1. Context
Medical tourism is generally defined an activity requiring individuals to travel to another country outside their place of residence (1). COVID-19 is the worst crisis ever faced by international medical tourism. The outbreak of COVID-19 has closed borders and harmed the medical tourism market. Asia-Pacific has reportedly lost 33 million tourists, suffering the most significant damage in this area (2). China has one million outbound medical tourists, plus one million health tourists, with the three top destination countries of South Korea, Japan, and the United States. South Korea hosts 350,000 medical tourists per year, with one in three coming from China. Beyond Southeast Asia, Iran also hosts 350,000 medical tourists, with 90% coming from local countries and the Gulf, which is a region with an increasing rate of COVID-19 infection. Italy has only small inbound medical tourism numbers and over 600,000 health tourism visitors (3).
Currently, hospitals tend to perform only emergency surgery procedures. It is believed that COVID-19 will disrupt the global medical tourism industry and may have permanent negative effects on the global economy. As any other industry, the medical tourism industry takes time to recover from the consequences of the current pandemic and must take small steps toward rejuvenation (4). Under such critical circumstances, supply and demand could create and strengthen new tourism paths (5), thereby leading to planning to restart the tourism industry after the COVID-19 pandemic (6), especially sustainable and postmodern tourism; this will allow unique and valuable opportunities to rethink and reset tourism (7).
A comprehensive review of the recent medical tourism literature shows a severe theoretical and practical lack of focus on medical tourists’ perceived risk to restart the medical tourism industry in the current pandemic based on a strategic approach. Therefore, the novelty aspect of the present study provides an opportunity to tourism executives to restart medical tourism platforms and design new policies and methods aimed at fostering sustainable tourism goals.
2. Objectives
The initial objective of the study was the reconceptualization of medical tourists' perceived risk in the COVID-19 pandemic, and the second objective was to develop strategies to reduce medical tourists' perceived risk in the current pandemic.
3. Literature Review
3.1. The Concept of Perceived Risk in the Pre-COVID-19 Pandemic
The concept of perceived risk was commonly discussed in contexts such as marketing and tourism management before the COVID-19 crisis which presented in Table 1 (8-18). Huang and Zhao (19) identified seven types of perceived risks, including quality, psychological, health, financial, environmental, loss of time, and social risks. In addition, Huifeng et al. (16) conducted online customer surveys in Chinese restaurants based on the theory of risk and communication to assess performance reliability and financial risks. Fazal-e-Hasan et al. (18) also investigated social and psychological risks and their impact on the intention to buy products. In another study, Olya and Al-ansi (20) identified Muslim tourists’ perceived risks of eating halal food while traveling abroad, classifying the concepts as health, psychological, environmental, social, qualitative, financial, and time-wasting risks. The aforementioned studies indicated that organizations and companies must attempt to reduce people’s perceived risks for positive consequences. Tables 1 and 2 summarize the findings of previous studies regarding the concept of perceived risk.
Table 1.
Perceived Risk Definitions
| Author(s) | Year | Concept | Definition | Field |
|---|---|---|---|---|
| Salehudin (21) | 2011 | Perceived risk | Consumer perception of the possibility of accidents that could be harmful to them because of purchasing a particular product. | Technological goods purchase |
| Maziriri and Chuchu (22) | 2017 | Perceived risk | Consumers' mental expectations of harm, meaning that any action of the consumer will have consequences that he can not predict with confidence, and some of them are unpleasant. | Goods purchase intention |
| Hwang and Choe (17) | 2020 | Perceived risk | The subjectively determined expectation of loss | Restaurant |
Table 2.
Perceived Risk Dimensions
| Perceived Risk Dimensions | Definition | Author(s) |
|---|---|---|
| Performance risk | - Consumer perception of risks cannot meet their needs. - If unusable goods or services are produced or a mistake occurs in their advertisements that cause the buyer to not meet expectations, potential losses will increase. | Salehudin (21), Nam and Quan (14) |
| Financial risk | - Consumer perception of the risks of buying a product with financial losses. - The possibility of losing money due to improper purchase decision - Possible monetary cost related to the loss of the initial purchase price | Salehudin (21), Maziriri and Chuchu (22), Bhukya and Singh (29), Nam and Quan (14), Hwang and Choe (17) |
| Convenience risk | Consumer understanding of the risks of buying a product which takes plenty of effort and time | Salehudin (21) |
| Psychosocial risk | - If the consumer uses poor services or poor quality products will be disappointed. - It is possible that consumer losses when shopping can cause depression. - It is possible that choosing and buying a product will spoil the consumer's self-perception | Salehudin (21), Maziriri and Chuchu (22), Nam and Quan (14), Hwang and Choe (17) |
| Time risk | - Time lost due to product failure. - Lost time because consumers are looking for information, purchase, use, repair, or replacement | Maziriri and Chuchu (22), Nam and Quan (14), Hwang and Choe (17) |
| Functional risk | Consequences of poor product performance at the level expected by customers | Maziriri and Chuchu (22) |
| Physical risk | Consumer fear that some products can harm their health or cause physical injury | Maziriri and Chuchu (22), Bhukya and Singh (29) |
| Social risk | - Reflection of frustration in people by friends and family if the store is chosen incorrectly. - Points to the potential harms of being in a person's social group as a result of adopting a product or service, which seems silly or unconventional due to unusual consumer behavior. | Maziriri and Chuchu (22), Nam and Quan (14) |
| Security risk | Possible harms when the online trading system is not secure or is hacked or attacked by cybercriminals that cause data to be lost or exposed | Nam and Quan (14) |
| Privacy risk | Refers to potential losses of control over personal. information | Nam and Quan (14) |
| Health risk | The possibility that the performance of a product or service results in a health hazard to the consume | Hwang and Choe (17) |
| Environmental risk | Travelers’ concerns about the environmental situations | Hwang and Choe (17) |
| Quality risk | Tourists’ worries about the quality of medical products will be lower than their expectations | Hwang and Choe (17) |
Regarding medical tourism, a few studies have been focused on the concept of perceived risk in the pre-pandemic period (10, 23-28). Tables 1 and 2 summarize the findings of the studies regarding perceived risk in medical tourism. These studies have mainly focused on four domains, including the use of the existing perceived risk definitions or developing a new definition, using the existing perceived risk dimensions or developing new dimensions, using the existing measures of perceived risk or developing new measures, and using the existing perceived risk measurement scales or developing new measurement scales. A comprehensive literature review of perceived risk in medical tourism shows that all the studies in this regard were conducted in the pre-COVID-19 pandemic. Therefore, the theoretical and practical lack of research in the current pandemic becomes evident (Table 2).
3.2. The Strategic-based Approach of Medical Tourism in the COVID-19 Pandemic
According to Georga (30), similar to most sectors, the medical travel market includes providers of various sizes. In the current pandemic, small and market-sensitive sectors (eg, medical travel consultants, startups, and small agencies/facilitators) tend to have a limited budget and cash flow and are most sensitive to fluctuations in the medical travel flow due to a phenomenon known as the 'COVpanic'. These individuals are likely to cut back on marketing and customer services immediately, dismiss personnel (if they have any), and potentially even disappear from the market. It may also be difficult for these individuals to restart their business after the COVID-19 crisis. On the other hand, medium-sized medical travel providers (eg, average-sized clinics/agencies) have a better position; they might consider the COVpanic simply as another crisis, possibly downsize their staff, reduce their spending, and cancel their participation in events. In addition, they will be more committed to maintaining their business through the crisis. Finally, large and well-established businesses in medical travel (eg, large clinics, hospitals, hospital groups, and the largest agencies) have heavily invested in an international patient business, which generated high revenues before COVID-19. These sectors are most resilient to a business downturn due to pandemics and may continue to invest in this business, taking a pragmatic approach to foreign patient cancellations. They consider the current pandemic as another passing crisis (Tables 3-5).
Table 3.
Perceived Risk Definitions in the Tourism Context
| Author(s) | Year | Concept | Definition |
|---|---|---|---|
| Khan et al. (27) | 2019 | Perceived risk | Perceived risk occurs when people sense a difference the incongruity and actual image |
| Sheng-Hshiung et al. (31) | 1997 | Perceived risk | It is likely to happen various unfortunate things for travelers on their destination |
| Cui et al. (32) | 2016 | Perceived risk | The perception of tourists' risk about negative effects may have occurred during their trip |
| Chen et al. (33) | 2012 | Perceived risk | Medical travelers have mental feelings about potential risks as well as intuitive judgments |
Table 4.
Perceived Risk Definitions in the Medical Tourism Context
| Author(s) | Year | Concept | Definition |
|---|---|---|---|
| Habibi and Ariffin (25) | 2018 | Perceived risk | The degree of risks related to unavailability of postoperative care, negligence, medical side effects, and complications |
| Seow et al. (26) | 2017 | Perceived risk | Tourists’ attitude in possible negative results that would occur from this transaction |
| Khan et al. (27) | 2019 | Perceived risk | Perceived risk is defined as the perception of medical tourism that may influence travel decisions |
| Sung and Ozuem (28) | 2017 | Perceived risk | Many issues, including ethical and legal issues, patient safety, and linguistic and cultural differences, need to be considered |
Table 5.
Perceived Risk Dimension in the Medical Tourism Context
| Perceived Risk Dimensions | Definition | Author(s) |
|---|---|---|
| Psychological risk | The suffering is caused by mental stress. | Kim and Um (24) |
| Financial risk | The possibility of monetary loss | Kim and Um (24) |
| Health at destination risk | Although patients travel for treatment, they may become infected with other dangerous diseases when hospitalized, which may worsen the patient's condition | Khan et al. (27) |
| Long air travel risk | Prolonged air travel may harm patients who have already been infected by reducing the blood supply to infected parts of the body, which worsens the condition of patients when they return home. | Khan et al. (27) |
| Destination related risks | Each destination has its advantages and risks depending on its circumstances, which may differ from other countries. Some of these risks are crime, robbery, and sexual assaults risks | Khan et al. (27) |
| Medico-legal risks | Many countries traveling to medical destinations have developing economies. These countries do not have fixed and strict laws to deal with abuse | Khan et al. (27) |
| Pre-operative and recuperation risks | Sometimes, patients prefer not to consult their doctor in their own country and consult directly with doctors abroad, which can lead to the termination of the existing medical file that he had in his own country | Khan et al. (27) |
3.3. Research Methodology
This qualitative research was conducted using content analysis to compare previously published studies regarding perceived risk and update this concept during the coronavirus pandemic by content analysis method. The core of strategic-based approaches was determined for this purpose as the most common approach to assessing the concept of 'perceived risk'. In the new strategic approach, researcher initially attempted to utilize this concept based on the COVID-19 pandemic to develop a new measurement scale. Following that, new strategies were formulated to improve medical tourists' perceived risk as a solution for safe planning and the recovery of the medical tourism industry during the COVID-19 pandemic.
4. Discussion
4.1. Reconceptualization of Medical Tourist’ Perceived Risk in the COVID-19 Pandemic
According to the World Tourism Organization (34), every country should conduct a risk-benefit analysis and decide on its priorities. The WHO also believes that essential emergency travel and humanitarian assistance should be prioritized in this regard. Cargo transportation should also be a priority to provide essential medical resources. As for passengers, elderly patients and those with chronic or underlying diseases should be prioritized.
4.2. Safe COVID-19 Destination Strategies
In terms of offers, they should be properly targeted, logical, realistic, and fitting to the needs of today’s clients. To stay informed, in addition to the IMTJ, updated research produced within the country or by others should be prioritized. There are many 'copy-and-paste reports' in the market, which use historic figures and offer little to no analysis of the future. Accreditation could also improve the standards of hospitals and clinics. However, there is no evidence suggesting that accreditation alone would bring in international business. The average medical traveler is likely less concerned about whether their medical travel agent has or does not have a certificate and is more interested in whether they are economical and efficient (35). According to Gillson and Muramatsu (36), COVID-19 has shifted healthcare resources across borders due to the strain on the capacity of healthcare systems (36). Many countries are now investing in the development of medical tourism facilities by inviting prominent medical professionals.
The WTO has published guidelines for restarting tourism due to the COVID-19 crisis (37). Moreover, the World Travel and Tourism Council have introduced new global protocols to restart tourism, entitled “Safe Travels” (38). The restart of tourism must proceed with COVID-19 supervision and security (39). Based on the aforementioned studies and planning in this regard, we have identified two main strategies as tools for the conversion of an unsafe destination into a safe destination in the current pandemic; these tools are country-based strategies and hospital-/clinic-based strategies.
Governments and medical tourism hubs play a key role in country-based strategies, which is referred to as the medical tourism index (MTI) by Fetscherin and Stephano (40). Accordingly, countries must keep infection rates low by implementing global health protocols, implement quarantine for up to 21 days, close their borders to countries with a high infection rate, increase the quality of medical services by reducing restrictions on the movement of healthcare professionals across borders and reducing barriers to telemedicine, increase tolerance for future crises throughout the world and strengthen the global health system, prepare short-term visa conditions (ie, M visa) to allow foreigners to enter the country and the visa to be issued faster, formulate new visa policies and demand a medical certificate from designated healthcare institutions, and provide guidelines for medical tourism before starting to welcome international visitors.
The MTI is a useful strategy based on the overall assessment of the standards and quality of service in different countries and has a direct impact on the selection and experience of medical tourists (40, 41). Therefore, the governments and countries that are targets of medical tourism must comply with the MTI during and after the COVID-19 pandemic. According to a review of the improvement processes against COVID-19 outbreak, medical tourism, as a part of the tourism management sector, is expected to recover from this unforeseen market shock fundamentally due to several forms of government interventions (5). Hospitals and clinics must be able to use pandemic-related strategies to assist in encouraging new patients. However, it is only possible if medical travelers feel safe traveling to the destination. We believe that this strategy should cover four key aspects, including hospitals' physicians and staff, equipment and technologies, physical environments, and accreditation to decrease patients' uncertainty and fostering a positive perception of safe destinations in medical travelers (Figure 1 and Table 6).
Table 6.
Definition of Perceived Risk Dimensions in the Time of the Pandemic
| Concept | Definition | Dimensions | Definition |
|---|---|---|---|
| Medical tourists' perceived risk | Medical tourists' subjective/cognitive (mind-driven) expectations and objective/actual (real-image driven) evaluation of the negative consequences/losses before/after making travel decisions to an unsafe covid-19 destination. | Psychological risk | Medical tourists' expectations and evaluation of the suffering caused by mental stress and tension due to an unsafe covid-19 destination choice. |
| Financial risk | Medical tourists' expectations and evaluation of waste the money due to an unsafe covid-19 destination choice. | ||
| Health risk | Medical tourists' expectations and evaluation of corona-virus transmission probability through travel to an unsafe covid-19 destination. | ||
| Legal risks | Medical tourists' expectations and evaluation of lack of the supportive laws in case of possible transmission with corona-virus due to travel to an unsafe covid-19 destination. | ||
| Performance risk | Medical tourists' expectations and evaluation of low-quality medical tourism providers' services due to travel to an unsafe covid-19 destination. | ||
| Facilities risk | Medical tourists' expectations and evaluation of possible negative outcomes related to facilities, equipment, and technologies during the trip due to travel to an unsafe covid-19 destination. | ||
| Time risk | Medical tourists' expectations and evaluation of time lost because of an unsafe covid-19 destination choice. |
Based on medical tourists’ perceived risk new conceptualization we propose below visual model:
Figure 1.
Visual model of medical tourists’ perceived risk new conceptualization in pandemic time
5. Conclusions, Suggestions, and Future Research Directions
According to Wang (42), clients’ perceived value is the driving force behind medical tourism and a key predictor of customer intentions. During health crises such as a pandemic, an unsafe and uncertain destination creates a negative destination image in medical tourists' minds, thereby increasing the perceived risk of medical traveling. Therefore, the only way to create a positive destination image and reduce medical travelers’ perceived risk is moving from an unsafe COVID-19 destination to a safe COVID-19 destination.
In the second step, we identified the dimensions of medical tourists' perceived risk based on the COVID-19 pandemic, which included psychological, financial, health, legal, performance, facility, and time risks. In the third step, two main strategies were developed as tools for the conversion of an unsafe destination into a safe destination in the COVID-19 pandemic; these approaches were a country-based strategy and a hospital-/clinic-based strategy.
Based on the proposed strategic-based approach, country-based and hospital-/clinic-based strategies could turn an unsafe COVID-19 destination into a safe COVID-19 destination. Finally, government agencies, medical tourism hubs, and hospitals/clinics should push the message of a safe COVID-19 destination to build trust and reduce the perceived risk of international medical tourists in the post-COVID-19 pandemic.
WOM is the most important acquisition channel in medical tourism marketing and recruitment (43). However, further studies are required to examine WOM guidelines and policies in medical tourism. As mentioned earlier, one of the members of the research panel works in the field of tourism and immigration in Europe, and field observations show that people have admitted that they would want to see and know about the offered medical services before they take a trip to a specific destination. Therefore, further investigations could be focused on online medical tourism to strengthen the trust and understanding of tourists. Moreover, hospitals and clinics must conduct regular health monitoring (manually or automatically) to overcome the current pandemic. Further studies could also be focused on identifying and developing management guidelines and policies to enable hospitals and clinics to maintain the health of tourists during health crises. Investigating the role of technology, robots, and artificial intelligence in restarting medical tourism during the COVID-19 pandemic is another research aspect worth exploring in this regard (Figure 2).
Figure 2.
Strategic-based approach framework to medical tourism industry recovery in covid-19 pandemic crisis
