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Read “Applications of Social Media for Medical Tourism Marketing” from the University Library. In text citation and reference mostly from the article “Applications of Social Media for Medical Tourism Marketing” Why is consumer choice important in health care marketing, and why is it especially important for medical tourism decisions? Which choice factors are most important to medical tourism consumers? How successful is social media marketing for consumer choice for medical tourism? How well did medical tourism providers perform in terms of maintaining customer intimacy, customer involvement, interaction, and gathering customer insights? Why are each of these elements important as part of the consumer decision-making process in this situation? Provided In text citation and reference Why is consumer choice important in health care marketing, and why is it especially important for medical tourism decisions? Which choice factors are most important to medical tourism consumers? How successful is social media marketing for consumer choice for medical tourism? How well did medical tourism providers perform in terms of maintaining customer intimacy, customer involvement, interaction, and gathering customer insights? Why are each of these elements important as part of the consumer decision-making process in this situation? Case study Applications of social media for medical tourism marketing: an empirical analysis Surej John, Roy Larke and Mark Kilgour School of Marketing and Management, The University of Waikato, Hamilton, New Zealand ABSTRACT Medical tourism has grown extensively over the past decade. Although social media is perceived to be an effective communication channel for both tourists and tourism providers, empirical analyses of how social media are used for medical tourism marketing are rare. Based on the “6Is” Social Media Monitoring Framework, this study examines how medical tourism providers distribute information, engage with online users, and influence the travel decisions of potential medical tourists. Findings indicate that medical tourism providers performed well in maintaining customer intimacy, although could do more to stimulate customer involvement, interaction, and gather customer insights. The study discusses ways to improve social media marketing. ARTICLE HISTORY Received 31 August 2016 Accepted 2 May 2018 KEYWORDS Medical tourism; social media; content analysis; digital marketing; tourism marketing Introduction The global medical tourism industry in 2015 was valued at between USD 45 and 70 billion, with nearly 12 million cross-border patients (Patients Beyond Borders, 2016). It is projected to grow at an annual rate of 15-25% for the next 10 years (Medical Tourism Index, 2016; Noree, Hanefeld, & Smith, 2016). To build awareness and trust in this high involvement, high-risk area, medical tourism providers need to offer timely, credible information to potential patients across the globe. Social media is widely used for communication and promotion in the tourism industry (Leung, Law, Van Hoof, & Buhalis, 2013), allowing for the provision of information to current and potential tourists (Zeng & Gerritsen, 2014), and providers can use social media to improve brand awareness, attitude, and customer commitment. Social forms of information are particularly important in high involvement, high-risk sectors (Kang, Shin, & Lee, 2014). The tourism literature on social media considers the motivations, influences, and impacts on tourists’ travel planning processes (Amaro, Duarte, & Henriques, 2016); word of mouth (Hudson, Roth, Madden, & Hudson, 2015); and user involvement and perceived enjoyment (Amaro et al., 2016). Studies have examined the benefits of social media as a marketing and promotional tool for providers (Howison, Finger, & Hauschka, 2015; Tiago & Verissimo, 2014). However, these studies did not look at the branding efficiencies of social media in relation to customer involvement, interaction, intimacy, influence, insight, or impact, and few have considered social media marketing strategies in the medical tourism industry. Our study aims to fill part of this gap. It addresses the following research questions: ● RQ1: How do medical tourism providers utilize social media for marketing activities? ● RQ2: Is there a significant difference in the use of social media by medical tourism providers across the two most populated platforms, Facebook and Twitter? RQ3: What are the major issues that medical tourism providers face when using social media in their marketing activities? To achieve these objectives, this study analysed the social media marketing strategies of 41 medical tourism providers, using the 6Is Social Media Monitoring (SMM) Framework (Stevenson & Hamill, 2012). Literature review Medical tourism relates to individuals who cross national borders with the objective of improving their health (Smith, Martínez Álvarez, & Chanda, 2011). Today, people travel across the world to access medical treatments ranging from standard health check-ups and dental treatment to cosmetic surgery and complex lifesaving surgeries (Crooks, Cohen, Adams, Whitmore, & Morgan, 2015). The most common treatments include “general health check-ups, eye care, dental care, dermatology, plastic and cosmetic surgery, transgender surgery, and rehabilitation” (Wongkit & McKercher, 2013, p.8). Medical tourism is a market-driven industry that is impacting healthcare provision globally (Fisher & Sood, 2014). Countries including Thailand, India, Singapore, Malaysia, Saudi Arabia, Turkey, and Mexico have developed, and actively promote, their medical tourism facilities (Goldbach & West Jr., 2010). Medical tourists are motivated by a range of factors including lower medical costs (Snyder, Johnston, Crooks, Morgan, & Adams, 2017), availability of high-quality healthcare (Guiry & Vequist, 2011), privacy of medical treatments (Singh, 2013), shorter waiting times (Li, 2014), inadequate insurance coverage in home countries (Henson, Guy, & Dotson, 2015), internationally accredited medical facilities (Grepperud, 2015), availability of speciality services that are unavailable in home countries (Crooks et al., 2015), and reputation of the facilities and practitioners for specific treatments (Fisher & Sood, 2014). Given that the choice of a medical service provider is a high involvement decision, consumers are likely to undertake extensive decision-making and include social sources of information (Kang et al., 2014). Research indicates that, in addition to medical costs, the most important decision criteria in choosing an international medical destination are factors related to assurance aspects such as provider and practitioner certifications and safety records (Singh, 2013; Wongkit & McKercher, 2016). Referrals from medical providers in the country of origin and pretravel online research are also important influencers (Singh, 2013). The travel component adds a range of additional challenges for medical tourism destination providers (below “providers”). Medical tourists do not choose only the provider but also the destination, so the customer image of the tourism destination is important (Pike & Page, 2014). Successful marketing of tourism destinations has been widely discussed (Kozak, 2002; Kozak & Rimmington, 2000; Mariani, Di Felice, & Mura, 2016), and providers need to consider destination choice factors when marketing their brand. Destination brands enhance customer destination image (Morrison, 2013) and assist in differentiating destinations from competitors. They also help to overcome the effects of intangibility, present consistency, and facilitate better customer segmentation (Morrison, 2013). Therefore, proper communication with stakeholders becomes vital for successful destination marketing (Stylidis, Sit, & Biran, 2016), and social media should prove an effective marketing tool for medical tourism providers. In relation to social media, the tourism literature recognizes three essential functions: (1) its ability to collect data relating to customer behaviour, trends, as well as post-experience feedback (Chan & Denizci Guillet, 2011; Denizci-Guillet, Kucukusta, & Liu, 2015); (2) its use as an effective promotional channel (Phelan, Chen, & Haney, 2013); and (3) its potential to enable engagement with customers (Hudson et al., 2015; Munar & Jacobsen, 2014). Customer research Social media is playing a growing role as a means to research customer preferences and motivations (Hays, Page, & Buhalis, 2013) both before, during, and after purchase. It can provide information relating to customer preferences and behaviour while overcoming geographic obstacles. For example, Hays et al. (2013) suggested three areas where social media analysis can be useful: audience size (e.g. number of followers), customer engagement (e.g. number of comments), and customer sentiment (e.g. types of comments posted, the number of likes and dislikes, etc.). Promotional channel Once preferences are understood, organizations can use social media as an effective method for communicating with customers in order to attract and to generate interest among potential customers (Roque & Raposo, 2016). Social media can provide highly targeted communications at relatively low cost with a global reach (Amaro et al., 2016). These elements are especially important in a niche sector such as medical tourism. An extensive body of research outlines the usefulness of social media as a promotional channel (Chen, Guevara Plaza, & Alarcón Urbistondo, 2016). Literature suggests that successful social media tourism marketing involves communicating both the benefits and the attractiveness of the destination (Buhalis, 2000). In the context of medical tourism, providers have been found to use numerous channels of communication, including traditional media (Jun & Oh, 2015) and social media sites such as Facebook, Twitter, and YouTube (Lee, Wright, O’Connor, & Wombacher, 2014). Most social media use aims to communicate the key benefits of medical tourism (Lee et al., 2014). Customer engagement and relationship building Unlike traditional promotion channels, social media is perceived as a powerful medium for interactive marketing. Given the importance of referrals for tourism marketing, it has significant potential when utilized in ways that lead to engagement and encourage interaction. This will result in retaining current customers (Hays et al., 2013) and provide opportunities for customized interactions (Harrigan, Evers, Miles, & Daly, 2017). To get the best return from social media marketing, Kietzmann, Hermkens, McCarthy, and Silvestre (2011) note that providers should recognize the functionalities of each social media platform, develop strategies that are suitable given the functionality of each, and curate the social media content and user interaction regularly. This engagement and relationship building through social media requires a substantial commitment of human resources. However, while there is significant potential for medical tourism providers to use social media in their marketing activities, research into the use of social media marketing by medical tourism providers remains limited. Research framework Marketers require a simple, yet comprehensive framework that can help to perform various marketing functions, including brand management, enhancing customer engagement, and relationship building over social media. Hays et al. (2013) examined the frequency and type of posts appearing on Facebook and Twitter published by destination marketing organizations representing the top 10 tourism markets in the world. The study suggested evaluating social media marketing across three key areas: audience size (e.g. number of followers), customer engagement (e.g. number of comments), and the customer sentiment (e.g. comments posted, the number of likes and dislikes, etc.). To develop strategies to monitor, understand, and respond to different social media activities, Kietzmann et al. (2011) proposed a social media framework with seven functional building blocks: identity, sharing, conversations, presence, relationships, groups, and reputation. The paper provided valuable insights regarding the applications of social media for practitioners but limited detail about the measurement and monitoring of the building blocks. In a similar framework, Chan and Denizci Guillet (2011) proposed social media evaluation criteria, recognizing the four major functions of digital marketing strategies: attracting, engaging, retaining, and learning. While such studies provide insights about the utilization of social media, for this article employs the broader SMM Framework, which has not previously been applied to the medical tourism industry. Stevenson and Hamill (2012) proposed the SMM as a tool to analyse the use and functional success of social media for tourism marketing. It includes six comprehensive key performance indicators (the 6Is): involvement, interaction, intimacy, influence, insights, and impact. Involvement refers to the level of customer involvement on social media platforms and can be measured by the number of users, fans, or followers (Phelan et al., 2013). Higher involvement relates to user satisfaction and positive attitudes (Chang, Chou, Yeh, & Tseng, 2016). Interaction is assessed in terms of users’ reading, posting, and commenting activities, including pictures, videos, and reviews (Aluri, Slevitch, & Larzelere, 2015). Intimacy measures the overall brand sentiment among customers (Stevenson & Hamill, 2012), the improvement of which is a primary motivation for firms to use social media (Dijkmans, Kerkhof, & Beukeboom, 2015), and which can be promoted through online content relating to the brand (Denizci-Guillet et al., 2015). Influence shows how a brand manages its advocacy, referrals, and recommendations for its customers and is assessed by the provider’s usage of social media posts (Denizci-Guillet et al., 2015; Stevenson & Hamill, 2012). Insight refers to the “level of actionable customer insight received from monitoring online conversations” (Stevenson & Hamill, 2012). Finally, impact refers to the effect of social media marketing activities benchmarked against core business objectives. The current study extends the SMM, analysing its suitability for monitoring marketing practices over social media for a sample of medical tourism providers. In the current study, the SMM provides for comprehensive analysis of all digital marketing objectives (e.g. measuring audience size, customer awareness, customer engagement, customer sentiments, customer retention, and customer insights) discussed in the literature. Furthermore, as the SMM is designed for monitoring social media practices for marketing, it is straightforward to administer and operationalize. Methodology This study employs both qualitative and quantitative research methods. First, Thailand was chosen as the sampling frame as it accounts for more than 40% of the global medical tourism market (Mellor, 2014; MTG, 2016), and we identified 41 international hospitals in Thailand (“providers”) accredited by the Joint Commission International (JCI, 2016), the leading body for international hospital. A list of the major medical treatments provided by these hospitals, and available to tourists, is provided in Table 1. Next, a content analysis of the user-generated social media content was performed. Content analysis of large qualitative data sets is a well-established technique and used widely for investigating social media use and content (Holsti, 1969; Lai & To, 2015). Links to social media platforms used by the 41 providers were identified on their corporate websites, and data were downloaded into NVivo content analysis software using the NCapture tool for the Google Chrome browser. Data were collected until data redundancy occurred across a 2-week period at the start of June 2016. Once the data were downloaded, a systematic review, analysis, and coding of the content were undertaken. We analysed the social media content based on the SMM. Forty-one items were used in this study to measure 6 dimensions of 2 social media platforms, Facebook and Twitter, the 2 most populated social networking platforms with, respectively, 1.79 billion and 1.18 billion daily active users (Facebook, 2016), and 1.3 billion registered users and 310 million monthly active users (Statista, 2016). Further, Facebook and Twitter were found to be widely used by medical tourism providers in Thailand. Among our sample of 41 medical tourism providers, 69% were found to be using Facebook and 45% Twitter, but far smaller proportions of the sample used other platforms. Facebook and Twitter differ widely regarding their services, usage, and reach (Hays et al., 2013). Facebook is a social connectivity channel assisting with networking people, while Twitter is a platform for networking ideas and thoughts, due to its microblogging characteristics. We analysed the data based on the SMM framework, using 41 items to measure 6 dimensions of 2 social media platforms, with measurement items recorded by frequency or count and coded as either present or absent. Table 2 provides a full break down of these criteria. SPSS version 24 software was used for further descriptive and statistical analyses of the collected data. Table 1. Major treatments provided by the medical tourism providers in the study. Medical tourism services Percentage Cardiac treatments 72.73 Cosmetic surgeries* 54.55 Dental treatments 50.00 ENT treatments 45.45 Paediatric treatments 45.45 Orthopaedic treatments 40.91 Obstetrics and gynaecology 36.36 GI and liver treatments 36.36 Eye centre 31.82 Cancer treatments 27.27 Women’s health centres 27.27 Breast treatments 27.27 Bone and joint treatments 22.73 Fertility treatments 22.73 *Including breast enlargement, breast lift, breast reconstruction, facelift, gender reassignment surgeries, liposuction, dermatology treatments for botox, aurora, laser treatments, and ulthera. Source: Compiled by authors based on the available information from the hospital websites and social media pages Results Our initial objective was to examine how medical tourism providers utilized social media for marketing activities. Content analysis was used to investigate the form of social media marketing strategy employed by providers, leading to the following key findings regarding user involvement, interaction, intimacy, influence, insights, and impacts over social media. Online user involvement Three providers had more than 100,000 followers on Facebook, but 56% had fewer than 10,000 followers, and 94% fewer than 10,000 on Twitter. Visitors to social media pages posted an average of 188 photos (Min: 0; Max: 2410; SD: 489). Most providers (89%, N = 32) displayed customer reviews with an average review rating of 3.71 from online customers (Min: 0; Max: 5; SD: 1.35). Online user interaction Facebook Pages were updated weekly by 37.5% of providers, while 37.5% did so on a daily basis, and 22% less than once a week. Similar results were found for Twitter. Most providers (82%) used social media as a promotional channel, consistent with previous findings (Mariani et al., 2016). Nearly 40% interacted with online users through online games and quizzes and encouraged users to participate in competitions and healthcare campaigns through Facebook. Providers responded well to customer queries, messages, and comments on Facebook, indicating the importance of this interaction in their marketing. Although almost 20% ignored customer inquiries completely, nearly 50% responded selectively, and 20% responded with personalized messages. However, only 12.5% replied to all comments/queries posted by online users. Online user intimacy Providers promoted their brands extensively to online users through both Facebook and Twitter. Nearly 91% used Facebook to introduce their brands and speciality services using various content types, including pictures, videos, and information posted on the “About” section of their Facebook Pages. These activities are intended to reinforce intimacy towards a brand, brand identity, and corporate reputation (Dijkmans et al., 2015). Nearly all providers (94%) included links from Facebook to their corporate web pages, but only 48% included links to other social media sites. Similar results were found for Twitter. Online user influence Images and videos have a strong influence on customers’ decision-making process (Bolan & Williams, 2008). We found 33,821 photos and 325 videos posted by 32 providers, almost entirely on Facebook, with a further 1254 photos and 5 videos on Twitter. Fifty-seven per cent of providers shared pictures of their facilities, with a quarter also using video. All 41 providers posted pictures for health campaigns, healthcare tips, and community welfare activities in social media. The association between pictures and videos posted on social media and the total number of fans/followers was also examined. Both photos (α = 0.443, p = 0.011) and videos (α = 0.388, p = 0.034) have a strong positive effect on the total number of Facebook likes, and the number of photos and videos also has a strong positive relationship between the total number of Facebook followers (α = 0.81, p = 0.001) and the total number of Twitter tweets (α = 0.760, p = 0.003). Capturing customer insights Potential medical tourists use social media to seek travel-related information including posts, comments, reviews, and testimonials, as well as details of the medical procedures available and other customer services. Patient testimonials and reviews are beneficial to both potential travellers and providers as an efficient instrument to collect customers’ overall experience, and to act as a reliable tool for new customers to learn about a provider. Nearly 88% of providers offered some form of online customer services, such as instant messaging, online feedback forms, reviews, and testimonials. Bumrungrad Hospital had the highest number of reviews (5301 reviews with an overall rating of 4.4/5.0), followed by Yanhee Hospital (2463 reviews and rating of 4.2/5.0). There was no significant association between the number of reviews and the overall rating of a provider, possibly because providers may remove unfavourable reviews. However, the number of user reviews has a significant positive correlation (α = 0.46, p = 0.004) with the number of Facebook Likes. In contrast, only 19% of providers published patient testimonials on Facebook, and no patient testimonials were available on Twitter Impact Marketers expect an increase in sales as the impact of their marketing and promotion efforts. Without access to operational data, the study estimated possible impact as a function of customer touchpoints, such as the provision of online booking facilities, secure online payment systems, reservation facilities (hotline telephone numbers), 24/7 dedicated call centres, email addresses, physical addresses, and maps. Most providers included all of this information, except secure payment systems, which were rare. Hotline reservation numbers, physical addresses and maps, email addresses, and call centre numbers were commonly provided. Online booking facilities were less common, and most of the 41 providers use Facebook’s messaging services. Findings indicate that significantly lower contact options were given on Twitter (µ = 2.42, SD = 1.13) compared to Facebook (µ = 3.75, SD = 1.19). A summary of the analysis is presented in Table 3. After analysing the current social media practices of medical tourism providers, we also examined differences in the use of social media for medical tourism providers by platform, Facebook and Twitter (see Table 4). Results indicated a significant difference between Facebook and Twitter regarding providers’ involvement, insights, and impact strategies. Results of the T-test indicated no significant difference between Facebook and Twitter regarding interaction. Facebook attracts a significantly larger number of followers than Twitter (p value = 0.11 < 0.05) - an unsurprising result given Facebook's 1.5 billion users (Statista, 2016), compared to 300 million active users on Twitter. Our study indicates that marketers have more opportunity to collect users' feedback and insights from Facebook than Twitter (p value = 0.006 < 0.05). Impact through the provision of customer touchpoints was also significantly higher on Facebook (p value = 0.022 < 0.05). Fortythree per cent of providers had an online booking facility for new customers through Facebook, while only 6% employed Twitter. No significant differences were found between Facebook and Twitter regarding interaction, intimacy, and influence factors. The final objective of this paper was to examine the major social media marketing issues. As discussed earlier, user involvement is directly related to influence and impact strategies, although only a few providers were actively involved in social media interactions, and none of the social media interaction strategies was adequate to influence or create intimacy among online users. Lack of dynamic content was apparent. The infrequency of updates on both Facebook and Twitter (see above) and inconsistency in responding to customer inquiries or comments were identified as issues, suggesting a lack of engagement on the providers' side. Also, the analysis demonstrated problems such as multiple accounts on the same social media platform, lack of proper customer involvement strategies and failure to influence customers over social media, inadequate customer interactions and lack of effort to collect customer feedback, as well as language constraints. Conclusion and implications In addition to the specific issues discussed above, there are three general findings for social media marketing of medical tourism services. These are discussed in relation to the common strategic applications of social media identified in the literature. Most providers in Thailand had fewer than 10,000 Facebook followers, indicating a low level of engagement. Engagement via social media platforms still requires an understanding of customer motivation. The data suggest that social media is not being adequately utilized as a customer research tool and more monitoring of what drives customer interaction could be undertaken. Many tools exist for this purpose, such as services provided by Social Bakers or Moz. To encourage potential customer engagement, successful cases should be posted and updated on a regular basis. It was surprising given the high risk and involvement of the sector that customer testimonials were rare and that response to customer comments was infrequent. Electronic word of mouth and online customer reviews have been found to be a major source of influence among medical tourists (Abubakar & Ilkan, 2016), and this is, therefore, an area for further consideration by providers. Consistent with previous findings (Duarte Alonso, Bressan, O'Shea, & Krajsic, 2013), providers used social media primarily to promote their services. However, they did not fully utilize the channel for research, customer involvement, interaction, or to influence destination choice. This is a significant problem given the potential global reach of social media. It is also important that providers use social media not just to promote to customers but also to other stakeholders who may influence customers and their destination, including residents and tourism providers. Providers in our study were less interested in customer interaction compared to previous studies. For example, Denizci-Guillet et al. (2015) found that hotel operators in China replied to customer queries and complaints rapidly through social media. However, our results showed that only 12.5% of the medical care providers replied to all customer queries on a daily basis in Facebook, 6.3% on Twitter, and 50% of the suppliers replied selectively. While social media platforms offer an increasing range of customer service features such as online booking facilities, secure online payment channels, and hotline reservation numbers, fewer than half the providers included such facilities through Facebook. As social media increasingly becomes a central customer touchpoint, providers need to offer such functions to both meet target audience expectations and as a potential competitive advantage. Building communities of interest is another option to improve customer interaction. Managing online communities around the medical provider's brands may be an effective strategy to strengthen the brand (Chikandiwa, Contogiannis, & Jembere, 2013). This study contributes to the marketing and tourism literature in a number of ways. First, it is evident that social media can enhance the marketing of tourism products and services by allowing suppliers to execute innovative forms of communication with their customers over large geographical distances. However, studies focusing on the monitoring and evaluation of social media use for the marketing of tourism services remain limited. Our research tries to fill that gap. Second, by investigating the social media behaviour of medical tourism providers, it extends Stevenson and Hamill's (2012) SMM framework and provides an illustrative application of the SMM. Third, it elucidates the need for customer involvement and relationship building in the marketing of medical tourism services over social media platforms as customer involvement is regarded as the prime antecedent of brand engagement and brand usage intention (Hollebeek, Glynn, & Brodie, 2014). The adoption and use of social media may differ in other countries and other tourism sub-sectors. Therefore, future studies should examine social media practices among other stakeholders in medical tourism including medical tourism companies, tour operators, travel and tourism boards, and others and compare social media marketing activities of medical tourism providers in other countries. Disclosure statement No potential conflict of interest was reported by the author

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