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Antecedents of hospital brand image and the relationships with medical tourists' behavioral intention

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IJPHM
10,4
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412
Received 10 February 2016
Revised 21 April 2016
24 June 2016
Accepted 3 August 2016
Antecedents of hospital brand
image and the relationships
with medical tourists’
behavioral intention
Tat Huei Cham, Yet Mee Lim, Nai Chiek Aik and
Alexander Guan Meng Tay
Faculty of Accountancy and Management,
Universiti Tunku Abdul Rahman (UTAR), Kajang, Malaysia
Abstract
Purpose – Medical tourism is growing rapidly in the recent years in various Asian countries. The
success of the hospitals engaged in medical tourism largely depends on their abilities in
maintaining the repeating customers and to attract new customers. Hence, the purpose of this
study is to examine the impacts of word-of-mouth and social media on hospital brand image. It also
attempts to examine the relationships between brand image, perceived service quality, patient
satisfaction and behavioral intention.
Design/methodology/approach – A questionnaire survey was used to collect data from 386 medical
tourists to test the proposed model. All the measurement scales adopted in this study were adapted from
the existing literature. The data collected in this study were analyzed using both SPSS and structural
equation modeling approach via AMOS.
Findings – The findings from the structural analysis indicated that both word-of-mouth and
hospital-generated social media have a significant impact on brand image. Hospital brand image
positively influences medical tourists’ perception of service quality, and their perceived service quality
is significantly related to their satisfaction, which in turn, leads to their behavioral intention.
Originality/value – This study is one of the few studies that considers the importance of hospital’s
brand image in influencing medical tourists’ perceptions on the quality of healthcare services that they
experienced during their medical trips. This research study also raises the significance of
word-of-mouth communication and social media that influence hospitals’ brand image, which has been
neglected by many studies.
Keywords Service quality, Social media, Word-of-mouth, Patient satisfaction, Behavioral intention,
Brand image
Paper type Research paper
International Journal of
Pharmaceutical and Healthcare
Marketing
Vol. 10 No. 4, 2016
pp. 412-431
© Emerald Group Publishing Limited
1750-6123
DOI 10.1108/IJPHM-02-2016-0012
1. Introduction
Medical tourism is a term commonly used to refer to the phenomenon of people
travelling from their resident country to another country for the purpose of receiving
medical treatments (Connell, 2013). Medical tourism has been defined as:
[…] a set of activities in which a person travels often long distances or across the border, to
avail medical services with direct or indirect engagement in leisure, business or other purposes
(Jagyasi, 2008, p. 9).
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We have seen a great increase in medical tourism in developing countries such as
Malaysia, Thailand, Mexico, Costa Rica, Taiwan and India. Various factors have
contributed to the significant growth of the medical tourism industry in these
developing countries – the availability of well-qualified doctors and medical staff, long
waiting lists in the home country, favorable economic exchange rates, high costs of
treatments in developed countries and relatively affordable air travel (Singh, 2013).
According to Pan and Chen (2014), medical tourism yields benefits to both the country
and the traveler. For the country, medical tourism is a two-pronged measure generating
revenue from both medical services and tourism. It also stimulates improvement in the
healthcare sector in the country by developing more medical specialists, enhancing the
quality of the medical services performed and investing in state-of-the-art medical
facilities. As for the travelers, the benefit is mainly financial. They get to receive quality
medical treatments and to visit the country at a relatively low cost, with much shorter
waiting time.
Although the traditional trend of medical tourism, i.e. Western patients traveling to
Asian countries for medical treatments, still remains popular (York, 2008); the
intercontinental medical tourism, i.e. Asian patients traveling to other Asian countries,
has become the latest trend in the industry (Cohen, 2010). Medical tourism has been
regarded as one of the most profitable in hospitality sectors for developing countries
(Han et al., 2013). Many Asian countries have taken advantage of this business
opportunity (Pan and Chen, 2014). Countries such as Malaysia, Taiwan, Singapore,
Thailand, India and South Korea have attracted more than four million medical tourists
in 2013, which is near 50 per cent of the estimated number of world’s medical tourists
(Patientsbeyondborders.com, 2015).
Among the countries in Southeast Asia, Malaysia is one of the popular medical
tourism destinations for medical tourists, mainly because of cheaper medical costs, high
rate of literacy, political and economic stability and favorable exchange rate (Yanos,
2008). Malaysia offers various medical services in a wide range of fields, including
cardiothoracic surgery, cosmetic surgery, cancer treatment, rehabilitative medicine,
orthopedics surgery, fertility treatment, dental treatment, pain management and
general screening (Bernama, 2010). In comparison to the neighboring countries such as
Singapore and Thailand, pricing for medical treatments in Malaysia is quite close to that
in Thailand but much lower than that in Singapore. Table I shows the average saving on
the pricing for medical treatments in Malaysia which are competitive in comparison to
that of its neighboring countries (Singapore and Thailand) and 60 to 80 per cent cheaper
than the costs in the USA.
With the increased demand, the competition in the medical tourism industry has
become more intense (Connell, 2013; Nazem and Mohamed, 2015). It is crucial for the
hospitals, the service providers, to employ effective marketing tools and strategies to
attract potential medical tourists and most importantly, to retain the existing ones (Han
et al., 2013). It has been reported that keeping the existing customers is about five times
more profitable than obtaining new customers (Chiu et al., 2012). Hence, the focus of this
study is to examine medical tourists’ intention to revisit their destination choice.
In the service industry, branding is an efficient means to create a competitive
advantage for a firm (Aziz et al., 2015; Kim et al., 2008). Brand image is considered as one
of the main factors influencing customers’ perception of the product or services
(Riezebos, 2003). It is a perception that is formed and held in the mind of the consumers
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Procedures
US$ Cost
Singapore
Thailand
Malaysia
Average savings
25 to 40%
Coronary artery bypass graft – CABG
88,000
54,500
Valve replacement with bypass
85,000
49,000
Hip replacement
33,000
21,400
Knee replacement
34,000
19,200
414
Spinal fusion
41,000
27,800
IVF cycle, excluding medication
15,000
9,450
Gastric bypass
18,000
13,500
Table I.
Full facelift
12,500
8,750
Comparing pricing of Rhinoplasty
6,200
4,750
medical treatments in
selected countries
Note: The value of medical treatments across countries
(US$)
Source: Adapted from Patientsbeyondborders.com (2015)
50 to 75%
23,000
22,000
16,500
11,500
16,000
6,500
12,000
5,300
4,300
60 to 80%
20,800
18,500
12,500
12,500
17,900
7,200
8,200
5,500
3,600
with regard to certain products, services (Robert and Patrick, 2009) or even a business
entity in the marketplace (Wu, 2011). Brand image is used to create awareness among
potential customers and to attract new customers. Although brand image plays a
significant role in the service industry, most studies on brand image emphasize on
tangible products and retail organizations. There are very limited empirical studies that
examine the concept of brand image on service organizations (Robert and Patrick, 2009;
Wu, 2011). That is, different service organizations can be recognized as “brands” and
how these “brands” play a role in attracting and retaining customers. This research area
remains scant, especially in the healthcare and medical tourism contexts (Cham et al.,
2015).
A review of the literature indicated that empirical findings pertaining to medical
tourism are still relatively rare (Abd Manaf et al., 2015; Han et al., 2015; Heung et al.,
2010). Most of the research studies in medical tourism are conceptually based (Connell,
2013; Crooks et al., 2011; Lunt et al., 2013). The perspectives of the medical tourists have
often been neglected in the studies (Hudson and Li, 2012; Manaf et al., 2015). This reflects
a research gap that is worth exploring further, especially customers’ perception of
service quality may substantially influence their satisfaction with the service
experienced and their intention to revisit. Furthermore, the influence of hospital brand
image on perceived service quality in healthcare is still largely under-examined (Wu,
2011).
Hence, the emphasis of this study is on the perceptions of the medical tourists. The
focus is on medical tourists’ satisfaction and behavioral intention based on how they
perceive the image of the hospitals they have visited and the services provided services.
Specifically, it aims to examine:
• the factors that influence hospital brand image;
• the relationship between hospital brand image and service quality; and
• the relationships between service quality, patient satisfaction and behavioral
intention.
Section 2 presents the literature review with regard to brand image, perceived service
quality, patient satisfaction and behavioral intention. Section 3 describes the research
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method and the results of the statistical analysis. Finally, this article ends with a
discussion section on the significant findings, academic and practical implications of the
study and the suggestions for future research.
2. Literature review and research hypotheses
2.1 Hospital brand image
Brand image refers to a set of perceptions about a brand, and it reflects a customer’s
overall impression of the brand (Keller, 1993). A business entity, just like a commodity,
is a brand in itself. When a hospital is seen as a brand, its patients will hold certain
judgments about the hospital, i.e. its brand image. In the current competitive business
landscape, company brand image has become vital for all the industries. Brand image
plays a major role in business strategic planning because it represents both the tangible
and intangible aspects of a firm. The tangible aspect includes the factual elements of
the firm such as products and buildings, whereas the intangible aspect includes the
emotional elements such as the firm’s identity and the perception of its customers
(Keaveney and Hunt, 1992). A superior brand image is a foundation for a hospital to hold
its market position (Brodie et al., 2009; Wu, 2011) because it plays an influential role in
the consumer decision-making process (Javalgi et al., 1992; Suhartanto, 2011; Yagci
et al., 2009).
2.2 Factors influencing hospital brand image
A consumer will engage in some inductive inference to form a perceptual image about an
object or event. Inductive inference is an important element in the image-forming theory
(Riezebos, 2003). Inductive inference refers to the process that influences a consumer’s
image creation of a product, service or an entity. According to Riezebos (2003),
marketing communication (e.g. social media communication, promotion and
advertising) and social influence (through word-of-mouth communication) are two
inductive processes that could influence the image creation of a consumer. These two
inductive processes were thus included in the present study to examine their impacts on
hospital brand image. A preliminary investigation indicated that Malaysian hospitals
rarely advertise their services in the international media front. Hence, this study has
excluded the impacts of traditional media communication such as magazines,
newspaper ads and other publications on brand image.
2.2.1 Social media communication. Since its inception in the earlier 1990s, social
media has increasingly become the preferred method of media around the world. Social
media tools such as chat rooms, forums, social websites or blogs have helped many
companies advertise and communicate with customers effectively (Kaplan and
Haenlein, 2010). This method of marketing communication has helped business
organizations establish a long-term relationship with their customers (Berthon et al.,
2007; Dijkmans et al., 2015). Past studies have revealed that social media communication
for businesses comes in two forms:
(1) firm-generated social media; and
(2) user-generated social media (Bruhn et al., 2012; Schivinski and Dabrowski,
2016).
According to Yang et al. (2008), firm-generated social media is a Web-based application
approach used to target consumers who cannot be reached with traditional media.
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Generally, firm-generated content increases the probability that a brand would be
incorporated into the customers’ mind in making purchase decision. Therefore,
firm-generated social media can be an effective marketing tool in brand image formation
(Schivinski and Dabrowski, 2016; Wang et al., 2012). Based on the support above, it can
be anticipated that hospitals are able to create awareness among their potential
customers effectively with the use of social media. Thus, it was hypothesized that:
H1. Hospital-created social media has a positive direct effect on hospital brand
image.
On the other hand, user-generated social media allows consumers to be involved in
the marketing activities, and it has become a main channel for transmitting
products/services information nowadays (Diffley et al., 2011). User-generated
communication is an influential source of information, and the information available
is reported to be more reliable and trustworthy (Dellarocas, 2003; Foux, 2006; Glover
et al., 2015). It allows consumers to broadcast the products and services they desire
and serves as a platform for them to share their views and opinions on products,
services and business entities (Diffley et al., 2011). Social media websites that
comprise user-generated reviews and comments can potentially affect consumers’
awareness (Bruhn et al., 2012; De Bruyn and Lilien, 2008) and their perception on the
image of the brands (Gensler et al., 2013; Xiang and Gretzel, 2010). As for the
purpose of this study, the evidence above revealed that user-generated social media
can potentially influence medical tourists’ perception and behavior. Thus, the
following hypothesis was developed:
H2. User-generated social media has a positive direct effect on hospital brand image.
2.2.2 Word-of-mouth communication. In this study, word-of-mouth refers to someone’s
personal communication with family members, friends and associates about the medical
services provided by overseas providers (Kotler, 2006). Social influence via
word-of-mouth has been considered as one of the most important factors that influences
brand image (Riezebos, 2003). It is one of the most influential and reliable approaches for
transmitting information among customers in the marketplace and in consumers’
decision-making (Cheung and Thadani, 2012; Xu and Chan, 2010). Word-of-mouth is
able to instill the brand message in the mind of consumers, and it leads to a better
understanding and impression of the brand as a whole. It has been found to have a
strong positive influence on customers’ perception of brand image and consequently on
their purchase intention (Jalilvand and Samiei, 2012). In addition, word-of-mouth has
also been reported to have a positive impact on brand awareness (Kiss and Bichler,
2008), brand trust (Ha, 2004), brand purchase intention (East et al., 2008) and
consumer-based brand equity (Bambauer-Sachse and Mangold, 2011). Thus, it was
hypothesized that:
H3. Word-of-mouth has a positive direct effect on hospital brand image.
2.3 Linking hospital brand image, perceived service quality, patient satisfaction and
behavioral intention
Perceived service quality in this study is defined as the customer’s overall
impression or assessment of the relative superiority or inferiority of the services
provided by the firm (Parasuraman et al., 1988). Service quality is an essential
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strategy for survival and success of an organization, as it has an impact on customer
purchase intention and organizational performance (Grönroos, 2008). A review of
past empirical studies showed that brand image directly influences perceived
service quality (Brodie et al., 2009; Cretu and Brodie, 2007; Zineldin, 2006). Zineldin
(2006) has argued that receiving good-quality care is a right of all patients and
providing good-quality care is an ethical obligation of all healthcare providers.
Therefore, the healthcare service providers are obliged to improve their service
quality to ensure that the patients are receiving quality medical service. Brodie et al.
(2009) found that brand image and perception of service quality are closely related,
as customers usually depend on brand image to infer the quality of the service and
their perceived risks. Thus, it was hypothesized that hospital brand image will have
a positive impact on medical tourists’ perception of service quality of the hospitals
that they engaged for medical treatments:
H4. Hospital brand image is positively related to perceived service quality.
Patient satisfaction is defined “as the degree of congruency between a patient’s
expectations of ideal care and his/her perception of the real care him/her receives”
(Aragon and Gesell, 2003, p. 229). Patient satisfaction is an interactive and reflective
process from the outcomes of service quality (Moliner, 2009). It has been argued that
patients consider service quality to be one of the most important factors that drives their
satisfaction (Chang et al., 2013; Manaf et al., 2015). Several studies in the healthcare
setting have found that hospitals’ service quality has a positive influence on patient
satisfaction (Ažman and Gomišček, 2015; Collier and Bienstock, 2006; Ladhari, 2009;
Markovic´ et al., 2014; Vinagre and Neves, 2008). Their studies reveal that the quality of
medical service should be emphasized by the healthcare service to ensure that patients
are satisfied with their medical treatments. Based on the evidence form the existing
literatures, it was postulated that:
H5. Perceived service quality is positively related to patient satisfaction.
Behavioral intention represents an individual’s decision or commitment to perform
a given behavior, and it often correlates with overt future behavior (Ajzen and
Fishbein, 1977). In other words, behavioral intention reflects a predisposition to
action. In this study, behavioral intention refers to the medical tourists’ tendency to
perform a given behavior, that is, their revisit intention to Malaysia and recommend
Malaysia as the medical tourism destination to their peers. In the general tourism
context, studies have found a significant direct positive connection between overall
tourists’ satisfaction and their intention to return to the destination (Chen and Chen,
2010; Hutchinson et al., 2009; Kim and Bang, 2015). Studies in the healthcare setting
have also found a positive relationship between patient satisfaction and behavioral
intention (Chaniotakis and Lymperopoulos, 2009; Choi et al., 2004; Kim et al., 2008;
Wu, 2011). Thus, it is hypothesized that there will also be a positive relationship
between patient satisfaction and behavioral intention in the medical tourism setting:
H6. Patient satisfaction is positively related to behavioral intention.
Based on the discussion above, the research model developed for this study is presented
as follows (Figure 1):
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418
3. Methodology
3.1 Sampling method
The target respondents in this study were medical tourists from Indonesia who came to
a northern state of Malaysia for medical treatments. As high as 70 per cent of the medical
tourism activities in Malaysia occur in this northern state, and the majority of the
medical tourists in this state are Indonesians. A total of 400 questionnaires were
distributed evenly to the target respondents at four major hospitals in the state (100
respondents from each hospital) with the use of quota sampling. These four selected
hospitals are similar with regard to the variety and quality of medical services provided,
and they are the main hospitals which host medical tourists in the state. Moreover, all of
these hospitals were also similar in size in terms of the number of beds, which is a
common indicator of hospital size (Goodstein et al., 1994; Kalisch et al., 2011).
It has been reported that a “critical sample size” of 200 is adequate to generate
acceptable statistical power for data analysis (Hair et al., 2010; Sivo et al., 2006). Thus, a
sample size of 400 is considered sufficient to represent a large medical tourist population
(Saunders et al., 2007). Moreover, the present researchers have imposed two selection
criteria before the questionnaires were distributed to the respondents. The two criteria
were:
(1) the respondents came to Malaysia for medical treatments; and
(2) they have and will be engaged in some tourism activities (e.g. vacation,
transportation services, shopping, accommodation services, sight-seeing, etc.)
during the medical trip.
The respondents who fulfilled these two requirements were then qualified as the
respondents in this study.
The researchers managed to collect all the questionnaires from each of the four
hospitals, as the researchers approached the respondents personally. After cleaning the
data (via outliers’ detection, multicollinearity detection and normality tests), 14
questionnaires were found unusable. Hence, the remaining questionnaires of 386 were
the final sample size for data analysis and testing of hypotheses.
3.2 Measurement scales
The measurement scales of the variables in study were based on the existing
instruments from prior research studies. Word-of-mouth was measured using five items
developed by O’Cass and Grace (2004) reflecting the influence of family/friends on
Hospital –
created Social
Media
User-generated
Social Media
Figure 1.
The research model
Word of Mouth
communication
H1
H2
H3
Hospital
Brand Image
H4
Perceived
Service
Quality
H5
Patient
Satisfaction
H6
Behavioral
Intention
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medical tourists’ attitude, ideas, understanding, decision making and evaluation on the
hospital brand. As for social media communication, the measurement scales were
adapted from Bruhn et al. (2012). According to Bruhn et al. (2012), the social media
communication in the business sector has an unswerving impact on the marketplace via
two forms:
(1) from the consumer themselves (user-generated social media); and
(2) from the media developed by the firms (firm-generated social media).
There are three items each for user-generated social media and hospital-created social
media. The firm-generated contents were measured in terms of users’ expectations from
the social media content which were generated by a firm, performance of social media
and satisfaction with the contents generated by a particular firm. As for the
user-generated contents, the measure was operationalized in terms of users’
expectations from the social media based on other users’ inputs, performance of social
media and satisfaction with the contents which were expressed by other users.
As for hospital brand image, the construct was measured using Hsieh and Li’s (2008)
three items in terms of personal experience, practicability and brand symbolic.
Perceived service quality was operationalized using the scale developed by Lam (1997),
reflecting the five dimensions of service quality–assurance, responsiveness, tangible,
empathy and reliability. Panjakakornsak’s (2008) scale was used to measure patient
satisfaction addressing the patients’ affective response to the overall service experience.
The scale measures the degree of patient’s satisfaction in terms of their medical service
experienced, their choice and their decision to consume services from a particular
hospital. Lastly, the measurement scale for behavioral intention construct was adapted
from the three-item scale developed by Choi et al. (2004). The three items measure the
degree to which the medical tourists:
(1) have a positive attitude towards the hospital;
(2) provide positive recommendation to others; and
(3) show signs of repeat purchase.
All the measurement scales used in this study are presented in the Appendix.
There are two sections in the survey questionnaire. Section A includes demographic
variables such as age, gender and marital status. Section B contains all the measurement
items of the variables in study as mentioned above, using a six-point Likert scale,
ranging from 1 ⫽ Strongly Disagree to 6 ⫽ Strongly Agree. The questionnaires used in
this study were made available in two languages, namely, English and Indonesian. The
process of the questionnaire translation for the present study was based on the
suggestion by Brace (2008). In this process, four certified translators who are also
marketing researchers and were familiar with both English and Indonesian. The
questionnaire was translated from English to Indonesian and back-translated into
English.
4. Data analysis and results
4.1 Sample profile
Table II presents the demographic characteristics of the respondents. The respondents
consisted of 54.40 per cent female and 45.60 per cent male. Majority of them were
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Variable
Classification
(%)
Gender
Female
Male
Single
Married
Divorced
Widowed
Others
25 years old and below
26-35 years old
36-45 years old
46-55 years old
56-65 years old
above 65 years old
Orthopedics (e.g. Joint, spine)
Cardiovascular surgery and care
Comprehensive medical checkup
Oncology (Cancer treatments)
Sight treatment/Lasik
Fertility care
Cosmetic/Plastic/Reconstructive surgery
Others
54.4
45.6
17.4
77.8
2.3
2.2
0.3
4.4
18.3
27.0
27.5
18.1
4.7
23.3
17.9
16.3
9.8
9.6
5.7
5.5
11.9
Marital
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Age Group
Medical service seeking
Table II.
Sample
characteristics
(n ⫽ 386)
Notes: The sample size of 386 was obtained after the “data cleaning” process as required for structural
equation modeling. The process of “data cleaning” consists of testing the normality, multicollinearity
and outliers of the data that are based on the suggestion by Hair et al. (2010)
married (77.80 per cent) and aged between 36 and 55 years. For the types of medical
treatment sought, most of the came for orthopedics treatments (23.3 per cent), followed
by cardiovascular surgery and care (17.9 per cent).
4.2 Confirmatory factor analysis
Confirmatory factor analysis (CFA) was used to obtain the model fit and to test the
discriminant and convergent validity of the constructs in this study. Based on the
suggestion by Hair et al. (2010), the selected criteria in evaluating model fit include
the values of normed chi-square (␹2/df), goodness of fit (GFI), root mean square error of
approximation (RMSEA), Tucker–Lewis index (TLI), comparative fit index (CFI) and
parsimony normed fit index (PNFI). A research model with a good fit would have the
following values: less than 3 for ␹2/df of greater than 0.85 for GFI, less than 0.08 for
RMSEA, greater than 0.90 for both TLI and CFI, and more than 0.50 for PNFI. The
results of CFA indicated that the model was a reasonable fit with the values of ␹2/df ⫽
1.507, GFI ⫽ 0.923, RMSEA ⫽ 0.036, TLI ⫽ 0.973, CFI ⫽ 0.977 and PNFI ⫽ 0.800.
To examine convergent validity, three criteria should be fulfilled as suggested by
Hair et al. (2010):
(1) the construct reliability (Cronbach’s alpha) should be greater than 0.7;
(2) the AVE for each of the constructs should be larger than 0.5; and
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(3) the standardized factor loading should be significantly linked to the latent
construct with at least a loading estimate of 0.60.
Table III shows that the Cronbach’s alpha for each of the constructs is well above the
recommended value of 0.70. The AVE values for all constructs exceed the minimum
standard of 0.50, and all value loadings for the items were greater than 0.60. These
results indicate that all constructs in the study achieved an acceptable level of
convergent validity.
The discriminant validity of the measures used in this study was assessed using the
guidelines provided by Fornell and Larcker (1981). Discriminant validity is assessed
based on the comparison of squared root of averaged variance extracted (AVE) values
for each construct and the correlations between the paired constructs. Specifically, the
squared root of AVE should exceed the correlation between any other two constructs.
As seen in Table III, all the squared AVE values for each of the constructs are greater
than the shared variance between constructs. The results show that the constructs in
this study have established acceptable discriminant validity.
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4.3 Structural model and hypothesis testing
Based on the output from Analysis of Moment Structures (AMOS), the structural model
provides a good fit where ␹2/df ⫽ 1.740, GFI ⫽ 0.911, RMSEA ⫽ 0.044, TLI ⫽ 0.961,
CFI ⫽ 0.965 and PNFI ⫽ 0.823. Given an adequate measurement model, the hypotheses
can be tested by examining the proposed structural model. Table IV summarizes the
path coefficients for all hypothesized paths in the model. For the antecedents of hospital
brand image, Table IV shows that both hospital-created social media (␤ ⫽ 0.187, p ⬍
0.05) and word-of-mouth (␤ ⫽ 0.211, p ⬍ 0.001) have a positive significant influence on
medical tourists’ perception of hospital image. Hence, H1 and H2 were supported.
Hospital brand image was found to have a positive influence on medical tourists’
perceived service quality (␤ ⫽ 0.469, p ⬍ 0.001), H4 was thus supported. The results
indicate that perceived service quality has a significant positive relationship with
patient satisfaction (␤ ⫽ 0.620, p ⬍ 0.001), H5 was also supported by the data. Finally,
patient satisfaction has a significant positive impact on medical tourists’ behavioral
intention (␤ ⫽ 0. 738, p ⬍ 0.001), which supports H6.
Constructs
WOM
HCSM
UCSM
IMAGE
PSQ
SATIS
INTENT
CR
F.L
AVE
1
2
3
0.947
0.928
0.895
0.822
0.839
0.872
0.832
0.880-0.906
0.882-0.930
0.812-0.882
0.705-0.839
0.694-0.792
0.782-0.818
0.770-0.825
0.782
0.772
0.740
0.607
0.509
0.630
0.624
0.884
0.106
0.265
0.212
0.174
0.224
0.341
0.878
0.530
0.202
0.067
0.102
0.072
0.860
0.172
0.138
0.161
0.150
4
5
6
7
0.779
0.368 0.713
0.375 0.473 0.794
0.376 0.500 0.608 0.790
Notes: WOM ⫽ word-of-mouth communication; HCSM ⫽ hospital-created social media; UCSM ⫽
user-created social media; IMAGE ⫽ brand image; PSQ ⫽ service quality; SATIS ⫽ patient
satisfaction; INTENT ⫽ behavioral intention; the diagonal entries (in bolds) represent the squared
roots of average variance extracted, and the off-diagonal entries (in italics) are the correlations between
constructs
Table III.
Test results on
convergent validity
and discriminant
validity
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4.4 Discussion and implications
Several findings of this study were worth noting. First, hospital-generated social media was
found to have a positive impact on hospital image. The social media serve as a “bridge” for
the international patients to visit hospital webpage, and this seems to have an influence on
their perceptual and decision-making process. The present study provides some evidence
that the inclusion of hospital website on social media and other online forums is useful in
creating a certain image of a certain hospital among the medical tourists. Therefore, it is
recommended that the hospitals to include various interactive media (i.e. audio, videos,
SlideShare, infographics, etc.) coupled with reliable customer service when creating and
managing their social media. It is also suggested for the hospitals to have a qualified team to
manage their social media platform, as these means of communication involved various
subjects of communication, ranging from general to specific/technical enquiries in regards to
the place and hospital that the medical tourists are about to visit.
Second, word-of-mouth plays an important role in influencing medical tourists’
perception of hospital brand image. When medical tourists receive positive feedback and
review with regards to a particular hospital in Malaysia, they are likely to perceive the
hospital more favorably. Word-of-mouth is considered to be more trustworthy, as the
information obtained is from patients’ family, relatives and friends (Lim and Chung, 2011).
Word-of-mouth can become an important information source, especially for those medical
tourists who are not users of the internet. This finding is consistent with prior studies, where
word-of-mouth communication was found to be an important factor in determining the
perception of brand image for products, services and entities (Jalilvand and Samiei, 2012;
Riezebos, 2003; Podoshen, 2008). Hence, it is recommended for the hospital to treat every
patient with respect and provide quality service that will spontaneously encouraged the
patients to recommend the hospital to their family and friends. Besides that, the hospitals in
the medical tourism industry should consistently mount on word-of-mouth marketing
campaign to encourage medical tourists to talk about them, in the hope to understand how to
coax them into talking more about the hospital.
Third, hospital’s brand image was evidently shown to have a significant positive
relationship with medical tourists’ perception on the quality of the service provided by
the hospital. This finding is consistent with the argument made by Wu (2011), whereby
patients often use brand image as a platform to perceive the service quality of the
hospital. Other studies that found a positive relationship between brand image and
perceived service quality include those by Brodie et al. (2009) and Suhartanto (2011).
Thus, hospitals may need to allocate a reasonable amount of resources for the purpose
of brand management. They may refine their promotion strategies by actively engaging
Hypothesized path
SRW
CR
H1. Hospital-created social media ¡ Hospital brand image
H2. User-generated social media ¡ Hospital brand image
H3. Word-of-mouth ¡ Hospital brand image
H4. Hospital brand image ¡ Perceived service quality
H5. Perceived service quality ¡ Patient satisfaction
H6. Patient satisfaction ¡ Behavioral intention
0.187
0.035
0.211
0.469
0.620
0.738
2.589*
0.649
3.565*
6.922*
9.267*
11.583*
Supported (Yes/No)
Yes
No
Yes
Yes
Yes
Yes
Table IV.
Hypothesis testing of
structural model
Notes: C.R. ⫽ critical ratio; S.R.W ⫽ standardized regression weight; * p value ⬍ 0.05
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in social media and word-of-mouth as mentioned above, and, at the same time,
improving the media advertising, enhancing public relations and any other means
which can improve the brand image in the eyes of customers.
Fourth, the results of the study indicate that perceived service quality and patient
satisfaction are positively related. This is consistent with the findings of the studies by
Alrubaiee and Alkaa’ida (2011) and Chang et al. (2013). Hospitals should provide
superior quality of healthcare services to create satisfaction among the patients.
Hospitals should recognize the importance of service quality by implementing
service-oriented strategies that take consideration of the various aspects, namely,
responsiveness, assurance, reliability, tangibles and empathy. For example, the
availability of the state-of-the-art medical technologies and facilities (the tangible
aspect) should be ensured to meet the requirements of the patients. As for the human
aspect, training of technical and soft skills should be provided to the staff for them to
perform their duties effectively. Moreover, the management of the hospitals should also
consider the importance of motivational factors such as incentives, promotion and
recognition that may help improve employees’ job performance.
Lastly, this study also provides evidence that satisfied patients would make
recommendation and intend to come back for second visit. This finding is consistent
with previous studies in healthcare, whereby patient satisfaction is significantly and
positively related to their behavioral intention (Choi et al., 2004; Kim et al., 2008; Wu,
2011). There is a need for the hospitals to assess their patients’ level of satisfaction on a
regular basis. Customer survey, suggestion box and any other feedback programs are
some ways to address patients’ satisfaction level. Any suggestions received from the
medical tourists should be highlighted by the management for improvement purpose.
Although this study has revealed some of the importance findings; however, there are
some limitations in this study. For example, this study only included respondents from one
country, i.e. Indonesia. Future research should cover medical tourists from other Western
and Eastern countries and do a comparison. This is a cross-sectional study with
respondents’ intention as the outcome variable. A longitudinal study would make a greater
contribution by examining the predictive power of intention in relation to actual behavior.
That is, whether respondents’ intention to revisit would lead to actual behavior of revisiting
for other medical treatments. Finally, a mixed method or triangulation approach may be
used in future studies for cross-reference in data analysis and for further insights in
respondents’ experience of medical tourism in the destination choice.
5. Conclusion
This research study has examined an integrated model from the consumers’ perspective in
medical tourism. Its contribution is twofold. First, it increases the understanding and
development of consumer behavior and branding theories in the medical tourism context.
Company brand image does play a role in influencing overseas patients’ perceptions and
attitudes, and factors which help form a particular image about the company’s brand include
social media and word-of-mouth communication. This is the theoretical contribution of the
study. Second, this study provides some practical value. The significant findings of the
study provide some reference points on enhancing the competitiveness of the hospitals and
future development in the medical tourism industry. Healthcare service providers would
understand what factors to emphasize in order to become more efficient in their international
marketing approach and in their service delivery process.
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With the growing number of medical tourists worldwide, medical tourism presents a
great business opportunity for the Malaysian healthcare and tourism industries. It is
important for Malaysian players to grasp and understand the expectations and
perceptions of the medical tourists in the hope of remaining competitive and sustainable
in this promising market. It is also important for them to recognize the value and
contribution of company branding. Branding of hospitals can be a source of
differentiation. It plays a critical role in market positioning and in promoting Malaysia
as a “medical hub” in the region of Southeast Asia.
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Perceived service quality
Brand image
Word of mouth
communication
Reliability
The staffs of this hospital perform the medical service right on the first time
The staffs of this hospital provide dependable services as promised
The staffs of this hospital are sincere to solve my problems
The staffs of this hospital provide services at the appointed time
This hospital keeps accurate medical records
(continued)
The level of this hospital’s social media communications for its brand meets my expectations
Compared with the very good social media communications of other competing hospitals, this hospital’s social
media communication for its brand performs well
I am satisfied with this hospital’s social media communications for its brand
The level of the social media communications feedback expressed by other users about this hospital’s brand meets
my expectations
Compared with the very good social media communications of other users’ feedback about other competing
hospital brands, the social media communications of users’ feedback about this hospital’s brand performs well
I am satisfied with the social media communications feedback expressed by other users about this hospital’s brand
My family/friends positively influenced my attitude towards this hospital’s brand
My family/friends mentioned positive things I had not considered about this hospital’s brand
My family/friends provided me with positive ideas about this hospital’s brand
My family/friends positively influenced my evaluation of this hospital’s brand
My family/friends helped me make the decision in selecting this hospital’s brand
This hospital’s brand possesses complete practical functions (medical services and adequate medical facilities)
This hospital’s brand possesses a positive symbolic meaning (good reputation, credibility and positive image)
I feel that this hospital’s brand can provides me with pleasant service experience
Tangible
This hospital has up-to-date equipment
The physical facilities of this hospital are visually appealing
The staffs of this hospital appearance are neat
The materials associated with this hospital are visually appealing
Hospital-created social
media
User-generated social
media
Items
Variables
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Appendix
Medical
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Table AI.
Measurement scales
of the variables in the
study
Table AI.
Behavioral intention
Empathy
The staffs of this hospital give individual attention to me
This hospital has convenient operating hours for my needs
This hospital has my best interests at heart
The staffs of this hospital understand my specific needs
I am satisfied with my decision to use the service at this hospital
My choice to come to this hospital is a wise decision
My experience at this hospital is satisfactory
I am not disappointed to use this hospital’s service
I will recommend that other people to use this hospital
I need medical services in the future outside my country of residence, I would consider this hospital as my first
choice
I will tell other people good things about this hospital
Assurance
The staffs of this hospital are trustworthy
I feel safe in receiving services from the staffs of this hospital
The staffs of this hospital are consistently courteous to me
The staffs of this hospital have the knowledge to answer my questions
Responsiveness
The staffs of this hospital are never too busy to respond my requests
The staffs of this hospital tell me when the services will be performed
The staffs of this hospital are always willing to help me
I received prompt service from the staffs of this hospital
Items
430
Patient satisfaction
Variables
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About the authors
Tat Huei Cham is an Assistant Professor at the Faculty of Accountancy and Management,
Universiti Tunku Abdul Rahman (UTAR), Malaysia. He holds a PhD from UTAR, Master’s
degree in Management Studies from the University of Hertfordshire (UK), MBA from INTI
International Laureate University (Malaysia) and Bachelor of Business Administration (Hons)
Entrepreneurship from UTAR. His research interests focus on medical tourism, information
technology, e-commerce, service industry strategy and operations, consumer behavior, service
marketing and organizational behavior. Tat Huei Cham is the corresponding author and can be
contacted at: [email protected]
Yet Mee Lim is Associate Professor at the Faculty of Accountancy and Management,
Universiti Tunku Abdul Rahman (UTAR), Malaysia. She holds a PhD from University of
Alabama (USA), MBA from the University of New Orleans (USA) and Bachelor of Science
(Business Administration) from University of Southwestern Louisiana (USA). Her research
interests focus on organizational behavior, knowledge management, user acceptance of
technology, e-commerce trend, service industry strategy, human resource management and
higher education.
Dr Nai Chiek Aik is Assistant Professor at the Faculty of Accountancy and Management,
Universiti Tunku Abdul Rahman (UTAR), Malaysia. He holds a PhD from Universiti Putra
Malaysia, Master of Finance from Royal Melbourne Institute of Technology and Bachelor of
Commerce from University of Southern Queensland. His research interests focus on medical
tourism, data envelopment analysis, mergers and acquisitions, corporate restructuring and
capital structure.
Alexander Guan Meng Tay is currently Doctoral Philosophy student at the Graduate School of
Business, Universiti Tun Abdul Razak (UNIRAZAK). His has an MBA (International Business)
from the Graduate School of Business and a Bachelor of Business Administration (Hons)
Marketing from Universiti Putra Malaysia. His research interests focus on medical tourism,
customer experience and experiential marketing, consumer behavior, service marketing and
organizational behavior.
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