Factors Influencing Patients Willingness to Participate in Medical Tourism

Saisudha Rajagopal, Lei, Guo, Zhi Min and Choo Institute of Systems Science, National University of Singapore 25, Heng Mui Keng Terrace, Singapore - 119615
Abstract Medical tourism is a growing industry, with developing countries offering a less expensive and easy access healthcare alternative for patients of develop countries. As many developing countries compete for a pie in the market share, it is important to have a good understanding of the factors that influence a customers decision to go for medical tourism. This paper presents the results of a qualitative study conducted in an attempt to elicit the cognitive and emotional factors that play a vital role in the decision to go for medical tourism. The paper proposes a conceptual model that illustrates the antecedents in the decision to pursue medical tourism. Keywords: medical tourism, antecedents, decision-making, cognition, emotion

INTRODUCTION
In the recent years, enormous emphasis has been made on creating awareness on healthcare. People are more proactively engaging themselves in acquiring health related knowledge. In developed countries, this knowledge has encouraged people to seek medical advice and intervention electively, resulting in a high growth in the demand for healthcare (Smith and Forgione, 2007). As a consequence of this high demand, issues such as escalating cost, long waiting period etc. are being witnessed by the patients. Developing countries have promptly yielded to this demand by opening their medical practices to tourist, leveraging on their cost disparity to provide less expensive treatments. The practice of people travelling beyond their homes seeking medical help has been in practice for many years now. However, recently a new dimension to this trend has surfaced. The tourism or hospitality sector has resorted to promoting the healthcare proficiency in addition to other tourist amenities to attract tourists (Goodrich and Goodrich, 1987). This trend has been coined as medical tourism or healthcare tourism. Globalization has blurred the country boundaries and language barriers. The awareness created due to access to world-wide information through the advent of internet has facilitated medical travel to a great extent. Thus, medical tourists are presented with a variety of options that range from neighboring countries to destinations half-way across the globe, low cost to premium quality, destinations that are tourist hot spots to exotic remote resorts very favorable for recuperating. Medical tourists are left to pick from the variety of destinations guided by their decision factors. Of the many factors that tourists consider when choosing between destinations, three factors stand out to be fundamental and most vital. These two factors are cost, quality and access to care. Many countries are battling rising healthcare costs as a consequence of an ageing population, shortage of healthcare providers etc. This rise in healthcare cost in their home country results in higher incentives when looking for more attractive, less expensive alternatives beyond their home (Helble, 2010). In some cases where the medical treatment required is more complex, the quality of the medical care is a driving factor to look for options beyond home. Many developing countries have upgraded their infrastructure and taken on board trained professionals, resorted to international accreditation or affiliation with renowned hospitals of developed countries in order to attract the affluent patients who are looking for high quality healthcare (Hopkins et al, 2010). These countries are

Corresponding author e-mail address: saisudha@nus.edu.sg

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also promoting their medical facilitys capability to provide immediate attention as opposed to the long waiting times the patients experience in their home countries. Healthcare is a paradigm in which the customers are seen to be reluctant as this is a service that they need rather than want (Berry & Bendapudi, 2007). In spite of this paradox in their expectation they have to actively participate and co-operate in order to achieve best results. Healthcare is an ecosystem that is very complex and home for niche knowledge and skill, not possessed by common man. This lack of knowledge makes customers vulnerable and heavily dependent on the service provider. This dependency necessitates a high degree of trust to be established. In medical tourism, where patients move across countries for healthcare services, the customers are even more vulnerable, as they are posed with challenges of acclimatizing to a different country, culture and lifestyle. The customers earlier experiences contribute to their cognition of their health issues and travel related apprehensions. The customers personality and circumstances trigger emotional apprehensions. These apprehensions have a significant contribution to the customers willingness to participate in medical tourism. In this paper, we attempt to understand the determinants in their willingness to participate in medical tourism, by first analyzing the extant literature, to understand what is said about medical tourism and later studying the findings of an exploratory study. As a result of the study we make some propositions and present a conceptual model that represents the relationship between the factors identified. This is followed by recommendations for future research that would validate and enable hypothesizing the propositions.

LITERATURE REVIEW
To study that factors that motivate participation in medical tourism, it is essential to scour the extant literature and identify what is known and analyzed about medical tourism, its growth, its benefits and the motivating factors. Medical tourism, a consumer-driven trend (Nakra, 2011), the result of a marriage between two well established service industries, posits itself as the low-cost, high-quality and easy access medical alternative for people across the globe (Helble, 2010). Due to these characteristics, this new service industry has gained international attention, inspiring many patients to consider it as a plausible alternative. Many of the little academic research on this field have been contextual, as they discuss the positive and negative effects of this phenomenon on the healthcare system of specific departure or destination countries. As developing countries actively promote medical tourism, heavy investment goes into upgrading the healthcare system. Due to this investment, the quality of healthcare in the country is upgraded and the local citizens, who form the bulk of the patients, get benefitted. However, this investment and the demand influenced by the foreign patients poses the risk of increased healthcare cost and neglected needs of the local citizens, thus proving pejorative to the healthcare system of the destination countries (Johnston et al 2010). With healthcare organizations from developing nations aggressively marketing their country as a medical tourism destination to the developed world, insurance companies and employers in developed nations are taking advantage of this phenomenon. Employers incentivize their employees to have medical care abroad (Pafford, 2009). With a choice of countries like Costa Rica, Brazil, India, Thailand, Singapore, Malaysia, Taiwan and many more, patients are left to weigh their options and choose a destination for the healthcare requirements. While, the extant literature discusses the implications of medical tourism on the healthcare system, the policies and social structure of the departure countries and destination countries, there is also some research done to understand the decision in the choice of destination. There are some theoretical models proposed for choice of country and facility. Two-stage Model (Smith and Forgione, 2007) proposes economic conditions, political climate and regulatory standards as determinants for choice of country, and cost, physician training, quality of care, accreditation as determinants for choice of facility. Supply and Demand Model of Medical Tourism (Heung et al., 2010) suggests including attributions and accessibility factors such as distance and airfare to choice of country, and also a set of determinants for choice of doctor/physician. These models discuss the objective factors that influence the choice of country, medical facility and the physician. However, healthcare is a very personal and important service (Berry & Bendapudi, 2007), and a lot of deliberation need to be exercised in the decision of resorting to medical tourism. Healthcare is a field where the responsibility of the outcome of the service is shared between the service provider and the customer, as the patients adherence to instructions plays
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a vital role in the success of a treatment or procedure. It is also an emotionally draining experience, more so in cases where the healthcare intervention sought is more complex. A patients behavior, cognitive and emotional factors dictate the willingness to co-create (Payne et al., 2008). Therefore, achieving a successful outcome is only possible if the patient is comfortable in the surrounding, and is in control of his emotions. Thus, resorting to medical tourism is a subjective decision that is determined by cognitive and emotional factors that the patient is experiencing at the time of decisionmaking. The cognitive aspect of consumer decision making is a sequential process proceeding through a logical problem solving approach (e.g. Cherian and Harris, 1990) to reduce decision complexity. The traditional cognitive decision sequence involves five steps of problem recognition, information search, alternatives evaluation, choice and outcome evaluation (e.g. Solomon, 1996). This rational approach to decision making focuses on the careful weighing and evaluation of products or service attributes to arrive at a choice. Criteria are often based on tangible attributes such as price and features (Schiffman and Kanuk, 2000). Consumers typically use one of two processing strategies: attribute processing or alternative processing (Payne et al., 1993). The former consists of processing information about a single attribute across all brands before information about a second attribute is considered. In contrast, alternative processing involves processing information about multiple attributes of a single alternative before considering information about a second alternative (Mourali and Pons, 2009). Thus, the attributes dictate the decision-making. However, there is interesting evidence in literature to prove that emotion or affect has an impact on the decision-making (e.g. Isen, 1993 and 2001). Studies illustrate that a positive affect enhances problem solving and subsequent decision making (Isen, 2001), while a negative affect such as fear is associated with appraisals of uncertainty about what happened and situational control for negative events (Han et al., 2007, p.159). Academic and practitioner literature that analyze the factors for patients to resort to medical tourismdiscuss the attribute processing or alternative processing in the decision-making from the perspective of the need for medical tourism, thus presenting medical tourism as an economically viable and growing service industry. While agreeing that the push from the insurance companies and pull factors such as relatively low-cost and easy access to healthcare could be influencers, the emotional condition and the uncertainties that plague the patients during decision-making make a vital contribution. Understanding this thought process will shed light on the implicit needs of the patients and allow the service providers to understand their customers better and try to absorb some of their underlying concerns, so as to position themselves as a more suitable and desirable service option to their customers. Though the current literature analyzes the economic, marketing and destination choice factors, the research is provider-centric and falls short of understanding medical tourism from the perspective of the cognitive and emotional factors that influence the patients decision-making. In this paper, we try to address this knowledge gap, by conducting an exploratory qualitative study with medical tourists, to elicit the implicit factors that influence a patients decision to resort to medical tourism as an option.

QUALITATIVE STUDY
To understand the factors, it is essential to discuss the decision-making process with customers who are undergoing the process of decision-making so that their thoughts can be captured at the moment of truth, for a precise understanding of their apprehensions. Seven focus group studies consisting of 40 respondents in all, was conducted. Each focus group had 5 to 6 participants with a mix of foreign nationals and local citizens who were posed with the situation of considering medical tourism for them or their immediate family members for their impending healthcare needs. They were asked about the key issues they are faced with in resorting to medical tourism. The data from the focus group discussion was recorded and the concerns cited by the participants were classified into categories. These were further organized as factors based on a higher level of abstraction of those concerns. The analyzed and classified data is presented in table 1.

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Table 1. Focus group data analysis Factors Credibility, Affordability Category Choice of country Items from Focus group data Which country will be suitable for me for this procedure Which hospital and doctor is best suited for me for providing this particular procedure/service Will the cost of procedure be manageable for me? Will the cost of flying to the country, accommodation and other expenses be manageable for me? Will I be able to avail of any insurance or financial aid if I choose to get treated in that country? I've never been to this country? How is the climate there? Will the climate suit my health condition? What is the spoken language? Can I handle with the languages I know? How do I commute? What are the means of transport? Is it easy to move around or do I need a guide? Will I get to decide the dates for the procedure How long will I need to stay in the country for treatment Will that country accept the pre-treatment diagnosis and test reports from my native country? How will the post-treatment care be handled? What if I need additional treatment for complications, after I return home? Will I be comfortable with the medical practitioners and care givers? Will the medical practitioner be in a position to understand my lifestyle needs and practices Will my family doctor back home be able to discuss my case with the care giving doctor? Once I am treated, I will need all my medical records so that I can have continued post-procedure care in my home country. Will all my medical records be released. What kind of VISA would I need to get medical treatment in that country? Will the immigration rules allow me to stay as long as it takes to get my treatment done? Will there be people to handle our flight tickets? Particularly, in cases where our stay needs to be extended? Will my family be able to accompany me? Will they be able to stay with me or in and around so that they can visit and take care of me? How easy is it to communicate with the rest of my family back home? Will we be able to couple some sightseeing along with the treatment? Is it possible to get food to our liking? What if my trip is delayed or cancelled? What if I have an accident during the trip?

Tacit knowledge

a know-how of the chosen country

Emotional discomfort Perceived lack of control

Timeframe for the procedure Pre and post treatment

Perceived lack Medical practitioner of sensibility and caregivers

Continuity treatment

in Sharing records

medical

Accessibility

Logistics

Perceived lack Family support of support system

Contextual Others variety, perceived lack of control

The purpose of the focus group study was to elicit the impediments to medical tourism. The analysis of the focus group data concentrated on eliciting all the concerns surfaced in the focus group discussions. The analysis revealed that some of the fundamental and obvious concerns that were related to credibility of the country, the hospital and the physician for a particular procedure, the
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affordability in terms of cost of procedure, travel, accommodation and perceived time loss, and accessibility to the country in terms of commuting and immigration regulations. These were well known factors that are also highlighted in other research findings and the earlier theoretical models. The important contributions of the focus group study, however, were the emotional and cognitive factors that are major inhibitors to decide on medical tourism favorably. The study provided insight into the dilemma and concerns that loom on the prospective medical tourists, during their decision-making. The study revealed the following seven additional factors that deal with the cognition and emotion of the participant or the prospective medical tourist.

Tacit Knowledge Disadvantage

Knowledge can be either explicit or tacit, which are complimentary and work in tandem (Nonaka, 1994; Nonaka & Takeuchi, 1995; Polanyi, 1966; Sternberg et al, 1995). Tacit knowledge is the knowhow or the insider knowledge that is personal, context-specific and ineffable (DEredita & Barreto, 2006). When dealing with new environment and situations, there is no way of being certain of the future. The explicit information, and therefore knowledge, is not sufficient to anticipate the situations, actions and reactions of the future, thus presenting large gaps in the information, relying on which one makes a decision. These gaps are usually filled by the tacit knowledge (Gioia, 1986), presenting a more clear picture of the future, and enabling higher quality decisions (Shina, 1990). The destination country being relatively new to the prospective medical tourist, they lack the knowledge about the country, its hospitals, facilities and healthcare practices. While data on these aspects may be obtained from various information sources, knowledge specific to their context can only be achieved through personal experience. This lack of tacit knowledge presents large gaps in the information, on the basis of which they need to make a decision, thus presenting a very cloudy future.

Perceived Lack of Control

Perceived control is a human driving force that motivates the consumer to face the circumstances with competence, superiority and mastery over the environment (White, 1959), while a lack of control renders the consumer powerless, with no ability to affect any change or have any control over an action. Consumers perceptions of control increase when they are presented with a choice to stay or move out of a service situation (Hui & Bateson, 1991). The concept of control has been operationalized as behavioral control, cognitive control and decision control, where cognitive control is the predictability and cognitive re-interpretation of a situation (Averill, 1973). Unpredictability leads to a perceived lack of control over the outcome. A perceived lack of control leaves the consumer concerned over the prospects, and the effectuality of their actions. Patients considering medical tourism have to deal with unfamiliarity of the foreign land, in addition to the apprehensions of their health condition. The patients willingness to go for medical tourism is over shadowed by the many unknown factors and fear of uncertainty looming over them.

Perceived Lack of Support System

Social support is said to act as a buffer for people experiencing life stress (Antonovsky, 1979). The health of a person can be predicted based on their social support. Research on social support demonstrates a predictive link between support and ones emotional and physical health (Eaton, 1978; Theorell, 1976). Going to a foreign land renders one devoid of the support system of family and friends. This could lead to a lot of stress and fear of uncertainty.

Emotional Discomfort
Discomfort is a negative emotional/physical state subject to variation in magnitude in response to internal and environmental conditions. (Miller et al, 1996) Emotional discomfort is the outcome of situations that make us feel alone, frustrated and hurt. Having to handle emotional situations alone with no one to share or comfort can be a taxing experience. Medical treatment is always associated with the affective qualities of pain. Patients are naturally enveloped by tension and fear regarding their health. The prospect of experiencing this uncertainty, fear and anguish alone in a foreign land and the probability any new complications getting uncovered during the treatment traumatizes them.

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Perceived Lack of Sensibility

Sensibility refers to the fact of being affected by complex emotional and aesthetic influences. Healthcare professionals need to be emotionally affected by the patients suffering in order to have a proper clinical understanding of the patients condition (Nortvedt, 2008). Ethnic and cultural differences between the consumers and service providers affect service quality perceptual evaluations (Etgar & Fuchs, 2011). Communicating could be a hassle due to differences in interpretation of non-verbal signals and values (R.R. Johnson, 2007; Wade, 2004). Difference in cultural characteristics, such as values and norms may bring out a variation in the service expectations and bring about feelings of mistrust and fear. Such cultural differences are bound to bring about a gap in the understanding of the patients suffering and may also cause differences in the perception of the healthcare service provided. During the decision-making, prospective medical tourists are concerned about such cultural and lifestyle differences and are plagued by the possibility of lack of sensibility between themselves and healthcare provider, as this lack of sensibility may lead to inappropriate judgment of their medical condition, and thus pose a health risk. Apprehensions regarding such differences loom up as a concern factor.

Contextual Variety
Contextual variety or the variation in the contextual needs of a consumer stems from the description of state dependent utility, where the decision to buy a product is influenced by the state dependent nature of the utility the individual gets from the product in future (e.g. Xie and Shagun, 2001; Shagun and Xie, 2000; Png, 1989). Change in the state of firm, environment or customer in use situations may trigger state dependencies, affecting the consumers willingness to pay at the point of purchase (Ng, 2008). Thus contextual variety is a vital determinant in the willingness of a customer to pursue a purchase. Healthcare tourism deals with wellness to elective and complex surgery requirements. As a result, the contextual need varies depending on the severity of the healthcare requirement. This variety in the contextual need and the other perceived unforeseeable needs at the point of consuming the service, presents a cause for concern, thus impacting the customers willingness to pursue medical tourism.

Continuity of Treatment
Continuity defined as care over time implies that the longitudinal connection between the provider and the patient establishes a trust and facilitates the provider to better understand the patients needs and respond appropriately (Dickinson & Miller, 2010). Research demonstrates that such a longitudinal relationship results in improved care outcome, better provider-patient satisfaction and lowered health costs (Atlas et al, 2009; DeVoe et al, 2009; Guthrie et al, 2008; Pandhi & Saultz, 2006; Smith et al, 2009). The continuity plays a higher role in healthcare procedures that deal with pre-treatment diagnosis and post-treatment review and progress monitoring. While patients are evaluating their options and considering medical tourism, the continuity factor plays a vital role, as the logistics involved in the process presents a barrier to such continuity. Though technological advancements suppress this concern to a certain extent, this is still a cause for concern among many patients considering the medical tourism option.

PROPOSITION DEVELOPMENT
Analyzing the factors identified by the focus group study, we found that some of the factors surfaced, act on other factors to moderate their effect, or have a cause and effect relationship with other factors. The individual effect of the factors or combined effect of more than one factor influence the decisionmaking. Thus, we formulated five propositions that capture this relationship. Proposition 1: An increased tacit knowledge disadvantage increases the perceived lack of control resulting negatively on the willingness to go for Medical tourism. A lack of tacit knowledge and a perceived lack of control independently have a negative influence on the decision to go for medical tourism, as both affect the confidence of the patient in exercising competence. However, lack of tacit knowledge has a positive effect on perceived lack of

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control. When the patient realizes that he/she is devoid of tacit knowledge, it increases the sense of lack of control and thus works against their confidence in pursuing medical tourism. Proposition 2: Perceived lack of support system increases the perceived lack of control thus creating negative emotion for the willingness to go for Medical Tourism. Being alone in a foreign land, devoid of family, when ones health is vulnerable, can be a traumatic experience. Particularly, when considering the possibilities of situations where decisions have to be taken during the course of treatment, due to situations posed by health condition or other environmental conditions, lack of family support makes one feel isolated and left to depend on healthcare-givers even for emotional support. During decision-making, a prospective medical tourist is affected by these feelings of isolation and dependency and thus perceives a sense of lack of control. Thus, perceived lack of support system has a positive effect on the perceived lack of control. Proposition 3: Perceived lack of a support system increases the emotional discomfort thus impacting the willingness to go for Medical Tourism negatively. Family plays a very important role in providing functional and emotional support to a patient, during treatment and recovery. The care and concern provided by the family and the knowledge of their presence makes a patient feel more encouraged to go though the medical treatment. A lack of such support system makes a patient lonely and aggravates the distress, thus having a positive effect on emotional discomfort. Proposition 4: Perceived lack of sensibility on the part of healthcare providers affects the willingness to go for medical tourism negatively. Travelling beyond home country implies that the healthcare professionals and care-givers would hail from a different culture and ethnicity. This difference in culture and ethnicity may serve as a barrier in communication with the healthcare professionals and care-givers. The healthcare professionals and care-givers may not be accustomed to the practices and life style of a person from a different culture and ethnicity, and thus fail to understand and appreciate certain personal demands. This perception of lack of sensibility on the part of the healthcare providers causes a resistance in the prospective medical tourist to pursue with the decision. Proposition 5: Concern regarding Continuity in treatment has a negative effect on the willingness to go for medical tourism. However, this is moderated by the healthcare context/ contextual variety. Continuity in treatment is a vital component to healthcare. However, since medical tourism refers to healthcare intervention ranging from wellness treatments and low-complexity procedures such as cosmetic surgery to high-complexity procedures such as heart bypass surgery and orthopedic surgery, the degree of need for continuity in treatment depends on the complexity. Thus the healthcare context moderates the need for continuity in treatment, thus resulting in a positive influence on the willingness to go for medical tourism.

Figure 1 - Conceptual model of the antecedents in the decision to pursue medical tourism The conceptual model presented above better illustrates the proposed seven factors and the relationship between the factors. The combined effect of these factors on the decision-making to pursue medical tourism is well illustrated through the conceptual model.
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DIRECTIONS FOR FUTURE RESEARCH

This exploratory study is done with an intention to understand the landscape of medical tourism and explore the emotional and cognitive decision-making process that patients undergo, while considering medical tourism. The proposed ideas and consequentially, the conceptual model proposed needs empirical evaluation in order to be established. It is important for the empirical study to analyze the medical tourism landscape from the perspective of the medical tourist and from the perspective of the service providers and policy makers, in order to understand the implications of the propositions. Further, it is also essential to conduct research on the effect of the apprehensions faced by the medical tourists during decision-making and during the consumption of the service, on the customer experience. Co-creation of value-in-use is dominant in this service sector. The antecedents to medical tourism bring in an interesting dimension to the act of co-creating value. In order for a customer to cocreate value, in spite of the reluctance, cognition and emotion play a vital role. It is our belief that cocreation of value stems from the factors that motivate participation in medical tourism and some of the factors identified in this exploratory study have a high degree of impact on the co-creation capability of the patients. Further research will provide provisions for absorption of some of the concerns of the patients by the service providers, thus facilitating sustained growth of this industry.

CONCLUSION
Medical Tourism is seeing its third wave, with developing nations aggressively promoting their medical facilities and coming to the rescue of patients who are faced with the increasing healthcare cost and long waiting times in the developed nations. However, in order for this trend to sustain, the developing countries will need to understand the subjective emotional and cognitive factors that influence the customers willingness to participate in medical tourism. The exploratory study reveals that prospective medical tourists are plagued by perceptions of tacit knowledge disadvantage, control, lack of support system, lack of sensibility on the part of healthcare professionals, emotional discomfort, concerns regarding continuity in treatment and contextual healthcare needs. These findings lead us to better understand the predicament of the prospective customers of medical tourism and thus the latent needs of the customers in order to serve them better.

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AUTHOR BIOGRAPHIES Saisudha Rajagopal is a Software Engineer in the Service Innovation Practice cluster of Institute of Systems Science, National University of Singapore. Her research interest is in service innovation and service design methods that enable delivering service systems that empower the users to co-create value. Dr. Guo Lei is a postdoctoral fellow with National University of Singapore. Dr. Guos research interest is in the understanding of value co-creation in service system (B2B relationships, technology use, and outcome-based contracting) and has published articles in the domain of management and marketing. She has involved in numerous research projects in the UK, China and Singapore. Choo Zhi Min is a Software Engineer in the Service Innovation Practice cluster of Institute of Systems Science, National University of Singapore. His research interest spans over the use of Web 2.0 and mobile technology to facilitate innovation in services to enable cocreation.

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