1. Introduction
Tourism has been changing its nature rapidly in recent years due to the amalgamation of the health and medical industries in tandem with tourists’ complex quests for rest, relaxation, leisure, fun, and sustainable tourism attractions in order to find overall improvement in their quality of life [
1,
2]. It is noted that many individuals are moving across national borders to find their optimal health status [
3,
4,
5]. While this style of human movement is similar to tourism, it is different from conventional traveling in terms of pleasure and rest, and is commonly termed medical tourism [
6,
7]. More precisely, medical tourism involves two different segments, that is, medicine and tourism, which have been deeply interlinked as of late [
6,
8]. However, these segments fall into a broader sense of health and maintenance, because individuals travel offshore in order to seek different diagnostic treatments, surgeries, dental care, cosmetic reasons, and lifestyle enhancement treatments/therapies, as well as holiday and vacation in therapeutic places [
2]. Despite medical interventions while traveling abroad, it is noted that medical tourists travel across the world in order to find better quality of life, and hence, medical tourism is often encapsulated into notions of health tourism as well [
9]. Reddy et al. [
10] further fueled the interlinked phenomenon of medical and health tourism, and noted it in terms of health and wellness tourism by narrating that medical tourists travel abroad for different health and wellness treatments, which may include alternative therapies, such as for example, spa, in health and wellness centers in tandem with experiencing tourism. Hence, health tourism is a broader umbrella term in order to include different conceptualizations of medical, health, wellness, and tourism [
1,
2]. It is noted that health and medical tourism have pervasively contributed to developing positive economic indicators for the participating destinations in health and medical tourism [
11,
12,
13]. For example, Cuba is enjoying 10% of its total national gross domestic product (GDP) from the country’s health and medical tourism sectors [
14], India earns US
$2.3 billion yearly from its health and medical tourism [
15], and the private sector of the United Kingdom (UK) earns 25% of its revenue from the 7% of international patients coming to the UK for their medical or health treatments [
16], to name a few. Consequently, many countries across the globe are actively participating in health and medical tourism in order to positively boost their economic indicators [
17,
18]. For example, Majeed et al. [
2] noted that there are 96 participating countries in medical tourism business, which are serving about 780 million tourists worldwide. From this perspective, it is noted that many countries are emerging as medical and health tourism destinations in Asia; for example, China, South Korea, Thailand, and India; in Europe, for example, Germany, Poland, and Hungary; in Latin America, for example, Brazil, Mexico, and Costa Rica; and in Africa, for example, South Africa and Cuba, etc. [
1]. Since medical and health tourism are moving parallel in their core nature, that is, health and well-being, the role of participating health and medical tourism destinations is getting more important in the present context in order to globally serve the varied health care preferences of consumers.
Health tourism involves medical treatments for optimal health and wellness notions. These notions are now perceived as achievable alongside the other attractions of sustainable tourism, such as for example, healthy food, comfortable accommodation, sightseeing, fresh air, clean water, beaches, natural landscapes, and adventure [
10,
17]. This is because the phenomenon of natural healing is directly related to the quality of the surrounding environment [
18]. Moreover, it is noted that the quality of one’s environment also determines the quality of one’s health [
19]; hence, it arguably comes under the scope of sustainable tourism. From this perspective, it can further be narrated that health tourism is highly concerned with the concept of a health place that offers infrastructure comprising of health facilities, necessary medical intervention, aesthetic services, and sustainable tourism attractions, for example, lodging, food and beverages (F&B), rentals, adventure, a pollution-free environment, fresh air, and mineral and thermal water therapies [
17,
20,
21,
22,
23]. Different scholars have noted the concept of a health place; however, their associated terminologies sometimes differ. For example, some scholars note them as therapeutic places [
24,
25], while others document this concept by calling such a place a health resort [
26,
27]. Although the concept of a health resort is passing through its embryonic stage, the concept is still vague. Nevertheless, it demands profound theoretical underpinnings in order to appropriately address health and wellness notions. Considering the biological connections among health, medicine, wellness, rest, relaxation, therapies, and alternative medicine treatments, the term “health resort” is considered appropriate to be used in the present study context. However, we will also provide some additional theoretical support in order to ensure consistency in different health care dimensions, and endeavor to contribute to the academic literature of health and medical tourism by encapsulating the broader notions of health and wellness into its emerging scope on empirical research grounds.
Health resorts include treatments and recovery places where tourists/travelers/patients may rest after being operated on, with or without experiencing alternative therapies. However, the insufficient availability of medical/health facilities in traditional hospitals/clinics/medical care centers has been noted previously in the academic literature [
26,
27,
28,
29,
30,
31]. In this scenario, a health infrastructure is meanwhile emerging that offers differentiated therapeutic places, medical facilities, appropriate medical supervision, traditional and complementary medicine (T&CM) treatments, alternative therapies, such as yoga for example, and health care experience with notions deeply grounded in the preferences of tourists/travelers for natural healings [
2,
20,
24,
26,
27,
32,
33,
34,
35], which also further fertile the conceptual grounds of the health resort. However, little academic attention has been observed that addresses the attractions and importance of the health resort in the health and tourism industries. Moreover, the attractions that international travelers may perceive and expect in a health resort context have not been analyzed in sufficient detail in the previous literature.
Many research works have identified the crucial role of individuals’ perception and evaluation in defining behavioral intentions [
19,
36,
37]. More precisely, expectations are discussed in determining tourists’ decision-making processes and their likely behavioral intentions in health and medical tourism contexts [
1,
2,
38,
39,
40,
41]. However, despite the seminal role of expectations, there has been little literature that attempts to empirically examine the role of expectations in determining international health tourists’/travelers’ behavioral intentions more precisely in a health resort concept. Additionally, empirical grounds for the likely relationships between the expectations of health tourists, evaluations of the attractions of a health resort, and their impact on their ultimate behavioral intentions are succinct. Scholars generally agree that cultural differences may influence tourists’/travelers’ behavioral intentions [
42,
43,
44]. However, such cultural implications are complicated to determine, even though they are considered important by the tourism stakeholders in order to define appropriate strategies for delivering satisfied tourism experiences to international tourists/travelers by meeting their expectations [
42,
45]. From this perspective, it is important to note that culture has its own role in determining international tourists’/travelers’ behavioral intentions for their health and wellness treatment while traveling globally. However, research that addresses the role of culture in shaping health tourists’ behavioral intentions in a health resort context is yet limited.
Addressing the mentioned research gaps, the present study endeavors to propose and validate a research model that examines and helps understand the behavioral intentions of international health tourists in the emerging context of a health resort. Moreover, the purpose of the study is also to better meet the preferences and expectations of international health tourists for their health treatments. Determining such expectations is complex due to travelers’ distinct cultural backgrounds, as well as the availability of a variety of medical care, wellness treatments, and tourism opportunities that have been rapidly changing in the recent past [
2].Hence, the probable associations among international health tourists’ perceptions and their evaluation of attractions for visiting a health resort, expectations, and behavioral intentions on empirical grounds are examined through the partial least square structural equation modeling (PLS-SEM) technique, by using data from 359 respondents comprising of Thai, Indian, and Chinese tourists/travelers at two international airports in China. This woven phenomenon is elucidated in a proposed research framework in the present study in order to testify the impact of expectations as a mediator on the relationship between perceived health resort’s attractions and health tourists’/travelers’ behavioral intentions. Further, the proposed research framework attempts to investigate whether culture moderately impacts the associations among perceived attractions of a health resort as well as expectations and behavioral intentions of Thai, Indian, and Chinese health tourists/travelers. This study offers theoretical underpinnings and discussions on the interlinked phenomena of health, medical, and sustainable tourism working together in order to develop and refine the concept of a health resort. This study has two important contributions to the budding knowledge of the health, medical, wellness, and tourism industries. First, theoretical concept development is undertaken in an attempt to remove the vagueness from the concept of the health resort, which is in its infancy. Second, the developed concepts of the health resort are empirically examined by gathering the responses of international tourists/travelers. Hence, this study attempts to stitch the broken connections of theory and its validation with some empirical findings. This study will not only contribute to filling theoretical gaps, it will also support future research work by providing a direction and platform through its empirical findings. Moreover, limitations surrounding the present study are documented after the discussions and implications.
5. Discussion and Implications
This study is triggered by the research quest that, despite the boom of health tourism, little is yet known about instrumental associations among affordability, risk-bearing level, medical facilities, and sustainable tourism attractions, as well as expectations in framing the behavioral intentions of international tourists/travelers in a health resort context. These associations are important to be considered in a health resort context because of the emerging connections between T&CM and conventional medical treatments, that is, allopathy and lifestyle treatment preferences of modern health tourists in tandem with sustainable tourism notions. The basic theme of the present study is to propose and validate a research model that is grounded in theoretical concepts and explicitly aims to understand the behavioral intentions of international tourists/travelers in order to visit a health resort for health care or other medical or quality of life improvement treatments. The primary intention is for the model to be developed by evaluating the perceptions and expectations of tourists in distinct cultural contexts. The proposed model conceptualizes the theory that tourists’ intentions to visit or stay in a health resort depend on their expectations and other interlinked attractions that they are likely to perceive. Theoretical underpinnings, which are encapsulated into the present study, elucidate that tourists’ expectations are the outcome of a multi-textured alignment of the perceived attractions of a health resort, and tourists’ expectations significantly mediate the relationship between perceived health resorts’ attractions and their behavioral intentions. The presented research model in this study claims a contribution to further developing the behavioral intentions concept of health tourists, patients, or travelers by sketching the perceived attractions of health resorts, which have hardly been studied in the literature. Moreover, an analysis and comparison of responses provided by the Thai, Indian, and Chinese travelers’ groups within a health resort’s conceptuality is another contribution that has been documented in the present study. This study paints some theoretical underpinnings alongside its empirical support of the canvas of health and wellness tourism in order to fuel discussions regarding the theoretical conceptualization of a health resort, which is in its infancy, in an attempt to boost research and development, and for the provision of better health services to tourists/travelers/patients. Hence, this study holds an important status in analyzing and applying the impact of international tourists’ perceptions about the attractions of a health resort.
Significantly positive associations are verified through structural equation modeling (SEM) among affordability, risk level, medical facilities, sustainable tourism, expectations, and behavioral intentions. This implies that providing affordable health care, a sustainable tourism experience alongside medical facilities, and the consideration of risk levels influences the expectations of tourists/travelers, and ultimately impacts their intentions to visit a health resort. These results are in line with the work of Plehn et al. [
38] in healthcare setups. Improving the health and wellness experience of tourists/travelers at the appropriate levels of their expectations could be an important consideration of health resort services’ providers when defining their health resort’s sustainability strategies. Health tourists may spread a positive word-of-mouth report regarding a health resort’s medical treatment and their healthcare experience when they perceive that staying in a health resort is affordable, less risky, and more valuable than the other medical locations, i.e., hospitals/clinics/standalone alternative health and medical practices.
The services providers of the health industry thus need to innovate sustainable ways that can mitigate the health care concerns of health tourists, as well as promise that health care resorts are culturally affordable, less risky, in tandem with improved medical facilities, and are also sustainable tourism attractions. It will help to shape the favorable decisions of health tourists in order to experience a health resort’s life. These efforts will bring growth in the health resort business and other interlinked industries, for example, hospitality, F&B, restaurants, and traveling, as well as improve the welfare of the local population by providing them with a business platform.
The results of the present study underpin implied notions that the behavioral intentions of health tourists might be significantly positive when they perceive good medical facilities at a lower risk level in tandem with sustainable tourism attractions. This implied notion is the crux of this study, which purports to frame the behavioral intentions of health tourists in a health resort context. The distilled results of the present study support that the stakeholders of health resorts, that is, doctors, medical staff, therapists, hospitals, clinics, T&CM practitioners, hotels, F&B services providers, spa/yoga experts, traveling agents, rentals, conventional tourism services providers, etc., endeavor to improve the standards of health, medical, and wellness care by providing adequate facilities, and simultaneously meeting the expectations of health tourists/travelers/patients, which may be instrumental in achieving the favorable decisions of tourists in order to experience health resort care.
Health tourism is rapidly changing its texture, and has promised fast economic growth for participating destinations across the globe [
1,
2]. For successful cross-border health tourism, tourists’ behaviors should be deeply understood, which may be potentially shaped by their distinct cultural norms. From this perspective, the metric invariance results of the present study are important to consider. The study results note that behavioral intentions significantly differ across Thai, Indian, and Chinese traveler groups. More precisely, the study results illuminate the relative importance of perceived attractions of a health resort in measuring international travelers’ perceptions, which play a synergistic role in developing positive behavioral intentions. In-depth analysis of the structural invariance reveals that sustainable tourism attractions significantly influence Thai travelers’ expectations and generate positive behavioral intentions for health resorts(
βSustainable tourism→
Expectations = 0.629,
p < 0.01;
βSustainable tourism→
Behavioral intentions = 0.735,
p < 0.01); however, medical facilities (Indian travelers:
βMedical facilities→
Expectations = 0.683,
p < 0.01;
βMedical facilities→
Behavioral intentions = 0.362,
p < 0.05; Chinese travelers:
βMedical facilities→
Expectations = 0.824,
p < 0.01;
βMedical facilities→
Behavioral intentions = 0.689,
p < 0.01), in tandem with risk level (Indian travelers:
βRisk level→
Expectations = 0.242,
p < 0.01;
βRisk level→
Behavioral intentions = 0.344,
p < 0.05; Chinese travelers:
βRisk level→
Expectations = 0.198,
p < 0.05;
βRisk level→
Behavioral intentions = 0.463,
p < 0.01) are found to be significantly influencing Indian and Chinese respondents’ behaviors regarding visiting health resorts. However, it is important to mention that medical facilities are considered comparatively more important than the other perceived attractions of health resorts among the three groups of international travelers. This implied notion underpins the need to deliver quality medical treatments, health services, and the competent availability of doctors, paramedical staff, pharmacists, T&CM practitioners, and post-operative care services in order to meet the expectations of health tourist/travelers or patients. Additionally, medical/wellness attractions, for example, medical and thermal baths, medical caves, climatic resorts, medical gas baths, therapeutic gymnastics etc., will certainly motivate Thai, Indian, and Chinese health tourists to avail health care in a health resort. Hence, a cross-cultural influence is evident from the analysis of this study, and the results are in line with the discussions made by Kang et al. [
42] and An et al. [
45].
Despite massive cross-border movements of health tourists, sophisticated research grounds do not yet succinctly note cross-cultural traveling behaviors. The present study’s findings will serve academics and professionals of the health, medical, wellness, and tourism industries in order to better conceptualize the impact of culture on health tourists’ perceptions and their ultimate decision-making for availing health care. Moreover, the findings of the present study can help health resorts’ marketers with developing innovative strategies in order to grab the attention of Thai, Indian, and Chinese health tourists (for example, cross-cultural marketing and advertising). The results may also help retain them as their loyal customers, and may further be applied to other tourists/travelers belonging to different nationalities. In order to meet the needs and expectations of Thai international travelers, health resorts’ professionals need to focus on improving sustainable tourism attractions (i.e., clean environment, hygienic health care facilities, clean water, therapeutic landscapes, as well as the development of scenic tourism attractions, that is, beaches, flora and fauna, wildlife, parks, etc. These sustainable tourism attractions can be developed in tandem with developing other tourism attractions, for example, cultural: historical buildings, museums, and religious institutions, etc.; traditions: folklore, handicrafts, and music, etc.; and entertainment: cinemas, zoos, nightlife, and cuisine, etc. The present study’s results show the underlining phenomena of health tourists’ expectations and their behavioral intentions by analyzing the perceived attractions in a health resort infrastructure. Nevertheless, deeper research efforts are further recommended in order to generalize the discussed results of the present study to a broader canvas of tourism with sustainability and health premises.