Antecedents of hospital brand image and the relationships with medical

tourist' behavioral intention

1.0 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). 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 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 millions of medical tourists in 2013, which is near to 50% of
the estimated number of world’s medical tourists (Patientsbeyondborders.com, 2015).

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 Among the countries in South East Asia, Malaysia is one of the popular medical
tourism destinations for medical tourists, mainly due to 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,
Malaysia’s pricing for medical treatments is quite close to Thailand but much lower than
Singapore. Table 1 shows that the average saving on the pricing for medical treatments in
Malaysia which are competitive to its neighboring countries (Singapore and Thailand) and
60% to 80% cheaper than the costs from the United States of America.

Table 1: Comparing Pricing of Medical Treatments in Selected Countries (US$)

Procedures US Cost Singapore Thailand Malaysia

Average Savings 25% to 40% 50% to 75% 60% to 80%
Coronary artery bypass graft - 88,000
54,500 23,000 20,800
CABG
Valve replacement with by pass 85,000 49,000 22,000 18,500
Hip replacement 33,000 21,400 16,500 12,500
Knee replacement 34,000 19,200 11,500 12,500
Spinal fusion 41,000 27,800 16,000 17,900
IVF cycle, excluding 15,000
9,450 6,500 7,200
medication
Gastric bypass 18,000 13,500 12,000 8,200
Full facelift 12,500 8,750 5,300 5,500
Rhinoplasty 6,200 4,750 4,300 3,600
Note: The Value of medical treatments across countries. Adopted from Patientsbeyondborders.
com (2015)

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.

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 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 with regards 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 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 (1) the factors that influence hospital brand image, (2) the relationship
between hospital brand image and service quality, and (3) the relationships between service
quality, patient satisfaction, and behavioral intention. The section below presents the
literature review with regards to brand image, perceived service quality, patient satisfaction,
and behavioral intention. The subsequent section describes the research method and the
results of the statistical analysis. Lastly, this article ends with a discussion section on the

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significant findings, academic and practical implications of the study, and the suggestions for
future research.

2.0 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 judgment
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 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

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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 90s, 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 to advertise and to communicate with
customers effectively (Kaplan and Haenlein, 2010). This method of marketing
communication has helped business organizations to 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 Dąbrowski,
2013). 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.
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 Dąbrowski, 2013; 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).

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Social media websites that comprise of 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 (WOM) 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 WOM 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, 2010; Xu and Chan,
2010). WOM 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, WOM 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 was 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 strategy for survival and
success of an organization as it has an impact on customer purchase intention as well as
organizational performance (Grönroos, 2007). A review of past empirical studies showed that

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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.,
2003; 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 Beinstock, 2006; Ladhari, 2009; Marković et al., 2015; 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

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the destination (Chen and Chen, 2010; Hutchinson et al., 2009; Kim et al., 2015). Studies in
the healthcare setting 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:

Hospital –
created Social
Media H1

Hospital Perceived Patient Behavioral

User-generated H2
Brand Image Service Satisfaction Intention
Social Media H4
Quality H5 H6

H3
Word of Mouth
communication

Figure 1: The Research Model

3.0 METHODOLOGY

3.1 SAMPLING METHOD

The target respondents in this study were medical tourists from Indonesia who came
to a northern sate of Malaysia for medical treatments. As high as 70% of the medical tourism
activities in Malaysia occur in this northern state and 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 regards to the variety

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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 since the researchers approached the respondents personally. After cleaning the data
(via outliers detection, multicollinearity detection, and normality tests), 14 questionnaire 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 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 respectively. The firm-generated contents were measured in
terms of users’ expectations from the social media content which generated by a firm,

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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 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 6-point Likert scale, ranging from
1 = Strongly Disagree to 6 = Strongly Agree. The questionnaires employed in this study were
made available in two languages namely English and Indonesia language. 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 language. The questionnaire was translated from English to
Indonesian language and back translated into English.

4.0 DATA ANALYSIS AND RESULTS

4.1 SAMPLE PROFILE

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Table 2 presents the demographic characteristics of the respondents. The respondents
consisted of 54.40% female and 45.60 % male. Majority of them were married (77.80 %) and
aged between 36 and 55 years old. For the types of medical treatment sought, most of the
came for orthopedics treatments (23.3%), followed by cardiovascular surgery and care
(17.9%).
Table 2: Sample Characteristics (n = 386)

Variable Classification Percentage (%)

Gender Female 54.4
Male 45.6
Marital Single 17.4
Married 77.8
Divorced 2.3
Widowed 2.2
Others 0.3
Age Group 25 years old and below 4.4
26 – 35 years old 18.3
36 – 45 years old 27.0
46 – 55 years old 27.5
56 – 65 years old 18.1
above 65 years old 4.7
Medical Service Orthopaedics (e.g. Joint, spine) 23.3
Seeking Cardiovascular surgery and care 17.9
Comprehensive medical checkup 16.3
Oncology (Cancer treatments) 9.8
Sight treatment/ Lasik 9.6
Fertility care 5.7
Cosmetic/plastic/reconstructive surgery 5.5
Others 11.9
Note: 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).

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 (χ²/df), Goodness of Fit (GFI), Root Mean Square Error of

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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 χ²/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 reasonable fit with the values of χ²/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 (3) the standardized factor
loading should be significantly linked to the latent construct with at least a loading estimate
of 0.60. Table 3 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 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 3, 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.

Table 3: Test Results on Convergent Validity and Discriminant Validity

CR F.L AVE 1 2 3 4 5 6 7
WOM 0.947 0.880-0.906 0.782 0.884
HCSM 0.928 0.882-0.930 0.772 0.106 0.878
UCSM 0.895 0.812-0.882 0.740 0.265 0.530 0.860
IMAGE 0.822 0.705-0.839 0.607 0.212 0.202 0.172 0.779
PSQ 0.839 0.694-0.792 0.509 0.174 0.067 0.138 0.368 0.713
SATIS 0.872 0.782-0.818 0.630 0.224 0.102 0.161 0.375 0.473 0.794
INTENT 0.832 0.770-0.825 0.624 0.341 0.072 0.150 0.376 0.500 0.608 0.790
Notes:

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a) 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.
b) The diagonal entries (in bolds) represent the squared roots average variance, and the off-diagonal
entries (in Italics) are the correlations between constructs.
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 χ2/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 4 summarizes the path coefficients
for all hypothesized paths in the model. For the antecedents of hospital brand image, Table 4
shows that both hospital-created social media (β = 0.187, p < 0.05) and WOM (β = 0.211, p <
0.001) have a positive significant influence on medical tourists’ perception of hospital image.
Hence, Hypotheses 1 and 2 were supported. Hospital brand image was found to have a
positive influence on medical tourists’ perceived service quality (β = 0.469, p < 0.001),
Hypothesis 4 was thus supported. The results indicate that perceived service quality has a
significant positive relationship with patient satisfaction (β = 0.620, p < 0.001), Hypothesis 5
was also supported by the data. Finally, patient satisfaction has a significant positive impact
on medical tourists’ behavioral intention (β = 0. 738, p < 0.001), which supports Hypothesis
6.

Table 4: Hypothesis Testing of Structural Model

Hypothesized Path S.R.W C.R. Supported

(Yes/No)
H1: Hospital-created social media Hospital Brand Image 0.187 2.589* Yes
H2: User-generated social media Hospital Brand Image 0. 035 0.649 No
H3: Word-of-Mouth Hospital Brand Image 0.211 3.565* Yes
H4: Hospital Brand Image Perceived Service Quality 0.469 6.922* Yes
H5: Perceived Service Quality Patient Satisfaction 0.620 9.267* Yes
H6: Patient Satisfaction Behavioural Intention 0.738 11.583* Yes
Notes: *p-value < 0.05, C.R. = Critical Ratio, S.R.W = Standardized Regression Weight

4.4 DISCUSSION AND IMPLICATIONS

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 Several findings of this study were worth noting. Firstly, 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 this 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.

Secondly, WOM 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. WOM is considered to be more trustworthy as the information obtained is from
patients’ family, relatives, and friends (Lim and Chung, 2011). WOM can become an
important information source especially for those medical tourists who are not users of the
Internet. This finding is consistent with the prior studies where WOM 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.

Thirdly, 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 found a positive relationship between brand image and perceived service quality

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include 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 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.

Fourthly, 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 crate 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 as 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 such as technical and soft skills should be provided
to the staff in order 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

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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.

5.0 CONCLUSION

This research study has examined an integrated model from the consumers’
perspective in medical tourism. Its contribution lies in two fold. Firstly, 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 oversea patients’
perceptions and attitudes, and factors which help to 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. Secondly, 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 to become more
efficient in their international marketing approach and in their service delivery process.

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 to remain 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 South East Asia.

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 Appendix: Measurement Scales of the variables in the study

Variables Items
Hospital-created 1) The level of this hospital’s social media communications for its
Social Media brand meets my expectations.
2) Compared with the very good social media communications of
other competing hospitals, this hospital’s social media
communication for its brand performs well
3) I am satisfied with this hospital’s social media communications for
its brand.
User-generated 1) The level of the social media communications feedback expressed
Social Media by other users about this hospital’s brand meets my expectations.
2) 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.
3) I am satisfied with the social media communications feedback
expressed by other users about this hospital’s brand.
Word of Mouth 1) My family/friends positively influenced my attitude towards this
Communication hospital’s brand.
2) My family/friends mentioned positive things I had not considered
about this hospital’s brand.
3) My family/friends provided me with positive ideas about this
hospital’s brand.
4) My family/friends positively influenced my evaluation of this
hospital’s brand.
5) My family/friends helped me make the decision in selecting this
hospital’s brand.
Brand Image 1) This hospital’s brand possesses complete practical functions
(medical services and adequate medical facilities).
2) This hospital’s brand possesses a positive symbolic meaning (good
reputation, credibility and positive image).
3) I feel that this hospital’s brand can provides me with pleasant
service experience.
Perceived Service Tangible
Quality 1) This hospital has up-to-date equipment.
2) The physical facilities of this hospital are visually appealing.
3) The staffs of this hospital appearance are neat.
4) The materials associated with this hospital are visually appealing.
Reliability
5) The staffs of this hospital perform the medical service right on the first
time.

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 6) The staffs of this hospital provide dependable services as promised.
7) The staffs of this hospital are sincere to solve my problems.
8) The staffs of this hospital provide services at the appointed time.
9) This hospital keeps accurate medical records.
Responsiveness
10) The staffs of this hospital are never too busy to respond my requests.
11) The staffs of this hospital tell me when the services will be performed.
12) The staffs of this hospital are always willing to help me.
13) I received prompt service from the staffs of this hospital.
Assurance
14) The staffs of this hospital are trustworthy.
15) I feel safe in receiving services from the staffs of this hospital.
16) The staffs of this hospital are consistently courteous to me.
17) The staffs of this hospital have the knowledge to answer my questions.
Empathy
18) The staffs of this hospital give individual attention to me.
19) This hospital has convenient operating hours for my needs.
20) This hospital has my best interests at heart.
21) The staffs of this hospital understand my specific needs.
Patient 1) I am satisfied with my decision to use the service at this hospital.
Satisfaction 2) My choice to come to this hospital is a wise decision.
3) My experience at this hospital is satisfactory.
4) I am not disappointed to use this hospital’s service.
Behavioral 1) I will recommend that other people to use this hospital.
Intention 2) I need medical services in the future outside my country of
residence, I would consider this hospital as my first choice.
3) I will tell other people good things about this hospital.

About the authors

Cham Tat Huei is currently a Lecturer and Doctoral Student at the Faculty of Accountancy
and Management, Universiti Tunku Abdul Rahman (UTAR), Malaysia. He received his
Master’s degree in Management Studies from the University of Hertfordshire (UK), Master
of Business Administration from INTI International Laureate University (Malaysia) and
Bachelor for Business Administration (Hons) Entrepreneurship from Universiti Tunku Abdul
Rahman (Malaysia). His research interests focus on medical tourism, information technology,
e-commerce, service industry strategy and operations, consumer behavior, service marketing
and organizational behavior.

Lim Yet Mee 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), Master’s degree (MBA) from the University of New Orleans (USA) and
Bachelor of Science (Business Administration) from University of Southwestern Louisiana

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(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. Aik Nai Chiek is an Assistance 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, Merger and Acquisition, Corporate
Restructuring, Capital Structure.

Alexander Tay Guan Meng is currently a Doctoral Philosophy student at the Graudate School
of Business, Universiti Tun Abdul Razak (UNIRAZAK). His Master’s degree in MBA
(International Business) from the Graduate School of Business, and Bachelor of Business
Administration (Hons) Marketing from Universiti Putra Malaysia. His research interests
focus on medical tourism, customer experience and experiential marketing, consumer
behaviour, service marketing, and organizational behavior.

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