT 1. The attention of the
its prominence in the practice may compromise literature is shifting from
practical and conceptual living organ donors, the critics and discussions of
domains of tourism. recipients, and potentially the worthiness of the MT
overseas resident patients industry to training and
awaiting a transplant. accreditation, risk
communication, and
business dimension-related

23
 areas.
2. The flow of patients 2. The number of patients 2. Contemporary MT
has reversed, directing awaiting transplants in issues, including trending
more to developing foreign countries is gravity, the actual market
countries from increasing, with a higher size, and the roles of every
developed countries. propensity for those citizens marketing channel,
with immigrant backgrounds. deserve critical analysis.
3. The growth of the MT 3. Poor vendor screening, 3. MT is enjoying steady
industry has infused selection, and matching in growth, with cosmetic and
prosperity to the the organ-exporting country bariatric surgery
destination countries, and poor record keeping, dominating media
but could impair the corruption, and human abuse discussions. There is a
equality of the local are factors discouraging growing need for
health care resource global transplant contemporary peer
distribution. commercialism. reviewed scholarship to
focus on patient mortality
in these areas.
4. The advent of new 4. The survival rates 4. Word of mouth is a
multimedia and following kidney and liver market driver with the
information transplants have drastically Internet having secondary
technologies has made improved owing to the influence. The motivation
major contributions to discovery of cyclosporine, factors are more layered
the MT industry’s advances in organ and dynamic than
growth. preservation techniques, and originally thought.
transplant immunology.
5. Training and 5. The growth in MT is
accreditation, risk largely attributed to the
communication, and manifestation of the torrent of
business dimensions are globalization and business
three important but privatization.
apparently weak areas
that must be fortified
and substantiated for all
participants in the MT
industry.
Source: Adapted from Chuang et al. (2014)

In Malaysia, medical tourism involves studies related to understand the tourists’

satisfaction and behaviour. Table 2.3 summarises medical tourism by subject in

Malaysia.

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 Table 2.3 Medical tourism subject study in Malaysia
Author Subject
1.Musa, Doshi, Wong, & Satisfaction of inbound medical
Thirumoorthy (2012) tourists in Malaysia
Musa, Thirumoorthi, & Doshi (2012) Travel behaviour among inbound
medical tourists
2.Zailani, Iranmanesh, Moghavvemi, Muslim medical tourists' satisfaction
& Musa (2016)
3.Rahman, Zailani, & Musa (2017) Muslim-friendly medical tourism
market
4.Moghavvemi, Ormond, Musa, Isa, Private hospital websites promoting
Thirumoorthi, Mustapha, & Chandy medical tourism
(2017)

2.1.1 The Characteristic of Medical tourists

Similar to medical tourism, there is also no universally accepted definition of medical

tourists. This section also reviews and defines a medical tourist as the potential

research participants in this study. Ehrbeck, Guevara, and Mango (2008, p.2) define

medical tourists as “people whose primary and explicit purpose in travelling is a

medical treatment in a foreign country”. However, Chuang et al. (2014, p.49)

provided a more detailed definition covering the medical activities, where they

defined medical tourists are ‘patients who travel internationally for non-urgent

medical treatments like organ transplants, stem cell treatments, reproductive services,

cosmetic surgery, and dental care. Basically, there are four types of tourists in the

context of medical tourism, namely 1) medicated tourists, 2) medical tourists proper,

3) vacationing patients, and 4) mere patients. However, Cohen (2008) classified

medical tourists into five categories such as mere tourists, medicated tourists, medical

tourism proper, vocational tourists, and mere tourists.

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Medicated tourists refer to people who receive treatment for accidents or health

problems that occur during an overseas holiday, while medical tourists proper is a

person who visits a country for some medical treatment, or who may decide on a

procedure once in a country. On the other hand, a medical tourist proper is a person

who combines their trip with medical services and tourism activities both planned in

advance and decided after arrival at the destination.

On the other hand, vacationing patients are people who visit mainly for medical

treatment, but make incidental use of holiday opportunities, usually during the

convalescence period. Finally, mere patients are people who visit solely for medical

treatment and make no use of holiday opportunities. As Crooks et al. (2010, p.2)

argue, ‘people who become ill or injured while travelling abroad and require hospital

care are not thought to be medical tourists, nor are expatriates accessing care in the

countries or regions in which they live’. Figure 2.6. Illustrates the leisure tourism

experiences of medical tourists.

In general, medical tourists tend to be higher income or supported by family members

(Deloitte, 2008; Gan & Federick, 2013). However, Guy, Henson, and Dotson (2015)

found socio-demographic profile has no influence on the intention to visit medical

tourism.

26
 Figure 2.6. Leisure tourism experiences of medical tourists
Source: Lovelock and Lovelock (2018)

Table 2.4 illustrates the medical tourist typology. Wongkit and McKercher (2013)

classified medical tourists into four market segments based on the purpose and nature

of trips. Dedicated medical tourists made medical treatment decisions before they

depart from the home. They see medical tourism as a priority reason or equally

important with a holiday for pleasure, for their travel decision. Meanwhile, the

hesitant medical tourist is people looking for medical treatment as a main or equally

27
important trip motive. However, they don’t make their ultimate decision and are

involved until they arrive at a destination. Conversely, the main reason for holidaying

medical tourists is to travel and also pre-planned treatment activity at their chosen

destination. The opportunistic medical tourist is the one who travels to a destination

primarily on holiday and they would only decide to seek treatment once at the

destination.

Table 2.4 Medical tourist typology

Trip Purpose Medical Pleasure Trip *

(equally to exclusively for (mostly to exclusively for
Decision Horizon treatment) pleasure)
Pre-plan Treatment Dedicated Medical Holidaying Medical

Tourist

Decision after Arrival Hesitant Medical Tourist Opportunistic Medical

* Note: other trip purposes, including business, can be included but were not

identified in this study.

Source: Wongkit and McKercher (2013)

Currently, there is no proper statistic documenting medical tourism and medical

tourists. As Ormond, Wong, and Chan (2014, p.1) noted, ‘the opacity and paucity of

available medical tourism statistics severely limit the extent to which medical

tourism’s impacts can be reliably assessed, forcing the researchers to consider the real

effects that the resulting speculation itself has produced and to re-evaluate how the

real and potential impacts of medical tourism are - and should be -conceptualized,

28
calculated, distributed, and compensated for’. Connell (2013, p.5) noted ‘no countries

produce official data on medical tourism, since they have no means of collecting

them, and no hospitals release data verified by an independent body. The numbers

stated by some countries and hospitals are substantial exaggerations, but inflated

figures imply growth and success, and encourage private sector investment and

national support’. Thus, it is very difficult to get reliable data and figures on medical

tourism.

Medical tourism benefits the sending countries in numerous ways (Beladi et al.,

2017). Medical tourism allows the residents access to quality health care services

(Beladi et al., 2017). The main reason for medical patients in developed countries to

seek medical treatment abroad is due to the expensive cost in the home country

(Connell, 2013). In addition, it helps to overcome medical personnel and

infrastructure restrictions and give medical tourists additional choice of treatment

abroad (Chanda 2002; Hopkins et al. 2010). Medical tourism exerts pressure,

particularly on the unbalanced public health system in many developing countries

(Helble 2011; Chen & Flood 2013). This is because of the movement of health

workers from the public to the private health care sector to look for better prospects

and cause workforce shortages in the public sector (Beladi et al., 2017). For example,

Chen and Flood (2013) outlined that the growing medical tourism in low-and middle-

income countries (LMICs) reduces the health care services of the local people.

29
Although medical tourism offers several benefits to local businesses and international

patients, many challenges and barriers arise. For example, few travel barriers cause

medical tourists’ to reconsider when participating in medical tourism. For instance,

Chen et al., (2012) concluded that lack of information, timelessness, no companion,

and unsatisfied itinerary are the main travel barriers. On the other hand, Horowitz and

Rosensweig (2007) highlight some of these issues and challenges and claim that a

competitive medical tourism facility must address several factors and offer to attract

more medical tourists. Notwithstanding the positive contribution of medical tourism,

some studies highlighted the negative side, especially on the locals (Arellano, 2007;

Burkett, 2007; Whittaker, 2008). For example, in some countries (i.e. Thailand and

India), an imbalance of social equity was discovered because private hospitals

concentrate more to attract foreign patients and cause the limited accessibility of

healthcare for locals (Arellano, 2007). Similarly, Cohen (2015) argued that medical

tourism burdens Israel’s economy because medical patients enjoy the medical

treatments at the expense of Israeli taxpayers.

Tham (2018) studied medical tourism from a domestic perspective. He acknowledged

Sunshine Coast, Australia is a good place for medical tourism, however, several

barriers confront the development. First, residents feel the ‘displacement effect’ on

their access to hospital facilities. Residents feel that medical tourism should help the

residents, not burden them. Second, there is a lack of cooperation in conceptualising

the potential domestic medical tourism. Finally, a hostile cultural attitude was found

to exist between practitioners. Nevertheless, small medical providers face several

challenges (Skountridaki, 2017). For example, training in medical tourism was valued

30
as below average (Sarantopoulos et al., 2014). Sengupta (2011) also criticised that

medical tourism may damage destinations by motivating private health care

development unresponsive to locals’ needs and resources.

2.2 Factors influencing motivations of medical tourist to receive medical

tourism abroad

Some medical tourism studies examined the motivation of the subject using the pull

and push factors. For example, John and Larke (2016) analysed the pull and push

motivations in medical tourism studies. For example, lower medical costs, service

quality, international accreditation of the medical facilities, and shorter waiting times,

are the pull motivations. Conversely, recommendations from friends, doctors, and

family, inadequate insurance coverage, and desire for privacy and confidentiality of

treatments are viewed as important push motivations. Insurance is another attribute

that ‘pushes’ people to travel abroad in search of affordable medical services because

of the lack of insurance coverage (Forgione, & Smith, 2007; Herrick, 2007; Richards,

2008; Garcia-Altes, 2005). Table 2.5 summarises the literature on medical tourism

based on pull and push factors.

Table 2.5 Summary of literature review on medical tourism

Factors Researchers
Push factors driving medical tourism
1. Globalization
The convenience of using the internet to Henderson (2004)
gather information
Globalization facilitates the ease of Carrera and Bridges (2006), Connell
travel between countries (2013)
The emergence of low-cost Turner (2007)

31
telecommunication and economy air
travel
2. Institutional Factors
Favourable regulation Bramstedt and Xu (2007); Palvia (2007)
Bonuses and cash incentives by McLean (2007); Milstein and Smith
employers (2006)
Incentives by insurance companies Vequist and Valdez (2008); Vitalis and
Milton (2009)
Pull factors driving medical tourism
1. Consumer-Specific
Cost Savings
Lower labour and training costs Carabello (2008); Horowitz and
Rosensweig (2007); Mattoo and
Rathindran, (2006); Turner (2007)
Lower malpractice insurance or litigation Carabello (2008); Forgione and Smith
costs (2007)
Less or no involvement of third-party Carabello (2008); Herrick (2007)
payers
Lower pharmaceutical charges Forgione and Smith (2007)
Minimal waiting lists Bies and Zacharia (2007); Connell
(2006); Horowitz and Rosensweig
(2008)
More personalized care Demicco and Cetron (2006); Fried and
Harris (2007)
Availability of treatments Brady (2007); Demicco and Cetron
(2006); Connell (2013)
Greater privacy and confidentiality Fried and Harris (2007); Horowitz and
Rosensweig (2008); Han (2013a)
Culture Connell (2013)
2. Country-specific
Political concerns Bookman and Bookman (2007);
Dhariwal (2005); Palvia (2007)
Social and cultural compatibility Seddighi et al. (2001); Connell (2013)
Economic Connell (2013)
Freedom from disasters Huan et al. (2004); Fernandez et al.
(2002)
Bioethical legislation Glinos et al. (2010)
International accreditation and reputation Mattoo and Rathindran, 2006)
Quality of care (e.g. surgical outcomes, Demicco and Cetron, (2006); Higgins
nurse-patient ratio) (2007), Connell (2013)
Advanced medical technology and Demicco and Cetron (2006)
equipment
Distance Connell (2013)
Deterrents for medical tourism
Continuity of care Forgione and Smith (2007); Turner
(2007)
Medical negligence and malpractice Horowitz and Rosensweig (2008);
Mirrer-Singer (2007); Turner (2007)
Psychological hindrance Carrera and Bridges (2006)
Ethical and moral issues Glinos et al. (2010)

32
 Medical complications Birch et al. (2010); Jones and
McCullough (2007)
Effects on destination economy
Support and benefit local healthcare Gahlinger (2008); Horowitz and
systems Rosensweig (2008)
Limit local access to healthcare Bramstedt (2007); Chinai and Goswami
professionals and facilities (2007);
Hazarika (2010); Vijaya (2010)
Source: Adapted and compiled by the author
The current research field of tourism has been emphasising the medical aspects of

travel, rather than tourist behaviour. Lovelock and Lovelock (2018) conducted a study

to understand medical tourists who seek medical treatment overseas that emphasizes

understanding the expectations, experiences and reflections. Lovelock and Lovelock

(2018) found four influential factors which include the medical procedure, personal

factors, destination factors, and financial matters. Han (2013) studied the intention

among foreign medical tourists and the impact by identifying the

perceptions/cognitions, affect, and trust attributes. Three dimensions (i.e., monetary

and convenience advantages, personal security, and availability of products/services)

were identified and trust is important while perceptions and cognitions, affect, and

trust was found to be significant mediators.

The most frequently mentioned demand factors are the relatively high cost of medical

care in the origin country (Connell, 2006; Gan & Frederick, 2011; Heung, Kucukusta

& Song, 2010; Smith, Martínez Álvarez & Chanda, 2011) and the quality of medical

care in comparison with that of the destination country (Glinos, Baeten, Helble &

Maarse, 2010), exclusion of health care insurance, long waiting times and quality

health care in home country (Connell, 2006; Gan & Frederick, 2011). In addition,

affordable air ticket and exchange rates also contribute to the growth of medical

33
tourism (Connell, 2006). Likewise, Lovelok and Lovelock (2018) identified four

influences that affect medical tourism as the medical procedure; personal factors (e.g.

travel experience, resilience, accompanying companions); destination factors; and

financial matters. Ye et al. (2008) summarise that destination attributes, health care

quality, promotions, companionship, costs, and reputation are more important than

destination attributes. Meanwhile, Yu, Lee, and Noh (2011) identified six factors that

escalate the attractiveness of medical tourism, namely affordability, large uninsured

population, alternative/innovative therapy, better quality care, ageing population &

long waiting time. Whereas, according to Borman (2004), high costs, lack of

insurance, under-insured, long waiting times, and domestically unavailable treatments

are some of the causes to go abroad to seek medical services.

Singh (2012) stated that high costs of treatment in rich countries, long waiting lists,

affordability of international air travel, exchange rates, and well trained medical

personnel are factors that assist the growth of medical tourism. In Thailand, several

motivations and factors influence the medical tourist's decision (Kanittinsuttitong,

2015). Medical focused tourists view medical treatment, services quality, cost,

quality, and reputation of hospitals and physicians are viewed as important

(Kanittinsuttitong, 2015). In contrast, tourism-focused tourists primarily emphasise

tourism-related services such as attractive destinations, the convenience of hotel and

travel, transportation, and entertainment (Kanittinsuttitong, 2015).

34
Mechinda et al. (2010) showed identified that loyalty towards medical tourism was

basically driven by several factors such as satisfaction, trust, perceived value,

destination familiarity, and destination image. The attractiveness of a medical tourism

destination is determined by several factors, such as country environment, quality of

medical facilities & services, and medical and tourism industry factors (Fetscherin &

Stephano, 2016). In addition to this, Chuang et al. (2014) revealed that some

treatments are prohibited or illegal in their home countries, making medical tourists

consider getting treatment overseas. Sometimes, the government’s strict laws and

regulations prohibit foreign investors to establish medical facilities and this has driven

many Chinese to travel abroad for medical treatment (Zhang et al., 2013).

Nevertheless, there are always arguments on the legal issue relating to the negligence

of medical services in some developing countries (Herrick, 2007; Whittaker, 2008).

Figure 2.7 demonstrates the medical tourism driver.

Lower cost care for medically

neccesary procedures
9%

Most advanced technology Quicker access for medically

40% neccesary procedures
15%

Better quality care for med-

ically neccesary procedures
Low cost care for discretionary 32%
procedures
4%

Figure 2.7. Medical tourism driver

Source: Ehrbeck, Guevara, and Mango (2008)

35
The factors influencing the choice of a medical tourism destination are summarized in
Table 2.6 as stated below:
Table 2.6. Summary of the factors influencing medical tourism
Factors
1. Medical technology
2. Medical facilities
3. Medical experts
4. International accreditation
5. Health care quality
6. Emotional service quality
7. Promotions, campaign
8. Costs
9. Reputation
10. Affordability
11. Large uninsured population
12. Alternative/innovative therapy
13. Better quality care
14. Ageing population
15. Long waiting time
16. Service quality
17. Lack of insurance coverage
18. Domestically unavailable
treatments
19. Language
20. Culture
21. Availability of care
22. Economic
23. Religiosity
24. Affordability of air travel
25. Exchange rate
26. Well trained medical personnel Singh (2012)
27. Medical procedures
Author
Yu et al. (2011)
Yu et al. (2011)
Yu et al. (2011)
John and Larke (2016)
Ye et al. (2008)
Wang and Beise-Zee (2010); Veerasoontorn et al.
(2011); John and Larke (2016);
Ye et al. (2008)
Ye et al. (2008); Kanittinsuttitong (2015); Borman,
(2004); John and Larke (2016); Singh (2012)
Ye et al. (2008); Kanittinsuttitong (2015)
Yu, Lee, and Noh (2011)
Yu, Lee, and Noh (2011)
Yu, Lee, and Noh (2011)
Yu, Lee, and Noh (2011)
Yu, Lee, and Noh (2011)
Yu, Lee, and Noh (2011); Borman (2004); John and
Larke (2016); Singh (2012)
Kanittinsuttitong (2015)
Borman (2004); Forgione and Smith (2007); Herrick
(2007); Richards (2008); Garcia-Altes (2005)
Borman (2004)
Saniotis (2007); Gupta (2008); Lee (2007); Burkett
(2007)
Connell (2013)
Connell (2013)
Connell (2013)
Crooks et al. (2010)
Singh (2012)
Singh (2012)
Lovelok and Lovelock (2018);
36
2.2.1. Cost

Cost is always perceived as the main motivation to pursue medical tourism abroad

(Tham, 2018). Travelling to developing countries for medical treatment is said to be

cost-saving (Essier & Casken, 2013; Lunt, Mannion & Exworthy, 2013). Previous

studies had identified that cost is the most significant consideration for medical

tourists (John & Larke, 2016; Singh, 2012). The escalating cost of medical treatment

has caused people to travel abroad looking for cost-saving treatment (Chuang et al.

2014). For instance, in the United States, the average health care spending per person

is $11, 674 (Deloitte, 2018), which encourage Americans to seek treatment abroad.

Table 2.7 compares the global medical procedures cost comparison (US$). It appears

that the cost of medical procedures in the USA is extremely expensive compared to

South East Asia countries.

Table 2.7 Global medical procedures cost comparison (US$)

Procedure US Thailand Singapore Malaysia

Heart bypass $130,000 $11,000 $18,000 $9,000

Valve replacement $160,000 $10,000 $12,500 $9,000

Angioplasty $57,000 $13,000 $13,000 $11,000

Hip replacement $43,000 $12,000 $12,000 $10,000

Hysterectomy $20,000 $4,500 $6,000 $3,000

37
 Knee replacement $40,000 $10,000 $13,000 $8,000

Spinal fusion $62,000 $7,000 $9,000 $6,000

Source: Global Health and Travel (2013)

Veerasoontorn et al. (2011) contended that neither cost nor medical quality but

patient-oriented, highly personalised service quality is considered to be a competitive

advantage of a medical destination. The cost of medication might be the least

considered as the repeat visits are based on patient satisfaction and bonding

relationship created with medical personnel. Thus, the experience of medical tourists

is of the utmost concern.

2.2.2. Waiting time

Contrary to expectations and popular knowledge regarding lengthier wait times in

European and American countries, patients from non-European and non-American

countries come and prefer Turkey due to the shorter wait periods (Sag & Zengul,

2018). Due to the fact that the majority of medical tourists pay out-of-pocket and

expect acceptable value for their money, health treatments must be delivered promptly

and without a wait for results (Mathijsen, 2019). A short waiting period, prompt and

fast attention for operations and other interventions are other benefits that contribute

to the expansion of medical tourism (Singh, 2019).

38
Earlier studies (Pillay et al., 2011; Xie & Or, 2017; Sun et al., 2017) found that long

waiting times will cause dissatisfaction among patients. They found patients wait for

more than two hours from registration to getting the prescription slip, while the

consultation with a doctor is merely an average of 15 minutes only. This is similar to

a study conducted by Blendon et al. (2004) that the waiting time for medical treatment

in European countries is at least two hours. In some countries like Singapore,

Thailand, and India, the duration of waiting is shorter and a patient could have an

operation the day after their arrival.

2.2.3. Technology

Korea has state-of-art medical technology, medical facilities and medical experts,

making it a well-known medical destination (Yu et al., 2011). Beautification appears

to be the potential growing segment under medical tourism (Chuang, Liu, Lu, & Lee,

2014). Therefore, the government incorporate medical tourism into the national

tourism development strategy.

The most advanced treatments and technology is used by many countries to boost the

medical tourism industry. For example, the Barbados fertility centre (BFC) is rapidly

growing in popularity as a destination for reproductive clinics and holistic therapies

(Sandberg. 2017). The adoption of cutting-edge technologies and procedures has been

heavily invested in by renowned institutions, particularly in supportive medical

technology and operating techniques (Singh, 2019). In this case, having

39
technologically savvy physicians, surgeons, and support staff is unquestionably an

attractor for health tourists.

2.2.4. Distance

The impact of travel distance is normally not taken into account in the medical

tourism studies, thus researchers should look into it in the future (Abubakar & Ilkan,

2016). Travelling abroad to receive medical treatment is borderless where the distance

between the host and home country is relatively short (Connell, 2013). Medical

competency and psychological distance play an important role in the choice decision

process, where the earlier is the most important determinant (Zhang, Seo, and Lee

(2013). However, the choice of destination differs subject to how severe of illnesses

(Zhang et al., 2013).

Informal medical travel is usually only a short distance away from home (Collins,

Medhekar, Wong, & Cobanoglu; 2011; Connell, 2016) for several reasons. For

example, Indonesians tourists prefer to travel in the Southeast Asia region like to

Singapore, Thailand, and Malaysia because short journeys save money while also

increasing familiarity (Connell, 2016). The proximity of one's home country to their

destination helps to lessen the danger of being exposed to anything unusual (Zarei et

al., 2018). Sometimes, medical tourists do travel long distance for medical treatment

if the medical services if not available at the home country (Fetscherin & Stephano,

2016; Hanefeld, Smith, & Noree, 2016). Middle Easterners are increasingly willing to

travel large distances to Asia for medical treatment (Kamassi, Manaf, & Omar, 2020).

40
2.2.5. Service quality

Emotional service quality plays an important role compared to other types of service

quality especially in targeting first-time medical customers (Wang & Beise-Zee,

2010; Veerasoontorn et al., 2011). In terms of customer service, medical tourists are

treated as valuable customers and customers are looking for the best service.

Veerasoontorn et al. (2011, p.153) confirmed this notion that ‘while they often feel

helpless and subordinated, medical tourism seems to liberate patients from a

perception of being treated as objects of medical procedures. It lifts them to a valued-

customer status’. Good service quality will attract repeat visitation, even in the

healthcare industry, where it is always associated with negative demand or trying to

avoid going back. Good quality of service will change the perception of this as

‘patients ‘look forward’ to going back to the hospital, the very thought of it is

uplifting and associated with positive emotions and comfort in times of sickness’

(Veerasoontorn et al. 2011, p.153). This is because of the relationship built between

the patient and medical personnel during their treatment in host countries.

In general, the quality of staff, followed by supporting services quality and

administrative services quality has satisfied the medical patient Manaf et al. (2015).

The satisfaction of medical treatment and services in a medical tourism hospital

would make medical tourists consider returning for medical treatment in the future.

41
The establishment of Joint Commission International (JCI) ensures the highest

standard of quality. Currently, there is a total of 1,076 JCI-accredited Organisations

worldwide, with over half being in Asia (Joint Commission International, 2019).

Table 2.8 summarised the top 10 Asian countries with JCI-accredited Organisations.

Table 2.8 Top 10 Asian countries with JCI-accredited Organisations

Countries Number of JCI-accredited

Organisations
1. United Arab Emirates 201
2. China 110
3. Thailand 65
4. India 38
5. Indonesia 28
6. Japan 27
7. South Korea 26
8. Singapore 22
9. Taiwan 14
10. Malaysia 13
Source: Adapted from Joint Commission International (2019)

2.2.6. Language

To deliver services that adhere to international standards, medical tourism

destinations require employees who are fluent in various languages and can

communicate effectively with patients (Crooks et al., 2010). The similarity of

language is another significant determinant of destination selection (Hanefeld et al.,

2015). Language is also embedded into decision making, where patients are expected

to receive treatment in a place where no language barrier (Saniotis, 2007; Gupta,

2008; Lee, 2007; Burkett, 2007). Nevertheless, differences in language, economic

condition, and political system seem not to be barriers to the patients. For example,

42
Yu and Ko (2012) argue that language is not a barrier but can be solved if the health

care service providers can speak English or the patient’s language (Gill & Singh,

2011; Heung et al., 2010).

Language is considered important for the first time medical tourist (Snyder, Crooks,

& Johnston, 2012). It is one of the consideration by medical tourists when choosing a

medical tourism destination (Ulaş & Anadol, 2016). Pan and Chen (2014) found

language similarities encourage Chinese mainland medical tourists to travel to

Taiwan. This is supported by Muth (2017) that the healthcare providers in Lithuania

speak Russian and ease of communication between service providers and medical

tourists. Momeni, Janati, Imani, and Khodayari-Zarnaq (2018) reported that language

is one of the barriers to the development of medical tourism in East Azerbaijan

province, Iran.

2.2.7. Privacy

Another factor that may motivate individuals to consider medical tourism is the lack

of privacy related to their health process and activities at home (Jadhav et al., 2014).

Seeking medical treatment outside of the nation of origin is frequently the most

accessible, effective, and risk-free approach to maintain privacy and confidentiality.

Privacy is termed as the lack of any disclosure of information concerning the medical

choice patients choose, the treatments they undergo, and the outcomes they encounter

43
to the patient's family, social network, health care system, or insurance industry

(Zolfagharian et al., 2018).

Additionally, the increased digitization of medical records worsens worries about

patient privacy (Zolfagharian et al., 2018). Privacy appears to be one of the

considerations by medical tourists, particularly patients seeking plastic surgery,

transgender surgery, and drug rehabilitation (Reddy et al., 2010; Horowitz et al.,

2007; Fisher & Sood, 2014). Meanwhile, the advantages of privacy and anonymity of

patients are highly of concern by European medical patients (Hudson & Li, 2012).

This is supported by Lunt, Mannion & Exworthy (2013) that certain medical tourists

enjoy the privacy and confidentiality afforded by medical tourism destinations. A

study carried out in the United Arab Emirates (UAE) reported that privacy is one

consideration for patients looking for reproductive treatment (Al-Hinai, Al-Busaidi, &

Al-Busaidi, 2011). Privacy concerns associated with health records should not be

ignored as a component of the medical tourism experience.

2.2.8. Cultural aspect

The Medical Tourism Association (2013) survey identifies “cultural and religion

match” or cultural similarity among the most important factors for medical tourism.

Culture plays a significant role in medical tourism, and Connell (2013) stated that the

predominantly Islamic state of Malaysia has become a preferred medical destination

44
for medical tourists from Islamic countries such as Indonesia and the Gulf. In Iran,

Goodarzi et al. (2014) reported that cultural affinity was a vital factor that shaped

medical tourist preferences. Ng, Lee, and Soutar (2007) examined the influence of

cultural distance on tourists’ destination choices. Esiyok, Çakar, and Kurtulmuşoğlu,

(2017) confirmed that cultural distance influences the choice of medical tourism

destination.

2.2.9. Religion

Religion has long been a powerful tool for attracting potential tourists and medical

tourists from neighbouring countries (Rokni & Sam-Hun, 2019). For example,

religiosity is an important variable that is always overlooked by medical tourism

studies. Being a Muslim country, Malaysia attracts a lot of medical tourists from

South East Asia, particularly those from Muslim countries such as Indonesia and

Brunei. Thus, sharia compliance medical services can be promoted to attract more

Muslim medical tourists (Suki et al., 2017). However, relatively few researchers have

used this factor in their empirical study. Religiosity is another consideration that can

attract medical patients to visit a similar religious destination (Crooks et al., 2010).

This is largely due to the medical patients may want to look for facilities that have the

same religious protocols (Connell, 2005). Religion plays a robust role as a key

element of cultural proximity, which can influence the option of a medical tourism

destination (Esiyok et al., 2016; Bookman, 2007).

45
Some countries such as Jordan and Malaysia take into consideration of culture in the

country to attract Muslim patients (Bookman, 2007, cited in Esiyok et al., 2016).

Psychological factors that influence the tourist’s selection of sharia-compliant medical

destination (Suki, Putit, & Khan, 2017). It was found that there is a significant

relationship between religiosity towards attitude and destination image.

2.3 Medical tourism in Malaysia: Issues and development

In Malaysia, medical tourism is recognised as a potential economic growth engine for

medical and non-medical segments (Klijs, Ormond, Mainil, Peerlings, & Heijman,

2016). The rapid growth of medical tourism has driven Malaysia to venture into this

promising sector (Aziz, Yusof, Ayob, Bakar, & Awang, 2015). In Malaysia, the

history of medical tourism started after the 1997 Asian Financial crisis, which drove

the private healthcare sector to look for foreign businesses and diversity in the

healthcare business (Lee & Fernando, 2015; Moghavvemi et al., 2017; Beladi et al.,

2017). As the sector has good prospects, the Malaysian government has given

extensive support to promote medical tourism as a world-class medical hub (Dahlui &

Azizm 2011; Lee & Fernando, 2015; Beladi et al., 2017).

Private hospitals promote medical tourism via websites (Moghavvemi et al., 2017).

The five measurements comprise 1) hospital information and facilities, 2) admission

46
and medical services, 3) interactive online services, 4) external activities, and

5)technical items. In recent years, medical tourism is used in many nations to

stimulate economic growth (Beladi et al., 2017). However, the growth may cause a

decline in public health care provision and workers’ productivity. This is similar to

the case in Malaysia. Beladi et al. (2017) found that medical tourism has a positive

effect on economic growth in non-OECD nations. Under the National Key Economic

Area (NKEA) plan, medical tourism has been recognised as a sector that can uplift the

economy of the Malaysian economy (The Star, 2017). The industry has noted a

double-digit annual growth, ranging between 16 – and 17 % annually (New Straits

Times, 2017). In 2016, the healthcare travel industry grew by 23% compared to

earlier years. It is forecasted by 2024, medical tourism contributes at least US$3.5

billion to the Malaysian economy.

Department of Statistics Malaysia (2016) released statistics on services statistics

health for private healthcare centres. In 2014, hospital services recorded the highest

gross output amounting to RM8.3 billion, followed by medical & dental services,

RM4.8 billion and other human health services, RM1.3 billion. Private health services

employed 95,644 persons. The state of Selangor dominated the private health services

in both gross output and value-added of RM3.8 billion (26.0%) and RM1.9 billion

(26.8%) respectively, followed by Federal Territory Kuala Lumpur and Penang.

These three states contribute over half of the gross output and total value added to

health services in the country.

47
Malaysia is aspiring to become the top medical tourism destination in South East Asia

by 2020 (Puvaneswary, 2015). Meanwhile, Halal Tourism is gaining popularity and

Malaysia has taken opportunities to offer medical services to patients from Muslim

countries in a halal way. In order to support this aim, the Malaysian government,

under the National Budget 2018, announced an allocation of RM30 million to MHTC

to promote Malaysia as the Asian Hub for Fertility Treatment and to uplift the

country’s healthcare travel industry (New Straits Times, 2017). Malaysia Healthcare

Travel Council (2017) outlined the top 6 treatments (i.e., cardiology, oncology,

orthopaedics, IVF, dental care and cosmetic surgery) pursued by medical tourists.

Figure 2.8 illustrates the breakdown of medical services by revenue in 2016.

Figure 2.8 Breakdown of Medical Services by Revenue 2016

Source: Malaysia Healthcare Travel Council & Cardas Research (2017)

Dental treatment is the most popular and dominant market in 2016, followed by

aesthetics/cosmetic surgery, orthopaedic, and health screening (Transparency Market

Research, 2018). Dental treatment was expected to contribute revenue close to

RM402.5 million whereas cosmetic surgery contributes revenue close to RM230

million (Penang Institute, 2016). The other treatments such as cosmetic surgeries, and

48
regular health screening would continue to expand rapidly and contributes substantial

benefits.

Malaysia’s healthcare industry has announced many global awards. In 2018, Malaysia

received nine awards from International Medical Travel Journal (IMTJ). Malaysia

was also selected as “Destination of the Year” for three consecutive years (2015 –

2018) and recognised by International Living as the country with the “Best Country in

the World for Healthcare” for three consecutive years (2015 - 2017). Malaysia also

received Asia Pacific Healthcare & Medical Tourism Awards 2018 for 18 categories

such as Medical Travel Organisation of the Year, Medical Tourism Hospital of the

Year in the Asia Pacific and so on (Malaysia Healthcare Travel Council, 2018).

International Living (2018) listed Malaysia's healthcare system as the world's best for

people looking to retire overseas. The reasons included the affordable cost, ease of

medium of communication (English) and the majority of the doctors trained in the

UK, US, and Australia. In addition, many accredited hospitals and specialists require

less waiting time. Thus, it attracts medical tourists from both developed and

developing countries (Aziz et al., 2015). On the other hand, Malaysia Healthcare

Travel Council (2017) summarised the 1) stated-of-art technology, 2) highly trained

doctors, 3) end to end services, and 4) ease of entry. Other than private hospitals,

there are more than 200 medical device manufacturers in Malaysia that are rigorously

regulated by the Medical Device Authority. In addition, the majority of the private

49
hospitals in Malaysia are ISO 9001 certified and most of the medical facilities are also

accredited by the International Society of Quality in Health Care. This inevitably

assures a high standard of use of medical equipment.

In terms of medical qualifications, most doctors are graduated and trained in the

world’s top medical schools such as the United Kingdom, Australia, Russia and so on.

End to end services is Malaysia's strongest competitive advantage through a public-

private partnership. This will reduce the hassle such as waiting time and make sure

medical tourists receive the best services. On the other hand, Malaysia is easy to

access and has fewer travel restrictions such as visas.

In supporting medical tourism, the Malaysian government provides tax incentives

where private hospital operators can claim a double deduction for expenses incurred

on the promotion of their services abroad. Meanwhile, the private hospital can get tax

exemptions. Furthermore, the Flagship Medical Tourism Hospital programme (eVisa

(Medical)) was introduced to encourage private hospitals' efforts in attracting medical

tourists. In terms of promotion, RM80 million (US$18.6 million) allocation was

directed to medical tourism campaigns in China and India (Puvaneswary, 2015). In

Malaysia, many public hospitals experience a shortage of doctors and increasing

medical costs and charges (Leng, 2010). The shortage of medical doctors is due to the

movement of doctors from public to private sectors instead of the good reputation and

better pay. This inevitable encourages the growth of private healthcare providers to

50
overcome the shortage of medical personnel. The Malaysian private healthcare sector

was badly affected during the 1997 Asian financial crisis (Leng, 2010), many

healthcare consumers were looking for public facilities instead of private facilities.

The establishment of private health care provides an additional option to crowded

public health care (Ormond et al., 2014).

With the promise of economic benefits of medical tourism, Malaysia is positioning

itself as one of the top medical markets, building a reputation in a number of health

care services such as IVF. There are many competitive advantages of medical tourism

in Malaysia such as lower cost, stated-of-art medical technology and equipment.

Malaysia is a favourable medical destination due to several competitive advantages

such as privacy, highly qualified medical staff, advanced facilities and equipment, and

affordable rates. The majority of the hospitals in Malaysia are accredited standards.

Accreditation is paramount when assessing the quality of care issue. For example, The

Joint Commission International (JCI) is the highest standards-setting and accreditation

body in health care. Currently, there are 13 JCI-accredited hospitals within the

country (Patients Beyond Border, 2018).

Healthcare in Malaysia is safeguarded by the laws and regulations. Many medical

bodies have been established to follow the laws and regulations. The Ministry of

Health is responsible to monitor compliance and establishing benchmarks and

regulations for quality assurance for all private hospitals. Meanwhile, under the
51
Private Healthcare Facilities and Services Act 1998, all private hospitals in the

country must be licensed and registered (Patients Beyond Border, 2018). The

Association of Private Hospitals of Malaysia (APHM) is an association representing

private hospitals and medical centres in Malaysia. It has been established during the

1970s and has more than 100 members (Association of Private Hospitals of Malaysia,

2019). The objectives of the APHM are outlined below:

 Ensuring patient safety and quality as a member of the National Patient Safety

Council, the Malaysian Society for Quality in Health and the Malaysian

Productivity Council.

 Working dialogues with public sector agencies including the Ministry of

Health Malaysia

 Participation in National working groups such as MPC, MITI and

MATRADE.

 Training programs for all Healthcare providers include the yearly Conference

and Exhibition and regular smaller group workshops on clinical and

administrative/managerial topics.

 Promotion of Health Tourism Activities regionally and internationally with the

Malaysia Healthcare Travel Council (MHTC)

Meanwhile, The Malaysian Medical Council (MMC) is a body corporate established

under the Medical Act 1971. The Council has the authority to create all policy

decisions. The functions of the MMC include the following:

• Registers only qualified doctors;

52
 • Prescribes and promulgates good medical practice;

• Promotes and maintains high standards of medical education; and

• Deals firmly and fairly with doctors whose fitness to practise is in doubt. The

core functions of the Council under the statute are as follows:

• To authorise the registration of medical practitioners;

• To maintain a Medical Register of all registered medical practitioners in

Malaysia;

• To issue practising certificates to registered medical practitioners;

• To promote, recognise and accredit medical education and training programmes

and institutions;

• To determine and regulate the conduct and ethics of registered medical

practitioners;

• To consider the cases of medical practitioners who, because of some mental or

physical condition, may be unfit to practise medicine;

• To review the competence of medical practitioner;

• To advise and make recommendations to the Minister of Health on matters

relating to the practice of medicine in Malaysia; and

• To perform such other functions to give effect to the Medical Act 1971 as may be

prescribed in the Act or assigned by the Minister.

The Association of Private Hospitals of Malaysia works closely with The Malaysian

Medical Council to promote medical tourism. The Malaysian Medical Council

53
safeguard the benefits of patients and guiding doctors by offering safe and competent

health care services for the country.

The Malaysia healthcare travel council (MHTC) was established in conjunction with

The Ministry of Health Malaysia to help foreign patients and their families visiting

Malaysia. According to George Medical Getaway (2018), there are 10 reasons why

medical tourists should choose Malaysia for their medical treatment. The ten reasons

include 1) exceptional medical services, 2) state-of-art facilities, 3) high qualified

medical professionals, 4) ease of communication, 5) no waiting time, 6) excellent

recuperation, 7) peaceful environment, 8) traveller’s paradise, 9) centralized location,

and 10) visa exemptions).

Malaysia has several strengths in developing medical tourism. For example, the

nation has many tourist attractions, lower treatment costs, professional doctors,

advanced medical equipment and facilities. Thus, the Malaysian government and

medical tourism stakeholders (i.e. clinics & hospitals) are collaborating in developing

medical tourism (Musa et al., 2012).

54
Compare with other developed and developing countries in United State and region,

the medical procedures cost in Malaysia is extremely low compared to United State

and relatively cheaper compared to developing countries. Patients Beyond Border

(2018) reported that Malaysia offers exceptional facilities and care, with costs 30-50%

lower than neighbouring countries. Table 2.9 summarises the review of literature on

medical tourism. Based on the Table, it can be said that medical tourism is a focus

point for many countries. Facilities, quality of services, qualified medical

professional staff, less waiting time, low medical costs, and privacy are main factors

influence medical tourists travel abroad for medical treatments

55
 Table 2.9. Review of Literature in Medical Tourism
Authors Location Methodology Main findings
1.Musa, Doshi, Kuala Lumpur, Sample: 137 respondents were sampled The findings suggested that medical tourists are
Wong, Malaysia using the combination of purposeful generally concerned with the hospital facility (i.e.
&Thirumoorthy and convenience samplings in five hospitality of staff, hygienic medical procedures,
(2012) private hospitals in Kuala Lumpur. general counter service, and registration system),
atmosphere (cleanliness, hygiene, comfort) and the
Analysis: Multiple regression analysis, professionalism of the doctors when they seek medical
t-test, and One Way ANOVA treatment in Kuala Lumpur.
Meanwhile, the satisfaction level among medical
tourists was very high. In contrast, medical tourist
expressed their dissatisfaction regarding the time spent
with physicians, the location of the hospital, and the
length of consultation.

The demographic profile (i.e gender, age group,

education) influenced the satisfaction.
2. Wang (2012) Taiwan The unit of analysis was Chinese The perceived benefits (i.e. perceived medical quality,
medical tourists travelling to China. A service quality and enjoyment) were found significant
non-random sampling technique was and had a positive influence on perceived value. It
employed by involving employees in means that perceived value was a key predictor of
one company. The survey yielded 301 customer intentions.
usable questionnaires and the results
were tested against the research model The results highlighted that the medical quality, quality
using the structural equation modelling of the service, and enjoyment as three important
approach. components that influenced the perception of value. For
example, the qualified medical professional staff, world-
The author used a confirmatory factor class medical equipment and facilities. Meanwhile, the
analysis (CFA) via AMOS 17.0 to test enjoyment offered is also important for medical tourists

56
 the model. Meanwhile, a reliability test so that they have a relaxed and memorable experience
was also performed to check the data. when they seek treatment in the host country. Finally,
medical tourists looking for safe treatment, if possible
zero risk.

3. Kim, Koo, South Korea The unit of analysis was international This study examined the roles of servicescapes,
Shin, & Lee medical tourists visiting Korea. emotions, and satisfaction in the development of
(2017) customer loyalty toward medical clinics and
This study utilised a simple random destinations.
sampling method. 25 medical clinics in
Seoul, with international medical The results reported that atmosphere, medical activity,
tourists, were invited to participate in staff, and the medical clinic had a significant effect on
the study. The questionnaires consist of positive emotion and influence the satisfaction among
bi-language (Japanese and Chinese). international medical tourists.
The respondents were actual medical
tourists. On the other hand, this study identified the mediating
effects of emotions and satisfaction. The results
Prior to the actual data collection, an identified atmosphere had significant indirect effects on
interview with medical staff (doctors loyalty toward the medical clinic and loyalty to the
and nurses) as well as medical tourists medical clinic via positive emotion and satisfaction.
was carried out to identify
servicescapes crucial in the medical The medical activity was also discovered to have a
clinic. significant influence on loyalty toward the medical
clinic via satisfaction

A total of 390 questionnaires were

returned but only 337 questionnaires
were usable.

Then, exploratory factor analysis (EFA)

57
 and confirmatory factor analysis (CFA)
was performed to analyse the results.
The results were also analyzed using
AMOS.
4. Alsharif, India, China, In the beginning, 128 private and public
Labonté, & Lu Jordan and the hospitals/health centres from six
(2010) United Arab countries were contacted via email and
Emirates regular mail. In the end, only six
countries participated in the survey.
The questionnaires comprise 5 Three reasons (i.e. cost, the reputation of the doctor,
demographic items and 17 medical
items and were mailed to the targeted
respondents. The questionnaires were
constructed in six different languages
and were distributed to international
medical tourists.
5.Moghimehfar& Iran Field evaluation (i.e documentary)
Nasr-Esfahani survey and questionnaire. The authors
(2011) obtained a medical record of non-
Iranian infertile couples who were
referred to the Isfahan Fertility and
Infertility Center during the last five
years.
58
The study has twofold. The objective of the study seeks
to recognize the source nationality of medical tourists
and their motivations to engage in medical treatment
overseas, services obtained and their experience
satisfaction level.
reputation of the facility) were found to be the most
significant reasons for selecting out-of-country care.
Waiting times and lack of available medical services
encourage medical tourists to seek treatment overseas.
The study found that a large number of medical tourists
seek dental services overseas as the current health
system does not cover dental. Meanwhile, organ
transplantation yield ethical issue. The study also
highlighted that the boom of medical tourism
nevertheless affected the poorer groups.
This study examined the factors influencing destination
choice in infertile couples in Iran.
Religious similarities were found to be an important
reason for Muslim infertile couples in Iran.
In addition, the lack of quality facilities and experts in
 their home country drives them to seek treatment
The questionnaire consists of 8 overseas.
questions and is measured by 5 points
Likert Scale. The validity of the
questionnaire was validated by a
university professor. The questionnaire
was available in 3 languages (i.e.
Persian, Arabic, & English)

80 infertile couples were contacted but

only 70 participated in the study.
However, only 68 questionnaires were
usable for analysis.

This study used simple statistical

analysis such as frequency and Chi-
Square test.

6. Zolfagharian, USA This study utilized primary and This study attempted to identify the determinants of the
Rajamma, Naderi, secondary data. Prior to the actual data medical tourism destination selection process in the
&Torkzadeh collection, information regarding USA.
(2018) medical tourism was obtained via
tourism literature. Subsequently, a The results indicated that price (medical cost) is the
focus group with 11 participants from major determinant for respondents who chose to seek
different backgrounds. medical treatment abroad. In addition, respondents also
indicated that privacy concerns as a determinant of
As a result of the focus group, 29 items medical tourism.
for the seven variables were discovered.
Only respondents who had prior Medical restrictions (i.e. long waiting time, regulations)
thought about, or experience with, encourage people to seek medical treatment abroad.

59
 medical tourism were selected to
participate in the study. Destination desirability was found to be another
determinant as medical tourists will explore tourist
Respondents were intercepted at attractions and activities (i.e. culture, tradition, & island)
various shopping locations. 560 they prefer during their treatment in the destination they
questionnaires were distributed and 539 desire.
were usable.

Analysis: Exploratory factor analysis

(EFA) and confirmatory factor analysis
(CFA) using AMOS. SEM was used to
test the conceptual model.

Respondents: American, Russian, The results indicated that country of origin influence the
7. An (2014) Korea Chinese, and Japanese medical tourists overall attitudes. Among the respondents, Russian
This study utilized face to face medical tourists had the highest positive attitudes. In
interviews. 930 respondents participate contrast, the Japanese had the highest negative attitudes.
but only 883 valid responses were This can be seen in the declining number of medical
received. tourists to Korea.

The questionnaire is translated into a It was reported that travel-related risks (i.e. emotion) are
few languages. The questionnaire the most influential factor among Russians, Japanese,
consists of 3 parts. All items were and Chinese while Americans are influenced mostly by
measured by 7-point Likert Scale. health-related risks such as hygiene and cleanliness.
However, Americans were generally not satisfied with
The data were analysed using SPSS. the extra cost and the reimbursement policy at home.
Some statistics include descriptive
frequency analysis. In addition, a The health-related risk factor was the most significant
reliability test was performed to test the contributor to Japanese attitudes.

60
 internal consistency while ANOVA
examine cross-cultural differences in American and Japanese attitudes are also affected by
the perceptions of eight sub-factors and cost factors but not by convenience factors.
attitudes among the 4 countries.
The convenience factor significantly affects Russian and
Chinese attitudes.
Stepwise regression was then
performed to examine the degree to Postoperative risk, access to information, and
which each of the eight sub-factors availability of procedures have different effects across
contributes to attitudes toward medical the four nations.
tourism.

8. Manaf et al. Malaysia A convenience sampling and self- This paper examined a few factors that drive medical
(2015) administrated questionnaire were tourists to look for medical treatment in Malaysian
employed. Only foreign patients private hospitals. This study identified three service
seeking medical treatment in Malaysia quality (i.e. medical staff, supporting services, &
were included in the survey. administrative). Medical staff quality was discovered to
predict patient satisfaction, perceived value and future
22 items on perceived quality were intention for treatment.
identified and a Likert scale of 1-5 was The demographic profile showed that the majority of the
employed. The questionnaire was in respondents were male, aged between 26 and 45, first-
Arabic, Indonesian Malay and English. time visitors, and self-employed. The majority of the
Back translation technique was used to medical tourists were from Indonesia and looked for
develop the Arabic and Indonesian medical check-ups. In terms of the source of
Malay questionnaire. information, they depend on word of mouth and they
contacted the hospital directly for medical
There were 173 valid and usable arrangements.
questionnaires for analysis. The data
was then analysed using SPSS. Overall, respondents were highly satisfying the quality
of staff, followed by supporting services quality and

61
 Analysis: Reliability test, factor administrative services quality.
analysis
Similarly, the cost of treatment in Malaysia is affordable
and this is an important perceived value by respondents.
In addition, respondents were satisfied with the
treatment and services received and they would consider
returning for medical treatment.

Regression analysis reported that service quality was

found to be a significant predictor of perceived quality.

9. Lee, Han, & Korea Before the survey, a focus group was
Lockyer (2012) carried out to validate predict and
predictor constructs. Then, new belief
constructs were then developed via a
questionnaire.
The questionnaire was translated into
Japanese. Face validity was also
assessed before the final set of
questionnaires. In addition, the
questionnaire was then validated by
tourism and medical experts.
The convenience sampling method was
utilised and respondents were
intercepted at various airport entry/exit
points. 237 valid responses were
collected.
This study utilised the Theory of Planned Behavior in a
medical tourism context.
Compare to previous studies, this study found
contrasting results. For example, attitude (AT) was
discovered a significant predictor in predicting Japanese
medical tourists’ intention to seek medical treatment in
Korea. Furthermore, there is a positive relationship
between attitudes and intentions. On the other hand,
Perceived Control Behavior (PBC) was found as the
strongest predictor among antecedents of intention to
travel to Korea for beautification purposes.
In terms of health treatment (HT) benefits, respondents
believed that they would have access to healthy food,
additional care and services, and cost-saving. It was
found that cost, information, community and safety
influence the decision-making process.
In terms of Beautification treatment (BT), respondents

62
 Analysis: SPSS believe that their surgical treatment is at low risk,
convenient, low cost, and operated by professionals.
The internal consistency of Some components (i.e. expense, information,
measurement items and construct communication, time and effort, and location) were
validity was tested via Confirmatory found to influence the decision-making process.
factor analysis (CFA). Then, Structural
equation modelling (SEM) was used to
test two dimensions of medical tourism
models.

10. Rodrigues, Global This study used a mixed-methods This study explored gender differences in cosmetic and
Brochado, Troilo, approach. The authors collected data dental treatment pursuit by medical tourists from all
& Mohsin (2017) from the Treatment Abroad website. around the world.
The respondents were from 29 clinics
across 15 nations. The authors divided the results into quantitative and
qualitative.

The authors reviewed 603 reviews Quantitative: The sample characteristic showed that
about cosmetic surgery and cosmetic there was slightly more post regarding cosmetic
dentistry. dentistry and the age of reviewers were middle age. The
reviewers were from 34 nations and mostly from
Analysis: Content analysis (i.e. reviews Europe. The reviewers were highly satisfied with the
of clinical experiences) using cosmetic dentistry treatment and gave high ratings.
Leximancer software. Then, the theme
and concepts were grouped based on
the qualitative content analysis Qualitative: The key themes and concepts were
approach. identified via Web content analysis. There were 7
themes generated such as clinic, treatment, time,
recommend, happiness, cost, and questions. The results
differentiated the gender in selecting the type of

63
 treatment. For example, males preferred cosmetic
dentistry while females prefer cosmetic surgery. In
addition, the healthcare experience of both genders was
also discussed.

The results of the frequency analysis reported 5 top

words (i.e. friendly, cleanliness, helpful, staff, &
confidence) as key medical tourism concepts.

11. Chuang et al. Not specific 1292 potential Chinese medical touristMedical competency is the most important determinant
(2014) of destination choice.
Analysed using McFadden’s Customers contemplating treatment for major diseases
conditional logit model. tend to choose healthcare services from economically
more developed countries
12. Thailand narrative analysis (face to face The underlying success factor for the sustainable
Veerasoontorn, interview) with medical patients from competitiveness of a healthcare destination is neither
13.Beise-Zee, and developed countries price nor medical quality, but patient-centred, highly
Sivayathorn personalised service quality.
(2011)
The low price might initiate interest in medical
treatment abroad, return visits are built on profound
patient satisfaction, and even bonding, between doctors
and nurses.

14. Pillay et al. Malaysia Self-administered questionnaires were
(2011) administered in 21 public hospitals
throughout Malaysia, involving 13463
respondents
Respondents wait for more than two hours from
registration to getting the prescription slip, while the
contact time with medical personnel is only on average
15 minutes.
Employee attitude and work process, heavy workload,
management and supervision problems, and inadequate

64
 facilities are among the contributory factors to the
waiting time problem
15. Chuang et al. Not specific 1292 potential Chinese medical tourist Medical competency is the most important determinant
(2014) of destination choice.
Analysed using McFadden’s Customers contemplating treatment for major diseases
conditional logit model. tend to choose healthcare services from economically
more developed countries

65
2.4 Tourism Index

According to Cambridge Dictinionary (2022), an index is ‘‘a number used to show the

value of something by comparing it to something else whose value is known’’. It

shows an indicator or measure of something. It allows people to understand

something and use it to make decision making. The tourism index is a metric used in

tourism research that illustrates the market positions by combining demand and

supply data from the tourism industry (Aubert, Jónás-Berki, & Marton, 2013).

Table 2.10 summarises the commonly used index in tourism studies The tourism

climate index (TCI) and The Travel & Tourism Competitiveness Index (TTCI) seems

to be popular index frequently used in tourism studies. However, the TTCI “seems

more a systematic collection (comprehensive notwithstanding) of data than a model

that reveals clear testable association among variables thereby facilitating inferential

analysis” (Croes & Kubickova, 2013, 147). Recently, the medical tourism index is

gaining attention in the healthcare and tourism literature.

66
 Table 2.10 Commonly used index in tourism studies.

Index Authors
1. Medical tourism index Aziz et al. (2015); Fetscheri & Stephano (2016),
Ghosh & Mandal (2019); Medical Tourism Index
(2021)
2. Holiday climate index Rutty et al. (2020); Scott et al. (2016)
(HCI)
3. Tourism climate index Alonso-Pérez et al. (2021); Fang (2015); Olya and
Alipur (2015); Rutty et al. (2020); Scott et al.
(TCI)
(2016)
4. The Travel & Tourism Bazargani and Kiliç, (2021); Croes and Kubickova
(2013); Crotti and Misrahi (2015); Nazmfar et al.
Competitiveness Index
(2019); Perez Leon et al. (2021); Rodríguez-Díaz
(TTCI) and Pulido-Fernández (2021)
5. Covid19 tourism Yang et al. (2021)
index
6. Price competitiveness Seetaram, Forsyth, & Dwyer (2016)
index
7. Global Bucher (2018)
competitiveness index
8. COVID-19 Risk Liu et al. (2021)
Exposure (CORE) index
9. Sustainable Castellani and Sala (2010)
performance index
10. Dark tourism index Powell, Kennell, and Barton (2018)

2.4.1 Medical Tourism Index (MTI)

According to Global Healthcare Resources (2019), the MTI measures the

attractiveness of a country as a medical tourism destination in terms of overall country

image and environment; healthcare and tourism attractiveness and infrastructure; and

availability and quality of medical facilities and services. Indexes ‘provide a simple

67
number for a complex phenomenon and allow a relative objective comparison across

countries’ (Fetscherin & Stephano, 2016). Medical Tourism Index is an integrated

index composed of indicators on three dimensions such as destination environment,

medical tourism industry, and quality of facilities and services, which involves 41

destinations from the five regions (e.g. Middle East, Asia, Americas, Africa, and

Europe). It serves as a benchmark performance for medical tourism destinations. The

index takes into consideration of 34 criteria and surveyed over 4,000 respondents. In

Asia, 20 countries are being considered, excluding Malaysia one of the leading

medical tourism destinations in the world. Table 2.11 summarises the participating

countries in Medical Tourism Index 2016.

Table 2.11. Participating countries in Medical Tourism Index 2016

Region Countries
1. the Middle East Abu Dhabi, Bahrain, Dubai, Egypt, Iran, Israel,
Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi
Arabia
2. Asia China, India, Japan, Korea, Philippines, Singapore,
Thailand, Taiwan
3. Americas Argentina, Brazil, Canada, Colombia, Costa Rica,
Dominican Republic, Jamaica, Mexico, Panama
4. Africa Morocco, South Africa, Tunisia
5. Europe France, Germany, Italy, Malta, Poland, Russia,
Spain, Turkey, UK
Source: Global Healthcare Resources (2019)

68
It is noted that the average score of Europe and America is between 64.5 to 63.6 while

Asia and the Middle East region are between 63.19 to 63.40, respectively. Meanwhile,

the African region has the lowest average score below 60. Table 2.12 Medical

Tourism Index region and score. There are two types of score, 1) average overall

score and 2) top destination score. A high score on the overall Medical Tourism Index

indicates that a country is very attractive as a medical tourism destination.

Table 2.12 Medical tourism index region and score

Region Average overall score Top destination score
1. Middle East 63.40 67.54
2.Asia 63.19 73.56
3.Americas 64.48 76.62
4.Africa 57.51 62.20
5.Europe 63.50 71.90
Source: Global Healthcare Resources (2019)

In terms of destination performance, Canada, the UK, Israel, Singapore, and India are

the top five medical tourism destinations. Looking at the sub-category, Canada, UK

and Singapore are the top three performers under destination environment countries.

For the medical tourism industry, India, Columbia, and Mexico are the top three

scorers. Meanwhile, in terms of quality of facilities & services, Israel, Germany, and

India appear to be the top three performers. Table 2.13 summarises the top five

medical destination ranking categories.

69
 Table 2.13. Top five medical destination ranking categories
Overall Destination Medical tourism Quality of facilities &
environment Industry services
1. Canada 1. Canada
(76.62) (78.69) 1. India (75.94) 1. Israel (81.60)
2. UK
(74.87) 2. UK (77.29) 2. Columbia (74.96) 2. Germany (77.88)
3. Israel
(73.91) 3. Singapore (73.26) 3. Mexico (74.17) 3. India (77.10)
4. Singapore
(73.56) 4. Israel (66.56) 4. Canada (74.13) 4. Canada (77.02)
5. India
(72.10) 5. India (67.50) 5. Dominican Republic (73.85) 5.UK (76.94)
Source: Global Healthcare Resources (2019)

It is essential to carry out additional research in the field of medical tourism in

order to advance the level of knowledge about the sector. In Malaysia, Yuhanis,

Zaiton, Khairil Wahidin, and Zulhamri (2015) developed a medical tourism

index based on five dimensions (i.e. service and physical facilities, cost, physician,

hospital reputation, and destination image). Their study was the first study to

develop medical tourism index in Malaysia. The study covered two important

considerations. First, the study integrates a variety of touservicesrvice. Second,

the study considered service providers and medical tourists destination. The

findings suggested that hospital reputation is the most important factor,

following by service and pyshical facilities, cost, physician, and tourism

destination image. Thus, it can be concluded that medical tourists see hospital

reputation as the utmost important consideration when choosing a medical

tourism destination. In Malaysia, all medical tourism service providers are

70
privately run by health group. In addition, most of the hospitals are accredited

under Joint Commission International (JCI).

Since then, Fetscherin and Stephano (2016) developed a Medical Tourism Index

based on four dimensions (e.g. country environment, medical tourism cost, tourism

destination, and facility and services).

Figure 2.9 outlines the dimensions of the medical tourism index. According to the

Global Healthcare Resources (2019), the discussion of the three dimensions is stated

below:

Medical Tourism Index

Country environment
1. Economy, safety, image
2. Culture
Medical tourism industry
1. Destination attractivess
2. Medical tourism costs
Facility services
1. Quality care
2. Reputation
3.Internationalization and accreditation
4. Patience experience

Figure 2.9 Dimensions of medical tourism index

Source: Adapted from Global Healthcare Resources (2019)

71
The details of each dimension can be summarised below:-

1. Country Environment

This sub‐index assesses the overall economy of the country, the safety and image of

the country, favorability of exchange rate as well as cultural aspects such as cultural

or language similarities.

2. Medical Tourism Industry

This sub‐index consists of two parts, tourism and medical part. It assesses the

attractiveness of a country as a tourism destination in terms of popularity of tourism

destination, weather conditions or cultural and natural attractions/sites as well as costs

associated with medical tourism such as cost of treatment, costs of accommodation or

costs of travel.

3. Facility and Services

This sub-index assesses the quality of care such as the doctor’s expertise, healthcare

standards, or medical equipment. It also assesses the reputation of doctors or hospitals

as well as the internationalization of staff and accreditation of the facility. Finally, it

72
also considers the overall patient experience such as the friendliness of staff and

doctors.

2.5 Theory of Planned Behaviour

There are many theories used in studying medical tourism, which includes Grey

(Dang et al., 2020), grounded theory (Cannon Hunter, 2007; Momeni et al.,

2018), expectation confirmation theory (Chou, Kiser, & Rodriguez, 2012’

Mahmud et al., 2020), social exchange theory (Mishra & Sharma, 2021);

spillover theory (Mishra & Sharma, 2021); framing theory (Lee et al., 2014;

Mason & Wright, 2011) prospect theory (Zolfagharian et al., 2018), and

complexity theory (Oyla & Nia, 2021). However, Theory of Planned Behaviour

(TPB) is widely used in the tourism and hospitality field. In medical tourism

studies, TPB is typically used to predict behavioural intention (Boguszewicz-

Kreft et al., 2020; Boguszewicz-Kreft, Kuczamer-Kłopotowska, & Kozłowski,

2022; Seow et al., 2017). Dash (2020) extended the theory to examine the medical

tourists’ intention in India.

Ajzen (1991) was the earliest scholar to bring the theory of planned behaviour (TPB)

to the field of psychology in order to explain how people make decisions. The TPB,

according to Ajzen (1991), is a development of work on the theory of reasoned action

73
(TRA), which contends that a person’s behaviours may be predicted using

behavioural intention, and focuses on three predictors: attitude, subjective norm, and

perceived behavioural control. According to Ajzen and Fishbein (1980), most human

behaviour is foreseeable because people make judgments based on logical thinking.

The use of TRA has been questioned, according to Han, Hsu, and Sheu (2010),

because non-volitional stimuli may influence a person’s actions in some situations.

The TRA is primarily concerned with volitional control, ignoring the relevance of

having access to readily available resources (Paul, Modi, & Patel, 2016). In many

situations, TRA is inadequate to predict a person’s intentions or behaviour. The TPB

model, on the other hand, can solve this problem because it fits the data well and has a

better intention prediction capacity than the TRA model. Han, Hsu, and Sheu (2010)

acknowledged that TPB has a high level of predictability for visit intention.

TPB can be used to explain why a customer wants to buy a given product or service.

For example, Asadi et al. (2020) explained that the theory has helped researchers to

better understand a wide spectrum of motivations and behaviours. In addition, the

theory also measures the level of intention to engage in a particular behaviour.

Besides the field of psychology, TPB has been used in other fields such as education,

tourism and hospitality and green consumerism (Yuriev, Dahmen, Paillé, Boiral, &

Guillaumie, 2020). Kalafatis, Pollard, East, and Tsogas (1999) concluded that TPB is

a strong model for predicting buying behaviour. According to Ajzen and Fishbein

(1980), most human behaviour is foreseeable because people make judgments based

on logical thinking and make decisions based on their assessment of the available

74
options. Normative blimieliefs were reported to have a significant impact on intention

in past studies.

TPB has its own weaknesses in explaining and predicting human behaviour.

Sniehotta, Presseau, & Araújo-Soares (2014) criticized the model's reliance on

rational reasoning, as well as its lack of subconscious, associative, and impulsive

variables, feelings, and private standards have been a source of criticism. To address

the TPB model’s limitations, Jang et al. (2015) have suggested that certain pro-social

characteristics be integrated into the model. Nevertheless, Wang et al. (2018) denote

that the additional attribute(s) must fit specific criteria, such as increasing the model’s

explanatory power and adding relevant and appropriate variables to represent a wide

range of behaviours.

Figure 2.10 Theory of Planned Behaviour Framework

Source: Adapted from Azjen (1991, p. 182)

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TPB is said to be one of the most influential elements in determining whether or not a

person will return to a particular destination (Hsu & Huang, 2012). In addition, it is

undeniable that choosing a tourism destination is a difficult, risky, and ambiguous

procedure (Soliman, 2021). As Bianchi, Milberg, and Cúneo (2017) argued, the TPB

has only been used in a few studies to predict visitors’ travel destination preferences.

Even though TPB has not been substantially used throughout the field of medical

tourism, previous studies have verified the favourable effects of the three attributes in

TPB on behavioural intention to engage in medical tourism (Chaulagain, Pizam, &

Wang, 2021). Ramamonjiarivelo, Martin, and Martin (2015) applied TPB to

understand the students’ intention to participate in medical tourism. On the other

hand, Dash (2020) extended the TPB by adding risk attributes to better understand the

intention of medical tourists to seek medical tourism in India.

2.6 Relationship between the TPB constructs and factors affecting behavioural

intention

In this section, the researcher discuss the relationship between the TPB

constructs and factors affecting behavioural intention.

2.6.1 Attitude and behavioural intention

Ajzen (1991) defined attitude as “the degree to which a person has a favourable or

unfavourable appraisal of the behaviour in question for forming consumer-intention

and consumer- behaviour”. Kim and Han (2010) explained that the attitude of a

person is a reflection of how they judge a particular sort of behaviour. In other words,

the attitude of a person toward performing a specific activity is impacted by their

76
behavioural intentions. An individual’s attitude is a constant expression of like or

dislike toward a certain thing and is also dependent on his or her belief that engaging

in a certain behaviour will result in a favourable consequence. As a result, consumers’

attitudes and behaviours, in other words, have a significant impact on their purchasing

decisions. Essential beliefs and assessments of the outcomes of a given behaviour can

be used to build attitudes.

An individual’s attitude determines their behaviour intention in a variety of situations.

For example, if an individual considers patronizing green hotels to be significant and

environmentally helpful, they will form a visit intention for green hotels. This is

supported by Cheng, Lam, and Hsu (2006) that an individual is required to assess the

benefits and drawbacks of engaging in a particular behaviour while determining

whether or not to participate in it. Attitude can be a significant factor in predicting,

describing, and influencing tourists’ behavioural intentions (Han, Hsu, & Sheu, 2010;

Bianchi, Milberg, & Cúneo, 2017).

In the medical tourism context, medical tourists may have a positive behavioural

propensity to participate in medical tourism if they have favourable attitudes

regarding medical tourism and feel that the result of the medical tourism activity will

be satisfying (Chaulagain, Pizam, & Wang, 2021). On the other hand, some

researchers studied the perceptions of Indonesian medical tourists in Malaysia, and

their findings suggested that attitude has a positive relationship with travel intention
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(Na, Onn, and Meng, 2015; Saragih & Jonathan, 2019). The results were further

validated by Saragih and Jonathan (2019), in their study of the Indonesian consumer

toward medical tourism experience in Malaysia.

Similarly, Lee, Han, and Lockyer (2012) found that attitude positively influenced

Japanese medical travellers’ intention to seek medical treatment in Korea. Chaulagain,

Pizam, and Wang (2021) and Dash (2020) also reported a positive relationship

between attitude and visit intention to a medical destination. The attitude was found to

be the strongest predictor compared to the other two attributes in the TPB (Martin,

Ramamonjiarivelo, & Martin, 2011). Similarly, Seow, Choong, Moorthy, and Choong

(2020) found the same findings.

Therefore, it is hypothesized that:

H1: There is a positive relationship between attitude and intention to visit medical

tourism in Klang Valley and Malacca.

2.6.2 Subjective norms and behavioural intention

The role of the subjective norm as a determinant of behavioural intention has been

well recognised in the fields of marketing and consumer behaviour. Subjective norms,

are primarily understood as perceived social pressure in the TPB framework. It is

concerned with the social influence that an individual feels to behave in a socially

78
acceptable manner. Subjective norms, including attitude and perceived behaviour

control, are thought to influence behaviour indirectly through their influence on

behavioural intentions rather than directly influencing behaviour. Terry (1999)

discovered that, of all the variables, subjective norms have the least impact on

behavioural intentions. In general, an individual’s behavioural intention is more

strong when his or her attitude toward a certain behaviour is more positive, and vice

versa. Subjective norms are required for other persons or groups who have personal

beliefs that they should not be pressured to execute a specific behaviour.

Peers, coworkers, family members and friends, as well as other influential members

of society, for example, may exert social stigma on a person’s decision to engage (or

not) in a particular undertaking. For example, if a parent or spouse does not want a

person to accomplish something, such as travel to another nation for medical

treatment, the person intends to visit will thus be low. In other words, subjective

norms influence one’s intention to perform a particular behaviour (Chaulagain, Pizam,

& Wang, 2021). For example, Lee et al. (2012), Dash (2020), Chaulagain et al.

(2021), reported a positive relationship between subjective norms and visit intention

to a medical destination. The results were further validated by Saragih and Jonathan

(2019), in their study of the Indonesian consumer toward medical tourism experience

in Malaysia. Seow, Choong, Moorthy, and Choong (2020) found that subjective

norms have a moderate effect. As a result, it is hypothesized that:

H2: There is a positive relationship between subjective norms and intention to visit

medical tourism in Klang Valley and Malacca.

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2.6.3 Perceived behavioural control and behavioural intention

Perceived behavioural control, on the other hand, reflects how easy or difficult it is for

an individual to demonstrate a particular sort of behaviour. In other words, it is an

assessment of a person's capacity to control a set of specific behaviours. Self-efficacy

in social cognitive theory is approximately identical to this concept. People’s

intentions/actions are positively influenced by their self-confidence in their capacity

to accomplish the behaviour (Baker, Al‐Gahtani, & Hubona, 2007). For example,

Han, Hsu, and Sheu (2010) mentioned that, although an individual has a positive

attitude/subjective norm regarding the expected behaviour, his or her behavioural

intention will be lower when he or she has less influence over carrying out a given

action due to a lack of required resources.

Likewise, Chen and Peng (2014) asserted that a person who can better regulate

external conditions when performing particular acts is more likely to do so. For

instance, some researchers (Chaulagain, Pizam, & Wang, 2021; Dash, 2020; Lee,

Han, & Lockyer, 2012) reported a positive relationship between perceived

behavioural control and visit intention to a medical destination. The results were

further validated by Saragih and Jonathan (2019), in their study of the Indonesian

consumer toward medical tourism experience in Malaysia. In their study to predict

medical tourism behavioural intention, Seow, Choong, Moorthy, and Choong (2020)

found that perceived behavioural control has the least effect. Therefore, it is

hypothesized that:

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H3: There is a positive relationship between perceived behavioural control and

intention to visit medical tourism in Klang Valley and Malacca.

2.6.4 Country environment and intention to visit

In this study, the country's environment is also known as the country's image. As

Insch and McBride (2004) noted, consumers’ evaluations of product attributes and

qualities, as well as their buying decisions, are influenced by their perceptions of their

home countries. It is worth noting that potential medical tourists assess nations not

just based on their medical facilities and services, but also based on their economic

and political stability, safety and security, and technological innovation. This is

supported by Cham, Lim, Sia, Cheah, and Ting (2021) who, in addition to country

image and pricing, tourists would think about safety and security when choosing a

vacation.

In the meanwhile, only a few research have looked into the impact of a country's

image on tourist destination choice (Chaulagain, Jahromi, & Fu, 2021). Abdul Manaf,

Hussin, Kassim, Alavi and Dahari (2015) contended that the country's environment

81
positively influences the satisfaction of medical tourists visiting Malaysia. It was

found that country image has a favourable impact on memorable travel experiences

and the intention to revisit a destination (De Nisco, Mainolfi, Marino, & Napolitano,

2015; Zhang, Wu, Morrison, Tseng, & Chen, 2018). Chaulagain, Jahromi, and Fu

(2021), revealed that the image of the country had the biggest beneficial impact on the

potential visitors to visit another country forr medical reasons. Furthermore, there is a

strong link between the image of a country and the likelihood of visiting it (Soliman,

2021). Therefore, it is hypothesized that:

H4: There is a positive relationship between the country environment and the

intention to visit medical tourism in Klang Valley and Malacca.

2.6.5 Tourism destination and intention to visit

One of the most important elements to take into account when deciding on a country

for medical tourism is the availability of tourist attractions (Fetscherin & Stephano,

2016). This is because when medical tourists travel to the host countries for medical

treatment, at the same time, they have the opportunity to travel (Heung, Kucukusta, &

Song, 2010). Tourism attractions have a considerable beneficial impact on the

intention to visit and revisit (Wang, Feng, & Wu, 2020). For example, Ghosh and

Mandal (2019) found that destination appeal (i.e., attractiveness) influences the visit

intention. Nevertheless, it was found that there is no relationship between tourist

attractions and the intention to revisit (Yang, Yang, Tseng, & Lin, 2015).

82
Although there is a relation between tourism destination and behavioural intention

(Collins, Medhekar, Wong, & Cobanoglu, 2019; Zhang & Lee, 2015), Choi,

Ashurova and Lee (2021) found an opposite finding, where a lack of tourist

attractions has an impact on medical tourism in Uzbekistan. Meanwhile, medical

tourists are not so concerned about sightseeing in another country because most of

those medical tourists travel to Russia for medical treatment as the main priority.

Therefore, it is hypothesized that:

H5: There is a positive relationship between tourism destinations and intention to visit

medical tourism in Klang Valley and Malacca.

2.6.6 Medical tourism cost and intention to visit

The cost that a consumer believes he or she needs to pay when engaging in a given

decision, such as buying a product or travelling to a destination, is known as

perceived cost. The concept of perceived cost, as well as related concepts like price

fairness and acceptance, have been thoroughly researched as influencing variables in

consumer decision-making studies (Chaulagain, Jahromi, & Fu; 2021; Pappas, 2017;

Ryu & Han, 2010; Rahman, 2019). In general, before making a purchasing choice,

consumers frequently compare prices offered by their competitor’s firms and

determine the fairness or acceptability of the price for a product or service (Cham, Ng,

Lim, & Cheng, 2018). This is because customers’ attitudes about the seller are shaped

83
by the fairness of pricing, which also serves as a criterion for evaluating product and

service experiences. In this study, price refers to the medical costs incurred by

medical tourists seeking treatment. Often, medical tourists will price compare and

choose a destination that offers affordable medical treatments. Medical tourists may

find it difficult to afford medical services due to high medical charges (Han & Hyun,

2014).

Medical operations are often more affordable in developing nations due to lower

labour costs and exchange rates, which renders medical tourism attractive to

individuals from wealthy nations. For instance, people from rich countries, travel to

developing countries for medical care because the expenses are far lower than in their

home countries. The importance of medical costs in determining medical tourists’

view of a behavioural intention has been emphasised by some researchers (Cham,

Lim, Sia, Cheah, & Ting, 2021; Chia & Liao, 2021; Ghosh & Mandal, 2019; Rahman,

2019). Affordability of treatment costs is viewed as an important consideration by

medical tourists (Ratnasari, Gunawan, Pitchay, & Mohd Salleh, 2021). Therefore, it is

hypothesized that:

H6: There is a positive relationship between medical tourism cost and intention to

visit medical tourism in Klang Valley and Malacca.

2.6.7 Quality of facilities and services and intention to visit

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It had been proven that there is a relation between perceived quality and behavioural

intentions (Muskat, Hörtnagl, Prayag, & Wagner, 2019). According to the findings of

Rodrigues, Brochado, Troilo, and Mohsin (2017), medical tourists consider the level

of service provided by hospitals to be the most important component in their

experiences, which increases the likelihood of return visits and positive ratings.

However, international medical tourists, on the other hand, perceive the quality of

healthcare treatment provided by hospitals to be more important than the service

provided by personnel (Han & Hyun, 2015). Similar to the country's environment, the

perceived quality of medical tourism services had the most beneficial impact on the

potential visitors to visit another country for medical treatment (Chaulagain, Jahromi,

& Fu, 2021).

Some researchers also posited a positive relationship between service quality and

satisfaction (Balcazar, Lee Rosenthal, Nell Brownstein, Rush, Matos, & Hernandez,

2011; Rad, Som, & Zainuddin, 2010). This is important agenda to retain medical

tourists and increase tourists’ satisfaction and loyalty (Ghosh & Mandal, 2019; Han &

Hyun, 2015). Sag and Zengul (2019) addressed that medical facility influences an

individual to visit medical tourist destination. Therefore, it is hypothesized that:

H7: There is a positive relationship between quality of facilities and service and

intention to visit medical tourism in Klang Valley and Malacca.

2.13 Conclusion

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This chapter first explains the theory used in this study, followed by a review of

medical tourism and medical tourists. Then, the chapter continues to discuss the

factors influencing motivations to receive medical tourism abroad. Meanwhile, the

chapter outlines the issues and development of medical tourism in Malaysia following

by illustrating the Medical Tourism Index. The following chapter describes the

methodology used in this study.

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter attempts to address the research methodology used for this study. This

chapter outlines the research design, operationalization of variables, data collection,

survey questionnaire development, sampling strategy, and procedures for data

analyses. Finally, the study ended with ethical considerations and a conclusion.

3.1 Research design

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A justifiable and reliable research design is necessary to answer the problem

statements and refine the robustness of a research study (Saunders, Lewis, &

Thornhill, 2012). Thus, some aspects in designing research, such as research

paradigm, methodical choice, a research strategy(ies), time horizon, and research

techniques and procedures are crucial. This is a descriptive and causal research

design. The descriptive method is considered to collect information about the current

situation.

This study utilises the calculation as suggested by previous studies (Fetscherina &

Stephano, 2016). In the context of methodical choice, the researcher has used a

quantitative method after taking into account the research objectives, hypotheses, and

models that were developed. In fact, there are various methodologies used in the

previous literature (i.e quantitative, qualitative, and mixed methods).

Although a qualitative method offers more in-depth explanations and results

compared to a quantitative approach, quantitative methods are more appropriate for

testing hypotheses to determine the validity and the reliability of the measured

variable (Sekaran, 2005). In addition, the quantitative research approach is widely

used in service marketing studies, mostly in the healthcare and medical tourism

setting (e.g. Choi et al., 2005; Lertwannawit & Gulid, 2011; Cham et al., 2015).

87
This study uses a survey-based research approach because this approach is versatile,

cost-effective, generalisable and reliable (Blackstone, 2012). A survey-based research

approach allows researchers to gather a large volume of data at one time, flexible, and

can provide information about respondents’ attitudes and beliefs (Zikmund & Babin,

2007). Based on the discussion above, survey-based research seems to be the most

fitting method to collect data.

Furthermore, a questionnaire survey was deemed to be suitable for this research as

this method is an economical and efficient way of collecting primary data across

hospitals within a shorter period. A self-administered questionnaire is ‘a questionnaire

that has been designed specifically to be completed by a respondent without the

intervention of the researchers (e.g. an interviewer) collecting the data’ (Lavrakas,

2008, p.803).

3.2 Sampling strategy

3.2.1 Target population

Defining a target population within the broader population of a potential sample with

the related parameters of a study is part of the sampling process that involves getting

generalisation of finding. Given that the main objective of the study is to identify the

factors that influence medical destinations by potential medical tourists, the target

population of the study was the international medical tourists travelling to Malaysia

seeking medical services in private hospitals in Klang Valley and Malacca during

2019 – 2020. Malacca was chosen in this study because it attracted significant amount

of tourists from neigbouring countries, such as Indonesia. Meanwhile, the city is a

UNESCO world heritage city and has many tourist destinations. The city is easiy

88
accessed by air and land transport. The city has attracted over half a million medical

tourists since 2015 (Murali, 2015). In 2018, there were 102,708 foreign medical

tourists visited Malacca and currently developed as the medical tourism hub

(Malaysia Healthcare Travel Council, 2019).

According to the statistics published by Malaysia Healthcare Travel Council, the

number of international visitors who travelled to Malaysia was 1,050,000 in the year

2017. Inadequate empirical research has been conducted with actual data from

medical tourists due to trouble in getting access to international medical tourists,

probably due to the hospital policy to protect the patient’s information and reluctance

to participate in research (Manaf et al., 2015). However, there are no statistics on the

distribution of medical tourists in each state and therefore it is very hard to estimate

the actual number of medical tourists in Klang Valley and Malacca. In addition, as

Ormond et al. (2014, p.2) argued ‘ the available data indiscriminately encompass all

registered patients with a foreign passport, which by default also encompass

expatriates, migrants, business travellers, and holiday-makers for whom health care

may not be the main motive for their stay’.

3.3 Sample size

The sample size is defined as ‘the number of units to be included in a study’

(Malhotra & Peterson 2006, p. 365). Presently, the issues of sample size remain a

subject of debate as there is no definitive and universal thumb rule to state an

89
appropriate sample size for research (Briggs, Morrison, & Coleman, 2012). Manning

and Munro (2007) emphasised a rule of thumb concerning sample size, whereby the

sample size beyond 300 is considered ‘good’, 200 is considered ‘fair’, and 100 is

considered ‘poor’. For a large population, a sample size of 350 is considered

reasonable (Saunders et al., 2012). As mentioned earlier, there is no actual population

for population and thus, an assumption of the proportion of medical tourists in Klang

Valley was made.

According to Nathan (2018), Penang and Klang Valley provide 76% of the market

share while roughly 60% of the total market share is from Penang alone (Chin, 2018).

Thus, by subtracting the contribution of the two destinations with Penang

contribution, the number of the contribution of Klang Valley is thus 16% (76% -

60%). Therefore, the total number of medical tourists in Klang Valley is 168,000

(1,050,000 * 16/100).

Yamene’s (1967) sample size formula was used to get the sample size required for the

study.

where
n = sample size
e= the precision level (95% confidence level)
N= population

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 168,000
n=
1+ N (e) 2

168,000
n=
1+ 168,000(.05)2
n = 399

3.4 Research instrument

3.4.1 Questionnaire design

The main data gathering for the current study is via a structured survey questionnaire.

The structured questionnaire was constructed based on the earlier literature. This

study referred to the guidelines by Fetscherin and Stephano (2016) and Global

Healthcare Resources (2019), which was deemed a well-established methodology

consideration and went through a rigorous methodology examination. A minor

modification of the index was performed to reflect the context of the study. Fetscherin

and Stephano (2016) further divided the original MTI (3 dimensions) into four

dimensions by adding one dimension (costs). Figure 3.1 presents the four dimensions

of the medical tourism index.

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 Medical Tourism
Index

Destination environment Facility services Medical tourism costs *

Medical tourism industry
1. Economy, safety, image 1. Quality care
1. Destination attractivess
2. Culture 2. Reputation 1. Cost of travel/airfare
3.Internationalization and 2. Cost of treatment/healthcare
accreditation 3. Cost of accommodation
4. Patience experience

* Additional dimension

Figure 3.1 Four dimensions of the medical tourism index

The questionnaire consists of 4 sections (see Apeendix). The first section of the

questionnaire collected information concerning the destination environment, tourism

destinations, tourism destinations, medical tourism costs, and facilities and services.

The reserachers adopted Fetscherin and Stephano’s (2016) medical tourism

constructs, which includes the destination environment (5 items), medical tourism

cost (5 items), facility services (17 items), and tourism industry (5 items). Meanwhile,

those variables in theory of planned behaviour, such as attitude (3 items), subjective

norms (3 items), perceived behavioural control (3 items), and travel intention (3

items) were adapted from (Dash, 2020) to reflect the medical tourism context.

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The researcher modified and converted the original ‘country’ to ‘destination’ to fit the

study. In this section, an additional variable, religion was added because of previous

studies (Esiyok, Çakar, & Kurtulmuşoğlu, 2017; Iranmanesh, Moghavvemi, Zailani,

& Hyun, 2018) found that religion is an important variable influencing medical

tourists' travel to Malaysia for medical treatment. Sections one measure the items

using a 5-point Likert- type scale, with end-anchors labelled “strongly agree” and

“strongly disagree” was used.

Second sections asked respondents to rate their agreement on several constructs

(attitude, subjective norms, perceived behavioural control, and intention) using a 5-

point Likert- type scale, with end-anchors labelled “strongly agree” and “strongly

disagree”. The details of the dimensions are summarised in Table 3.1.

Table 3.1 Questionnaire design

Dimensions Scale No. of

questions
Destination Environment 8
1. Stable exchange rate 1-5
2. Low corruption 1-5
3. Cultural similarity 1-5
4. Overall positive country image 1-5
5. Language similarity 1-5
6. Safe to travel to country 1-5
7. Stable economy 1-5
8. Religious similarity 1-5

Tourism Destination
1.Popular tourist destination 1-5

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2.Exotic tourist destination 1-5 5
3.Weather conditions 1-5
4.Attractiveness of the country as a tourist destination 1-5
5.Many cultural and natural attractions 1-5

Medical Tourism Costs

1.Cost of treatment 1-5
2.Healthcare costs 1-5
3.Cost of accommodation 1-5 5
4.Costs to travel 1-5
5.Affordability of airfares 1-5

Facility and Services

1.Doctor's training 1-5
2.Doctor's expertise 1-5
3.High healthcare quality indicators (e.g., low infection 1-5
rate)
4.Reputation of doctors 1-5
5.High quality standards (e.g., ISO, NCQA, ESQA) 1-5
6.High quality of care 1-5
7.State-of-the-art medical equipment 1-5
8.Quality in treatments and materials 1-5
9.Accreditation of the medical facility (e.g., JCI, ISQUA) 1-5 17
10.Reputation of the hospital/facility 1-5
11.Country medical reputation 1-5
12.International certified doctors 1-5
13.Internationally certified staff 1-5
14.International educated doctors 1-5
15.Friendliness of staff and doctors 1-5
16.Family recommendation of doctors 1-5
17. Family/friend recommendation of the hospital/facility 1-5

Attitudes
1. I predict that I should travel to Klang Valley and 1-5
Malacca to receive my medical treatment in the near
future.
2. I plan to travel to Klang Valley and Malacca to receive 1-5 3
my medical treatment in the near future.
3. I intend to travel to Klang Valley and Malacca to 1-5
receive my medical treatment in the near future.

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 Subjective norms
1. People who influence my behavior think that I should 1-5
travel to Klang Valley and Malacca to receive my
medical treatment
2. I would travel to Klang Valley and Malacca to receive 1-5 3
my medical treatment because many of my friends have
already traveled abroad to receive medical treatment.
3. People who are important to me think that I should 1-5
travel to Klang Valley and Malacca to receive my
medical treatment.

Perceived behavioural control

1. Traveling to Klang Valley and Malacca to receive 1-5
medical treatment would be entirely within my control.
2. I would be able to travel Klang Valley and Malacca to 1-5 3
receive my medical treatment.
3. I have the resources, knowledge, and ability to travel 1-5
to Klang Valley and Malacca to receive my medical
treatment.

Travel intention
1. Traveling to a foreign country to receive my medical 1-5
treatment would be a good idea.
2. I like the idea of traveling to a foreign country to 1-5 3
receive my medical treatment.
3. Traveling to a foreign country to receive my medical 1-5
treatment would be a pleasant experience.
Source: Developed by the researcher

For third section, respondents were asked to give a value of each medical tourism

dimension (1) Destination environment, 2) Medical tourism industry, 3) Medical

tourism costs, and 4) Quality of facility and services. Each value should be not more

than 100 points. This information was used to caluculate the weightage.

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The fourth section collects information about the demographic profile and trip related

information. The demographic profiles of the respondents includes gender, age,

education level, occupation, nationality and country of residence. Meanwhile, the trip

related information ollects information on the importance of different dimensions

stated in sections one to four, insurance coverage, alternative medical tourism

destination, and suggestion for medical tourism destinations.

3.4.2 Pilot study

Before the actual data collection, a pilot test was conducted and determine the

reliability and validity of the measures. As Zikmund (2003) notes, the pilot test guides

the main study and offers a chance for refining the practical techniques rather than

explaining a theoretical framework. The pilot study is a relatively small scale

undertaken to determine appropriate sample size and improve the research design

prior to actual data collection. The questionnaire was tested by conducting a pilot test

with 20 conveniently selected respondents at one of the hospitals in Klang Valley.

The actual data collection was carried out for six months. However, the data

collection is subject to approval from the selected hospital.

A pilot study was conducted before the data collection. The purpose of the pilot study

is to ensure that the instructions and content of the questionnaire are clear and

understandable to the respondents and also to test the reliability and validity. After the

pilot test, Cronbach’s Alpha value was used to examine the reliability of the pilot test.

A total of 30 results were obtained. The pilot results showed that all variables are

above 0.70 and passed the threshold of the reliability test. However, the result of the

96
pilot study was not used in this study. Based on the 400 responses, the reliability for

each dimension was above the 0.70 threshold (see Table 3.2).

Table 3.2. The reliability of dependent and independent variables

Variable Dimension No. of Items Cronbach Alpha

Dependent variable Behavioural intention 3 .946

Independent variable Attitude 3 .933

Independent variable Subjective norm 3 .927

Independent variable Perceived behavioural control 3 .943

Independent variable Destination environment 8 .864

Independent variable Tourism destination 5 .787

Independent variable Medical tourism cost 5 .748

Independent variable Facility and Services 17 .913

3.4.3 Research procedure

Before the actual data collection, three criteria were set to qualify as a respondent.

First, the respondent must be a foreign medical tourist travelling to Malaysia for

medical service. Second, the respondent must be at least 18 years old due to ethics

consideration. Third, the respondent must have a direct engagement in any tourism

activities (e.g. accommodation services, transportation services, sightseeing,

97
shopping, and vacation) during the medical trip. Realise it is extremely difficult to get

the information of actual medical tourists due to the privacy protection policy of all

hospitals. Thus, this study used convenience sampling and several steps were carried

out to ensure the respondents are qualified to participate in the survey. Additional

criteria were set out as below:

1. The respondents were screened to make sure they are medical tourists but not

expatriates or local residents.

2. The respondents were asked if they were at least 18 years old.

3. The selected hospitals are registered under Malaysia Health Tourism Council.

A consent letter was sent to hospitals in order to get approval from the hospitals to

conduct the research. To minimize the disturbance of medical tourists and the privacy

of the respondents, the questionnaires were only distributed at some places where

respondents will be easily accessed such as hospital lobbies, cafeterias, and waiting

areas. Respondents were approached after getting consent from the hospital. The

questionnaires were distributed after getting the agreement from the respondents.

Respondents were briefed and explained the purpose of the survey and they will be

informed that their participation is voluntary, and they can stop the survey

immediately without giving any reasons. Meanwhile, due to the COVID-19

pandemic, the researcher also received help from hospital staff to help potential

respondents in filling out the questionnaire.

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According to the statistics circulated by Malaysia Healthcare Travel Council (2021),

the number of international visitors who travelled to Malaysia was 1.22 million in the

year 2019. However, because there are no data on the distribution of medical tourists

by state, estimating the real number of medical tourists in both states is difficult. As

indicated by Nathan (2018) and Chin (2018), Penang and Klang Valley occupied 76%

of the market share, whereas around 60% of the total market share is from Penang.

Thus, by subtracting the contribution of the market share of Penang, the number of

contributions of Klang Valley is thus 16% (76% - 60%). Therefore, the total number

of medical tourists in Klang Valley is 195,200 (1,220,000 * 16/100). Meanwhile, the

author assumed that there are about 8% of medical tourists visited Malacca.

Therefore, the total number of medical tourists in Malacca is 97,600 (1,220,000 *

8/100).

Finally, the total population of medical tourists for Klang Valley and Malacca are

292,800. The authors then used Raosoft (2021) to determine the sample required for

the study. As the total population of both destinations are 292,800, therefore, the

sample required is 384. To get an accurate proportion of the sample, the authors also

calculated the sample required for both destinations using a proportionate sampling

technique. The sample size required for Klang Valley was 257 while the sample size

required for Malacca was 127. Table 3.3 outlines the sample required for the study.

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 Table 3.3. The sample size required for the study
Destination Population Percentage (%) Sample required (n)

Klang Valley 195,200 66.6 257

Malacca 97,600 33.4 127

Total 292,800 100.0 384

3.5 Reliability and Validity

The reliability and a valid number of items in each dimension and scale are crucial in

the research study (Kyle, Graefe, Manning, & Bacon, 2003), Gross & Brown, 2008).

Validity is ‘the accuracy of a measure or the extent to which a score truthfully

represents a concept’ (Zikmund et al., 2014). After the survey questionnaire was

developed, a validating procedure was carried out. First, the initial questionnaire was

reviewed by the researcher’s supervisor and the panel members for comments and

suggestions. The comments and suggestions of the panel members were the basis for

the final draft that was submitted for validation.

Content validity refers to the ‘degree that a measure covers the domain of interest’

(Zikmund et al., 2014, p.307) so that it offers sufficient coverage of the research

questions guiding the study. Meanwhile, criterion-related validity refers to ‘the ability

of a measure to correlate with other standard measures of similar constructs or

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established criteria’ while construct validity ‘exists when a measure reliably measures

and truthfully represents a unique concept; consists of several components including

face validity, content validity, criterion validity, convergent validity, and discriminant

validity’ (Zikmund et al., 2014, p.307).

Meanwhile, Daly (2007, p. 254) explained that for reliability, “the emphasis is placed

on the sustainability of the results”. Reliability analysis was utilized to understand

internal consistency, and correlation analysis was employed to understand the

relationship of each variable. Reliability is the extent to which a variable or set of

variables is consistent in what it is intended to measure (Hair, Back, Babin, Anderson,

& Tatham 2006). Similarly, it is an indicator of a measure’s internal consistency

(Zikmund et al., 2013). They argued that in order to understand reliability,

consistency is deemed important. As Cooper and Schindler (2014) noted, reliability

‘is a necessary contributor to validity but is not a sufficient condition for validity’.

This is supported by Zikmund et al. (2014) that reliability ‘is a necessary but not

sufficient condition for validity. A reliable scale may not be valid’.

The reason for performing a reliability test is to make sure the reliability of the survey

instrument. Therefore, a pilot test was carried out before the actual data collection to

ensure the reliability and validity of the survey instrument. In general, reliability is

normally measured using coefficient alpha with a minimum of 0.6 to be considered

reliable. Table 3.4 presents the rule of thumb of Cronbach alpha. To safeguard

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construct validity, only variables developed and used in the historical studies will be

adopted.

Table 3.4 Rule of thumb of Cronbach Alpha

Alpha coefficient range Strength of association

0.9 Excellent

0.8 to <0.9 Very good

0.7 to <0.8 Good

0.6 to <0.7 Moderate

<0.6 Poor

Source: Adapted from Hair et al. (2003)

This study adopts most of the medical tourism index dimension utilised by

Fetscherin and Stephano (2016) as their study followed a rigorous methodological,

statistical and index construction procedure to construct psychometric sound

measurement. The dimensions include 1) Destination environment, 2) Tourism

destination, 3) Medical tourism cost, and 4) Facility and Services.

3.6 Data Analysis

3.6.1 Descriptive analysis

In terms of analysis, data were analyzed via both univariate and multivariate

techniques with the Statistical Package for Social Sciences (SPSS) software. The

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researcher summarize and organize characteristics of a data set by presenting

the socio-demographic profile of respondents using descriptive analysis

(frequency, mean, standard deviation). There were a few steps of data analysis.

First, the accuracy of the collected data was checked via data screening. It is an

important process to check for the errors in coded and collected data in order to retain

the accuracy before the actual data analysis. Then, different variables were analysed

using descriptive statistics, followed by factor analysis and reliability test using

principal component analysis with varimax rotation.

The data were sorted out and classified based on the objectives of the study.

Descriptive statistics were used to calculate the demographic profile of medical

tourists and their medical travel characteristics. Respondent’s demographic profiles

comprise gender, age, marital status, education background, nationality, and income.

Furthermore, respondents’ travel characteristics were categorized into the importance

of medical tourism, source of information, medical health insurance coverage,

alternative destination, medical treatment arrangement, the suggestion to friends and

relatives, and medical tourism expenses.

3.6.2 Pearson correlation analysis

The correlation analysis aids in determining the significance of independent variables’

effects on the research's dependent variable, as well as any probable relationships

between variables. A correlation analysis will suggest whether the hypothesis is

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substantiated or not. Correlation analysis is most suitable for interval or ratio variables

(Zikmund et al., 2013).

To use correlation analysis, there should be at least two or more continuous variables

(i.e., interval or ratio level) and the normality of the bivariate must be ascertained. It

means that both variables are presumed to be normally distributed.

Pearson correlation test was used to answer research objective 2. A Pearson

correlation coefficient, denoted r, was calculated to calculate the linear relationship

between two variables. All the independent variables (Attitude, Subjective norm,

Perceived behavioural control, Destination environment Tourism destination,

Medical tourism cost, Facility and Services) and a dependent variable

(behavioural intention) were analysed to determine the correlation between

variables.

The value is between − 1 and 1, where 0 is no correlation, 1 is total positive

correlation, and − 1 is total negative correlation (Nettleton, 2014). For example, a

correlation value of 0.9 between two variables would indicate that a significant and

high positive relationship exists between the two variables. However, the strength of

correlation coefficient is differ based on disciplines. In the field of medical, the

correlation coefficient is slightly strict (Chan, 2003). The details of the correlation

strength is summarised in Table 3.5.

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 Table 3.5 Correlation strength table

Correlation coeffifient Strength of correlation

0 no linear relationship

0 and 0.3 (0 and −0.3) weak positive (negative)

0.3 and 0.7 (0.3 and −0.7) moderate positive (negative)

0.7 and 1.0 (−0.7 and −1.0) strong positive (negative)

Source: Ratner (2009)

3.6.3 Multiple regression analysis

The goal of regression analysis is to predict the values of a continuous, interval-scaled

DV based on the values of the IV. Multiple regression analysis refers to a statistical

analysis used to support and examine the relationship between a single dependent

variable (DV) and a set of independent variables (IVs) by looking at the

independent’s variable valuable effects on the dependent variable (Hair, Black, Babin,

& Anderson, 2013). It is a multivariate approach that is usually used in market study

(Sekaran & Bougie, 2011). Regression can contain either less than interval IVs, but

the DV must be continuous.

In this study, multiple regression analysis was used to verify the results of bivariate

analyses, and to show the mutual relationship of dependent variable on seven

independent variables. For instance, the dependent variable in this study is

intention to visit medical tourism destination while the 7 independent variables

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include Attitude, Subjective norm, Perceived behavioural control, Destination

environment Tourism destination, Medical tourism cost, Facility and Services.

Multiple regression analysis requires variables to be quantified on an interval or ratio

scale, such as age, party size, and income. However, sometimes, independent

variables are non-metric in structure (Wang et al., 2006).

3.7 Composite indicator calculation

What follows is the composite index calculation which consists of normalizing or

standardizing the data, weighting and aggregating the data and calculating the MTI

values for the various countries considered.

3.7.1. Standardizing data

Since all items are measured using 5 points Likert scale rating, this is easy to measure.

A ‘Percentage of Scale Maximum’ (% SM) method was employed percentage. This

method converts any Likert Scale score into a standardized score with 2 conditions.

First, all initial score (Likert Scale 1-5) has to be recoded into 0-4 score, as shown in

Table 3.6. This procedure was recommended by Fetscherin and Stephano (2016).

Likert scale re-converted into 0, 1, 2, 3, & 4 to match point scale. For example,

Liker scale 0 = 0 point, 1 = 25 points, 2 = 50 points, 3 = 75 points, 4 = 100 points.

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 Table 3.6 Likert scale conversion Table

Source: Adapted from Fetscherin and Stephano (2016)

Second, there is a formula to 'standardize' the Likert scale to scores between 0 and

100 since there are diverse numbers of items per factor. For example, if one has a 5

point Likert scale (0-4) with 7 items the calculation becomes: [actual total scale score

is, say, 20]. Then standardized score = (20 x 100)/(7 x 4) = 2000/28 = 71.42.

Likert scale with 1-5 coding: = (mean factor – ¼) x 100 or Likert scale with 0-4

coding: = (mean factor/4) x 100.

3.7.2. Weighting and aggregating factors

There are diverse methods (e.g., statistical, mathematical, equality and participatory)

to calculate the weights for the factors. However, each approach has its advantages

and disadvantages. This study use the‘ participatory approach’ to weigh the factors

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which were for Destination Environment, Tourism Destination, Medical Tourism

Costs and Facility and Services. Linear aggregation is possible when all indicators

have the same measurement unit and there are no conflict effects between factors

(same direction and sign). Both requirements are met and therefore the linear

aggregation method is used. The most used linear aggregation method is to sum the

weighted and normalized sub-indicators (e.g., destination environment, tourism

destination, medical tourism costs and facility and services) with the following

formula:

Where

xij = item i in factor j

wj = weight for factor j

m = number of items in factor, and

n = number of factors

3.8 Conclusion

This chapter started with introducing the research design, sampling strategy, and

sample size. Subsequently, this chapter detailed the research instrument, reliability

108
and validity of this study. Finally, the study explained the analysis used in this study.

The next chapter reports the results of the findings.

CHAPTER 4

RESEARCH FINDINGS

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4.0 Introduction

This chapter consists of seven sections. The first section presents the introduction of

the study followed by the findings of the study. The third section reports the

regression analysis results, followed by the multiple regression analysis results. Next,

section 5 reports the summary of the hypotheses testing, followed by the medical

tourism index. Lastly, the conclusion is presented.

4.1 Research Findings

In this section, the descriptive information of the respondents, including their

demographic profile, travel patterns, activities performed, and information sources are

presented. The total sample collected was 400, where 250 respondents were surveyed

at 3 hospitals in Klang Valley while only 150 respondents were surveyed from only

one hospital in Malacca.

4.1.1 Demographic Profile and Characteristics of the Respondents

Table 4.1 reports the socio-demographic profile of the respondents. Overall, males

accounted for the majority of respondents. As mentioned above, with 78.8% are

males, indicating that the female respondents are far less than the male respondents,

who accounted for only 21.2% of the samples. In terms of age, the respondents were

spread across four age groups.

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In general, the respondent whose ages ranged from 18-29 years old represented 1.0%

only. Of the remaining age groups, 36.3% were between 30-29 years old and 42.5%

were 40-49 years old, and the remaining 20.2% were 50 years old and above. Over

half the respondents reported themselves to be married, while the remaining indicated

that they are either single (41.5%) or divorced (4.2%).

In terms of nationality, about 85.0% of the respondents are from Indonesia, and 9.0%

of the respondents are from Singapore. There are only 12 respondents (3.0%) from

China and 11 respondents from Vietnam (3.0%). Malaysia is famous among

Indonesian due to its geographic proximately to the country. As for the education

level, three respondents indicated that they had only attended primary school (0.8%).

On the other hand, 9.0% of the respondents are high school graduates, 34.0% of the

respondents were diploma graduates, 54.0% of the respondents had a degree and only

2.2% of the respondents had a postgraduate degree (Master’s or PhD degree).

In terms of occupation, the majority of the respondents are self-employed,

constituting almost half (48.0%) of the responses. Meanwhile, about 37% of the

respondents indicated that they are private-sector employees while about 15% of the

respondents are working in the government sector. The remaining respondents

indicated that they are either retirees (0.5%) or unemployed (0.3%). In terms of

income, the majority of the respondents reported their income over RM 25,000, while

22.5% reported their income less than RM 10,000, 14.7% reported their income range

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between RM 10,000 and RM 14,999, and only 12.7% of respondents indicated their

income to be range between RM 20,000 and RM 24,999.

Table 4.1: Summary of Respondent’s Demographic Profile

Frequency Percentage
Variable
(n = 400) (%)
Gender
Male 315 78.8
Female 85 21.2

Age
18-29 years old 4 1.0
30 - 39 years old 145 36.3
40 - 49 years old 170 42.5
Above 50 years old 81 20.2

Marital status
Single 166 41.5
Married 217 54.3
Divorced/Separated 17 4.2

Nationality
China 12 3.0
Indonesia 341 85.0
Singapore 36 9.0
Vietnam 11 3.0

Education background
Primary School 3 0.8
High School 36 9.0

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 Diploma 136 34.0
Bachelor Degree 216 54.0
Postgraduate 9 2.2

Occupation
Government Servant 59 14.8
Self-employed 192 48.0
Private sector employee 146 36.5
Unemployed 1 0.3
Retiree 2 0.5

Income
Less than RM 10,000 90 22.5
RM 10,000 – RM 14, 999 59 14.7
RM 20,000 – RM 24, 999 51 12.7
RM 25,000 – RM 29, 999 111 27.8
More than RM 30,000 89 22.3

4.1.1 Trip related information

Table 4.2 shows the frequency of visits of the respondents. In terms of frequency of

visit, the majority of the respondents (69%) mentioned that they had visited Malaysia

between 2 to 3 times for medical tourism, and 11.3% mentioned they had visited

Malaysia 4-5 times for medical tourism. On the other hand, 16.4% of the respondents

said they had visited Malaysia for medical tourism and only 12 respondents (3%) said

they are first-timers.

Table 4.2 Frequency of visit

Frequency (n = 400) Percentage (%)

1 12 3.0

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 2-3 277 69.3
4-5 45 11.3
More than 5 66 16.4

The respondents were also asked about their health insurance coverage plan in their

country (see Table 4.3). The results showed that the majority of them said they are

insured under the insurance purchased directly from an insurance company (46.2%)

while another 44% of the respondents reported that are not insured. Nine per cent of

the respondents said they have purchased a Medicaid, medical Association or any

kind of government assistance plan. The remaining respondents said they have

medicare or other types of healthcare insurance or coverage plan.

Table 4.3. Health insurance coverage/health coverage plan

Frequency Percentage
(n = 400) (%)
1. Insurance purchased directly from an
185 46.2
insurance company
2. Medicare 2 0.5
3. Medicaid, Medical Association or any
36 9.0
kind of government assistance plan
4. Any other type of healthcare insurance
2 0.5
or coverage plans
5. Uninsured 175 43.8

Respondents were asked to rank the top three sources of information they sought

before deciding to embark on a medical trip. The findings reported that the medical

tourism intermediary’s website, advice of doctors/ physician in the home country, and

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the website of the hospital in Malaysia are the top three sources of information.

However, none of the respondents indicate reading the testimonies of other patients

who had surgery abroad as a source of information. Table 4.4 shows the sources of

information before deciding to embark on a medical trip.

Table 4.4. Sources of information before deciding to embark on a medical trip

Frequency Percentage
(n = 400) (%)

1. Advice of doctor/physician in the home

237
country 20.7
2. Word-of-mouth from friends or relatives 215 18.8
3. Medical tourism intermediary’s website 299 26.1
4. Website of the hospital in Malaysia 231 20.2
5. Online medical communities 117 10.2
6. Medical tourism weblog (blog) 46 4.0

In terms of travel arrangements for medical treatment in Klang Valley and Malacca,

over half (54.8%) of the respondents said they went through medical travel

intermediaries’ websites and the remaining 45.2% said they went directly to the

hospital in Malaysia. The details of the travel arrangements for medical treatment are

summarised in Table 4.5.

Table 4.5. Arrangement for medical treatment

Frequency Percentage

115
 (n = 400) (%)
1. Directly with the hospital 181 45.2
2. Through medical travel intermediaries’
219 54.8
website

4.1.2 Importance of attributes of medical tourism

Respondents were asked to rate the importance of attributes of medical tourism. Table

4.6 and Figure 4.1 illustrates the important attributes of medical tourism. Sixty per

cent of the respondents rated the medical tourism industry as the main reason they

seek medical tourism in Klang Valley and Malacca. The second important attribute

was related to medical tourism costs (32.8%), followed by the quality of facilities and

services (5.3%) and destination environment (0.8%).

Table 4.6. The important attributes of medical tourism

Frequency
Percentage (%)
(n = 400)
1. Destination environment 3 0.8
2. Medical tourism industry 245 61.3
3. Medical tourism costs 131 32.8
4. Quality of facility and services 21 5.3

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 Important of medical tourism attributes
Country environment
400

200

Quality of facility and services 0 Medical tourism industry

Medical tourism costs

Figure 4.1 Radar chart of medical tourism attributes

4.2 Descriptive findings

4.2.1 Descriptive analysis of destination environment

Respondents mostly agreed that all items under the destination environment influence

their intention for medical tourism. Table 4.7 shows the mean and standard deviation

of the destination environment. Based on the findings, safe to travel to the destination

has the highest mean score (Mean 4.79, SD = 0.46), indicating that respondents saw

the destination as a safe destination. In addition, it was reported that stable economy

(SD = 0.61) and religious similarity (SD = 0.64) rank the second highest mean score

of 4.68. Low corruption has the lowest mean score of 3.66 (SD = 1.53), indicating

that this item is the least considered.

Table 4.7 Mean and standard deviation of destination environment

n Mean Std. Deviation

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 1. Stable exchange rate 400 4.53 0.64

2. Low corruption 400 3.66 1.53

3. Cultural similarity 400 4.57 0.76

4. Overall positive destination image 400 4.56 0.61

5. Language similarity 400 4.57 0.73

6. Safe to travel to a destination 400 4.79 0.46

7. Stable economy 400 4.68 0.61

8. Religious similarity 400 4.68 0.64

4.2.2 Descriptive analysis of medical tourism

Similar to the destination environment, respondents mostly agreed that all items under

medical tourism influence their intention for medical tourism. Table 4.8 shows the

mean and standard deviation of the medical tourism attribute. Based on the findings,

‘attractiveness of the destination as a tourist destination’ has the highest mean score

(Mean = 4.86, SD = 0.39), indicating that respondents saw Malaysia as an attractive

tourist destination. In addition to it, it was reported that ‘weather conditions’ (Mean =

4.84, SD = 0.61) and ‘many cultural and natural attractions’ (Mean = 4.84, SD = 0.64)

ranks the second highest mean score of 4.68. The remaining two items ‘popular

tourist destination’ and ‘exotic tourist destination’ (SD = 0.64) had the same mean

score of 4.80.

Table 4.8 Mean and standard deviation of medical tourism

n Mean Std. Deviation

1.Popular tourist destination 400 4.80 0.47
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 2.Exotic tourist destination 400 4.80 0.45

3.Weather conditions 400 4.84 0.46

4.Attractiveness of the destination as a tourist 400 4.86 0.39

destination

5.Many cultural and natural attractions 400 4.84 0.40

4.2.3 Descriptive analysis of medical tourism costs

Respondents were also asked about the medical tourist cost in Malaysia. In general.

respondents were highly agreed that all items under the medical tourism cost

influence their intention for medical tourism. Table 4.9 shows the mean and standard

deviation of medical tourism cost items. Based on the findings, ‘the cost to travel’ has

the highest mean score (Mean = 4.92, SD = 0.27), indicating that respondents see the

costs to travel to Malaysia as affordable. In addition to it, it was reported that

‘affordability of airfares’ (Mean = 4.91, SD = 0.30) and ‘cost of accommodation’

(Mean = 4.91, SD = 0.28) ranks the second highest mean score of 4.91. Finally, the

item ‘cost of treatment’ (SD = 0.64) had mean score of 4.80 (SD = 0.34).

Table 4.9 Mean and standard deviation of medical tourism cost

n Mean Std. Deviation

1.Cost of treatment 400 4.89 0.34

2.Healthcare costs 400 4.90 0.33

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 3.Cost of accommodation 400 4.91 0.28

4.Costs to travel 400 4.92 0.27

5.Affordability of airfares 400 4.91 0.30

4.2.4 Descriptive analysis of quality of the facilities and services

On the other hand, respondents were asked to rate the medical tourist facilities and

services in Malaysia. In general. respondents were highly agreed that all items under

the facilities and services influence their intention for medical tourism. Table 4.10

shows the mean and standard deviation of the quality of the facilities and services

items. Based on the findings, five items ‘Doctor's training’ (SD = 0.27), ‘Doctor's

expertise’ (SD = 0.29), ‘High quality standards (e.g., ISO, NCQA, ESQA)’ (SD =

0.27), ‘International certified doctors’ (SD = 0.26), and ‘Friendliness of staff and

doctors’ (SD = 0.27) has the highest mean score of 4.93, indicating that respondents

viewed Malaysia medical tourism facilities and services met their expectations.

In addition to it, it was reported that ‘State-of-the-art medical equipment (Mean =

4.91, SD = 0.29), ‘Reputation of the hospital/facility (Mean = 4.91, SD = 0.32)’ and

‘High quality of care’ (Mean = 4.91, SD = 0.28) ranks the second highest mean score

of 4.91. Finally, the ‘Accreditation of the medical facility (e.g., JCI, ISQUA)’ has the

lowest mean score of 4.87 (SD = 0.35).

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Table 4.10 Mean and standard deviation of quality of the facilities and services

Std.
n Deviatio
Mean n
40
1.Doctor's training 0 4.93 0.27
40
2.Doctor's expertise 0 4.93 0.29
3.High healthcare quality indicators (e.g., low 40
infection rate) 0 4.90 0.32
40
4.Reputation of doctors 0 4.89 0.32
5.High quality standards (e.g., ISO, NCQA, 40
ESQA) 0 4.93 0.27
40
6.High quality of care 0 4.92 0.28
40
7.State-of-the-art medical equipment 0 4.92 0.29
40
8.Quality in treatments and materials 0 4.89 0.34
9.Accreditation of the medical facility 40 4.87 0.35
(e.g., JCI, ISQUA) 0
40
10.Reputation of the hospital/facility 0 4.92 0.27
40
11. Destination medical reputation 0 4.91 0.29
40
12.International certified doctors 0 4.93 0.26
40
13.Internationally certified staff 0 4.91 0.32
40
14.International educated doctors 0 4.90 0.33
15.Friendliness of staff and doctors 40 4.93 0.27

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 0
40
16.Family recommendation of doctors 0 4.91 0.30
40 4.91 0.31
17. Family/friend recommendation of the 0
hospital/facility

4.2.5 Descriptive analysis of attitude

Respondents were asked to rate their attitude towards medical tourism in Klang

Valley and Malacca. The findings suggested that the respondents generally agreed

that their attitude influences their intention for medical tourism. Table 4.11 shows the

mean and standard deviation of attitudes items. Based on the findings, item ‘I predict

that I should travel to Klang Valley and Malacca to receive my medical treatment in

the near future’ has the highest mean score of 4.45 (SD = 0.53). In addition to it, it

was reported that ‘I intend to travel to Klang Valley and Malacca to receive my

medical treatment in the near future’ (Mean = 4.44, SD = 0.54) ranks with the second

highest mean score of 4.91. Finally, the item ‘I predict that I should travel to Klang

Valley and Malacca to receive my medical treatment in the near future’ has the lowest

mean score of 4.39 (SD = 0.52).

Table 4.11 Mean and standard deviation of attitudes

Std.
n Mean Deviation
1. I predict that I should travel to Klang Valley 400 4.45 0.53
and Malacca to receive my medical treatment in
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 the near future.

2. I plan to travel to Klang Valley and Malacca 400 4.39 0.52

to receive my medical treatment in the near
future.
3. I intend to travel to Klang Valley and 400 4.44 0.54
Malacca to receive my medical treatment in the
near future.

4.2.6 Descriptive analysis of subjective norms

Other than attitudes, the findings suggested that the respondents generally agreed that

subjective norms influence their intention for medical tourism. Table 4.12 shows the

mean and standard deviation of subjective norms items. Based on the findings, the

item ‘People who influence my behaviour think that I should travel to Klang Valley

and Malacca to receive my medical treatment’ has the highest mean score of 4.72 (SD

= 0.51). In addition to it, it was reported that the item ‘People who are important to

me think that I should travel to Klang Valley and Malacca to receive my medical

treatment.’ (Mean = 4.71, SD = 0.50) ranks the second highest mean score of 4.91.

Finally, the item ‘I would travel to Klang Valley and Malacca to receive my medical

treatment because many of my friends have already travelled abroad to receive

medical treatment.’ has the lowest mean score of 4.69 (SD = 0.52).

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 Table 4.12 Mean and standard deviation of subjective norms

Std.
n Mean Deviation
1. People who influence my behaviour think 400 4.72
0.51
that I should travel to Klang Valley and
Malacca to receive my medical treatment

2. I would travel to Klang Valley and 400 4.69 0.52

Malacca to receive my medical treatment
because many of my friends have already
travelled abroad to receive medical
treatment.
3. People who are important to me think that 400 4.71 0.50
I should travel to Klang Valley and Malacca
to receive my medical treatment.

4.2.7 Descriptive analysis of perceived behavioural control

The findings also reported that the respondents generally agreed that perceived

behavioural control influences their intention for medical tourism. Table 4.13 shows

the mean and standard deviation of perceived behavioural control items. Based on the

findings, item ‘Traveling to Klang Valley and Malacca to receive medical treatment

would be entirely within my control’ has the highest mean score of 4.76 (SD = 0.47).

In addition to it, it was reported that item ‘I would be able to travel Klang Valley and

Malacca to receive my medical treatment’ ranks the second highest mean score of

4.75 (SD = 0.49). Finally, the item ‘I have the resources, knowledge, and ability to

travel to Klang Valley and Malacca to receive my medical treatment’ has the lowest

mean score of 4.74 (SD = 0.50).

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 Table 4.13 Mean and standard deviation of Perceived behavioural control

Std.
n Mean Deviation
1. Traveling to Klang Valley and Malacca 400 4.76 0.47
to receive medical treatment would be
entirely within my control.

2. I would be able to travel to Klang Valley 400 4.75 0.49

and Malacca to receive my medical
treatment.

3. I have the resources, knowledge, and 400 4.74 0.50

ability to travel to Klang Valley and
Malacca to receive my medical treatment.

4.2.8 Descriptive analysis of intention

Respondents were also asked about their travel intention. The findings also reported

that the respondents generally agreed that perceived behavioural control influences

their intention for medical tourism. Table 4.14 shows the mean and standard deviation

of perceived behavioural control items. Based on the findings, the item ‘Traveling to a

foreign destination to receive my medical treatment would be a good idea’ has the

highest mean score of 4.80 (SD = 0.48). In addition to it, it was reported that item ‘I

like the idea of travelling to a foreign destination to receive my medical treatment’

ranks the second highest mean score of 4.79 (SD = 0.50). Finally, the item ‘Traveling

125
to a foreign destination to receive my medical treatment would be a pleasant

experience’ has the lowest mean score of 4.78 (SD = 0.49).

Table 4.14 Mean and standard deviation of travel intention

n Std.
Mean Deviation
1. Traveling to a foreign destination to receive 400 4.80 0.48
my medical treatment would be a good idea.

2. I like the idea of travelling to a foreign 400 4.79 0.50

destination to receive my medical treatment.

3. Traveling to a foreign destination to receive 400 4.78 0.49

my medical treatment would be a pleasant
experience.

4.2 Pearson Correlation analysis results

The results showed that the correlation results between destination environment and

medical destination are 0.666, destination environment and medical tourism costs is

0.340, destination environment and facility and services is 0.387, destination

environment and attitude is -.428, destination environment and subjective norms are

-.032, destination environment and perceived behavioural control 0.056, and

126
destination environment and intention is 0.085. The correlation results showed that six

independent variables (e.g. tourism destination, medical tourism costs, facility and

services, attitude, subjective norms, perceived behavioural control) had a significant

relationship with the dependent variable, behavioural intention. Among these factors,

facility and service have the highest significance and relationship, while destination

environment has no significance among others.

Among other variables, there was a high positive correlation between facility and

services and medical tourism costs, r= .75, p = .000. Other high positive correlation

variables include intention and perceived behavioural control r= .75, p = .000.

Similarly, the findings also suggested that there was a positive correlation between the

subjective norms and perceived behavioural control, r= .69, p = .000. This indicated

that there is a high correlation between the two variables. It is interesting to see that

there was a negative correlation between destination environment and attitude, r=

-.43, p = .000. This indicated that there is a moderate negative correlation between the

two variables. The details of the Pearson correlation analysis are presented in Table

4.15.

127
 Table 4.15. Pearson Correlation Analysis
Destination Medical Facility Perceived
Environmen Tourism Tourism and Subjective behavioural
t Destination Costs Services Attitude norms control Intention
1. Destination Pearson Correlation 1.000 .666 **
.340 **
.387 **
-.428 **
-0.032 0.056 0.085
Environment Sig. (2-tailed) 0.000 0.000 0.000 0.000 0.522 0.268 0.089
2.Tourism Pearson Correlation .666 **
1.000 .545 **
.571 **
-0.068 .174 **
.254 **
.270 **
Destination Sig. (2-tailed) 0.000 0.000 0.000 0.173 0.000 0.000 0.000
3.Medical Tourism Pearson Correlation .340 **
.545 **
1.000 .750 **
.138 **
.373 **
.449 **
.474 **
Costs Sig. (2-tailed) 0.000 0.000 0.000 0.006 0.000 0.000 0.000
4.Facility and Pearson Correlation .387 **
.571 **
.750 **
1.000 .239 **
.476 **
.558 **
.554 **
Services Sig. (2-tailed) 0.000 0.000 0.000 0.000 0.000 0.000 0.000
5.Attitude Pearson Correlation -.428 **
-0.068 .138 **
.239 **
1.000 .512 **
.373 **
.294 **
Sig. (2-tailed) 0.000 0.173 0.006 0.000 0.000 0.000 0.000
6.Subjective norms Pearson Correlation -0.032 .174 **
.373 **
.476 **
.512 **
1.000 .694 **
.599 **
Sig. (2-tailed) 0.522 0.000 0.000 0.000 0.000 0.000 0.000
7.Perceived Pearson Correlation 0.056 .254 **
.449 **
.558 **
.373 **
.694 **
1.000 .752 **
behavioural control Sig. (2-tailed) 0.268 0.000 0.000 0.000 0.000 0.000 0.000
** ** ** ** ** **
8.Intention Pearson Correlation 0.085 .270 .474 .554 .294 .599 .752 1.000
Sig. (2-tailed) 0.089 0.000 0.000 0.000 0.000 0.000 0.000
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).

128
4.4 Multiple Regression Results

Table 4.16 illustrates the model summary of the analysis indicating the results of R, R

squared, Adjusted R squared and standard error of the estimate for the model. The

findings showed that R has the value of 0.778 and R squared 0.605 where the R

squared determines that approximately 60.5% relation of independent variables can be

explained by the model.

Table 4.16 Model summary

Model R R Square Adjusted R Std. Error of the
Square Estimate
1 .778a .605 .598 .29605

The ANOVA test was also applied to determine the significant results and to make a

decision on whether to reject or accept a hypothesis. Based on the findings, it was

shown that the df = 7, F value is 85.67 and is significant at p = .000 level. The details

of the ANOVA is summarised in Table 4.17.

Table 4.17 ANOVA table

Model Sum of df Mean Square F Sig.
Squares
Regression 52.559 7 7.508 85.671 .000b
Residual 34.356 392 .088
Total 86.916 399

To test the hypotheses, multiple regression analysis was used to assess the variables in

this study. Each variable’s significance value indicates whether a hypothesis should

129
be accepted or rejected. For example, if the significant value is lower than 0.05, the

hypothesis is accepted, and vice versa. Table 4.18 demonstrates the coefficients of

multiple regression analysis based on the dependent and seven independent variables.

The findings suggested that out of the seven independent variables, four independent

variables were found to be significant at a .05 level. The four variables are medical

tourism cost ( p = 0.05), quality of facilities and service ( p = 0.014), subjective norms

( p = 0.007), and perceived behavioural control ( p = 0.000).

Table 18. Coefficients of multiple regression analysis

Model Unstandardize Standardize t Sig. Collinearity

d Coefficients d Statistics
Coefficients
B Std. Beta Tolerance VIF
Error
(Constant) -.75 .40 -1.88 .06
1. Attitude -.04 .04 -.05 -1.17 .24 .51 1.94
2.Subjective norms .12 .04 .13 2.73 .00 .43 2.31
3. Perceived .57 .04 .56 11.88 .00 .44 2.23
behavioural control
4. Destination -.04 .04 -.05 -1.02 .30 .38 2.60
environment
5.Tourism destination .01 .07 .00 .13 .89 .41 2.41
6.Medical tourism cost .19 .10 .08 1.78 .05 .41 2.43
7. Quality of facilities .33 .13 .14 2.45 .01 .31 2.19
and service

Medical tourism cost was found to have a significant positive relationship with

medical tourists’ intention to visit Klang Valley and Malacca (β = 0.191, p < 0.005).

130
Therefore, hypothesis 3 was supported. Similarly, the study also supports hypothesis

4, where the quality of facilities and service was found to have a significant positive

influence on the intention to visit Klang Valley and Malacca (β = 0.337, p < 0.005). In

addition, subjective norms (β = 0.128, p < 0.005) were found to have a significant

positive influence on the intention to visit Klang Valley and Malacca and support

hypothesis 6. Finally, this study supported hypothesis 7, where perceived behavioural

control (β = 0.572, p < 0.005) was found to have a significant positive influence on

the intention to visit Klang Valley and Malacca.

4.4 Summary of the hypothesis testing

The hypotheses were developed in the literature review chapter, it speculated

relationship existed between each independent and dependent variable based on the

past research findings. However, from the results obtained from multiple regression

analysis, the status of research hypotheses was examined and summarized in Table

4.19. Based on the Table, three hypothesis (hypothesis 1, hypothesis 4, and hypothesis

5) are not supported whereas another four hypothesis (hypothesis 2, hypothesis 3,

hypothesis 6, & hypothesis 7) are supported.

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 Table 4.19. Summary of Hypotheses
Hypotheses Statements Sig level Decision
H1: There is a positive relationship between attitude and .243 Not
intention to visit medical tourism in Klang Valley Supported
and Malacca.
H2: There is a positive relationship between subjective .007 Supported
norms and intention to visit medical tourism in
Klang Valley and Malacca.

H3: There is a positive relationship between perceived .000 Supported

behavioural control and intention to visit medical
tourism in Klang Valley and Malacca.

H4: There is a positive relationship between destination .304 Not

environment and intention to visit medical tourism Supported
in Klang Valley and Malacca.

H5: There is a positive relationship between tourism .892 Not

destinations and intention to visit medical tourism in Supported
Klang Valley and Malacca.

H6: There is a positive relationship between medical .050 Supported

tourism cost and intention to visit medical tourism in
Klang Valley and Malacca.
H7: There is a positive relationship between quality of .014 Supported
facilities and service and intention to visit medical
tourism in Klang Valley and Malacca.

4.6 Medical Tourism Index

The researcher followed Fetscherin and Stephano’s (2016) development of the

Medical Tourism Index procedure (see Chapter 3). Based on the findings in Table

4.20, the overall rating score for both destinations is the Destination environment

(87.6), Tourism destination (95.7), Medical tourism cost (97.7), and Quality of

facilities and service (97.7). For an individual destination, the performance of

132
Malacca is better than Klang Valley for all components. Medical tourists who visited

Malacca (99.1%) viewed medical tourism costs as attractive compared to Klang

Valley (96.7%).

Meanwhile, medical tourists who visited Malacca (99.0%) viewed the quality of

facilities and service as attractive compared to Klang Valley (96.7%). Similarly,

medical tourists who visited Malacca (96.4%) viewed the destination environment as

attractive compared to Klang Valley (82.8%). Medical tourists who visited Malacca

(98.6%) viewed tourism destinations as attractive compared to Klang Valley

(93.8%).

Table 4.20 Comparison of Medical Tourism Index of Klang Valley and Malacca

Overall Klang Malacca

Valley

1. Destination environment 87.6 82.8 95.4

2.Tourism destination 95.7 93.8 98.6

3.Medical tourism cost 97.7 96.7 99.1

4. Quality of facilities and service 97.7 96.8 99.0

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Figure 4.2. Comparison of Medical Tourism Index of Klang Valley and Malacca

Figure 4.3 Radar chart for medical tourism index of Klang Valley and Malacca

134
4.7 Conclusion

The findings suggests that most of the medical tourists are male, married, aged

between 40-49. Most of the medical tourists are from Indonesia. Majority of them had

a bachelor’s degree and self-employed. It was found that most of the medical tourists

are earning high income, with over half of them earn more than RM25,000.00 per

month. The finding drawn from the data showed that destination environment,

tourism destination, and attitude has no statistical relationship with the intention to

visit medical tourism in Klang Valley and Malacca. The following chapter concludes

the study by offering a discussion of results, implications, limitations and suggestions

for future research.

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 CHAPTER 5

CONCLUSION

5.0 Introduction

In this chapter, the overall findings will be discussed including the recap of research

questions and objectives and the research hypotheses. This study sought to answer

three objectives. The first objective was to explore the characteristics of medical

tourists travelled to Klang Valley and Malacca while the second objevtive was to

examine the factors influencing medical tourists’ to seek medical treatment in

Klang Valley and Malacca. Finally, the third objective was to develop a medical

tourism index for Klang Valley and Malacca. A discussion of existing research

findings compared to the past research findings for determining finding consistencies

was presented. Furthermore, this chapter will also make research recommendations on

the findings and discuss research implications, contributions, and limitations.

5.1 Summary and Discussion of the Findings

Medical tourism is a significant and rapidly expanding industry that offers substantial

economic prospects. It is an important aspect of the service economy, and medical

tourists play an important role in the growth of the tourism industry. The government

of Malaysia is intended to transform the country into a world-class tourism

destination, while medical tourism has been seen as the key contribution to boosting

the national economic developments. In the following sub-sections, the details of the

summary based on research objectives will be discussed.

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5.1.1 Charateristic of the medical tourists

The findings suggests that most of the medical tourists are male, married, aged

between 40-49. Most of the medical tourists are from Indonesia. Majority of

them had a bachelor’s degree and self-employed. It was found that most of the

medical tourists are earning high income, with over half of them earn more than

RM25,000.00 per month. Consistent with previous studies, most of the medical

tourists visited Malaysia were from Indonesia (Musa et al., 2012; Ormond &

Sulianti, 2017; Ratnasari et al., 2022; Saragih & Jonathan, 2019). Similarly, it is

not surprised to see most of the medical tourists are middle aged between 40 and

59 (Ratnasari et al., 2022) due to health-related problems. However, in term of

gender, this study found more male than female, which contrasts with previous

literature (Ratnasari et al., 2022; Yeoh, Othman, & Ahmad, 2013). In term of

occupation, this study is consistent with previous studies who reported most of

the Indonesian medical tourists are self-employed and afford to pay for medical

tourism trip abroad (Ratnasari et al., 2022; Saragih & Jonathan, 2019).

5.1.2 Factors influencing medical tourists’ to seek medical treatment in Klang

Valley and Malacca

The findings revealed factors that determine tourists’ behaviours to visit medical

tourism in Klang Valley and Malacca. However, it will be hard to attract potential

medical tourists to Klang Valley and Malacca without a better knowledge of the

significance of these variables in determining their travel intentions. To sum up, the

137
current study investigated the factors influencing the medical tourist’s intention to

participate in medical tourism. Four of the seven hypotheses proposed for this study

were supported by the findings.

Based on the outcomes of the current study, there are a few points worth mentioning.

The empirical findings show that the only two TPB variables (subjective norms,

perceived behavioural control) have a favourable and significant impact on tourists’

intention to visit Klang Valley and Malacca. However, attitude (hypothesis 5: Beta =

-. 049) was found no significant impact on tourists' intention to visit Klang Valley and

Malacca. This is in contrast with the findings of previous research (Chaulagain,

Pizam, and Wang, 2021; Martin, Ramamonjiarivelo, & Martin 2011), where the

attitude was found to be significantly correlated with individuals’ intention to

participate in medical tourism. More precisely, the findings show that people’s

favourable attitudes have no impact on their intention to participate in medical

tourism.

On the other hand, these results are in agreement with previous research (e.g. Han et

al., 2010; Han & Kim, 2010; Hsu & Huang, 2012; Lam & Hsu, 2006), suggesting that

a rise in a person’s subjective norm and perceived behavioural control leads to an

increase in their intention to do something.

138
The findings (hypothesis 6: Beta = .128) show that people who are interested in

medical tourism are influenced by others' opinions and tend to act in accordance with

other's (i.e., family and friends, colleagues) expectations. Medical tourists came to

Malaysia for medical treatment after being advised to do so by persons they see as

significant such as their friends or family. This is consistent with prior research

findings that subjective norms were a significant predictor of behavioural intention.

This study is consistent with a previous study by Perkasa (2016), who stated that

patients from Indonesia sought medical care in Malaysia based on the advice of their

acquaintances, particularly those who had previously sought medical treatment in

Malaysia.

Similarly, the findings (hypothesis 7: Beta = .572) also demonstrated that people’s

perceived behavioural control was linked to their intention to travel for medical

treatment. The findings suggest that those who think they lack the knowledge and

information about medical tourism, as well as believe that travelling to a foreign

nation for medical care is out of their control, are less likely to engage in medical

tourism. This finding contradicted those of prior medical tourism research, which

found no significant links between behavioural control and intention to participate in

medical tourism (Martin, Ramamonjiarivelo, & Martin, 2011; Lee, Han, & Lockyer,

2012). However, it is consistent with Chaulagain, Pizam, and Wang’s (2021) study,

where they discovered that the most significant influence on behavioural intention

was perceived behavioural control. It is also true that medical tourists have more

resources, and the more resources they have, the simpler it is for them to make a

decision.

139
In the tourist environment, the intention to visit is crucial, and hospitals that wish to

flourish in the competitive field of medical tourism must have this intention.

However, this study is in contrast with other studies and did not find a positive

relationship between destination environment and behavioural intention. Since the

majority of the respondents are Indonesian and share similar cultures, languages, and

religions. Therefore, the destination environment was found not significant in this

study.

Medical tourists consider the facility and service provided by hospitals to be an

important component, which increases the likelihood of visit intention. Although

treatments are usually accessible in-home nations at a higher cost, this is a driving

force behind medical tourism (Hanefeld, Horsfall, Lunt, & Smith, 2013). Thus,

medical tourism cost is another factor that could influence the intention to visit

medical tourism. This study is inconsistence with the finding reported by Abd Manaf,

Hussin, Kassim, Alavi, and Dahari, (2015), where their study shows that medical

tourism costs are not the most important factor, perhaps because the majority of the

Indonesian medical tourists seeking better quality treatment and costs are not so

important.

Customers’ decisions to engage in a particular activity and spread favourable word-

of-mouth are influenced by perceived price. The current finding is consistent with

140
Han and Hyun's (2015) findings, which suggest that, in the context of medical

tourism, hospitals must realise the crucial role of price fairness and employ this

approach when supporting more cost-effective ways to increase consumer retention

and maximise profit.

Recently, researchers in marketing and tourism have paid close attention to the image

of a country or country's environment. Unfortunately, it has received very little

attention in the context of medical tourism (Mohammad Jamal, Chelliah, & Haron,

2016). The significant impact of facilities and services on the intention to visit Klang

Valley and Malacca demonstrates the crucial relevance of medical tourists’ health and

well-being in the medical tourism environment.

5.1.3 Medical tourism index

The medical tourism index allows stakeholder to benchmark and compare the

medical tourism destination in different regions. Since its establishment, medical

tourism index developed by healthcare resources does not cover Malaysia as a

destination. Therefore, one of the objectives of the study was to develop a

medical tourism index for Malaysia. Specifically, the medical tourism index also

sub-divided to measure two popular medical tourism destinations in Malaysia,

namely Klang Valley and Malacca.

141
The early medical tourism index comprises five dimensions (i.e., service and

physical facilities, cost, physician, hospital reputation, and destination image)

which was developed by Yuhanis et al. (2015). On the other hand, Medical

Tourism.com (2022) measured three dimensions (e.g., destination environment,

medical tourism industry, quality of facility and services). Subsequently, the

medical tourism index was furthered refined by Fetscherin and Stephano’s

(2016) which includes four dimensions (i.e., country, tourism, medical costs,

medical facility and services).

The findings suggested that the overall rating for both destinations is considered

good, with three dimensions score above 95 (i.e., Tourism destination (95.7),

Medical tourism cost (97.7), and Quality of facilities and service (97.7)).

Meanwhile, Destination environment score 87.6. As for individual destination,

the findings showed that the performance of Malacca is better than Klang Valley

across all components. Medical tourists who visited Malacca viewed medical

tourism costs as attractive compared to Klang Valley. This is probably due to the

cost of living and traveling in Malacca is slightly lower than Klang Valley. On

the other hand, the quality of facilities and service in Malacca are more

attractive compared to Klang Valley. Medical tourists also viewed Malacca

destination environment as more attractive compared to Klang Valley. This is

probably because there is more tourist’s attraction in Malacca and it is the

UNESCO World Heritage Site. These informations are important for destination

marketing organisation as well as hospitals.

142
5.2 Implications of the Study

The conducting of research is to benefit different users and audiences. On the other

hand, the research study would explore some new insights or changes in current

phenomena, and therefore this section will discuss the research implications of the

current research study. This research has had both theoretical and practical

implications, which will be elaborated on in the following sub-sections.

5.2.1 Theoretical implications

From the theoretical standpoint, the results of a study will have various implications

for different users and audiences when it comes to decision making. As a result, the

implications of the current study findings are addressed in this section. Thus,

researchers will be able to identify more appropriate assessment items and delve

deeper into the influential constructs in the decision-making processes of international

medical tourists.

This study answered the first research objective by adding contributions to the

medical tourists’ profile and the travel-related information of the medical

143
tourists. Previous studies usually presented basic socio-demographic profiles of

medical tourists, however, the travel-related information of medical tourists are

often not taken into account. In this study, travel-related information (i.e.,

frequency of visit, health insurance coverage, source of infromation, arrangment

of medical treatment) of medical tourists were identidied.

The findings of this study have answered second research objectives, which to

examine the factors influencing medical tourists to seek medical treatment in Klang

Valley and Malacca. It appears that medical tourists used diverse mixes of these

beliefs throughout their decision-making processes. For example, the finding of this

research found that attitude does not have a statistical relationship with the intention

to visit medical tourism in Klang Valley and Malacca. This is something quite

interesting compared to previous studies. Nonetheless, the majority of previous

research results established a link between attitude and behavioural intention. The

discrepancy in the findings pointed to a shift in medical tourists’ attitudes toward

medical tourism. Furthermore, this study enhances the medical tourism index by

adding cultural similarity items into destination environment dimension. The

initial dimension of this study is country environment and was modified as

destination environment.

This study looked into the impact of a destination environment on the intention to

visit a medical tourism destination, which had received little attention in the prior

literature (Chaulagain, Jahromi, & Fu, 2021). The favourable destination environment

of a medical tourism location would increase the level of intention to visit that

144
destination. In this context, the destination's environment has played a key role in

medical tourism. These findings provide additional justifications to the findings of a

few existing research on the impact of a destination environment on tourist behaviour

intentions. For example, the current study in line with those of Chaulagain, Wiitala,

and Fu (2019) and Chaulagain, Jahromi, and Fu (2021), who found that destination

and destination image has a favourable impact on the intention to travel to Cuba as a

general tourist destination.

5.2.2 Practical implications

This research has a number of practical implications for medical tourism destinations,

especially for hospitals that rely on medical tourism as an additional source of

revenue. The information about medical tourist’s sociodemographic profile and

the trip-related information are useful for destination marketing organisation to

plan tourism related activities that are suitable for medical tourists. Meanwhile,

hospital can utilise the information to better target their customer segment. Since

most of the medical tourists are from Indonesia, hospital can attract tourists

from other regions.

Various stakeholders in the medical tourism sector may build and implement a more

holistic and successful marketing plan to generate a more positive view of medical

tourism for potential tourists by identifying aspects impacting individuals’ medical

tourism behaviour. For example, a favourable destination environment (e.g., stable

economy, country image) can aid a particular hospital in increasing potential medical

tourists’ intention to travel to the destination for medical treatment. From the eyes of

145
the respondents, Malaysia has a positive country image (political stability) and

stable economy. To promote a favourable image of the destination environment,

governments should enhance economic, political, social, and technical circumstances,

as well as safety and security in the destination.

Since the impression of the quality of medical tourism facilities and services has a

considerable impact on medical tourists' decision to travel to a medical tourism

destination, medical tourism locations must develop and sustain their product quality

to attract more medical tourists. Hospital marketing managers can also advise

potential tourists about the high-quality treatment processes and innovative medical

technology that are accessible in their hospitals. Meanwhile, destination marketers

and hospitals should spend money to upgrade and promote tourism infrastructure and

medical tourism services. In addition, the findings of the study may be used as a

reference by some academics in the hotel industry and those involved in hospital

administration to better understand how the quality of facilities and services has a

significant impact on international medical tourists.

One of the main motivations for visiting medical tourism destinations is the relatively

lower cost of treatments. As a result, it is critical for medical tourism hospitals to

make their rates affordable and not to charge fees that are higher than those of their

competitors. For example, Cham et al. (2021) suggested that hospitals are encouraged

to collaborate with the Ministry of Health Malaysia in defining medical service rates
146
using a Competitive Pricing Strategy to make sure the rate is competitive among other

industry players in medical tourism.

Finally, the study compared the medical tourism index based on the four scales

(destination environment, Tourism destination, Medical tourism cost, and Quality of

facilities and service. The findings suggested that among the four scales, medical

tourism cost and quality of facilities and service are viewed as important determinants

when medical tourists choose their medical tourism destination. Therefore, destination

marketers and hospitals managers should focus more on the quality of facilities and

services and offer competitive cost of treatment for medical tourists. Compared to

Klang Valley, Malacca scored high across the four scales (Destination environment,

95.4%, Tourism destination 98.6%, Medical tourism cost 99.1%, Quality of facilities

and services 99%). This could be due to the perceived image of the destination, where

the standard of living in Malacca is generally lower than Klang Valley. Meanwhile,

Malacca is a UNESCO world heritage city and is easy accessed by medical tourists

from Indonesia via water and air transport.

5.3 Research Limitation and Suggestions for Future Research

Although there were few theoretical and practical contributions highlighted, this

research is subject to some limitations, and future research is needed to validate the

findings of the findings. First, notwithstanding the uniqueness of the study sites, the

147
study's scope was limited because it was limited to Klang Valley and Malacca only,

implying that the findings are restricted in their generalizability. According to Glen

(2002), the research limitations affect the research settings and also generate impacts

on the generalizations and reliability of the research findings. Therefore researchers

should reliably identify all possible research limitations, and acknowledge them to the

audience so that they can be aware of these limitations when making decisions upon

the research findings. Future studies may incorporate other medical tourism

destinations to make a comparison.

Second, the information of the study was collected from Asian respondents only and

the majority of them are Indonesian (85%). Previous studies found that cultural

differences and country of origin may influence tourists’ behavioural intentions.

Therefore, it is suggested that future research should collect data from more countries

so that it offers valuable evidence for comparison of cultural differences and country

of origin in medical tourists’ behavioural intentions. This information would enable

the creation of customised promotional campaigns for medical tourists from various

geographic segments. Understanding the kind of health care services medical tourists

from a certain geographic region want and why they come to Malaysia for treatment

allows for the creation of focused initiatives that contribute to greater quality and

more tailored services.

Third, this study did not consider if participants' behavioural intentions differed

depending upon the type of health condition or disease they were suffering from. This

148
is because an individual’s intentions to seek medical care in a foreign nation may vary

depending on their health status or disease-related conditions (Chaulagain, Jahromi, &

Fu, 2021). As a result, subsequent research that takes into account the aforementioned

variables may yield different results.

Fourth, this study is quantitative in nature. Future studies should consider qualitative

research to better understand the underlying factors influencing behavioural intention.

Meanwhile, future study may consider mixed method to verify the findings.

Finally, future research might look at the influence of the current pandemic caused by

COVID-19 on medical tourists' intentions to visit Klang Valley and Malacca.

149
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Appendix

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Dear respondent,
I am a PhD student pursuing at Universiti Putra Malaysia (UPM). I am currently
conducting my thesis with the title “Developing a Medical Tourism Index (MTI)
within Klang Valley and Malacca, Malaysia” in purpose to complete the PhD degree
program. The purpose of this study is to develop a Medical Tourism Index based on
your valuable answers. You are required to provide answer for four categories (i.e.,
(1) country environment (2) medical and tourism industry (3) Medical tourism costs
and (4) quality of facility and services. There are 4 sections included in this
questionnaire which that Section 1 is about your agreement on medical tourism
construct: (1) country environment (e.g., country is safe), (2) medical and tourism
industry (3) Medical tourism costs and (4) quality of facility and services (e.g.,
doctor’s experience). For Section 2, you are required to assign a value to each group
to indicate how important do you feel about each group. Section 3 asks about your
information based on theory of planned behaviour (i.e., attitude, subjective norms,
perceived behavioural control, and intention to visit). The last section is about your
demographic profile.

This questionnaire will take approximately 20 to 25 minutes to complete. All the

information provided through this survey would be handled with strict confidentiality.

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The outcome will not appear any identity information of you as all the results from
the research will be reported as statistical summaries only.

If you have any questions or concern about the research, please do not hesitate to
email me at wongdaidi@yahoo.com. Your participation is greatly appreciated and
thanks for your cooperation in spending time to complete the survey.

Yours sincerely,
_______

Wong Dai Di
PHD Candidate

Section 1
This section indicates the statements regarding country environment (e.g., country is
safe), (2) medical and tourism industry (3) Medical tourism costs and (4) quality of
facility and services (e.g. doctor’s experience). Please circle in the appropriate box to
indicate your agreement or disagreement with the following statements as related to
Klang Valley and Malacca as a Medical Tourism Destination.

Destination Environment Strongly Disagree Neutral Agree Strongly

Disagree Agree
9. Stable exchange rate 1 2 3 4 5
10. Low corruption 1 2 3 4 5
11. Cultural similarity 1 2 3 4 5
12. Overall positive country 1 2 3 4 5
image
13. Language similarity 1 2 3 4 5
14. Safe to travel to country 1 2 3 4 5
15. Stable economy 1 2 3 4 5
16. Religious similarity 1 2 3 4 5

Tourism Destination Strongly Disagree Neutral Agree Strongly

Disagree Agree
1.Popular tourist destination 1 2 3 4 5
2.Exotic tourist destination 1 2 3 4 5
3.Weather conditions 1 2 3 4 5
4.Attractiveness of the country as 1 2 3 4 5

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a tourist destination
5.Many cultural and natural 1 2 3 4 5
attractions

Medical Tourism Costs Strongly Disagree Neutral Agree Strongly

Disagree Agree
1.Cost of treatment 1 2 3 4 5
2.Healthcare costs 1 2 3 4 5
3.Cost of accommodation 1 2 3 4 5
4.Costs to travel 1 2 3 4 5
5.Affordability of airfares 1 2 3 4 5

Facility and Services Strongly Disagree Neutral Agree Strongly

Disagree Agree
1.Doctor's training 1 2 3 4 5
2.Doctor's expertise 1 2 3 4 5
3.High healthcare quality 1 2 3 4 5
indicators (e.g., low infection rate)
4.Reputation of doctors 1 2 3 4 5
5.High quality standards (e.g., 1 2 3 4 5
ISO, NCQA, ESQA)
6.High quality of care 1 2 3 4 5
7.State-of-the-art medical 1 2 3 4 5
equipment
8.Quality in treatments and 1 2 3 4 5
materials
9.Accreditation of the medical 1 2 3 4 5
facility (e.g., JCI, ISQUA)
10.Reputation of the 1 2 3 4 5
hospital/facility
11.Country medical reputation 1 2 3 4 5
12.International certified doctors 1 2 3 4 5
13.Internationally certified staff 1 2 3 4 5
14.International educated doctors 1 2 3 4 5
15.Friendliness of staff and 1 2 3 4 5
doctors
16.Family recommendation of 1 2 3 4 5
doctors
17. Family/friend recommendation 1 2 3 4 5

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 of the hospital/facility

Section 2: Theory of Planned Behaviour related constructs.

This section indicates the statements regarding to the theory of planned behaviour
behaviour (i.e., attitude, subjective norms, perceived behavioural control, and
intention to visit). Please circle in the appropriate box to indicate your agreement or
disagreement with the following statements as related to your attitudes, subjective
norms, and perceived behavioural controls on the intention to visit Klang Valley and
Malacca.

Attitudes Strongly Disagree Neutral Agree Strongly

Disagree Agree
1. I predict that I should travel to 1 2 3 4 5
Klang Valley and Malacca to
receive my medical treatment in
the near future.
2. I plan to travel to Klang Valley 1 2 3 4 5
and Malacca to receive my
medical treatment in the near
future.
3. I intend to travel to Klang 1 2 3 4 5
Valley and Malacca to receive my
medical treatment in the near
future.

Subjective norms Strongly Disagree Neutral Agree Strongly

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 Disagree Agree
1. People who influence my 1 2 3 4 5
behavior think that I should travel
to Klang Valley and Malacca to
receive my medical treatment
2. I would travel to Klang Valley 1 2 3 4 5
and Malacca to receive my
medical treatment because many
of my friends have already
traveled abroad to receive medical
treatment.
3. People who are important to me 1 2 3 4 5
think that I should travel to Klang
Valley and Malacca to receive my
medical treatment.

Perceived behavioural control Strongly Disagree Neutral Agree Strongly

Disagree Agree
1. Traveling to Klang Valley and 1 2 3 4 5
Malacca to receive medical
treatment would be entirely within
my control.
2. I would be able to travel Klang 1 2 3 4 5
Valley and Malacca to receive my
medical treatment.
3. I have the resources, 1 2 3 4 5
knowledge, and ability to travel to
Klang Valley and Malacca to
receive my medical treatment.

Travel intention Strongly Disagree Neutral Agree Strongly

Disagree Agree
1. Traveling to a foreign country 1 2 3 4 5
to receive my medical treatment
would be a good idea.
2. I like the idea of traveling to a 1 2 3 4 5
foreign country to receive my
medical treatment.
3. Traveling to a foreign country 1 2 3 4 5

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 to receive my medical treatment
would be a pleasant experience.

Section 3

1.The previous statements can be combined into four groups: (1) country
environment (e.g. country is safe), (2) medical and tourism industry (3) Medical
tourism costs and (4) quality of facility and services (e.g. doctor’s experience).
How important do you feel is each group? Using a total of 100 points, please assign a
value to each group.

Dimension Point
1) Destination environment (e.g., stable economy, country
image)
2) Medical tourism industry
3) Medical tourism costs
4) Quality of facility and services
Total 100

Section 4: Demographic profile and trip related information

Please tick (√) ONLY ONE response in the appropriate box.

1) What is your gender?

o Male
o Female

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 2) What is your marital status?
o Single
o Married
o Divorced/Separated

3) What is your age?

o _____________ years old

4) Nationality
o _____________

5) What is your education background?

o Primary School
o High School
o Diploma
o Bachelor Degree
o Postgraduate

6) What is your occupation?

o Government Servant
o Self-employed
o Private sector employee
o Student
o Unemployed
o Retiree
o Other: Please specify ___________

7) What is your gross monthly income in your currency?

o ___________

8. How many times have you traveled on a medical trip to Malaysia including this
trip?
_________ times

9. Please rank the TOP THREE sources of information you sought before making the
decision to embark on this medical trip.

_____ Advice of doctor/physician in your country

_____ Word-of- mouth from friends or relatives
_____Medical tourism intermediary’s website
_____Website of hospital in Thailand
_____Online medical communities

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_____Medical tourism weblog (blog)
_____Reading the testimonies of other patients who had surgery abroad
_____ Other (please specify)__________________________________

10. What is your health insurance coverage/health coverage plan?

o Insurance through a current or former employer or union

o Insurance purchased directly from an insurance company
o Medicare
o Medicaid, Medical Assistance or any kind of government-assistance plan
o TRICARE or other military healthcare
o Any other type of healthcare insurance or coverage plans
o Uninsured
o Don’t Know

11. If you have not visited Malaysia for medical tourism, which medical tourism
destinations you would like to visit?
o ______________

12. How did you arrange for this medical treatment?

o Directly with the hospital
o Through medical travel intermediaries’ websites
o Other (please specify)____________________________________

13. Would you suggest your friends and family to visit Malaysia for medical tourism?
o Yes
o No

4. How much (in your currency) you spend for your medical treatment abroad?
___________

Thank you for your help.

176
 LIST OF PUBLICATION

1. Di Wong, D., Isa, S. S., Bidin, S., & Kassim, R. (2022). Medical Tourism Index: A
Comparative Study of Klang Valley and Malacca. International Journal of Social Science
Research, 4(1), 216-228.
2.

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