Sea , sun , sand and ... . selecting surgery : an exploration of health , medical and wellness tourist ' s mobility

Mass tourism facilities depend on repeat visitors as well as attracting new rst time tourists. As these traditional sun and sand holiday destinations mature, tourism promoters are bundling opportunities to attract a different kind of tourist. Since many of these resorts are all-inclusive facilities and include a Spa, one potential expansion may be to market to health, medical or wellness tourists. Geographic research in travel and tourism has found that individuals either repeat visits to the same destination or diversify their choices. This paper highlights the decision-making process of tourists and how it may be related to the niche market of health, wellness, and medical tourism. It uses data from a survey that gathered the travel patterns and motivations, and socio-demographics of medical tourists. Consumers who exhibit different travel behavior rank hospital accreditation and American hospital afliation more important than those who repeat travel behavior.


Introduction
For centuries travel to distant lands to relax in mineral waters has been fashionable (Towner, 1996;Dinu, Zbuchea and Cioaca, 2010;Lunt, Mannion, and Exworthy, 2013).Today tourists are seeking not only a bath, but may also want cosmetic surgery or a knee replacement (Goodrich and Goodrich, 1987;Hall, 1992;Goodrich, 1993;Hall, 2003;Smith, 2006;Bookman and Bookman, 2007;Smith and Puczkó, 2009;Erdeli et al. 2011;Connell, 2013;Ormond, 2014;Roanghes-Mureanu and Tudoricu, 2014).These consumers, collectively called ©2015 Human Geographies; The authors DOI:1 5 92 1 0.5719/hgeo.201 . .provide this service to their foreign patients (e.g., Han and Hwang;2013), research into these travel patterns is timely.First a literature review on health, medical and wellness tourism will be provided.Then a discussion of travel behavior will be illustrated linking it to the tourist.The methods to collect the travel behavior data are presented next, and results from the analysis.We conclude with a discussion of primary ndings.

Literature review
In this section of the paper the relevant literature on health, medical and wellness tourism and mobility or destination travel behavior will be summarized.Health, medical and wellness tourism is nothing new.Historically, wealthy individuals have traveled far to seek the therapeutic benets of mineral waters, clean mountain air and peaceful surroundings (Mitman, 2003).Today one denition of this phenomenon is the one found by United States' Senator Gordon Smith (2006) in his statement to the Special Committee on Aging in the United States Senate said "Medical tourism refers to the practice of patients seeking lower-cost health-care procedures abroad, often packaged with travel and sightseeing excursions." While this denition is a good starting point, a review of the literature offers additional explanations (Hancock, 2006;Bookman and Bookman, 2007;Lunt, Horsfall and Hanefeld, 2015).Since affordable health care and medicine are not available for many citizens, a low-cost operation overseas is a reasonable expense, even after adding the travel and lodging costs.
As the world population ages, travel choices for seniors is likely to expand as well, dependent of course on increased time available offset by lower disposable income (Fleischer & Seiler, 2002;Kattiyapornpong & Miller 2009).Given this varied need, demand for health, medical and wellness care is expected to continue.Further since the demand varies so greatly, so are the destinations that attract these tourists.
Beyond the need for these kinds of procedures, the tourist is also concerned about a quality experience (Lunt, Horsfall and Hanefeld, 2015).Overall, cost, postoperation facilities and climate of the destination, reputation of the doctor, facility, and possible accreditation and/or afliation with a hospital at home and the desire to return home or the lack of availability of the treatment are the main reasons to travel for care.
While based on a modest response rate, the 2013 MTA Medical Tourism Survey Report (Medical Tourism Association, 2013) found that nearly 80% of the demand for medical travel was inuenced by the interest in saving money.Further, the MTA found that cosmetic surgery was the most sought after procedure.Mexico and India were the most popular medical tourist destinations in the study.
Since health, medical and wellness tourism is a mobility concern, an introduction into travel is presented next.Travel occurs because people seek alternatives in space where participation in some activity takes place (Shaw, Agarwal & Bull, 2000).Travel behavior is considered to be an example of utility maximizing behavior (Cooper, 1980;Hanson, 1980;Louviere & Timmermans, 1992;McFadden, 1974;Tussyadiah et al., 2006).However, unlike travel to work, health, medical and wellness tourist choice behavior is voluntary since an individual seeks to meet desired objectives by selecting among alternative hospital, clinic or spa destinations and choosing one.In particular, travel for health, medical and wellness care is assumed to be a function of the health care system, population characteristics, health behavior and perceived health status (Andersen, 1995).Each of these socio-economic and demographic factors is sensitive to policy implementation (Kutter, 1981).In order to investigate the inuence of these factors, a review of spatial travel behavior will be introduced.
Travel behavior can be viewed in one of two ways: either people visit the same place repeatedly, or they tend to exhibit diversied travel.It has long been thought that much of travel was exemplied by repeating patterns, that is to say, a systematic or non-random selection of travel choice was found.For instance, Marble and Bowlby (1968) investigated repetitious travel for households.They found people would repeat visits 75% of the time indicating a degree of travel concentration.For consumers, this may be an example of brand loyalty, where individuals attempt to reduce the risk of a poor selection (Sheth & Venkatesan, 1968;Gitelson & Crompton, 1984;Oppermann, 2000).Contemporary tourism literature notes the importance of this 'place attachment.'The health, medical and wellness tourism example here would recognize that the tourist is sensitive to quality, satisfaction, trust and cost (Han and Hyun, 2015).Gitelson and Crompton (1984) noted the dependence of vacation destinations on repeat visitation.Their research into repeat travel found ve primary reasons for this behavior: reduction of risk that the trip would be unsatisfactory, meeting the same kind of tourist, emotional attachment, a desire to further explore a chosen destination or the interest in showing others.
It has also been found that repeat visitors tend to stay longer and are involved in more local activities (Wang, 2004;Hwang & Fesenmaier, 2011).Yoon and Uysal (2005) add that motivations and satisfaction are additional elements that contribute to destination loyalty.But repeat visitation may not be the ultimate goal for a destination.Research in the Mediterranean region found that repeat visitation to 'sun and sand holiday destinations' may also reect the destination's inability to attract new visitors and a lack of appeal (Alegre & Cladera, 2006).Thus, many destinations are in a constant state of reinventing themselves to reach out to a tourist who has not yet visited.
Further, while repeat visitation may be a characteristic of some mobility, some geographers have questioned the reliance on only one form of travel choice.Hanson and Huff (1988) for example, explain repeat travel as a function of poor research design.The authors found that repeat travel was characteristic of short sampling schemes, and when travel patterns were considered for longer periods of time, considerable variation in behavior was found to exist.
Previous research by Hanson (1980) reviewed the travel behavior literature and found several possible explanations of diversied travel behavior.
First, an individual may be motivated to diversify travel from the desire to reduce uncertainty by learning about the available options.Second, travel diversication may result from an interest to spread risk by developing a portfolio of regularly visited destinations.For the shopper, this may be the process of visiting several stores to nd out which has the best prices, widest selection and so forth (Smith, 1978).
A third possibility for travel diversication may come about because of temporal, spatial and modal constraints.In this instance, the consumer may be short on time and/or lack the family automobile and be forced to patronize the neighborhood convenience store rather than the large supermarket.In a tourist context, this could be the experience for a family who takes a weekend picnic to the local park and goes to the Black Sea for the longer family vacation.It is obvious that travel distance plays a role in the visitation patterns as well.Although, rst-time visits to new and exotic destinations may make the longer distances needed to travel less of a disutility (Moutinho & Trimble, 1991;Nicolau, 2008).Another reason Hanson (1980) found was the need to reduce boredom by adding variety.This strategy may be classied as risk taking, collecting or trophy hunting (McAllister & Pessemier, 1982).Fifthly, a person may seek different destinations for various reasons (e.g., sunbathing at a Caribbean island versus downhill skiing in the Alps).
Next, travel diversication may be present when the tourist wishes to combine several activities into a single trip.In this example, long-haul travel yields maximum utility by meeting the different needs of all travel companions by, for example, combining business with pleasure travel (Tideswell & Faulkner, 1999;McKercher & Wong, 2004).
Hanson identies a nal reason for different travel strategies based on the origin of the particular trip.A trip originating at home will differ from those that begin at work.However, while the destination may differ between the two starting points, Kitamura and Kermanshah (1984) found that the home location was still important for non-home based destination choice since the home may be the nal destination of the experience.
Is the health, medical and wellness tourism industry interested in repeat visitation or diversied travel behavior from their clients?Perhaps both type of client is needed.Repeat visitation may be required for the spa treatment, yet rsttime visitors need to be attracted as well.
One can summarize travel as existing along a continuum of behavior (Huff & Hanson, 1986).At one end, the behaviour is completely stochastic (where stops are entirely independent and random) and at the other end, completely habitual or repetitive.Huff & Hanson (1986) believe that observed travel falls somewhere in between.
The question for researchers is then to identify which type of behavior can be expected and under what conditions.For the purpose of this research, the dependent variable is the actual travel of a sample of health, medical or wellness tourists along this continuum anchored by the travel experience of likely to go to the same destination again (repeat travel), likely to try a new destination with different types of activities (diversied travel), or likely to try a new destination with similar activities (something in between).

Methods
In order to assess the mobility of tourists, a survey was deployed.The survey instrument was designed to collect information about these tourists: the socioeconomic characteristics, motivations, and travel planning strategies, where they traveled, and what procedures they sought.The respondents were given an opportunity to rank the importance of factors that might inuence their mobility.The survey instrument was pretested, and a few minor adjustments were made.A call for participation in the study was published in the Tico Times, a weekly Englishlanguage newspaper published in Costa Rica.In addition to this, the survey was promoted online on relevant distribution lists, medical tourism blogs, and expat forums.The survey instrument was hosted on an online survey site and while the respondent's Internet Proticol (IP) address was known, we did not explore the origin of the individual user since we assured condentiality in the data collection.
The survey was open to all who traveled abroad for health, medical and wellness procedure and 135 individuals responded to the call.About half of the sample identied their future interest in travel.For this study, actual travel, instead of those just planning a trip, was used and yielded a modest sample of 65 medical tourists.Given the convenience sampling procedure, it is impossible to determine the randomness of the data.Thus, the results are merely provided as an exploration of the travel behavior of health, medical and wellness tourists.

Results
The Central American country of Costa Rica was the most popular destination for the tourists.Nearly 37% of the sample visited this country, followed by 19% to Mexico, and 13% to India.Given that the survey instrument was heavily marketed in Central America, these results should come by no surprise.Hong Kong and Singapore garnered 4% of the sample each.One or two tourists in the sample each sought procedures in Canada, Colombia, Malaysia, Taiwan, Thailand or Turkey.
Dental care was sought by 43%, and cosmetic surgery was obtained by 23% of the sample.These gures are consistent with the reputation of medical treatment in the Central American region (Judkins, 2007).Orthopedic (knee and hip) procedures were obtained by 11%, and bariatric care was found for 8%.The tourists tend to be older, with 54% of the sample being 50 years or older.Most are men (61%) and well educated (72% with a college degree or higher).Participants tended to be married and had a moderate income ($25,000 -$49,900 US).
In order to assess the relative importance of travel behavior on medical tourists, tests of statistical association and correlation were undertaken.The respondents were asked about situations that were important to the individual as a medical tourist.They coded their response on a ve-point Likert Scale from Not Very Important to Very Important (i.e., 1 to 5 respective).Since most of the answers were noted as important or very important, a recoded table simplied the data to simply not important, indifferent and important (1, 2, and 3 respective) and maintains the ordinal scale of the data.Further, it was necessary to recode the data, to eliminate missing values for the categorical and ordinal statistical analysis.Table 1 summarizes the descriptive statistics of the data.Sea,sun,sand and …. selecting surgery 123 Cost, reputation of the doctor and facility and post operation opportunities were the most important factors to our medical tourists.While the other factors were less important, the larger standard deviation indicates a signicant variation in the importance of these inuences.In the analysis, the least important motivation was 'Procedure not available at home'.This suggests the sample decided to travel for something that might have been available at home and that the other reasons were more important.
To test the importance of these factors with the travel behavior of the tourists, the Chi Square and Gamma Tests of Association were used.In so doing a contingency table was created with the travel behavior continuum on one axis (i.e., likely to go to the same destination again, likely to try a new destination with similar activities, likely to try a new destination with different types of activities) and the ranking of the factors on the other.Table 2 highlights the ndings.
The importance of whether or not the chosen clinic was afliated with an 2 American hospital was statistically signicant (X =8.68, df=2, p=0.10; 124 Bristow & Yang Gamma=0.44,p=0.05).This suggests that afliation is more important to those tourists who exhibit diversied travel behavior.Likewise, hospital accreditation was also important to those who diversify their travel choice (Gamma=0.53,p=0.05).The doctor's reputation was ranked high by all medical tourists, and thus no signicant variation was found.This analysis suggest that future diversied travel behavior is more likely to occur when the destination has some external accredidation and/or is linked to an American hospital.Both may be considered some assurance of quality.
As more and more tourist destinations attempt to build a health, medical and wellness tourism reputation by bundling existing clinics, spas, and hospitals with traditional tourist infrastructure, the analysis seeks to explore the potential attraction in an example.Costa Rica is selected as the case study since the country has a history of extensive ecotourism founded on a wealth of natural resources and protected park areas.Adding to this, the country has a reputation of excellent health care facilities (Cook, 2007;Fallas, 2009).
The results of our analysis found that many of the Costa Rica medical tourists exhibit a stronger propensity to repeat travel behavior, clearly a measure of place attachment with the Latin American country (Table 3).Those who sought medical care elsewhere were individuals who exhibited variety seeking behavior.While not 2 a signicant difference, our modest sample size may explain this (X =2.28,p=0.131;Gamma = 0.0393,p=0.140).The data suggests that the Costa Rica is likely to attract tourists who have travelled there before rather than rst-time visitors.The challenge for the expanding opportunities in the region would be to encourage a rst-time visit to Costa Rica, and to continue to market the destination to repeat travelers.

Discussion
The decision-making process of tourist is a complex relationship between the individual and the destination.One element of the behavior is the consumers' decision to travel to someplace new or return to a favored vacation spot.Adding to this mix, the need to include a health related procedure away from home complicates the decision-making process.A bad meal in a restaurant or a noisy hotel room does not rank as important as a successful operation in a foreign clinic.Thus, the tourist provider needs to be fully aware of the health, medical and wellness tourists' travel planning.
This travel behavior has been shown to exist along a continuum.At one end, the consumer is content with visiting the same destination time and time again.The holiday is safe and secure and satises all the traveler's needs, so no new stimulation is necessary.At the other end, the variety seeking behavior of the tourist demands different and new stimulation.The barriers to new and different travel are overcome in order to achieve a different set of goals for the traveler.For health, medical and wellness tourists, who may be under the stress and strain of traveling to a distant land for treatment, it is necessary to overcome the hurdles of travel in order to get that tourist, or patient, to visit a clinic.While cost tends to be the greatest concern among these tourists, the familiarity of the chosen destination does play a role in the decision-making process.While the sample explored in this study is heavily weighted toward travelers to Central American tourist facilities, several factors inuencing travel were found to be statistically signicant.For variety seeking health, medical and wellness tourists, some assurance of quality, either through international accreditation or some afliation with an American hospital was an important element inuencing travel behavior.Similar experiences may be found in the other major destinations.Eastern Europe and Southern Asia are attractive destinations for their particular market.Since our sample was concentrated in the western hemisphere, even if different motivations exist to inuence the travel for those in the East, the end result, the benecial treatment at a health, medical or wellness facility is still the most important aspect.
Because the survey was administered online, there is no attempt to infer the ndings to the population of all health, medical and wellness tourists.Even so, research by Litvin and Kar (2001) found signicant differences in travel patterns as reported when scholars use both on e-surveys compared to traditional in-person surveys.Since the sample in this study was obtained entirely online, little variation could be expected with this modest database.Further, it is our attempt to explore the travel behavior of health, medical and wellness tourists in this descriptive study.And given that medical records are private, any insight into this mobility from people who have actually travelled is useful as we explore this behavior.

Conclusion
The challenge for tourist facilities seeking to expand into the growing eld of health, medical and wellness tourism is to assure the repeat visitor that the clinics can address their needs while at the same time reaching out to rst-time visitors.Wang (2004) would suggest that attention to repeat visitors provides the greatest benet to destination management than providing extra attention to rst-time visitors.It is true that travelers displaying spatial behavior along the continuum have to be treated as two or more market segments.Repeat customers are critical for tourist destinations and clinics to succeed in the competitive world of tourism (Han & Hyun, 2015).
This study offered an exploratory investigation of health, medical and wellness tourists based on their actual travel behavior.By linking the travel behavior to the motivations behind the trip, several characteristics were found to be statistically signicant.A larger random sample might yield different inuences, yet for this baseline study we have found that elements of familiarity or safety are most important to the diversifying tourist.And for the manager of the tourist destination, this is the factor that must be overcome to attract a rst time visitor.
Future research in travel behavior of health, medical and wellness tourists should explore the specics of the treatment sought.Heart surgery is likely to be a rst time experience; the hospital should not be looking for a repeat client.On the other hand, spa and wellness opportunities need to attract repeat tourists in addition to the rst time visitor.This treatment continuum is quite different from the travel continuum describe in the paper.But in either case, there can be no one market in tourism.The individual has certain needs and expectations, and the world of health, medical and wellness tourism must meet those challenges.

Table 1 .
Factors important to medical tourists

Table 2 .
Statistical Tests for Future Travel

Table 3 .
Medical tourists chosen destination by propensity to diversify travel