A Conceptual Study of Human and Non-Human Factors in Determining Medical Tourists’ Satisfaction
Hana Mazahery1*, Shankar Chelliah1
1 School of Management, Universiti Sains Malaysia, Penang Island, Malaysia
*Corresponding Author: mazaheri.hannah@gmail.com
Accepted: 1 June 2020 | Published: 15 June 2020
________________________________________________________________________________________
Abstract: Medical tourism has become one of the most beneficial industries for the economy cycle of those countries which have potential. On the other hand, considering how important it is for developing countries in particular to grow their revenue through foreign exchange currency, taking advantage of this multi-billion-dollar industry is a significant opportunity that they cannot disregard. Moreover, medical tourists’ perception and satisfaction play a crucial role in this field since they can lead the country to receive more visitors and be a stronger pole in this industry. Hence, this study aims to present a conceptual examination on the importance of evaluating medical tourists’ satisfaction through the categories of human and non-human factors.
Keywords: Medical Tourism, Medical Tourists’ Satisfaction
___________________________________________________________________________
1. Introduction
Nowadays tourism is one of the most significant industries to help promoting the income in countries. Therefore, improving its efficiency would lead to higher revenue as well as more opportunities of employment for countries. Consequently, attracting this financial source from outside of the country’s borders would have a crucial influence on developing the country. Due to the availability of the necessary potential and resources for development, countries can greatly benefit from this industry. Medical tourism is known as one of the most important ways of attracting tourists (Saadatnia & Mehregan, 2014).
2. Literature Review
World Tourism Organization (1995) defines tourism as “the activities of person’s travelling to and staying in places outside their usual environment for not more than one consecutive year for leisure, business and other purposes”. In accordance with this definition, tourism activities do not merely contain recreational and leisure purposes but also include business, medical and other possible purposes as well. Healthcare-oriented travels may be curative to receive the required treatment or preventive/wellness-related (Aydin & Karamehmet, 2017).
On the other hand, the definition of health is denoted by The World Health Organization (1946) as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Hence, health treatment would encompass all services which improve one’s level of physical, mental and social well-being as well as preventing potential relevant problems (Aydin & Karamehmet, 2017).
Since health is indubitably the most important possession of human being, travelling beyond country’s borders to seek various treatments to improve one’s health has become significantly common among population (Yang et al., 2015). As mentioned by Cohen (2012), poor level of health would significantly affect the quality of life and is a matter of concern for all people.
Based on the aforesaid, medical tourism could be defined as going from the residence to another place to receive health-related services. Moreover, medical tourists may take this opportunity to enjoy the touristic and recreational attractions as well which is known as the secondary concern since the primary concern would be receiving health-related services (Bookman & Bookman, 2007; Genç, 2012). This newly innovated industry could have a tremendous influence on country’s economic and social life that specially developing countries cannot disregard (Hunter, 2007; Heung et al., 2010).
THEME 1: Global Medical Tourism
It is suggested by estimations that 750,000 citizens of USA took journeys abroad to receive health-related services in 2007 (Zamani-Farahani & Henderson, 2010). As stated by Patients Beyond Border (PB, 2018), approximately 11 million people travel abroad by health-related purposes annually and in 2017, 1.4 million of this population were Americans who travelled beyond US borders to receive treatment.
As stated by Stephano (2018), nowadays medical operations in various range from dental and cosmetic to orthopedic surgery can be offered in diverse countries by affordable cost as well as high quality. She also adds that the top 10 global medical tourism destinations are India, Brazil, Malaysia, Thailand, Turkey, Mexico, Costa Rica, Taiwan, South Korea and Singapore.
High cost medical treatments in Europe and USA, have driven plenty of patients to other countries to seek health services and medical treatments (Hosseini, Maher, Safarian, Ayoubian, Sheibani-Tehrani, Amini-Anabad & Hashemidehaghi, 2015). Medical tourists may save 40% to 90% of the cost when they travel beyond borders to receive healthcare services compared to receiving such services at their home countries (Bookman & Bookman, 2007; Merrell et al., 2008). Accordingly, cost can be one of the motivations that is driving patients to seek treatments beyond their countries’ borders.
On the other hand, Even though, people from developed and wealthy countries tend to go to developing countries to seek healthcare services because of the less medical expense, they do not overlook the quality-related concerns (Sarwar, Manaf & Omar, 2012; Ferdosi, Jabbari, Keyvanara & Agharahimi, 2013). Therefore, it is needless to mention that all industries including medical tourism, are required to improve quality in their services in order to survive.
Furthermore, many people in developed countries do not receive the healthcare services they demand whether due to the limited insurance coverage or lack of suitable or sufficient supply of the relevant services (Aydin & Karamehmet, 2017). This causes the problem of accessibility and availability which results in a conflict with the quality of life (Aydin &
Karamehmet, 2017). Hence, westerners who are not covered by a suitable insurance coverage or are not willing to wait to receive these services may prefer an international destination which will provide them with their desired treatments and services in a timely procedure (Cohen, 2012).
The development of medical tourism is effected by multiple factors such as high expense of medical operations and surgeries in developed countries, the growth of international travel options which are reasonably priced, quality enhancement of standards in developing countries, increasing the desire for dental and cosmetic operation, maturity increment in medical tourism operations, the support of the government and increasing the communication technologies and information (Cohen, 2012; Connell, 2006; Deloitte, 2009; Eisslera &
Casken, 2013; Laing & Weiler, 2008; OECD, 2012; Pafford, 2009).
THEME 2: Medical Tourists’ Satisfaction
Satisfaction has been defined by various researchers through diverse concepts; Vavra (1997) considers the customer satisfaction definition to be based as a procedure, emphasizing the psychological, perceptual and evaluative processes that have contributed to the satisfaction of customer through the process of service delivery. Patients’ satisfaction is identified to be the patient’s perceptual understanding of the received services compared to the expected services (Mohammad Varzi, Saki, Momeni, Rajabi Vasokolaei, Khodakaramifard, Arab Zouzani &
Jalilian, 2016). Satisfaction is a complex process of human being which covers both cognitive and affective processes, coupled with psychological and physiological effects (Oh & Park, 1997). Satisfaction is often conceptualized as the final result of the comparison between expectations and perceptions of a service (Oliver, 1980; Ross, Frommelt, Hazelwood &
Chang, 1987; Spreng, MacKenzie & Olshavsky, 1996; Tam, 2005).
Researchers have indicated the significance of considering overall perceptions of patients on medical care (Baltussen, Ye, Haddad, & Sauerborn, 2002; Carmichael, 1996; Davies & Ware, 1988) and they also have proposed that in the medical care systems’ design and management, patients’ satisfaction shall be taken as an important criterion of assessment (Carmichael, 1996; Davies & Ware, 1988; Donabedian, 1988). The assessment is considered to be a crucial quality indicator that requires constant evaluation in light of the serious competition in the industry of health tourism (Yellen et al., 2002).
Gaining a great level of patients’ satisfaction often results in loyalty and procreates a considerable level of affirmative word-of-mouth that will be of great benefits in a long-term success (Yucelt, 1994). Patient satisfaction is considered to be a highly favorable result of hospital’s clinical care and it might even be counted as health status’s element (Donabedian, 1988).
Patients expressing their dissatisfaction or satisfaction can be a judgement on hospital care’s quality in all its dimensions. Whatever its limitations and strengths are, patients’ satisfaction shall be an indispensable indicator to assess the care quality of hospitals (Torcson, 2005).
Furthermore, Patients’ satisfaction can be defined as the level of which patients are pleased with their healthcare, outside and inside of the offices of doctors (Heath, 2016).
Accordingly, it is safe to say that patients’ satisfaction is of great importance to the medical tourism industry, since it is a significant element and a great indicator of the level of healthcare quality and how it is perceived by patients. Therefore, a higher level of patients’
satisfaction leads to a more accredited word-of-mouth and finally it will result in the development of medical tourism industry in the country.
THEME 3: Human Factors
As stated by World Health Organization (2012), human factors apply anywhere humans work and the universal essence of human fallibility is acknowledged by human factors. These factors can be counted as great contributors to various healthcare events (WHO, 2012).
Human factors can lead to crucial and sometimes fatal consequences.
Nevertheless, healthcare system can grow safer by identifying the potential faults, development of systems and plans to learn from previous mistakes, in order to lower the possibility of their effects and occurrence (WHO, 2012). Hence, this study has adopted WHO’s (2012) explanation of human factors in measuring medical tourists’ satisfaction through the elements of medical care, emotional support and human interaction, ethical conduct and patient safety.
In the concept of medical tourism, human factors can refer to multiple affairs such as medical care, emotional support, ethical conduct and patient safety.
Medical Care: In this field, medical care basically focuses on the quality of the relationship between doctors and patients. When doctors take the opportunity to be with their patients by listening and explaining to them and when patients find doctors available whenever they need, it makes patients feel that they are truly cared for and this directly increase the level of patients’ satisfaction (Gaur et al., 2011).
In this context, explaining refers to doctors delivering enough information to patients about their health situation, home care, medication, necessary medical treatment and its process whilst listening describes the perspective of patients on doctors’ tendency to assign a specific time to listen to patients and consider their issues (Gaur et al., 2011). Listening illustrates the level of one’s attention which will positively affect the satisfaction degree of customers (Swan & Oliver, 1987).
Emotional Support: Emotional support is an essential element to social support by assuring people that they are valued, loved and cared for (Cobb, 1976). In medical tourism industry, emotional support mostly explains the relation among patients and hospital’s staff including nurses, receptionists and caregivers. It has been strongly proposed that emotional support dimension of patients’ care shall be particularly considered by quality improvement professionals (Adamson, Bains, Pantea, Tyrhwitt, Tolomiczenko & Mitchell, 2012).
Increasing the quality of performance in this field can positively and correspondingly affect the overall patients’ satisfaction (Gesell & Wolosin, 2004). Moreover, it can lead to the faster recovery from the sickness as well (Nicassio & Smity, 1995; Willson & McNamara, 1982;
Zhang et Al., 2008).
Ethical Conduct: On this matter, hospitals must take all feasible complications and risks that may occur during patients’ treatment under precise consideration so that they can determine relevant required regulations and enforce them in all involved departments of the hospital to solve the risks or drop down its possibility into minimum (Thilagavathi, 2016).
Since hospitals, as organizations have ethical commitments to the society to render medical services in accordance with certain standards, ethical conduct has been identified to play a
significant role in measuring the satisfaction of patients (Snyder, 2012; Turner, 2007; Leon- Jordan, 2010). Considering the perspective of patients, receiving required medical treatment as well as being given correct and sufficient information within medical consultation are ethical (Moghimehfar & Nasr-Esfahani, 2011; Tattara, 2010; Turner, 2007).
Patient Safety: Patient safety is described by the World Health Organization (WHO) as the absence of avoidable damage to a patient in the healthcare process and minimizing the possible risk of unnecessary damage related to healthcare services to an acceptable level.
It was reported by the Beryl Institute that patients’ experience is affected by all patient safety, quality and service (Wolf, 2016) whereas Kalshetti & Pillai (2008) also mentioned patient safety as one of the challenges to medical tourism. Hence, Absence of safety standards in the host country may be a disappointing item to health tourists who care about security and safety criteria which is enforced by law (Aydin & Karamehmet, 2017).
THEME 4: Non-Human Factors
By taking WHO’s (2012) explanation of human factors into account, non-human factors’
definition can be excluded. Accordingly, non-human factors apply wherever humans do not work and interact. Accordingly, in the concept of this study, non-human factors essentially contain the factors whose effects are not directly related to themselves and they are not directly effective through individuals, although they could be indirectly and eventually tracked down to human beings such as physical environment, cost and waiting time.
Physical Environment: As stated in the study of Nazem & Badaruddin (2015), physical environment could be analysed by two dimensions: Physical Quality and Service Environment. Parasuraman & Zeithaml (2002) defines physical quality as “involving physical aspects associated with the service such as equipment or building”, for instance:
Hospital equipment or facilities, hospital building, modern technology, hospital competence (Nazem et al., 2015).
On the other hand, Sweeney (2008) implies the definition of service environment as:
“external and internal environments…organizational culture and business philosophy…physical ambience and the setting” such as: Level of hygiene, weather and air quality, ventilation, cafeteria (Nazem et al., 2015).
In a study conducted by Saadatnia & Mehregan (2014), it was resulted that the factor of hospital’s facilities and equipment is more affective and important than expertise and skills of the hospital staff from managers’ point of view in attracting the health tourists. Furthermore, Brokenshire (2008) refers to high quality of services as one of the main reasons which make Malaysia one of the top five destinations in medical tourism among health tourists and foreign investors.
Cost: According to the study conducted by Sultana, Haque, Momen & Yasmin (2014), it is stated that in health tourism, the cost of health services or medical fees, accommodation, transportation and food are fundamental matters to evaluate the level of destination attractiveness.
It has been stipulated in the study that Medhekar, Wong & Hall (2018) conducted in India that all healthcare tourists indicated that they had made cost savings due to their trip overseas
to receive health-related services. According to the Confederation of Indian Industries (CII), India’s main feature that attracts medical tourists is low cost services and treatments which are provided by accredited hospitals compared to developed countries that carry out same services.
Caballeron & Mugomba (2007) defines medical tourism as travelling to another country to receive higher quality services at a lower cost and more differentiated care from their country of residency. In US, the basic factors that have been recognized to have diminished patients’
financial ability to afford medical services in their country of residency are increment of medical expenditures as well as lower credit limit of credit corporations and banks (Stepnano, 2009). In addition, absence of health insurance, under insured and uninsured patients who shall cover either entire or part of their medical expenses by themselves has resulted in unaffordability of medical cost in US (Peters & Sauer, 2011; Turner, 2007; Menvielle et al., 2011; Leon-Jordan et al., 2010).
Since the beginning of this century, high cost surgery is one of the reasons that uninsured or underinsured patients would travel from developed countries to developing ones such as Thailand, India, Malaysia and Mexico for medical treatment.It has been concluded in the study conducted by Alsarayreh, Mahasneh & Al Nawaiseh (2017) in Jordan that cost factor as well as the exchange rate is positively related to patient’s satisfaction.
Waiting Time: With reference to Segen's Medical Dictionary (2011), waiting time refers to the time which NHS – National Health Service - patients wait (in days) in between the times that they are advised by a consultant to take the further required action and the patient is set on the waiting list and the day that the required action actually takes place.
In the last century, affluent people from developing countries such as Thailand and India would seek medical related services in developed countries like USA and UK, if it was not available in their country of residency. However, one of the reasons as to why uninsured or underinsured patients would prefer to travel to developing countries (such as Thailand, India, Malaysia and Mexico) from developed ones to receive healthcare services in the current century is the long waiting list (Connell, 2013; Deloitte, 2008; Horowitz et al., 2007; Turner, 2010).
Medhekar et al. (2018) stated in their study in India that most of the health tourists specially the ones from US, UK and Australia had travelled to India to seek treatment due to the long waiting list of the hospitals in their resident state compared to the host country. In general, the factor of “long waiting time in the home country” was expressed as the reason that patients from developed countries had travelled abroad for surgery, since they could no longer bare the physical pain and difficulty. Following interviewing 24 health tourists in this study, the theme of waiting time was ranked first based on the level of importance.
In the same study, a patient from Canada expressed his/her satisfaction indicating that they have to wait for a year or more in their own country in the public health system for a knee replacement which has been causing pain and movement difficulty for him/her while in that hospital India the surgeon team was visited immediately and all diagnostic tests and exams were done on the same day. Another patient referred to his/her destination choice for a hip surgery as a “wise one” since his/her movements had already been deteriorating and waiting list of the hospital in their home country was too long. Long waiting time to receive treatment
could push patients to seek faster services globally (Luigi, Michael, & Valerie, 2013; Suzuki, 2013). Hence, fast service positively affects customer satisfaction in medical tourism (Alsarayreh et al., 2017).
3. Conclusion
Medical tourism can provide developing countries with opportunities to make progression in their countries and also host countries in this industry can benefit from the economic advantages of medical tourism (Waikar, Cappel & Tate, 2011). Considering today’s international policies and challenges for developing countries, raising their revenue through foreign exchange currency is a significant opportunity that they cannot disregard. Hence, it is crucial for developing countries by enough potential, to assign their attention to development of this billion-dollar industry and make a remarkable contribution to their economy cycle.
Medical tourism industry has shaped a well-established market in the destination countries due to patients travelling to receive medical treatments and services. This phenomenon has a long history and it is important to be used as a precious service industry in the industrial world of today (Najafi Nasab, Agheli, Andrade, Sadeghi & Faraji Dizaji, 2018).
On the other hand, medical tourists as the main players of this field, play the most essential role in medical tourism industry. Therefore, in order for countries to grow and develop in this industry, they need to be fully aware of health tourists’ perspective and how to keep them satisfied. It is needless to mention that satisfied patients will bring accredited reputation for the hospitals and the destination and eventually lead the country to be a strong pole in this industry. In a study conducted by Mohammad Varzi, Saki, Momeni, Rajabi Vasokolaei, Khodakaramifard, Arab Zouzani & Jalilian (2016), it has been resulted that in spite of the observed deficiencies in any of the area, we shall pay attention to patients’ preferences and needs as well as patient-centered issues to increase and strengthen the level of health care quality. Considering patients’ preferences, will result in care provision improvement and gaining a stable care practice, not to mention it is morally appreciated. Therefore, it is required to guide the organization management toward managing the customers’ preferences since this type of management considers the customer as a basic factor and providing his requirements will have a great significance.
Accordingly, based on the aforesaid, it can safely be said that evaluating medical tourists’
satisfaction in this industry is of great importance for the countries which are stepping forward in this field toward progression. Subsequently, a higher level of medical tourists’
satisfaction will lead to a greater number of health tourists in destination countries and eventually result in a stronger foundation in global medical tourism.
Medical Tourists’ Satisfaction
Low High Human Factors
Medical Care
Emotional Support
Ethical Conduct
Patient Safety
Non-human Factors
Physical Environment
Cost
Waiting Time
Low High Medical Tourism Globalization
Figure 1: The relevance of the Human and Non-Human Factors’ effects on Medical Tourists’
Satisfaction and Medical Tourism Globalization
At the same time, considering the present literature, it can be concluded that evaluating medical tourists’ satisfaction can be a significance examination in this industry which can be done through two categories of human and non-human factors. As per covered in third and fourth theme of the current study, the dimensions of human and non-human factors can both be effective on the level of medical tourists’ satisfaction.
However, although previous researchers have already studied and confirmed the effectiveness of the mentioned dimensions on medical tourists’ satisfaction, these factors have not yet been studied in the same study through the categories of human and non-human factors. Now evaluating the satisfaction level of medical tourists based on these categories will enable the relevant organizations and management to realize which department needs more improvement and they should focus more on.
Consequently, to improve human factors which represent the direct role of individuals (including doctors, nurses and other relevant staff), educating and training strategies can be taken into account. Nevertheless, to develop the non-human factors, organizations can concentrate on management strategies as well as updating the technology and related facilities.
References
Dictionary, S. M. (2011). Waiting Tme. Retrieved from https://medical- dictionary.thefreedictionary.com/waiting+time
Aydin, G., & Karamehmet, B. (2017). Factors affecting health tourism and international health-care facility choice. International Journal of Pharmaceutical and Healthcare Marketing, 11(1), 16–36. https://doi.org/10.1108/IJPHM-05-2015-0018
Liu, I.-C., & Chen, C. (2013). Cultural Issues in Medical Tourism.
Varzi, A. M., Saki, K., Momeni, K., Rajabi Vasokolaei, G., Khodakaramifard, Z., Arab Zouzani, M., & Jalilian, H. (2016). The Health Tourists’ Satisfaction Level of Services Provided: A Cross-Sectional Study in Iran. Global Journal of Health Science, 8(9), 294.
https://doi.org/10.5539/gjhs.v8n9p294
Hasbullah, N., Mahajar, A. J., & Salleh, M. I. (2014). A Conceptual Framework of Extending the Theory of Planned Behavior: The Role of Service Quality and Trust in the Consumer Cooperatives. International Journal of Business and Social Science, 5(12), 142–148.
Retrieved from https://ijbssnet.com/journals/vol_5_no_12_november_2014/17.pdf%0D لاس یرگشدرگ
ناه یرری د مت . (n.d.). Retrieved from http://internationalhta.com/یرگشدرگ- متلاس- د- یرری- - ناه
Renée-Marie Stephano. (2018). Top 10 Medical Tourism Destinations in the World.
Retrieved from https://www.medicaltourismmag.com/article/top-10-medical-tourism- destinations-world
د متلاس رگشدرگ هلنس کر د وک ۴
دش هدز هنمت . (2019). Retrieved from
https://tejaratnews.com/د وک -کر-هلنس-یرگشدرگ- متلاس- د-۴-هنمت
Iran sees a decline in health tourist influx. (2017). Retrieved from https://www.tehrantimes.com/news/419848/Iran-sees-a-decline-in-health-tourist-influx Shabaninejad, H., Gorgi, H., & Ziaee niri, A. (2016). Ranking the Effective Factors in
Attracting Health Tourists in Tehran: Application of Multi-criteria decision-making model. Journal of Biology and Today’s World, 5(11), 203–208.
https://doi.org/10.15412/j.jbtw.01051103
Haque, A., Yasmin, F., & Anwar, N. (2018). Factors Determinant of Patients ’ Satisfaction towards Health Tourism in Malaysia. 1(May), 1–18.
Shabestari Bahrami, S. (n.d.). Health Tourism in Islamic Countries and Iran.
Hattangadi, V. (2016). Why study of National Character is important? Retrieved from https://drvidyahattangadi.com/why-study-of-national-character-is-important/
Turner, L. (2007). Medical Tourism - Family medicine and international health-related travel.
Canadian Family Physician, 26(11), 1009–1014. https://doi.org/10.1016/0006- 2952(77)90236-2
Oyur Celik, G. (2017). The relationship between patient satisfaction and emotional intelligence skills of nurses working in surgical clinics. Patient Preference and Adherence, Volume 11, 1363–1368. https://doi.org/10.2147/ppa.s136185
Delgoshaei, B., Ravaghi, H., & Abolhassani, N. (2012). Importance-Performance Analysis of Medical Tourism in Iran from Medical Tourists and Medical Services Provider ’ s Perspective. Middle East Journal of Scientific Research, 12(11), 1541–1547.
https://doi.org/10.5829/idosi.mejsr.2012.12.11.39
هب متلاس یرگشدرگ زی یرری ماس5 دس یمت لاد د نیلیمت. (n.d.). Retrieved from http://www.salamatnews.com/news/264289/-ماس- یرری-زی-یرگشدرگ- متلاس-هب-5-د نیلیمت- لاد- یمت-دس
Azimi, R., Mahmoudi, G., & Esmaeili, H. (2017). Ranking Factors Affecting the Attraction of Foreign Medical Tourists in Hospitals Affiliated to Mashhad University of Medical Sciences Based on Marketing Mix Model. 47(10), 1593–1598.
Waikar, A. M., Cappel, S. D., & Tate, U. S. (2011). Challenges and Opportunities for Developing Countries from Medical Tourism. Journal of Business and Economics May Print. Journal of Business and Economics, 2(5), 397–404. Retrieved from http://mds.marshall.edu/mgmt_faculty
Saki, K., Varzi, A. M., Momeni, K., Khodakaramifard, Z., Arab Zouzani, M., Jalilian, H., &
Rajabi Vasokolaei, G. (2017). Tourists’ satisfaction of hospital services in Iran: A case study of Lorestan province. Shiraz E Medical Journal, 18(6).
https://doi.org/10.5812/semj.13797
Torcson, P. J. (n.d.). Patient Satisfaction: the Hospitalist’s Role. Retrieved from https://www.the-hospitalist.org/hospitalist/article/122984/patient-satisfaction-
hospitalists-role
Sag, I., & Zengul, F. D. (2018). Why medical tourists choose Turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights. https://doi.org/10.1108/jhti- 05-2018-0031
Huei, C. T. (2016). A study of medical tourists ’ behavioural intention in relation to hospital brand image and the mediating effects of perceived value and trust. (April).
Mahmoudifar, Y., Tabibi, S. J., Nasiripour, A. A., & Riahi, L. (2016). Effective factors on the development of medical tourism industry in the West Azerbaijan Province, Iran: Pattern presentation. International Journal of Medical Research & Health Sciences, 5(7), 620–
630. Retrieved from http://www.ijmrhs.com/medical-research/effective-factors-on-the- development-of-medical-tourism-industry-in-the-west-azerbaijan-province-iran-pattern- presentati.pdf
Izadi, M., Ayoubian, A., Saadat, S. H., Zarnaq, R. K., Abbasi, S., Moein, N., & Hekmat, M.
(2012). Medical Travel : The Ethical and Legal Challenges. 1(1), 23–28.
Jha, D., Keller Frye, A., & Schlimgen, J. (2017). Evaluating variables of patient experience and the correlation with design. Patient Experience Journal, 4(1), 33–45. Retrieved from http://pxjournal.org/journalAvailableat:http://pxjournal.org/journal/vol4/iss1/5 WHO. (2012). Course : To Err is Human Topic : Why applying human factors is important
for patient safety Summary. 1–3.
Wan Normila Mohamad, Azizah Omar, M. S. H. (2013). The Moderating Effect of Medical Travel Facilitators in Medical Tourism. Procedia - Social and Behavioral Sciences,
65(ICIBSoS), 358–363. https://doi.org/10.1016/j.sbspro.2012.11.134
Hui, T. K., & Wan, D. (2009). Health-care tourism in Singapore. In Advances in Hospitality and Leisure (Vol. 5). https://doi.org/10.1108/S1745-3542(2009)0000005010
Viswanath Reddy, L. K. (2017). Evaluating Medical Tourism Prospects of Joint Commission International Accredited Hospitals in the Kingdom of Saudi Arabia. Health Science Journal, 11(2), 1–8. https://doi.org/10.21767/1791-809x.1000496
Kumar, J., & Hussian, K. (2016). Factors affecting medical tourism destination selection: A Malaysian perspective. Journal of Global Business Insights, 1(1), 1–10.
https://doi.org/10.5038/2640-6489.1.1.1000
Mohammad Nayef Alsarayreh, M. S. M. M. K. H. A. A. N. (2017). A Study of the Determinants Influencing Customer Satisfaction in the Medical Tourism Industry in Jordan. International Review of Management and Marketing, 7(3), 349–356. Retrieved from http://iaset.us/view_archives.php?year=2017&id=32&jtype=2&page=2
Saadatnia, F., & Mehregan, M. R. (2014). Determining and Prioritizing Factors Affecting to Increase Customers Attraction of Medical Tourism from the Perspective of Arabic Countries (Case Study: Iran-Mashhad Razavi Hospital). International Journal of Marketing Studies, 6(3), 155–162. https://doi.org/10.5539/ijms.v6n3p155
600,000 HEALTH TOURISTS TO IRAN FROM MAR-JULY. (2019). Retrieved from https://www.imtj.com/news/600000-health-tourists-to-iran-from-mar-july/
Krishnan, T. D. (2016). Factors Determining International Patients Revisit Intention for Medical Treatments in Malaysia.
Momeni, K., Janati, A., Imani, A., & Khodayari-Zarnaq, R. (2018). Barriers to the development of medical tourism in East Azerbaijan province, Iran: A qualitative study.
Tourism Management, 69(June), 307–316.
https://doi.org/10.1016/j.tourman.2018.05.007
Pre-Test. (n.d.). Retrieved from https://www.insightsassociation.org/issues- policies/glossary/pre-test
شهنک10 متلاس رگشدرگ د یدص د. (2017). Retrieved from http://www.iribnews.ir/fa/news/1968024/شهنک-۰۱-یدص د-د -رگشدرگ- متلاس
Nazem, G., & Mohamed, B. (2015). Understanding Medical Tourists’ Perception of Private Hospital Service Quality in Penang Island. Asian Culture and History, 8(1), 100.
https://doi.org/10.5539/ach.v8n1p100
International Patient Safety Goals. (n.d.). Retrieved from https://www.jointcommissioninternational.org/improve/international-patient-safety- goals/
Seyed Mojtaba, H., Ali, M., Omidreza, S., Ali, A., Donya, S.-T., Hossein, A.-A., & Zahra, H.
D. (2015). Development Strategy of Health Tourism in Iran. International Journal of Travel Medicine and Global Health, 3(4), 161–167. https://doi.org/10.20286/ijtmgh- 0304143
No Title. (n.d.). Retrieved from https://medicaltourism.com/Forms/price-comparison.aspx Medical travelers hold significant share of arrivals in Iran: tourism chief. (2019). Retrieved
from https://www.tehrantimes.com/news/439444/Medical-travelers-hold-significant- share-of-arrivals-in-Iran
Najafi Nasab, M., Agheli, L., Andrade, M. V., Sadeghi, H., & Faraji Dizaji, S. (2018).
Determinants of Medical Tourism Expansion in Iran: Structural Equation Modeling Approach. 7(1), 1–8. https://doi.org/10.22099/ijes.2018.30739.1485
Adamson, K., Bains, J., Pantea, L., Tyrhwitt, J., Tolomiczenko, G., & Mitchell, T. (2012).
Understanding the Patients’ Perspective of Emotional Support to Significantly Improve Overall Patient Satisfaction Patient Satisfaction: An Industry Focus, but What Have We Learned? Healthcare Quarterly, 15(4), 63–69. Retrieved from
http://www.nationalresearch.ca/uploads/Links/HQ_vol15_no4_-Adamson.pdf
Medical Tourism in Iran Hits New Record in Four Months. (2019). Retrieved from https://ifpnews.com/medical-tourism-in-iran-hits-new-record-in-four-months
Medical tourism fetches Iran $1.2b in last fiscal year. (2019). Retrieved from https://www.tehrantimes.com/news/433195/Medical-tourism-fetches-Iran-1-2b-in-last- fiscal-year
No Title. (n.d.). Retrieved from http://mohht.ir/index.aspx?siteid=430
Khan, M. J. (2018). Antecedents of Destination Image and Visit Intention Among Sub- Saharan African Patients to India.
متلاس یرگشدرگ یربیرب مین کر یرری شریزفی. (2019). Retrieved from https://www.irinn.ir/fa/news/676320/شریزفی- یرری-کر- -مین-یربیرب- یرگشدرگ- متلاس
Namin, A. T., & Malekzadeh, N. (2017). Identifying and prioritizing the factors relating to Tehran ’ s medical tourism. 6(4), 581–593.
Sultana, S., Haque, A., Momen, A., & Yasmin, F. (2014). Factors affecting the attractiveness of medical tourism destination: an empirical study on India- review article. Iranian Journal of Public Health, 43(7), 867–876. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25909055%0Ahttp://www.pubmedcentral.nih.gov /articlerender.fcgi?artid=PMC4401052
Heath, S. (n.d.). Patient Satisfaction and HCAHPS: What It Means for Providers. Retrieved from https://patientengagementhit.com/features/patient-satisfaction-and-hcahps-what-it- means-for-providers
Saiprasert, W. (2011). An Examination of the Medical Tourists Motivational Behavior and Perception: A Structural Model. 55.
Chelliah, S., Khan, M. J., Krishnan, T., Kamarulzaman, M. E. B. M., & Goh, N. E. (2018).
Factors influencing satisfaction and revisit intention among international exchange students in Malaysia. Journal of International Education in Business, 12(1), 111–130.
https://doi.org/10.1108/JIEB-07-2018-0026
Sarantopoulos, I., Vicky, K., & Geitona, M. (2014). A Supply Side Investigation of Medical Tourism and ICT Use in Greece. Procedia - Social and Behavioral Sciences, 148, 370–
377. https://doi.org/10.1016/j.sbspro.2014.07.055
Ngwira, C., & Kankhuni, Z. (2018). What attracts tourists to a destination? Is it attractions?
African Journal of Hospitality, Tourism and Leisure, 7(1), 1–19.
Beladi, H., Chao, C. C., Ee, M. S., & Hollas, D. (2019). Does Medical Tourism Promote Economic Growth? A Cross-Country Analysis. Journal of Travel Research, 58(1), 121–
135. https://doi.org/10.1177/0047287517735909
Rao, V. P., & Choudhury, R. R. (2017). A Study of the factors Influencing Customer Satisfaction Medical Tourism in India. International Review of Management and Marketing, 7(3), 349–356.
Ghazali, M., Darmesh R., D., Kee Mun, W., & Thinaranjeney, T. (2012). How Satisfied are Inbound Medical Tourists in Malaysia? A Study on Private Hospitals in Kuala Lumpur.
Journal of Travel and Tourism Marketing, 29(7), 629–646.
https://doi.org/10.1080/10548408.2012.720150
Mahdavi, Y., Mardani, S., Hashemidehaghi, Z., & Mardani, N. (2013). The Factors in Development of Health Tourism in Iran. 1(3), 113–118.
Rezaee, R., & Mohammadzadeh, M. (2016). Effective factors in expansion of medical tourism in Iran. Medical Journal of the Islamic Republic of Iran, 30(1), 1–6.
Medhekar, A., Wong, H. Y., & Hall, J. E. (2018). Factors influencing inbound medical travel to India. Journal of Health Organization and Management, 33(2), 155–172.
https://doi.org/10.1108/JHOM-08-2018-0234
