An Integrative Review of Patients' Experience in the Medical Tourism.

Medical tourism has emerged as an industry due to the constantly improved information technology and decreasing cost for transportation. Evidence on how medical tourists develop their medical travel and their experience keeps growing. This article aims to provide an integrative review to understand medical tourism from the patients' perspective. PRISMA procedures were followed. All the literature was published from January 1, 2009, to May 4, 2019, in peer-reviewed journals in CINAHL and MEDLINE/PubMed. Johns Hopkins Nursing evidence level and quality guide were used to evaluate evidence level. Twenty-one studies including 8 quantitative, 10 qualitative, and 3 mix-method studies were reviewed. Low cost, short waiting list, quality, and procedures available were the motivators to treatment abroad. The Internet, former tourists' testimonial, and physician and facilitators' advice were the predominant resources consulted. Perceived value of medical quality directly affected patients' overall satisfaction. Our integrative review has led to the identification of many factors related to medical tourist's experience. We suggest further empirical researches on (1) the patients' decision-making process of motivators and barriers, (2) the factors related to patients' experience on the health care quality, and (3) the strategies to ensure the continuity of care.

What do we already know about this topic?

Medical tourism has emerged as an industry due to improved health technology, decreased cost for transportation, and innovative information technology. It is estimated that the number of medical tourists in the world was 14 to 16 million in 2017. The ongoing increase in medical travel flow brings both opportunities and challenges for the health care industry.

How does your research contribute to the field?

In this review, we intend to develop a comprehensive understanding of the existing knowledge about medical tourism from the patients’ perspective.

What are your research’s implications toward theory, practice, or policy?

We suggest promoting the implementation of standards and guidelines of linguistic and cultural competency. Additional cultural competency training such as cross-cultural knowledge and skills and sensitivity toward the diversity norms of other cultures should be offered in schools and hospitals. Moreover, strategies for promoting continuity of care should be implemented to ensure that millions of medical tourists can receive optimal health care.

Medical tourism has emerged as an industry due to improved health technology, decreased cost for transportation, and innovative information technology. Individuals travel thousands of miles to seek treatment abroad.[1] The US cross-border exports of medical services have more than doubled in the past 10 years with a continuous growth at 7.7% compound annual growth (CAGR). In addition, imports of medical services to the United States have increased up to 24% CAGR.[2] It is estimated that the number of medical tourists in the world was 14 to 16 million in 2017.[3] The ongoing increase in medical travel flow brings both opportunities and challenges for the health care industry.

Medical tourism has been popular for centuries since the ancient Greeks and Egyptians swarmed to baths and hot springs to current surgery abroad. Although a growing number of valuable and relevant studies have addressed the new trend of medical tourism, majority of them focused on the opportunities and challenges it created for the global market and each national health care service[4]; a few studies started to shed light on how the new trend of the medical tourism affected patients’ health care–seeking behavior such as the motivators and challenges.[5] A common misperception among scholars and the general public is that wealthy classes are the mainstream population with access to care abroad. Moreover, most people hold a similar opinion that medical tourists who come from developing countries tend to seek treatment in developed nations. Accordingly, in this review, we intend to develop a comprehensive understanding of the existing knowledge about medical tourism from the patients’ perspective.

The advance in information technology drives the rapid development of medical tourism. The Internet becomes the most common source that tourists use to acquire an initial understanding of a potential destination hospital.[6] Clicking “treatment abroad” on Google generated more than 33 000 000 results on May 4, 2019. However, no tool could be used to assess the accuracy and reliability of information sources. In addition, online information may lead to unrealistic expectations and uninformed decisions.[7] Subsequently, certain patients turn to facilitators or brokers when choosing a destination hospital.[8] Others may adopt the family physician’s advice. The fragmented evidence of medical tourism information continues to grow. However, none of the literature reviews has focused on how the tourists consult information and how to decide a destination.

Patient satisfaction with the medical tourism is also a critical indicator of health care quality and predict patients’ intention of revisiting. Medical tourists seek quality in their interaction with health care providers in the destination hospital. Employee’s responsibility and attitude, tourists’ perceived value, and other factors such as environment, food, and communication shape their own understanding of health care quality and thereby influence their experience. In addition, medical tourists divided health care quality into medical and service qualities.[9] Moreover, a growing number of studies have investigated medical tourists’ perception on this aspect of health care. However, literature review has scarcely established a comprehensive review concerning medical tourists’ experience in health care quality when they seek treatment abroad.

Accordingly, the present study aims to explore a full understanding of the medical tourism that forms the patient’s perspective. In addition, it attempts to answer the following research questions:

Research Question 1: What are the motivators and barriers for medical tourists?

Research Question 2: What are the information sources, and how do they make a decision?

Research Question 3: What is the medical tourist’s experience on the quality of service?

Methods

The integrative review followed PRISMA.[10] Our team investigated 181 peer-reviewed studies related to medical tourists’ experience in medical tourism.

Data Sources and Search Strategies

This research performed an electronic search for articles related to our topic in MEDLINE/PubMed and CINAHL Complete from January 1, 2009, to May 4, 2019. Such combing sets no limitation on the country. Medical Subject Headings (MeSHs) were used to search for articles. Four main concepts were found, namely, Medical Tourism, Global Health, Patient’s Satisfaction, and Perception. The Boolean phrases used included the following: (1) (“medical tourism” [MeSH] OR “global health” [MeSH] AND “patient’s satisfaction” [MeSH] AND [“Patients”] [MeSH]) and (2) (“medical tourism” [MeSH] OR “global health” [MeSH] AND [“patient”] [MeSH] AND “perception” [MeSH]). The search in CINAHL database was conducted using the following keywords: Medical Travel, Medical Tourism, Patient Satisfaction, Patient Experience, and Patient Perception. Boolean phrases were (1) Medical Travel OR Medical Tourism AND Patient Satisfaction and (2) Medical Travel OR Medical Tourism AND experience. Hand searching supplemented the search strategy, and these strategies identified 99 and 79 articles in PubMed and CINAHL Complete, respectively. Four articles were found through hand searching.

Study Selection and Data Collection Process

In the first stage, all abstracts were reviewed on the basis of the evaluation of inclusion/exclusion criteria to determine potentially relevant articles (n = 78). Inclusion criteria were studies on tourists who were (1) 18 years of age or older and (2) seeking treatment abroad or immigrants who access care to the homeland. Articles that do not focus on medical tourists’ perspective were excluded (n = 32). In the second stage, 46 articles remained for a full-text review. Inclusion criteria were primary studies regarding medical tourism and reports of studies related to patients’ perspective regarding their perception or experience of medical tourism. No limitations were placed on destination country and type of treatment. All studies on (1) tourists seeking treatment due to political issues such as refugees, (2) literature reviews, (3) case study, or (4) editorials or reports were excluded (n = 24). A total of 22 articles remained. During the peer-review process, 1 article was eliminated because such participants who accessed care abroad were residents in the US-Mexico border region. Thus, a total of 21 articles were included in the current integrative review. The literature selection process is depicted in a PRISMA diagram[10] (Figure 1).

Figure 1.

PRISMA diagram.

Data Analysis

The data analysis process followed the updated integrative review method by Whittemore and Knafl[11] including the steps of data extraction, display, comparison, and drawing conclusions. Data extraction was independently completed by 2 reviewers (T.X. and W.W.). The data extraction form was designed on the basis of the research questions. Data items include the author (publishing year), purpose, research design, destination country, participants, research method, themes, and significant findings of studies (Table 1). A descriptive synthesis approach[12] was employed to present the results due to the inclusion of studies incorporating many types of research methods. The motivators and barriers, patients’ consult information, and experience were highlighted in the significant findings section. The common themes were emerged from the data analysis process. The relevant risk of bias and methodological quality of included studies were evaluated on the basis of the Cochrane Collaboration tool.[13] Johns Hopkins Nursing evidence level and quality guide[14] were used to evaluate the level of evidence which rate the strength of research evidence from level I to level V and the quality of evidence as grades A, B, and C.

Table 1.

Reference Summary Table.

Authors (publication year)	Study design	Purpose	Sample characteristics	Destination	Data collection	Variables measures	Significant findings		Gaps	Level of evidence
							Motivators/barriers to medical tours	Medical tourists’ consulted information and experience
Crooks et al[15]	Qualitative	To explore patients’ attitudes, decision making, and experience on treatment aboard	14 Canadian medical tourists who had gone abroad for hip or knee surgery to treat osteoarthritis	India, Cuba, and Germany	Semi-structure phone interviews over a 6-month period	None	● Desiring to maintain active lives drove them to research alternative treatments.● Contacting with surgeons abroad and former patients facilitated decision making.● Wait list is too long in Canada, which is the main motivator.	● Comfortable making decisions on their own, not dependent on the health care providers. Gathering information from Web site, friends, family, health care providers, and facilitators.● Patients had the unweaving attitude about procedure urgency and necessity	Little attention has been paid to the experience about the health care quality.	Level II-B
Culley et al[16]	Qualitative	To find the UK patients’ experience on cross-board care	51 patients who had sought the fertility treatment abroad	Spain and the Czech Republic is the most popular destination countries	In-depth, semistructured interview, systematic thematic coding method.	None	● Desiring for timely donor gametes and low cost is primary reason.● Perception of better success rates overseas and previous unsatisfactory care in the United Kingdom were the pull-and-push factors.● Waiting times and donor’s availability, clinic reputation and former patients’ recommendations affect destination decision making.	● 44% had no assistance from health care professionals; only 6 patients received help from clinics;● The Internet was the main source of information and peer support	80% participants were female, 20% were male, and this imbalance of distribution may affect the findings.	Level III-A
Drinkert and Singh[6]	Quantitative	To evaluate American medical travelers’ experience	260 Americans who access care abroad for dental (32.3%), medical checkups (16.2%), and cosmetic treatments (11.9%)	Mexico (16.5%), the United Kingdom (13.5%), Canada (12.7%)	Survey through Qualtrics	None	● Costs● Destination choice is affected by word-of-mouth (26.2%) and physician’s advice (30.8%), Internet (13.5%), and transportation factors.● Destination is the leading factor that affects tourist’ perception of quality, followed by Facilities and Availability.	Not discussed in this article	The questionnaire did not include the experience of service, patient-perceived value, and satisfaction. Online survey may result in the recruited younger respondents that affect the generalizability of findings.	Level II A
Eissler and Casken[17]	QualitativeConceptual framework of Health-seeking behavior	To explore patients’ experience and to understand the phenomenon of medical tourism	15 Alaska medical Tourists(5 for medical care, 5 for dental care, and 5 for a combination of the 2, procedures include orthopedic surgery, dermatology consults, bariatric, dental care, etc)	7 participants received care in Thailand, 5 in Mexico, 3 in Eastern Europe, 1 in Costa Rica, and 1 in India	Interviewhermeneutic process of inquiry	None	● Pre-travel: unmet health care needs, high cost, perceived failures within the local health care system were the push factors for seeking care abroad.● Newspapers, the Internet, radio, books, and personal contacts were the main way to research the destination hospital and country.	● Positive feelings regarding staffing, security, and met needs of medical service: “I was amazed by the level of staffing.” “I feel secure there, so secure. It feels good knowing that I can get the medical care that I need.”	Alaskans like medical traveling, their experience may not be generalizable to other states	Level III-A
Footman et al[18]	Qualitative	To examine patients’ experience, challenges faced by professional and patients regarding dialysis tourist	3 directors, 16 health care providers, and 47 dialysis patients from 9 countries were interviewed	From European Union to United Kingdom	Semistructured interviews	None	● Health care providers reported the most common barrier is language, but interpreter assisted with them.A few patients reported poor communication between the tourist center and the home center● About 50% patients searched the hospital through the Internet and mentioned marketing should be improved.● The perception of safeness was important during the pre-travel stage.	● High level of satisfaction with service quality was reported. A few patients reported higher medical quality than dialysis at home. Language barrier was noted.	The study was conducted in only 2 treatment centers, so the sample is small and may not enough to generalize the conclusions.	Level II-B
Gerdts et al[19]	Qualitative	To document the socio demographic characteristics, travel, and abortion-seeking experience	58 women who sought medical abortion in United Kingdom	41% of participants were from Western Europe. Nearly one-third of women were from Ireland/Northern Ireland, 5% were from Northern or Eastern Europe, and 18% were from the Middle East	Survey	A 32-question, self-administered, paper-based questionnaire	● The reason for caring abroad is abortion not being legal in their home country (51%), passed the gestational limit (31%), 4 respondents were refused by the clinician.● 53% of respondents used the Internet to search destination clinic.	Not discussed in this study	Little attention on the patient experience on service quality and staffing quality.	Level II-B
Guiry et al[20]	Quantitative	To compare experience and potential US medical tourists’ expectation	219 engaged medical tourism and 1369 potential medical tourists for dental care, surgery, cosmetic surgery, eye surgery, medical examination, and Orthopedics.	The destination was Mexico (28.3%), India (16.4%), Canada and United Kingdom (11%)	Online Survey	SERVQUAL scale developed by Parasuraman et al (1988)[21]	None	● Experienced medical tourists had lower expectations on service quality than potential tourists in 11 from 15 SERVQUAL items (P < .05).● Significant difference was found on 5 detentions: Tangibles dimension (P = .036); Reliability(P = .002); Responsiveness (P = .009); Assurance (P = .000); Empathy (P = .023)	The number of potential medical tourists were 6.25 times the experienced respondents	Level II-B
Han and Hyun[22]	Quantitative	To explore the relationship among perceived quality, satisfaction, trust in staff and medical clinic, and perceived value and intention of revisiting the clinic	309 medical tourists who actually experienced medical treatment/health care/aesthetic service	Korea.Patients came from China (37.8%), Japan (33.7%), American (10.9%), and other countries (Philippines 4.7%, Canada 4.3%, Taiwan 4.0%, Russia 2.3%)	Survey	Self-developed model	Not mentioned in this article	● Perception of medical quality and service quality positively affected tourists’ satisfaction.● Trust in the health care workers and trust in the clinic also affected patient’s satisfaction; Trust is the leading factor that affect the revisiting the clinic● Perception of quality and service quality positively affect the intention to revisit Korea medical care	Prominence of cosmetic surgery resulted in imbalance distribution of male and female respondents.The exact type of procedures was not reported.	Level II-B
Hudson et al[23]	Qualitative	To report participants’ experiences of treatment abroad	51 participants sought fertility treatment abroad	18 countries in Europe, United States, Barbados, India, South Africa, and Australia	In-depth interviews	None	● Need an egg donor was the leading factor for 71% respondents	● 95% of respondents reported positive experience and 5% reported a negative experience;● The positive aspect includes easily access to care, be able to negotiate and control over their treatment, and good quality treatment;● The negative experience mainly focused on complexity of facilitating care and a sense of uncertainty about the implications of treatment. Unfamiliar with the environment, language barrier, and culture difference were also the challenges.	Small number of male respondents (n = 10) may influence the generalizability of findings.	Level III-A
Johnston et al[8]	Qualitative	To examine the decision-making process	32 Canadians for what treatment	Canada	Interview	None	● 21 patients sought surgery that was not offered in Canada, and 11 sought treatment due to domestic unprofessional procedure● Motivations were low cost, waiting list, procedure unavailability and combined wait-listing and availability;● Main Information resource were word-of-mouth, Internet, media familiar with the care system of other country, 1 forgot the source;● The destination making was based on previous travel or living experience and affordability.● Decision-making supports were from former patients’ testimonial and word-of-mouth communication than doctors’ advice.● Physician’s advice was rarely adopted, facilitators, and clinics abroad plays a role in decision-making process.	Not discussed in this article	Only English speaker was recruited, it may lead to bias of findings.	Level III-B
Manaf et al[9]	Quantitative	To examine service quality, perceived value, overall satisfaction and future intention	173 international participants: 31.2% for comprehensive checkup, 14% for heart surgery, 8% for cosmetic surgery, 5% for lasik and sight treatment and 5% for dental treatment	Malaysiafrom 21 different countries	Survey	Self-administered questionnaire	None	● Service quality consists of medical staff quality, supporting service quality and administrative quality.● Tourists were most satisfied with medical staff quality, followed by supporting services quality and Administrative services quality;● Patients perceived the value of treatment was high, cost is cheaper than Thailand and Singapore;● Medical staff quality is the only factor that predicts patients’ future intention and overall satisfaction.	The high proportion of medical checkup may affect the generalization of study findings.	Level II-B
Karuppan and Karuppan[24]	Qualitative	To examine the motivations and implication for health care system	9 medical travel facilitators	The United States	In-depth interviews	None	● Uninsured patients, cosmetic surgery patients, and seeking easier access to certain procedures (stem cell treatments, reproductive service);● Cost is the leading factor for treatment abroad, followed by procedure unavailability in the United States (hip resurfacing) and long waiting time	● The factors that influence decision making include cost saving, insurance status, risk procedure, difficulty of access care in the United States;● The tangible, reliability and assurance dimensions of quality positively influence the motivation of access care abroad;● Perception of risks related to postoperative care, stay time, and intercultural competence were negatively associated with the health-seeking behavior.	Facilitators’ claim may not fully represent patients’ experience.	Level III-A
Kim et al[25]	Quantitative	To compare the perception between medical travelers and non-seekers of subjective well-being (SWE)	123 Japanese and 168 Korean participated medical travel. Compared with those visitors who did not participate health tour program (167 Japanese and 275 Korean, respectively)	Japan and Korea	Survey	SWE Questionnaire (Campbell, 1976)[26]	None	● Medical tourists perceived a higher level of SWE than those non-participants.● “Overall satisfaction,” “Intention to participate again,” and “recommend to friends and family” were higher in the patients than non-participants. Satisfaction levels after tourism activities was positively associate with SWE.	SWE is a psychological estimation tools, future study needs to further examine the application of this tool in patient’s experience.	Level II-A
Ozan-Rafferty et al[27]	Qualitative	To identify the push-and-pull factors for seeking care abroad	36 individuals for hair transplant, followed by dental care, Lasik, and other procedures	Turkey	Narrative analysis	23 messages and 13 blogs	● Push factors were lack of treatment options in home country (8%), cost (61%), lack of insurance coverage (14%); Pull factors were comparative value (67%), physician expertise and responsiveness (58%), familiarity with Turkey (14%), facilitator availability (36%), and price (64%).	● 91% had a positive impression of Turkey, 58% mentioned perceptions of physicians, 91% of perceptions were positive; 14% mentioned they received follow-up; 64% pleased the value of the investment; 19% were not satisfied with the experience, the main reason is the language barrier, followed by food, transportation, and employee behavior.	Not mentioned in this article	Level II-B
Panteli et al[28]	Quantitative	To identify patients’ experience of medical services.	17 543 Germany respondents for dental care abroad	European Union/European Economic Area (EU/EEA)	Survey	Europabefragung (2012)[29] questionnaire of satisfaction and continuity of care	● A trust relationship with provider (46%) was the most important factor to repeat health care abroad, followed by combination of vacation and cost saving;● Medications were prescribed that were not available in Germany affected the management continuity.	● 80% reported that no information change between the treating physicians abroad and their physician back home. The main way of information exchange is patients themselves (58%), followed by written correspondence (33%). Telephone (6%), fax (2%), or email (1%).	The questionnaire response rate is 41%, which is not high in the spectrum of mail response rate in health care research.	Level II-B
Prajitmutita et al[30]	Quantitative	To explore the factors that affects medical tourists’ attitudes and behaviors	330 international patients were randomly selected (75.5% were from Europa) for treatments (surgery, cosmetic, dental procedure, checkup or other kind)	Thailand	Survey	Service quality—SERVQUAL scale (Parasuraman et al, 1988)[21] Patient-perceived value—SERV-PERVAL scale developed by Petrick (2002).[31] Patient satisfaction questionnaire (Oliver, 2010)[32] Behavioral intentions questionnaire developed by Zeithaml, Leonard, Parasuraman (1996)[33]	None	● Perception of value contributes more to satisfaction with the service provider, comparing with service quality they received.● Service quality has a direct effect on both patient-perceived value and patient satisfaction;● Perceived value directly indicated the patient intention, followed by the service quality, patient-perceived value, and patient satisfaction influenced each other.	The data were collected from a single center, generalizable of findings might be limited.	Level III-A
Rodino et al[34]	Mixed method	To explore the motivations, clinical care, counseling, and support experience	137 participants from Australian (105, 76.6%) and New Zealand (32, 23.4%) accessed to cross-border reproductive care	Australia and New Zealand	Survey	cross-border reproductive care (CBRC) questionnaire (self-developed)	● 41.6% reported the primary reasons were egg donation, followed by the surrogacy (37.2%), social sex selection (15.3%), sperm donation (4.4%), and double gamete donation (1.5%);● Motivations: procedure unavailable in home country (57.3%), long waiting list (41.2%), better success rate abroad (33.9%), not legal in their home country (49.2%), more choice of donors abroad (44.4%), and others.	● Consulted information through the Internet (59.1%, of patient forums 31.4%), 11.7% through media (TV or newspaper), 5.8% through professional sources.● 91.2% reported their medical needs were met and treatment was safe (89.4%);● The main supportive source was family members (83%), friends (72.9%), professional workers (72.9%), Internet group (52.5%), followed by others.● Due to the absence of formal counseling, respondents relied on the Internet, more supportive counseling was needed.	Imbalance on male and female (89%) respondents may affect the findings of patients’ experiences	Level II-A
Rodríguez-Reimundes et al[35]	Quantitative	To analyze the characteristics and health outcomes of patients who had a transplant tourism	830 patients who performed a kidney transplant surgery	The United States (32.8%), Bolivia (29.3%), Brazil (17.2%) and others	A retrospective study	None	None	● No difference was observed between travelers and controls for 1-month and 1-year renal function and 1-year and 5-year graft survival.	Less attention has been paid to the patient’s experience	Level I-B
Snyder et al[36]	Qualitative	To discusses the experiences of Canadians with multiple sclerosis seeking treatment abroad	15 patients who had sought chronic cerebrospinal venous insufficiency (CCSVI) treatment abroad	Not reported	Interview on phone	None	None	● Three themes emerged: losing faith, nurturing hope, forming trust;● Travelers experienced a loss of faith in the Canadian health system and neurologist.● Nurturing hope for treatment abroad, worsening health and quality of life was the driving factor;● Peer-support networks are the trusted source, own networks include face-to-face and virtual and online information were also trustworthy; the trust relationship with the physician who performed treatment for them was also important.	None	Level III-B
Suzana et al[37]	Qualitative and quantitative mixed	To assess the affordability, continuity, and quality of treatment abroad	815 medical travelers from the Maldives received investigation and 120 of them received an additional investigation	India, Sri Lanka, and other	A cross-sectional survey and an additional semistructured questionnaire	Questionnaire	● Procedures are not available in their home country	90% of patients were satisfied with the last treatment. The concerns mainly focus on the continuity of care (87.5%);● An expectation for the availability of the procedures and service in the home country is the most common view.	Low response rate (32%) among the subset of respondents may bring possible bias.	Level II-B
Van Balen et al[38]	Quantitative and qualitative	To describe the motivations and experience of patients who sought kidney transplantations abroad	22 patients who traveled for kidney transplantation	From Macedonia/Kosovo (10), the Netherlands (7), and Sweden (5) to Pakistan, India, Iran, Russia, Colombia, China, Iraq	Interview	None	● Motivations: no choice available than treatment abroad, Life on dialysis is depressing, a long wait time is another factor, perception of being discriminated against by the Swedish health care system, the procedure is not available at Macedonia/Kosovo, not trust in the local health system	● 17 patients did not inform their local health providers, 5 consulted medical information;● The majority perceived the medical care as “good” or “sufficient,” but almost all patients mentioned a lack of hygiene in the hospital	No theory of framework provided	Level II-B

Results

Overview of the Studies

A total of 21 studies remained in this review, and all the included records were published from 2011 to 2018. In addition, all included studies were assessed as of fair or good quality based on the Johns Hopkins evidence level and quality guide.[14] Eight were quantitative studies, 10 were qualitative, and the other 3 used a mix of quantitative and qualitative methods. Most quantitative studies used survey method, and qualitative research used in-depth interview to collect data. The mixed methods were conducted via surveys and interviews. The most frequently purchased destination countries were Mexico, India, the United States, and the United Kingdom. The frequently used procedures were dental care, cosmetic surgery, and reproductive treatment, apart from comprehensive checkup. By reviewing all included articles independently using notes, keywords, and phrases, 2 reviewers (T.X. and W.W.) identified 3 common emerging themes among these 21 articles that remain relevant to medical tourists’ experiences, namely, (1) motivators (n = 13) and barriers (n = 3), (2) consulted information sources and decision-making support (n = 14), and (3) perceived quality of health care (n = 6). Three themes interacted with each other and collectively contributed to answering the interaction review questions.

Motivators and Barriers for Medical Tourism

Thirteen studies reported the predominant motivators for treatment abroad, including low cost, short waiting list, quality, insurance status, distance, and domestically unavailable procedures. Four studies in the United States[6,16,24] and Canada[39] indicated that the leading motivator for medical tourism is the low cost in the destination countries followed by the short waiting list. Five studies indicated that patients from the Maldives and other developing countries such as Macedonia/Kosovo seek care abroad because the procedures were either unavailable or illegal in their local origins.[19,27,34,37,38] For instance, medical abortion is illegal in selected areas in Western Europe. For certain specific procedure such as fertility treatment, donor’s availability in destination country was the leading motivator for planning medical travel.[16,23] Four studies identified the perception of better quality abroad and dissatisfaction with local health care as the primary reasons for medical tourism.[8,16,17,36]

Language barrier was identified as the most common barrier.[18,23,27] It has led to miscommunication and anxiety between patients and health care professionals. Research with 66 respondents (n = 47 patients and n = 19 health professionals) indicated that physicians and nurses were expected to speak more than 1 language due to limited interpreter availability.[18] Other barriers affecting the patient’s experience included unfamiliarity to the environment, culture difference, food, transportation, and employee behavior.[23]

Information Sources and Decision Making for Medical Tourism

Consulting information is a vital step prior to traveling for a medical procedure. Owing to limited information, patients typically take a longer time making the ultimate decision to access care abroad than treatment in their home country.[6] The Internet was the primary source tourists use to initially learn a potential destination country followed by word-of-mouth and peer-support networks.[6,8,9,15,16,18,19,34,35]

Many factors drove the decision making about the destination. Drinkert and Singh[6] reported that 30.8% of medical tourists adopted physician’s advice followed by word-of-mouth (26.2%) and the Internet (13.5%) to decide on the destination hospital. However, in a study of 32 Canadians who sought treatments abroad, former patients’ testimonial and word-of-mouth communication have more influence on patient’s intention than doctors’ advice.[8] Moreover, certain medical tourists solely depended on facilitators or brokers when selecting a destination hospital abroad.[6,8,37,38] These medical tourists rarely adopted their physician’s advice and did not inform their physicians of overseas treatment. Drinkert and Singh[6] and Han and Hyun[22] showed that familiarity and cultural similarity were other important factors for tourists planning a medical trip.

Experience in Quality of Health Care

Six studies reported the quality of health care as perceived by medical tourists. In these studies, quality of health care consists of many factors, including service, medical staff, and quality, and patient-perceived value.[9,18,22-24,30] Patients perceived a high level of service and medical quality in destination hospitals including the following: easy access to care,[23] the ability to communicate the treatment with health care providers,[23] trust relationship with physicians,[22,36] and obtained good health outcomes.[23] Manaf et al[9] conducted a survey of 173 international patients from 21 countries in Malaysian hospitals. Tourists were most satisfied with the staff quality followed by supporting and administrative service quality. Rodino et al[34] interviewed 137 patients who sought reproductive care in Australia and New Zealand. In addition, they found that more than 90% of respondents reported that their medical needs were met, and treatment was safe.

The perception of high quality positively affects patients’ intention to revisit the hospitals.[9,24,25,30] The perception of value contributes more to overall satisfaction than the service quality, and it directly influences the intention to revisit.[30] Service quality has an opposite effect on patient satisfaction and perceived value. Trust in the provider and the clinic contributes to patient satisfaction and is an effective indicator for the future intention to revisit.[22] Guiry et al[20] surveyed 219 engaged medical tourists and 1369 potential medical tourists and showed that their perception of the quality of health care was significant associated with the expectations.[20] The potential medical tourists had expectations over 6 times higher than those of experienced individuals. Hence, the expected service quality is higher, and such perception may influence their evaluation of the quality they received in the destination hospitals.

Panteli et al[28] and Suzana et al[37] indicated the concern for the continuity of care. After returning to their home country and when a complication occurs, the local clinic is unwilling to provide care. In addition, certain prescribed medication may be unavailable in local clinics. Hence, patients are compelled to travel back to the clinic abroad for treatment. Another concern is the continuity of information. In a German study[2] of 17 543 medical tourists with access to care in European Union/European Economic Area countries, only 1 in 3 received follow-up care. More than 80% of respondents reported no information exchange between the international hospital and the family physician.

Discussion

Many scholars, including some in the health care system, mistakenly believe that medical travelers from wealthy classes of developing countries seek treatment in the developed nations. However, our literature review showed an increasing number of medical travelers who access care from developed countries to certain less-developed nations. For example, Americans traveled to Mexico for dental care[6] and Canadians went to India and Cuba for hip or knee surgery.[9] Moreover, medical tourists are becoming increasingly interested in destination hospitals that can provide competitive quality and more affordable prices than other institutions worldwide such as those in India, Korea, and Iran.

Medical travel was driven by diverse motivators and may vary depending on which treatment was used. Patients from developing countries predictably continue to travel to developed health systems for high-quality treatment. However, for selected developed countries such as America[6] and Canada,[8,9] patients’ leading motivators to access care abroad were the low cost and short waiting list in destination countries rather than the quality of health care. Even with the same expenditure, Canadian and American people would prefer to access care abroad to avoid the long waiting list in their respective countries.[6,8,9,24,33] Lunt et al[40] supported the finding that deteriorating conditions such as high cost and a long waiting list in developed countries push an increasing number of patients to seek treatment abroad. Alternately, pull factors in the developing countries, including the innovation, high efficiency, and competent service quality, appear to keep attracting patients worldwide. This finding is supported by an investigation of 800 participants from 40 countries. The decision to treat is remarkably increased if the participants were told that Asia is known for high-quality care, low cost, and short waiting times.[41] Interpreters were provided in many big medical centers. However, our patients continued anticipating health care providers to speak 1 more language. Moreover, culture difference was found to impede effective communication between patients and health care providers. This finding explained why patients opted to choose a familiar or similar language and culture as their destinations.[22,25]

Information Sources and Decision Making

Having access to information is a vital step in decision making for medical tourism. Notably, most of the patients use mixed information such as online information and former patients’ testimonies in formulating their decision. We found that the accessibility and reliability of online information remain to be the greatest barriers for tourists to make an informed decision. Excessive information includes advertisements and social media sites that pop up on the screen and consequently confuses the patients. Word-of-mouth plays an important role in medical tourists’ decision-making process. The former patients become “ambassadors” in spreading information about the destination hospitals to interested others, and the former in turn affects the decision making of the latter.[42] Certain patients solely rely on the facilitator company to decide the destination hospital. Health care professionals and patients should be provided with precise information about transportation, booking service, and detailed information about procedures.[18] Few of the facilitator companies were operated by professional groups. Inaccurate resources emerged because of outdated statistics and missing important information. Such limitation may lead to unrealistic expectations and uninformed decision making. These findings are aligned with Rodino et al[32] that additional supportive counseling is needed for patients. The perception of safety and risks during information consulting may also affect medical tourists’ decision making.[24]

Experience in the Quality of Health Care

Patients likely evaluate the staff and service quality rather than the medical procedure itself. Compared with the perception of service quality, perceived value (if the quality had a reasonable price) directly predicted the future intention of revisiting, and it would lead to a recommendation to other potential medical tourists. In addition, a trusting relationship with the clinic abroad and providers can facilitate the process of decision making on treatment abroad. The local doctor’s advice was one of the main supportive sources for medical tourists. However, certain patients avoided discussing their plan with family physicians. This kind of fractured trust in the physician-patient relationship would affect the follow-up care for the tourists returning to their respective homelands.

Implications

Language and culturally competent care are the most common barriers to health care delivery. The US government has developed standards and guidelines of linguistic and cultural competency that aims to promote health equity at the national and state levels. Promoting the implementation of these standards is essential in providing culturally appropriate care. Additional cultural competency training such as cross-cultural knowledge and skills and sensitivity toward the diversity norms of other cultures should be offered in schools and hospitals. Moreover, strategies for promoting continuity of care should be implemented to ensure that millions of medical tourists can receive optimal health care. Such strategies include increasing the information exchange between family physicians and overseas clinics and providing follow-up care for medical tourists after they return to their respective homelands. Destination hospitals’ official websites should provide additional valuable information for potential medical tourists including transportation, booking service, and procedural information due to the limited availability of information. Peer-support forums are highly recommended.

Limitations

Limitations of this review are the relatively low level of evidence in majority of the studies, which were survey studies and qualitative semi-structure interview. Although the methods are appropriate answering the integrative review questions, limitations of the self-reporting studies may affect the results. In addition, the language restriction of only English-language sources was included and reviewed brought systematic bias and affects the conclusions.

Conclusions

This integrative review provides an overview of current knowledge on medical tourism from the patients’ perspective. Our findings led to the identification of factors related to medical tourists’ experience including the following: the motivators and barriers, information sources, and decision making, apart from the experience of the quality of care. Despite many published articles addressing medical tourism, additional theoretical and empirical research can facilitate our complete understanding of patients’ experience in the medical journey. Thus, we suggest the following additional empirical studies: (1) the patients’ decision-making process of motivators and barriers, (2) the factors related to patients’ experience in the health care quality, and (3) the strategies to ensure the continuity of care.