In search a medical tourism marketing pattern in Iran: The case of cultural sensitivities

Abstract

Health tourism has a significant financial benefit in the current industrial world. In addition, attention is being paid to the medical and cultural sensitivities in the development of the medical tourism industry, which increases the willingness of foreign patients to receive health care and treatment. The purpose of this study was to investigate the role and importance of the factor of paying attention to the medical and cultural sensitivities of international patients in the proposed pattern of medical tourism marketing. In the stage of exploratory factor analysis, the proposed pattern including 9 factors with 60 items after confirmatory factor analysis confirmed and the ‘attention to the cultural and medical sensitivities’ factor with 6 variables ranked 8 among other factors. Regarding the issue of medical and cultural sensitivities of foreign patients, it can be expected that patients will be more intimate and sympathetic during admission to medical centres and receive health care services, which will increase their sense of security and trust towards health workers. Healthcare activists and government officials are expected to give special attention to the cultural and medical sensitivities in developing short-term and long-term plans for the development of the health tourism industry.

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International Journal of Healthcare Management
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In search a medical tourism marketing pattern in
Iran: The case of cultural sensitivities
Fatemeh Najafipour Moghadam, Irvan Masoudi Asl, Somayeh Hessam &
Mahmoud Mahmoudi Farahani
To cite this article: Fatemeh Najafipour Moghadam, Irvan Masoudi Asl, Somayeh Hessam
& Mahmoud Mahmoudi Farahani (2020): In search a medical tourism marketing pattern in
Iran: The case of cultural sensitivities, International Journal of Healthcare Management, DOI:
10.1080/20479700.2020.1732647
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In search a medical tourism marketing pattern in Iran: The case of cultural
sensitivities
Fatemeh Najafipour Moghadam
a
, Irvan Masoudi Asl
b
, Somayeh Hessam
c
and
Mahmoud Mahmoudi Farahani
d
a
South Tehran Branch, Islamic Azad University, Tehran, Iran;
b
Department of healthcare Services Management, School of Health
Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran;
c
Department of Health Care Management, South
Tehran Branch, Islamic Azad University, Tehran, Iran;
d
Department of Biostatistics, Research Center, Tehran University of Technology,
Islamic Azad University, Tehran, Iran
ABSTRACT
Health tourism has a significant financial benefit in the current industrial world. In addition,
attention is being paid to the medical and cultural sensitivities in the development of the
medical tourism industry, which increases the willingness of foreign patients to receive
health care and treatment. The purpose of this study was to investigate the role and
importance of the factor of paying attention to the medical and cultural sensitivities of
international patients in the proposed pattern of medical tourism marketing. In the stage of
exploratory factor analysis, the proposed pattern including 9 factors with 60 items after
confirmatory factor analysis confirmed and the ‘attention to the cultural and medical
sensitivities’factor with 6 variables ranked 8 among other factors. Regarding the issue of
medical and cultural sensitivities of foreign patients, it can be expected that patients will be
more intimate and sympathetic during admission to medical centres and receive health care
services, which will increase their sense of security and trust towards health workers.
Healthcare activists and government officials are expected to give special attention to the
cultural and medical sensitivities in developing short-term and long-term plans for the
development of the health tourism industry.
ARTICLE HISTORY
Received 2 July 2019
Accepted 9 February 2020
KEYWORDS
Cultural sensitivity; health
tourism; medical tourism
marketing; marketing;
pattern; Iran
Introduction
Tourism produces positive effects on the economy,
society, culture, and environment including its con-
tribution to GDP, improvements to infrastructure,
the protection and renaissance of culture and
increases in environmental awareness [1]. Medical
Tourism has been favoured by health care providers
in other countries around the world trying to attract
and accommodate medical travellers. As a result,
there has been a growing concern for the creation
of professional standards to protect the quality and
safety of patient care and the types of business
opportunities that are available in this new industry
[2]. As far as supply factors are concerned, hospital
accreditation, geographical distance, and cultural
familiarity emerge as important determinants of des-
tination country selection in the literature by
patients; moreover, geographically and culturally
related issues are often analyzed in conjunction
with other factors that affect international medical
tourism. Although the nature of marketing of tour-
ism services is different from those of other services
such as banking or transportation, all the P10 items
of McCarthy (1975) including product, price,
location/distribution and promotion, individuals,
physical evidence and processes, participation, perso-
nalization, can be extended to the health tourism
industry [3].
In Iran, in order to solve the problems caused by
dependence on oil exports, it is necessary to invest in
the production and export of those products and ser-
vices that can generate foreign exchange earnings. In
some cases, the country has a set of defined products
and services that can be converted into the capital by
investment and can be used as a source of currency
income [4]. According to the2017 World Economic
Forum (WEF), with 5.2 million international tourists
entering Iran, about $ 3.5 million has been paid by
them [5]. Iranian tourism industry –despite enormous
potentials –has faced a number of challenges including
wide-ranging nuclear-related sanctions, the negative
public image in the Western countries and lack of effec-
tive management of resources [6]. Moreover, the devel-
opment of this industry itself will promote the quality
of the services of hospitals and treatment, and create
employment in the health sectors and archive the
world standards leading to earning incomes and
foreign exchange and economic, social, cultural and
political prosperity in the country [7]. However, the
lack of coverage of health insurance, the lack of trans-
parency of costs, and the lack of medical packages that
© 2020 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Irvan Masoudi Asl drirvanmasoodiasl@yahoo.com Department of healthcare Services Management, School of Health Management and
Information Sciences, Iran University of Medical Sciences, Tehran, Iran
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
https://doi.org/10.1080/20479700.2020.1732647

are barriers to medical travel have been challenging
providing facilities such as hoteling facilities,
interpreter, transportation, tourist tours, and defects
of the hospitals surveyed [7].
Medical tourism represents a growing health care
market, and this group of travellers presents unique
challenges for public health and clinical medicine. In
addition to traditional travel health recommendations,
medical tourists have unique health needs and should
be advised accordingly. Some of these needs include
ensuring current medical conditions are stable enough
for travel and the need for appropriate follow-up care
after procedures [8]. Results contribute to the limited
empirical research on the consumer dynamics and
underpinnings of an industry experiencing rapid
growth in an environment of significant change and
uncertainty. Findings may also assist medical tourism
marketers to serve those already inclined to travel
abroad for healthcare services better, and to create
more favourable predispositions among those not cur-
rently inclined to do so [9]. Of course, this type of tour-
ism is due to the sensitivity of the health of individuals
to the required standards, including the availability of
technical and scientific knowledge, as well as medical
and therapeutic infrastructure. The goals for this type
of travel should be meeting these standards as a prere-
quisite for their success in attracting tourists from their
perspective [10]. Culture is seen as a pathway to the
transformative social practices, where individuals
transform their previously fixed behaviours in different
transnational contexts. In simple language cultural
diversity can be understood in many different ways.
It is often referred to like the mixture of different
human groups societies or cultures in a specific geogra-
phy or in the Globe (as a whole). The diversity could
also be understood by differences in race ethnicity
nationality religion or language among various groups
within a community organization or nation. Individual
values beliefs customs traditions and backgrounds also
bring cultural diversity [11]. Considering the impor-
tance of marketing in the prosperity of health tourism
and limited research, it was attempted to identify the
medical and cultural factors along with other factors
to design a marketing pattern appropriate to the struc-
ture of existing rules and resources. The present study
was applied in a descriptive-correlational and cross-
sectional study aiming for the investigation of the
importance of medical and cultural sensitivities in the
proposed medical tourism-marketing pattern.
Methodology
The present study was applied using a descriptive-cor-
relational and cross-sectional study. The statistical
population consisted of all the people working in the
medical universities of the country in the field of health
tourism: 630 active people in the field of health tourism
were selected by simple random sampling. A
researcher-made questionnaire was used to collect the
research data. The questionnaire was developed based
on an interview with experts and tourism activists in
the field of marketing and tourism with the Likert
scale in a completely opposite = 1, opposite = 2, neither
agree nor disagree = 3, agree = 4, totally agree = 5. To
assess the validity of the content of the questionnaire,
from the viewpoint of professors, experts, and for
determining the content validity, quantitatively, two
content validity coefficients (CVR) were higher than
0.62 and Content Validity Index (CVI) was higher
than 0.79. Cronbach’s alpha coefficient (0.82) and test
re-test and correlation (0.92) were used to assess the
reliability of the questionnaire(N=40).
After confirmation of the validity and reliability, 630
questionnaires were completed. In order to verify the
validity of the proposed conceptual pattern, factor
analysis was used that was conducted in two explora-
tory factor analysis and confirmatory factor analysis
(second-order). After performing the exploratory fac-
tor analysis, 9 components and 60 items whose factor
load was above 0.3were extracted. After the corrections
were made in the original conceptual pattern, the vali-
dated factors were extracted from the confirmatory fac-
tor analysis of LISREL 8.8. Goodness-fit indicators for
all components, the calculation of the suggested pattern
for health tourism marketing was confirmed.
Findings
The results of the sample sufficiency test
(Bartlett)
In this research, in order to examine the existence of
the conditions for factor analysis, assuming the society
is normal, and the sampling accuracy index (KMO)
and Bartlett’s test have been used. The results of this
test showed that due to the lower level of a significance
level of Bartlett test, the correlation between the terms
is appropriate for 0.05, and with KMO index larger
than 0.6, the number of samples is sufficient for factor
analysis (Table 1).
Results of exploratory factor analysis
At this stage, the responses of the samples were entered
into SPSS version 22. Items with a factor load above 0.3
were selected for the continuation of the analysis and
the factor loads below 0.3 were not considered. Accord-
ing to these results, 3 items of the analysis process were
eliminated. The results are presented in Table 2.
Table 1. KMO and Bartlett tests.
sampling adequacy index(KMO) df χ
2
Significance level
0.712 1953 30457.296 0.001
2F. N. MOGHADAM ET AL.

As shown in Table 3, the contribution of the first
factor with a special value of 15.76 and a 25.02% var-
iance is very significant, and the contribution of the
other factors is quite distinct. All of the indicators of
the questionnaire consisted of 9 main factors and
explained %57.22 of the total variance.
As shown in Table 4, all factor loads are larger than
0.5 and are %95 reliable in the confidence level, so all
items remain in the model and there is no reason to
remove them.
The results of Table 5 confirm the divergent validity
of all variables in the model. It is worth mentioning
that the divergent validity is calculated for variables
that are directly measured by the questions of the ques-
tionnaire and do not include the second to the top, and
all factor loads are larger than 0.5 and are %95 reliable
in the confidence level, so all items remain in the model
and there is no reason to remove them [12].
According to Table 6, estimated values for pattern
fitting indices show that research data with factor
structure and theoretical basis of the research is appro-
priate to fit, which indicates that the questions are con-
sistent with the theoretical constructs; therefore, the
proposed pattern can be confirmed.
The study results indicated that nine factors (pro-
motion, procedures and methods, partnership, phys-
ical evidences, medical package, product, paying
attention to cultural and medical sensitivities, cost
and people) were found effective in the Iranian ver-
sion of medical tourism pattern on the development
of the medical tourism services offering(AVE: 0.64,
CR: 0.966and Cronbach’s alpha: 0.941). Based on
the results, the factor of paying attention to the medi-
cal and cultural sensitivity with 6 components (Table
4) ranked 8 in the proposed pattern and, according
to Table 5, has indicators (AVE: 0.575, CR:
0.888and Cronbach’s alpha: 0.854). Thus, our data,
based on the fitness indicators, have confirmed the
role of paying attention to the cultural and medical
sensitivity factor along with other factors in the pro-
posed pattern, and the proposed structure is
confirmed [12].
Discussion
Our findings show the role and importance of the
factor of paying attention to the medical and cultural
sensitivities along with other factors in the proposed
pattern. According to Pakjou research, policies and
interests, traditions, cultures, and customers are tar-
gets that should be up to standards before reaching
the intentions of tourists. With a wide range of reli-
gious, ideological, philosophical ethical backgrounds,
Iran can set new standards in services and medical
tourism [13]. Findings of the literature of Khan and
et al., a review suggests that Medical Tourists’per-
ceived risks about destination and travel motivations
Table 2. The matrix of rotating agents after turning in the varimax.
Factor1
Factor
loading Factor2
Factor
loading Factor3
Factor
loading Factor4
Factor
loading Factor5
Factor
loading Factor6
Factor
loading Factor7
Factor
loading Factor8
Factor
loading Factor9
Factor
loading
Q42 0.719 Q38 0.785 Q47 0.806 Q28 0.373 Q54 0.854 Q22 0.686 Q62 0.811 Q2 0.736 Q20 0.728
Q27 0.706 Q37 0.733 Q49 0.795 Q29 0.419 Q55 0.687 Q21 0.646 Q63 0.797 Q4 0.735 Q23 0.487
Q41 0.686 Q39 0.686 Q48 0.608 Q16 0.749 Q56 0.677 Q18 0.53 Q60 0.491 Q1 0.718 Q24 0.440
Q43 0.525 Q36 0.603 Q46 0.576 Q19 0.674 Q52 0.68 Q57 0.529 Q58 0.542 Q5 0.424 Q17 0.495
Q44 0.498 Q34 0.504 Q50 0.538 Q53 0.42 Q14 0.517 Q61 0.41 Q6 0.678 Q25 0.602
Q45 0.449 Q40 0.473 Q51 0.484 Q11 0.405 Q59 0.508
Q30 0.733 Q10 0.625 Q15 0.428
Q26 0.463 Q12 0.724 Q8 0.493
Q35 0.737
Q31 0.541
Q32 0.651
Q33 0.700
Q13 0.423
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3

will have an impact on the image of medical tourism
destinations [14].
There are many advantages in health tourism in
Iran, among which the most important ones are pro-
viding low-cost health care, short waiting times and
the highest quality of services and care, as well as the
most experienced specialists and the most up-to-date
technologies, access to biotechnology, biological
drugs, stem cells, and restoration, spinal cord injury
[15]. For instance, promoting Halal or Islamic tourism
would help in attracting lucrative Muslim tourist mar-
ket and embracing the rapidly changing dynamics of
global tourism, of which Halal tourism is an integral
part [16]. Tourism social entrepreneurship (TSE) is
suggested as a market-based strategy to address social
problems while maximizing the benefits and minimiz-
ing the negative consequences that tourism may pro-
vide to the host communities. To date, there is a
limited understanding of how TSE can be a catalyst
for sustainable community development [17].
Table 3. Specific values and explained variances by the factors extracted from the exploratory factor analysis.
Special values of extracted factors before rotation Special values of extracted factors after rotation
factor
special
amount
%Variance
explained
%Cumulative of variance
explained
special
amount
%Variance
explained
%Cumulativeof variance
explained
1 15.76 25.02 25.02 6.26 9.94 9.94
2 4.111 6.52 31.54 6.13 9.73 19.67
3 3.31 5.25 36.79 4.47 7.09 26.76
4 2.72 4.31 41.1 3.91 6.20 32.96
5 2.46 3.91 44.99 3.56 5.61 38.57
6 2.15 3.41 48.41 3.42 5.43 44.01
7 2.10 3.17 51.58 3.08 4.88 48.89
8 1.79 2.84 54.42 2.75 4.36 53.24
9 1.77 2.81 57.22 2.51 3.98 57.22
Table 4. Convergent validity (second-order factor loads and AVE index) and reliability (Cronbach’s alpha and CR).
Main variable Component
Convergent Validity Reliability
Second -factor
analysis
Rank in
pattern R
2
t-
value AVE CR
Cronbach’s
alpha
Marketing of medical tourism
services pattern
Promotion 0.98 1 0.96 20.65 0.64 0.966 0.941
Procedures 0.88 4 0.77 17.50
Partnership 0.48 9 0.23 9.82
Evidence 0.83 5 0.69 16.13
Medical Package 0.77 6 0.59 16.74
Product 0.91 2 0.83 17.83
Medical and Cultural
Sensitivity
0.55 8 0.3 9.65
Cost 0.75 7 0.56 14.75
People 0.91 3 0.83 22.79
Table 5. Standardized coefficients and the significant number of pay attention to the medical and cultural factor of medical tourism
services marketing pattern.
Hidden variable Apparent variable
Convergent Validity Reliability
λR2
t-
Value AVE CR Cronbach’salpha
Medical and
cultural
sensitivity
In the provision of health, there is pay attention in offering treatment and
healthcare services to international patients to their clinical histories
(medicinal allergies, past record of special diseases and so forth) and the
documents are kept in this regard.
0.5 0.25 - 0.575 0.888 0.854
Healthcare and treatment services are offered to international patients
based on necessity and minimum side effects.
0.63 0.40 11.06
In Iran, it is easy to prepare Halal food. 0.93 0.86 13.18
Disclosing the patient’s secrets and providing information about the
treatment to others (without the consent of the patient or his guardian)
is prohibited.
0.82 0.67 12.61
Cultural differences are considered in verbal communication (using a
translator or assigning a fluent English speaking staff) as well as non-
verbal communication.
0.77 0.59 12.27
There are enough facilities for performing religious practices for followers
of all divine religions in Iran.
0.62 0.38 11.03
Table 6. Indicators of fitting the factors of medical tourism
services pattern in Iran.
Index name Basic model Modified model Allowed range
χ
2
5.568 2.758 3>
)GFI) 0.78 0.85 0.8=<
)AGFI) 0.73 0.81 0.8=<
)RMSEA) 0.165 0.068 0.10>
)CFI) 0.85 0.96 0.9=<
)NFI) 0.84 0.90 0.9=<
)NNFI) 0.84 0.92 0.9=<
)IFI) 0.85 0.96 0.9=<
4F. N. MOGHADAM ET AL.

According to Momeni et al., to obtain competitive
advantages, Iran needs to implement long-term plans
to strengthen infrastructures and cultural reforms.
Further participation of the private sector is required
to strengthen the infrastructures and plan for a more
efficient application of mass media and local and pro-
vincial press to enhance awareness and cultural reform.
Finally, systematic plans with broker phenomenon and
enforcing hospitals from the perspective of inter-
national accreditation should be included in the agenda
of medical tourism authorities [18].
Culture is seen as a pathway to the transformative
social practices, where individuals transform their
previously fixed behaviours in different transna-
tional contexts. Women transmitted local knowledge
by customizing trips to meet their guests’various
needs and interests as well as engage in the cultural
transformation. Visits from the homeland leading to
tourism activities turned mobile women into hosts,
tourists, and tourist-agents –confirming the signifi-
cance of tourism for women as a vehicle for empow-
erment [19]. Business programmes are expected to
perform with cultural sensitivity in international
and intercultural professional environments [20]. It
is preferable for a female Muslim to be cared for
by females and a male Muslim by males. This is
most important during confinement when strict
privacy is very essential. Only female health workers
should be present and exposure should be kept to a
minimum [11].
Today, the medical tourism industry has an esti-
mated growth rate of up to 25% year-over-year for
the next 10 years and it is estimated that 3–4% of
the world’s population will travel internationally for
healthcare [21]. In recent years, policymakers have
begun to embrace behavioural economics to make
interventions for human behaviour and decision
making [22]. The most frequently mentioned
demand factors are the relatively high cost of medical
care in the origin country and the quality of medical
care in comparison with that of the destination
country. As far as supply factors are concerned, hos-
pital accreditation, geographical distance, and cultural
familiarity emerge as important determinants of des-
tination country selection in the literature by
patients; moreover, geographically and culturally
related issues are often analyzed in conjunction
with other factors that affect international medical
tourism [3]. Different industries use various market-
ing strategies to attract clients and make more
profit. Also, the development of this industry itself
will promote the quality of the services of hospitals
and treatment creating the employment in the coun-
try’s health sector achieving world standards, and
ultimately leading to earning income and foreign
exchange and economic, social, cultural and political
prosperity in the country [7].
Today there is great receptiveness towards Medical
Tourism. When patients are travelling overseas there
is an emergence of new consumers and they show a
completely different behaviour pattern. As a result of
developments in communication tools information
technology and increased social media exchanges,
they have been exposed to different cultures and devel-
oped new ideas and viewpoints [11].
Conclusion
According to our findings and considering the impor-
tance of paying attention to ‘the cultural and medical
sensitivity factor’and its 6 components in the proposed
pattern of medical tourism marketing, including ‘pay-
ing attention to the medical sensitivities and patient
clinical records’,‘providing services with minimal
side effects and complications’,‘preparing Halal
food’,‘protecting the secrets of the patient’,‘paying
attention to the cultural sensitivities’in verbal and
non-verbal communication, ‘providing facilities for
performing religious duties’, it is expected that policy-
makers and planners pay special attention to the fac-
tors influencing the development of tourism
marketing and promotion of this industry.
Globalization across all sectors has brought com-
plex cultural needs in an already culturally diverse
world. Understanding culture and behaviour was
important in healthcare to provide comprehensive
care with a delightful experience but it has certainly
become essential in Medical Tourism as patients
arrive with different cultural beliefs and from differ-
ent geographies. Understanding of Culture in Medi-
cal Tourism is a two-way process as the patient
needs to understand the destinations cultural beliefs
as much as providers need to know and understand
the patients’cultural beliefs.
Given a large number of citizens of neighbouring
countries including Iraq, Afghanistan, Oman visit
Iran for pilgrimage, tourism and treatment each year,
it is important to pay attention to cultural and medical
sensitivities in the provision of health tourism services.
Paying attention to the medical and cultural sensi-
tivities associated with health care staffwith foreign
patients leads to their trust in the medical staffand
the consolidation of human and friendly relations. In
fact, it can be expected that with the special attention
of the providers of care services and medical care to
the cultural sensitivities of foreign patients, they will
feel empathy in receiving services, relax and have
more confidence in their health, and in the field of vis-
iting their country. They share their positive experi-
ences with relatives, friends, and others that this will
have a positive effect on attracting foreign patients. it
is suggested that Conducting communication courses
and paying attention to the cultural sensitivities of
foreign patients from neighbouring countries of Iran
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5

for receiving medical services will be very helpful in
facilitating the communication of medical staffwith
foreign patients.
Contribution
Masoudi I, Hessam S, Mahmoudi Farahani M, and
Najafipoor Moghadam F designed research; Masoudi
I, Hessam S, and Najafipoor Moghadam F, conducted
research; Mahmoudi Farahani M, analyzed data; and
Najafipoor Moghadam F, Masoudi I, Hessam S,
wrote the paper. Masoudi I, had primary responsibility
for final content. All authors read and approved the
final manuscript.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
Notes on contributors
Irvan Masoudiasl, Ph.D. in Health service management,
Department of healthcare Services Management, School of
Health Management and Information Sciences, Iran Univer-
sity of Medical Sciences, Tehran, Iran.
Fatemeh Najafipour Moghadam, Ph.D. Student in Health
Service Management, South Tehran
Branch, Islamic Azad University, Tehran, Iran. Her work
and research interests include cultural sensitivity in medical
tourism.
Somayeh Hessam, Assistant Professor, Department of health
service administration, South Tehran Branch, Islamic Azad
University, Tehran, Iran. Her work and research interests
include the effectiveness of cultural sensitivity in medical
tourism.
Mahmoud Mahmoudi Farahani,Professor, Department of
Biostatistics, Research Center, Tehran University of Tech-
nology, Islamic Azad University, Tehran, Iran. His research
interests include the impact of biostatistical research on
healthcare management practices in medical tourism.
ORCID
Fatemeh Najafipour Moghadam http://orcid.org/0000-
0001-8466-6456
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