Background

Many researchers today agree on the importance of the global health tourism industry. Due to the substantial revenue it generates for host countries, it remains a key focus for policymakers (1). Health tourism refers to traveling to a location away from one's home to improve mood or health, recuperate, or undergo diagnostic, therapeutic, or medical interventional procedures (2, 3). Health tourism includes wellness tourism, nature therapy tourism, and medical tourism. In wellness tourism, individuals travel without undergoing medical procedures, with the intention of preserving and enhancing their physical and mental health, relieving stress, or re-energizing. In contrast, nature therapy tourism refers to traveling aiming at using natural and traditional treatments (such as hot springs or mud therapy). When an individual travels for the purpose of disease assessment, diagnosis, or treatment, it is called medical tourism, which is directly related to a person's health and is therefore considered the most important form of health tourism (2, 4).

Various aspects of health tourism (such as innovation, economics, and marketing) should be taken into account. In recent years, marketing in the field of health tourism has emerged and is currently developing, highlighting a need for further study and attention (5). According to the American Marketing Association's (AMA) definition, marketing is a set of institutions, activities, and processes leading to creating, communicating, delivering, and exchanging offerings that are regarded valuable for customers, employers, partners, and society, at a larger scale (6). Different types of marketing, including electronic marketing, online marketing, integrated marketing, and social marketing, are used to advertise and attract health tourists (7-10).

Countries like Germany, Spain, the United States, Canada, Brazil, Mexico, Egypt, Australia, South Korea, India, and Malaysia have made significant plans, investments, and advancements in health tourism (11, 12). Furthermore, in recent years, regional and neighboring countries like Turkey, Jordan, and the United Arab Emirates have set ambitious goals for health tourism and implemented policies aimed at developing this industry (13-15). In contrast, despite possessing the necessary potential, Iran has not yet achieved significant success in the field of health tourism (16, 17).

Introductory training in health tourism enhances the effectiveness of individuals in this field. Employees who have not completed basic health tourism training often face challenges with communication skills when interacting with health tourists (18). A study conducted in Tabriz on employees at four healthcare centers that host health tourists showed that 43% of these employees were unfamiliar with the concept of health tourism, which presents a significant challenge in this sector (19). The globalization of the health tourism sector increasingly necessitates graduates who can work professionally. Given that health tourism is a high value-added sector, providing academic training and cultivating a professional workforce in this area seems essential. Currently, several countries worldwide offer academic programs to train professionals in health tourism, and there are university graduates with expertise in this field. In total, there are 25 academic programs (in the form of 18 fields of study) ranging from associate to PhD degrees in health tourism in 12 countries, including the United Kingdom, Germany, Austria, Italy, Spain, the United States of America, South Korea, and Turkey. These programs offer majors, such as “Health Tourism, Health Tourism Management, Commercial Tourism, Health and Sports, Health Tourism and Leisure Management, Spa and Wellness Management, etc.” (18). Although training conferences and workshops on health tourism are held in Iran, the lack of academic training in this field is particularly noticeable. Hence, policymakers in the country must prioritize the development of a professional workforce in the field of health tourism (20).

One of the inherent duties of the Ministry of Health, Treatment, and Medical Education is to determine the required academic fields of study and educational levels. The lack of efficient and professional personnel in the field of health tourism highlights the need to train skilled and competent individuals in this area. Moreover, in line with the Ministry of Health’s Medical Sciences Education Transformation and Innovation Package, one of the goals and executive policies of medical science education is to design new interdisciplinary programs, short-term courses, and research periods based on regional capacities and needs. However, the necessity and needs assessment of academic training and human resource cultivation in this field should first be taken into account. Given that faculty members are considered a group of societal experts and among the most important resources for scientific knowledge and needs assessment in educational design, the present study was conducted to determine the necessity of establishing an academic major in health tourism and marketing from the perspective of faculty members at Hormozgan University of Medical Sciences in 2022.

Objectives

The current study aimed to determine the necessity of establishing an academic major in health tourism and marketing from the perspective of faculty members at Hormozgan University of Medical Sciences.

Methods

This study was applied in terms of its purpose and employed a cross-sectional design. The statistical population consisted of 309 faculty members from 7 faculties and 25 departments at Hormozgan University of Medical Sciences. Faculty members with at least one year of experience who consented and were willing to participate were included in the study, while those who withdrew, did not complete the questionnaire, or terminated their employment were excluded (Table 1).

Table 1. Frequency distribution of participating faculty members based on faculty

Based on the Morgan table, a sample size of 185 was determined. However, due to the exclusion and withdrawal of some participants, 177 faculty members at Hormozgan University of Medical Sciences ultimately participated in the study using a stratified sampling method.

A researcher-made questionnaire was used to collect data. Since no standardized questionnaire existed to investigate this topic, a researcher-made questionnaire was developed and administered. To prepare the questionnaire, we used credible sources, other studies in the field of health tourism, the Ministry of Health's application form for creating educational programs (specifically for needs assessment), and the feasibility study for establishing an academic major at the University of Applied Science and Technology. To compile the questionnaire, we first searched for and reviewed articles on health tourism and marketing in Persian and English from scientific databases [including the Institute for Scientific Information (ISI), Google Scholar, PubMed, and Magiran]. We extracted and reviewed various definitions and classifications of health tourism, and based on these theoretical definitions and classifications, we formulated components of “capabilities and capacities, benefits of developing health tourism, and marketing necessity.” Based on a review of the Ministry of Health's application form for creating educational programs (specifically for needs assessment) and the justification plan for the necessity of establishing an academic major at the University of Applied Science and Technology, the components “necessity of training specialized human resources and alignment with policies” were extracted, and corresponding questions were formulated. The questionnaire was comprised of three sections: Introduction (introducing the questionnaire and stating the research's purpose), personal specifications (gender, field of study, highest academic degree, work experience, academic rank, and faculty of employment), and questions (31 questions/items). The questions were scored using a five-point Likert scale ranging from 1 to 5 (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). Each question was assigned a score from 1 to 5. This section evaluated the necessity of establishing an academic major in health tourism and marketing, which included five components: “Capacities and capabilities,” “benefits of developing health tourism,” “necessity of marketing,” “necessity of training specialized human resources,” and “alignment with policies.”

Questions 1 through 6 focused on the “capacities and capabilities” component, investigating Iran's existing potentials, capacities, and capabilities in natural resources, medical centers, treatment methods, specialists, as well as traditional and modern medical treatments, all in the context of developing health tourism. Questions 7 through 12 focused on the “benefits of developing health tourism,” exploring the the existence of economic, health, scientific, political, social, and international benefits of developing health tourism within Iran. Questions 13 through 18 focused on the “necessity of marketing” component, dealing with the importance and need for marketing and public relations at the international scale to develop health tourism in the country. Questions 19 through 24 focused on the “necessity of training specialized human resources” component, examining the need for training expert human resources to develop the health tourism. Finally, questions 25 through 30 focused on the “alignment with policies” component, which includes two distinct sub-sections: “Alignment of health tourism development with the country's general policies and the Ministry of Health's programs and duties” (questions 25-27) and “alignment of establishing an academic major in health tourism and marketing with the country's general policies and the Ministry of Health's programs and duties” (questions 28-30), dealing with the alignment of the health tourism field’s growth and development, as well as the establishment of an academic major in this field, with the country's general guidelines and policies, and with the Ministry of Health's overall plans and duties. Question 31 presents the core question of the questionnaire and the research, which is included in the total score of the questionnaire. The total score of the questionnaire ranges from 32 to 155.

After drafting the research questions and designing a researcher-made questionnaire, five experts in curriculum planning, educational research, and medical education evaluated the quality, clarity, comprehensibility, simplicity, and accuracy of the dimensions and questions. They also assessed the relevance of the questions to the research objectives, revised some items, and removed others. Finally, the questionnaire was finalized. Subsequently, the questionnaire was then provided to 10 evaluators (university professors) to assess its content validity [using the content validity index (CVI) and the content validity ratio (CVR)]. Following the analysis of the results, the CVR and CVI were calculated as 0.80 and 0.94, respectively, which indicated that the questionnaire had good content validity. To determine the questionnaire's reliability, Cronbach's alpha coefficient was used. The questionnaire was administered as a pilot study to 20 faculty members at Hormozgan University of Medical Sciences. The resulting Cronbach's alpha coefficients for the components of “capacities and capabilities,” “benefits of developing health tourism,” “necessity of marketing,” “necessity of training specialized human resources,” and “alignment with policies” were reported as 0.85, 0.83, 0.76, 0.74, and 0.90, respectively. The overall Cronbach's alpha for the total scale was reported as 0.90, which confirmed its appropriate reliability.

Initially, the normality of the data was examined using the one-sample Kolmogorov-Smirnov test. Subsequently, the normal data (the capacities and capabilities component) were analyzed using the parametric one-sample t-test, while the non-normal data (other components) were analyzed using non-parametric tests, including the binomial/
proportion, Mann-Whitney U, and Kruskal-Wallis tests. All analyses were conducted through SPSS version 24 (IBM Corporation, Armonk, NY). Since no prior research established a hypothetical mean score for the one-sample t-test, and given that a five-point Likert scale (1 to 5) was employed for scoring the questionnaire in this study, a value of 3 that denoted the intermediate and midpoint score in the answersheet was chosen as a hypothetical mean score for the one-sample t-test. This value was also set as the cutoff point for the Mann-Whitney U and Kruskal-Wallis tests.

Results

The results demonstrated that 55.4% of the participants were female, and 44.6% were male. Furthermore, 53.7% of participants were graduates from medicine, dentistry, pharmacy, or clinical and medical specialties, while 46.03% studied paramedicine, nursing, basic sciences, or other fields. Additionally, 32.2% of participants had 1 to 10 years of work experience, 38.4% had 10 to 20 years, and 29.4% had over 20 years. Regarding academic degrees, 6.2% held a master’s/general doctorate degree, 7.4% held a fellowship, 77.3% held a PhD/medical specialty, and 9.1% held a subspecialty. Concerning academic rank, 6.2% of participants were instructors, 68.9% were assistant professors, 20.9% were associate professors, and 0.4% were professors (Table 2).

Table 2. Frequency distribution of personal specifications of participating faculty members

The results of the one-sample t-test revealed a significant difference in the mean scores of “capacities and capabilities” from the perspective of faculty members at Hormozgan University of Medical Sciences (Table 3). Consequently, with a 95% confidence interval (CI), it can be concluded that these faculty members believe that Iran possesses the necessary capacities and capabilities for the development of health tourism.

Regarding the “benefits of developing health tourism” component, participants believed that the development of health tourism in Iran would bring benefits to the country. Additionally, concerning “the necessity of marketing” component, they commented the necessity of marketing in the field of health tourism in Iran (P < 0.001). In terms of the “necessity of training specialized human resources,” also, participants believed that training an expert workforce in the fields of health tourism and marketing seemed necessary.

On the “alignment with policies” component (health tourism development), based on the observed ratio, developing health tourism aligned with the overall policies and plans of Iran and the Ministry of Health. Moreover, on the “alignment with policies” component (establishing an academic major), the participants believed that establishing an academic major in the field of health tourism and marketing aligned with the overall policies and plans of Iran and the Ministry of Health. Concerning the necessity of establishing an academic major in health tourism and marketing, the observed ratio of participants believed the necessity of establishing an academic major in health tourism and marketing (P > 0.001) (Table 4).

Table 3. Mean scores of the capacities and capabilities of developing health tourism from the perspective of participating faculty members

SD: Standard Deviation

^*One-sample t-test

Table 4. The necessity of establishing an academic major in health tourism and marketing and its components from the perspective of participating faculty members

^*Binomial/proportion test

An examination of the differences in the perceived necessity of establishing an academic major in health tourism and marketing and its components among male and female graduates from various academic fields of study, individuals with different academic degrees, academic ranks, and work experience exhibited no significant differences in the mean scores of any of the variables.

Discussion

The present study's findings demonstrated a significant difference between the mean scores of capacities and capabilities from the perspective of faculty members at Hormozgan University of Medical Sciences and the hypothetical mean score of the test. Other studies, in line with the current research, have suggested that “the quality of healthcare” and “high level of expertise” were two of the most appealing factors in medical tourism in Iran (16). Additionally, with its skilled medical personnel, advanced medical facilities, and high capacity for attracting medical tourists, Iran is considered an important destination for medical tourism globally, particularly within the Islamic world (17). However, some research, contrary to the findings of the present study, has concluded that the coefficient of promotion is unacceptable in public hospitals and at an only moderate level in private hospitals (8).

Moreover, marketing problems, international issues, culture, transfer, brokerage, management, and certain policymaking are among the main barriers to the development of medical tourism in Iran (21).

As revealed by the results of this study, faculty members at Hormozgan University of Medical Sciences believe that developing health tourism in Iran would benefit the country. A study aligned with this research reported that due to its high income and increased therapeutic tourists, medical tourism has become a focus for many countries (17). In addition, as a dimension of tourism, it contributes to a country's sustainable development and economic dynamism and is regarded as a national strategy for raising a country's income and a pillar of national security (19). The connection between the healthcare and tourism industries in many countries has also culminated in the creation of one of the largest service industries, i.e., the “medical tourism industry,” which offers significant benefits like job creation and revenue generation (22).

Based on the results, faculty members at Hormozgan University of Medical Sciences believe that marketing in the field of health tourism is essential in Iran. Aligned with the present findings, previous studies have identified “marketing” as one of the most significant factors in the rapid development of health tourism in Iran (23). One of the primary sources for medical tourists when choosing a destination is internet-based information, playing a crucial role in their decision-making. Another key factor is the patient's awareness of the capabilities and expertise of the destination country's medical staff. Creating this awareness requires appropriate advertising and well-structured hospital website content. Additionally, it is crucial to provide information about the various specialties and treatment services available at the destination country’s medical centers, as tourists pay close attention to this factor during their decision-making. Patient's awareness of the medical staff's capabilities and expertise necessitates proper advertising, while informing patients about various specialties and services of medical centers, is also considered essential (7). Through integrated marketing, by adopting international standards, hospitals and medical institutions can both enhance their international credibility and build tourists’ trust. Increased attention to media advertising can improve the status of hospitals, culminating in attracting more medical tourists and expanding this industry (8). By leveraging social marketing tools, it is also possible to foster a positive perception of a health tourism destination, thereby creating the conditions for people to be more inclined to undertake medical trips (9).

Faculty members at Hormozgan University of Medical Sciences believe the necessity of training specialized human resources in the field of health tourism and marketing. Aligned with the current study’s findings, investigations on four hospitals in Tabriz, Iran, revealed that a high percentage of respondents (43.3%) were unfamiliar with the concept of health tourism, presenting a significant challenge to the topic of health tourism (19); of course, even basic training in health tourism enhances an individual’s effectiveness. Employers not taken initial health tourism training can merely perform simple tasks, and they often have difficulty communicating with health tourists from diverse cultural backgrounds (18).

According to the results of the current study, faculty members at Hormozgan University of Medical Sciences believe that developing health tourism aligns with the general policies and plans of Iran and the Ministry of Health. A study that supports the findings of the present research showed that medical tourism significantly contributed to the national income of many countries, generating an estimated $100 billion in annual revenue for governments. The Iranian government has plans to cover up to 30% of the country's healthcare needs by the end of the Fourth Development Plan through the export of medical products and services (24).

From the perspective of faculty members at Hormozgan University of Medical Sciences, establishing an academic major in health tourism and marketing aligns with the overall policies and plans of Iran and the Ministry of Health. Consistent with the findings of the present study, previous research has reported that the health tourism market, in addition to facing various challenges, such as the emergence of new players and a lack of a defined mechanism, has suddenly been confronted with the more significant challenge of widespread presence of inexperienced individuals in this field. On the other hand, Iran's small share of health tourists and its concentration in just a few cities indicate the underdeveloped nature of this sector. Therefore, launching a university course in the field of health tourism presents a golden opportunity to attract investment and build capacity to become an educational hub in the Middle East and West Asia (20).

Finally, according to the obtained results in this research, faculty members at Hormozgan University of Medical Sciences believe that establishing an academic major in health marketing and tourism is necessary. Currently, a total of 25 academic programs (in the form of 18 fields of study) ranging from associate to PhD degrees in the field of health tourism in 12 countries. These include 3 PhD, 10 master, 10 bachelor, and 2 associate programs in the United Kingdom, Croatia, Germany, Austria, Italy, Estonia, Spain, Hungary, the United States of America, Ireland, South Korea, and Turkey, offering majors such as such as “Health Tourism, Health Tourism Management, Commercial Tourism, Health and Sports, Health Tourism and Leisure Management, Spa and Wellness Management, etc.” (18). The lack of academic training for health tourism majors is palpable. Therefore, policymakers should consider holding short-term courses and launching an academic program (20). The globalization of the health tourism sector increasingly necessitates graduates who are able to work with various human resources, both domestically and abroad. Given that health tourism is a high value-added sector, and the number of academic programs for increasing professional human resources in this field is insufficient globally, providing academic training and cultivating a professional workforce in this area is essential (18).

The present study's findings revealed that none of the participants' personal specifications, including gender, work experience, academic rank, academic degree, and field of study had a significant effect on the mean scores for the necessity of establishing an academic major in health tourism and marketing and its components. This can be interpreted to mean that all age groups, academic ranks, fields of study, and academic degrees are in agreement regarding the necessity of establishing this academic major and its components.

Health tourism is a competitive industry, and other nations undoubtedly have plans to expand their services. Hence, each country monitors the current activities of its competitors to ensure it is on the right track and has an acceptable rate of growth and progress (16). In Turkey, academic and university education in health tourism is currently provided, with 5 academic programs in the form of two fields of study, including “Health Tourism Management” and “Health Tourism Education” at the master's level, three programs of which are under the supervision of the University of Social Sciences and two at the University of Health Sciences in this country. Additionally, there are two associate academic programs entitled “Health Tourism Management.” However, Turkish researchers believe that offering this field of study at the PhD and bachelor's levels is essential (18). In contrast, health tourism in Iran remains underdeveloped and is in its early stages. The Iranian Ministry of Health formally recognized medical tourism in 2003. Subsequently, in 2004, following the integration of the Iranian Cultural Heritage Organization into the Tourism Organization, it was introduced as an independent industry (24). Consequently, it seems that Iran requires immediate and fundamental action in health tourism to avoid falling behind its neighbors and other countries, and is attempting to grow and expand this industry through macro and foundational planning.

Medical tourism is a rapidly growing sector in many countries around the world. Some nations have begun offering academic programs in this area, producing graduates specialized in health tourism. The establishment of a dedicated academic major in health tourism and marketing is a crucial step in developing the healthcare industry. The growth of the health tourism sector, along with the increasing importance of marketing within the healthcare industry, has created a demand for professionals trained in both fields. The establishment of this academic major would help train human resources equipped with a comprehensive understanding of health tourism and marketing principles, as well as the essential skills needed for the effective management and marketing of healthcare services. Additionally, the curriculum should address legal and ethical considerations and emphasize the importance of sustainability within the industry. Students will thus have the opportunity to gain both academic and practical experience through internships and real-world projects, preparing graduates to become leaders, managers, planners, and experts in the field of health tourism and marketing.

A limitation of this study was the difficult and time-consuming process of collecting data from faculty members at Hormozgan University of Medical Sciences due to their heavy workload. Future research is recommended to explore the necessity of establishing an academic major in health tourism and marketing in other academic communities and universities. Additionally, conducting research to design and develop a proposed curriculum for various academic levels of health tourism and marketing field of study could be a valuable future research topic.

Conclusion

With its vast facilities and capacities, Iran provides a suitable platform for expanding health tourism and attracting health tourists. While marketing is essential for attracting health tourists, academic education and the training of skilled and competent professionals in this field are also crucial. Just as leading countries in health tourism have established academic majors and trained specialized human resources in this field in recent years, the establishment of an academic major in health tourism and marketing is a necessary step for the development of the healthcare industry. The growth of the health tourism sector, along with the rising importance of marketing in the healthcare industry, has created a need for specialists who are trained in both fields.