Investigate the Importance of the Promotion factor in the Marketing of Therapeutic Tourism Services

Article History: Received: 3 Jul 2018 Revised: 4 Oct 2018 Accepted: 20 Dec 2018 Background: Medical tourism represents the travel of individuals to receive health care and treatment to another country. One of the important factors in the marketing of medical tourism is promotion. The purpose of this study is to investigate the importance of promoting factor in the proposed marketing pattern of medical tourism services. Methods: This study is a Descriptive-Correlational research method and an applied research in terms of purpose conducted in2017. The statistical population of the study consisted of all staff of medical centers and active units in the medical tourism area of the medical Science Universities in Iran and 630 of them were selected as a statistical sample by using simple sampling method. The data collection tool was a questionnaire with 63 questions related to tourism marketing components with scoring based on Likert scale. The validity of the questionnaire was evaluated by experts' judgment and reliability was measured by using Cronbach's alpha coefficient (0.82) and Test re Test (0.92) in SPSS22. Results: According to the standard estimates of path coefficients, the promotion factor with score of 0.98 consisted of 8 components ranked first among others was determined. Conclusion: Considering the importance of the promotion component, Policy makers in the field of medical tourism services should pay special attention to promotion and related issues in order to properly identify the Capacities and capabilities of active centers globally.


Introduction
he principles of the health tourism industry are medical and recreational tourism. Medical tourism include surgical procedures and medical treatment, as well as outpatient services (surgery, ophthalmology and some cosmetic surgeries), and recovery tourism mainly involves relaxationrelated activities , lifestyle changes, mineral springs, spiritual treatments, nursing homes and retirement homes (1) .Therapeutic tourism is one of the most important indicators of the tourism industry, which has high socio-economic benefits for countries. According to the definition of therapeutic tourism, patients are entitled to other countries to use cheaper and better quality health care than the homeland (2). Medical tourism has grown for several reasons. Various studies have suggested that the main reasons for the growth of medical tourism include: increasing the waiting list in advanced countries, increasing international exchange rates, the Internet (with the development of the communication network, new companies , the interface between international patients and the hospital network, which provides patients with basic information), low cost of services in developing countries, modern technology and equipment that are in line with new health services (3) . In fact, there are six factors affecting people's demand for health trips such as: price, quality, availability, timeliness, out-of-range treatment and differentiation, taking into account the benefits of medical tourism in this regard. The low cost of services, the proper equipment, and qualified physicians with rich historical attractions and highquality therapeutic capabilities can take advantage of opportunities in the health services market (4). Although the nature of health tourism marketing is different with the marketing of other services such as banking or transportation, all of the P10 cases referred to by McCarthy (1975) Includes: Product, Price, Location. Distribution and Promotion, Individuals, Physical evidence and Procedures, Partnership, Personalization, and Signs Mixed with Marketing for Services Separated from Each Other (5). Patient education, privacy, and medical sensitivities and patient culture, have also been added to the above mentioned cases due to the nature of medical tourism (6).Iran has many capacities for attracting health tourism. Mineral springs can be found in most of the country, the desert areas of Qom, the infertility wards of Shahid Sadoughi Yazd, dentistry, dialysis centers, and all kinds of cardiac surgery, plastic and orthopedy ,eye in Mashhad and Tehran hospitals, bone marrow transplantation and kidney transplantation in Shahid Nemazi hospital in Shiraz. Herbal medicine services in Hamadan (7) .The cheaper price of medical services in Iran than other countries in the world, its quality and its bestknown methods of medical science in the world are one of the most important reasons that can boost medical tourism in Iran (8). According to the World Economic Forum (9), Iran ranked 69th among the 137 countries surveyed and ranked 8th among the 13 Middle East and North African countries (10).According to 2017 tourism business assessment, Iran in 2016, Iran ranked 41th among 41 countries (10).
Iran has several capacities to promote health tourism, but poor marketing efforts are being made to attract foreign patients in Iran. Inappropriate coordination between the organizations responsible for medical tourism, the lack of a comprehensive system for collecting information on the arrival of medical tourists to Iran, the ineffectiveness of information systems about the tourism capabilities of Iran and the lack of infrastructure necessary for the development of this industry is one of the main reasons that has led the Iranian tourism therapeutic industry No desirable position (11).
According to Momeni et al, Iran in order to obtain rivalry abilities with countries of the region in attracting medical tourists, need to perform long-term plans to strengthen infrastructures and cultural reforms. Further participation of the private sector is needed in strengthening the infrastructures and planning for more efficient use of mass media and local and province press in order to enhance awareness and cultural reform. international accreditation should be included in the policy agenda of the province's medical tourism (12). Considering the role of various factors in the marketing pattern of medical tourism, this paper attempts to study the factors mentioned with emphasis on promotion component in the marketing about the provision of medical tourism services in Iran.

Materials and Methods
The present study Descriptive-Correlational in terms of its purpose conducted in2017. All the staff of medical centers and active units in the medical tourism sector of the universities of medical Sciences, were the statistical community of this study. The sample size (for each variable question was calculated for ten people) 630 were estimated and were selected as a statistical sample with simple sampling method. Data collection tools, was questionnaire consist of 63 questions in the field of medical tourism based on the Likert scale in a completely opposite = 1, opposite = 2, neither agree nor disagree = 3, agree = 4, totally agree = 5 ranke. To assess the validity of the experts' judgment, the Cronbach's alpha coefficient (0.82) and Test re Test (0.92) were used to measure the reliability of the questionnaire. data was entered in SPSS 22 . For analyzing the validation factor and presenting the pattern, the Lisrel 8.8 software was used. Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication, double publication and submission, redundancy, etc.) have been completely observed by the authors. Thesis code is 14121213962008. It is necessary to mention that this study tried to comply with Helsinki declaration principles. Also, informed consent was obtained before completing the questionnaires.
According to the standard estimates of path coefficients, the promotion rate was 0.98, the dimension of the process and the method was 0.88, the participation dimension was 0.48, the dimension of the evidence and the symptoms was 0.83, the dimension of the medical package 0.77, the product dimension 0.91, the cultural and medical sensitivity was 0.55, cost was 0.75, and the people was 0.91.
As shown in Table 2, all factor loads are larger than 0.5 and are 95 % reliable in the confidence level, so all items remain in the pattern and there is no reason to remove them, the promotion factor is ranked first and the other factors are ranked 2 to 9, which indicates the importance of the promotion factor in the proposed project.
-According to Table 3, the variable use of slogans, logos, brochures by the active medical centers in the field of medical tourism at 80 % had the highest Standardized factor loading and the Variable creation of information sites for the introduction of facilities and new treatment methods and equipment by the active medical centers had the lowest Standardized factor loading at 0.63. Table 4 shows that after corrections, all values above 0.9 estimated and are acceptable. Finally, the estimated values for pattern fitting indicators show that the data of the research pattern with the structure of the factor and the theoretical basis of the research is suitable fit.

Discussion
According to the results of the present study, the first-ranking promotion factor with 8 components was identified in 9 factors which indicates the importance of the component mentioned in the marketing process Along with other components. It seams Active medical centers in the field of medical tourism should focus on the planning and activities of virtual marketing based on the issues listed in Table 3, including: virtual online marketing, virtual tours, public relations through communication channels (TVs) , Radio, magazine, CD, newspapers and the dissemination of news related to health tourism, holding seminars in related areas, distributing brochures and pamphlets, and creating dedicated sites for providing information and management in educational films. This study was conducted with the results of Suba et al. (13), study on the need for smart managers to use marketing tools to increase the attractiveness of their centers for customers, Also, according to KUO-Ting which is needed for the globalization of the tourism industry, attention is required for marketing channels and international co-operation (14). According to Hopkins et al. (15), The Internet plays an important role in this industry, as it provides a key link between potential providers and potential consumers. In recent years, consumers have been searching the web for information on health and existing health interventions. For them, several studies have shown that email is a tool for the purchase of products and services. Even on some attractive websites, consumers can contact their specialists or surgeons, flying facilities and collections tourism is also coordinated. According to Ching-Chi studies (16) on tourism , Internet communication is the best and most appropriate channel for information .Also, based on the study of Mehrjodi (17), a map was prepared in which medical tourism information was collected from electronic media, newspapers, magazines and academic materials. According to their map, the components of the medical tourism market include customer benefits, legal framework, infrastructure, products, consumer markets, communication channels, intermediaries, and social issues. Other Momeni et al. (18), research results show that marketing, international issues, culture, transfer, brokerage, management, and policy problems are the main barriers to the development of medical tourism.

Conclusion
This research and other studies show the importance of promotion factor of the proposed marketing strategy for medical tourism in order to identify the capabilities of centers including new therapies, equipment, and manpower in the field of medical tourism throughout the country, which can lead to more attention of non-Iranian patients for care services And treatments in Iran. As research constraints, the relative collaboration of some respondents in completing the questionnaire was a time constraint for presence in order to explain how the questionnaire was completed, which was resolved by following several occasions in order to receive the opinion.
Based on the present study, it seems that, policy makers and managers should be serious attention in this regard while listing the proposed measures as follows: -The requirement and establishment of facilities for all active medical centers in the field of medical tourism for the purpose of conducting virtual tours in order to provide medical facilities to attract the attention of health tourism applicants -Improvement of facilities and effective information for the purpose of the participation of medical centers and companies active in the field of medical tourism in international exhibitions and conferences in the marketing of the provision of medical tourism services -Need more attention managers and Policy makers of medical centers about marketing strategies and Policy for health tourism using of mass media and international television networks to introduce medical centers active in the field of medical tourism and cross-border advertising.