China’s Health Tourism and Marketing

Background: China has been recently considered as an essential component of the world health tourism market. Nevertheless, limited studies, if any, have focused on marketing China’s health tourism. Methods: Through the stratication sampling survey method, the present study collected 351 valid questionnaires. Results: The present study identied possible attributes and resources to market health destinations in China; and all the identied attributes were classied into four factors: basic services, health services, religious services, and social services. Conclusions: Safety was considered to be the top attribute of health destinations; and the most effective way to do marketing of health tourism in China is through events. Furthermore, travel pattern of health tourism is also identied.

prediction from visa showed that the scale of medical tourism might add up to 3 trillion dollars worldwide by 2025. As a result, an emerging tourism market with high pursue in health will lead to a boosting market shortly. However, few studies have explored the attributes and resources that are considered the important marketing elements of health tourism in China. According to the exception in Heung and Kucukusta's research [9], many current studies have failed to answer the question "What would accelerate the marketing of health tourism in China?" Thus, in order to have an overall picture of health tourism in China, it is of great necessity to explore the detailed important elements of marketing health tourism in China. As a result, the present study aims to investigate which attributes and resources would be considered important in health tourism development; to identify the effective methods to promote health tourism in China; and to provide practical implications for tourism practitioners regarding the strategic development in the future.
Health tourism research and its development Regarding the de nition of health tourism, the consensus has not been reached among academic researchers. The teams such as "health tourism", "medical tourism", "wellness tourism", "well-being tourism" have been frequently seen in publications, but each of them describes different concepts in health tourism [10]. Based on the ndings of the retrieved health-tourism related articles, three main themes were identi ed, that is, health tourist markets (demand), health tourism industry development and promotion (supply), and health tourism impacts and policy (external environment). Many existing studies have focused on identifying factors and reasons that help tourists making decisions in their healthrelated travels. It was believed health-related travel usually caused by three motivations: to be away from home, to pursue health, and to get leisure setting [11]. Those studies only provide a general view, but they did not touch any in-depth research on why and what wellness tourists' demands [12]. To very recent, a contrast study of evaluation of South Korean wellness tourist's satisfaction and motivation between their rst and return visits was published [13]. For medical tourists, It was found that the market relied heavily on commercial promotion activities [14]. Moreover, It was claimed that excellent medical facilities and quali ed medical staff were key factors to attract medical tourists [15]. It was indicated that enhancing the quality of a product of health tourism would improve tourists' satisfaction [16].
A number of studies have been done in terms of supply chain about health service, such as hotels and hospitals at destinations. It was analyzed the situation and the future trend of the entire industry [17]; It was surveyed promotional paper-based materials used in Indian health tourism [14]. It was utilized a qualitative way to analyze the competitiveness of medical tourism in Singapore [18]. It was identi ed a region-based measurement standard called Medical Tourism Index (MTI) to assess whether a country would be attractive to medical tourists [19].
Besides, the environment of the holistic development environment is another research focus on health tourism. Policy, barrier, ethic, welfare, and background of the industry are ve main factors to be considered. It was revealed the low cost became the main reason for uninsured or underinsured medical tourists to travel outbound [8]. It was found medical tourism impacted the justice in low-and middle-income destination countries [20]. Ii was reviewed the policies and background of the growingly popular South Korea medical tourism industry [21]. It was concerned on the legal climate of other medical tourism, psychology, tourism, health and wealth, ethic challenges [22]. Many studies pointed out that health tourism would be the new trend soon, and it would in uence the economic development of a destination country. It was insisted that the international practice of wellness tourism would impact the global distribution of practitioners [23].

Health Tourism in China
China has a long history of maintaining a healthy life. Health tourism has become popular in the past years due to the fast growth of economy in the country though only a few international research groups have noticed the potentials hidden in this vast potential market. Up to date, only 17 papers were relevant to Chinese health tourism available in the ISI database. Among them, Heung's groups conducted in-dept research of Chinese health tourism market from a cultural perspective, resources and marketing [9,24]. It was investigated the associations between tourism experiences and subsequent self-rated health using Chinese older adults as samples [25]. It was examined the factors that motivate tourists from the US,

Methods
A structured questionnaire was distributed using strati cation sampling method and snowball sampling online [28]. First, seven researchers were asked to send the questionnaire to ve friends who were the most trustable ones in their social network. Then these thirty-ve respondents helped to involve more respondents by sending a questionnaire to ve of their trustable friends in the same way. To collect appropriate sample set that re ects the distribution of the overall tourists' population, demographic information of the respondents were extracted for ltering purpose. Data were collected recently, and a total of 351 valid questionnaires were used for further analysis using SPSS.

Results
Attributes for health tourism destination development According to the literature reviewed in Section 2, some attributes were identi ed as helpful in the development of health tourism destinations in China. The respondents were asked to rate agreement of the importance of each attribute on a ve-point Likert-type scale (from 1 = Strongly Disagree, to 5 = Strongly Agree). Table 1 shows the descriptive statistics of the attributes.
The results reveal that a safe environment is a prime attribute with a mean of 4.61. The "Fresh air and clean water" is the second favorable one for the development of health destination, followed by relaxing environment, tranquil environment, healthy diet, beautiful landscape, natural resources, high-quality therapeutic services/practitioner, accommodations, convenient transportation, cultural resources, and health center, all score above 4. Entertainment facility, geriatric nursing services, Chinese medicine treatment, Chinese Kong-Fu/Taiji, convention center and religious resources rank among the lowest.
ANOVA test was used to analyze the difference between the groups. Result in Table 2 reveals few differences were found according to the importance of the attributes. The differences existed in the convention center and Chinese Kong-Fu/Taiji. Young people below the age of 25 and those who do not have a marriage thought convention center is a useful attribute. Aging people between the age of 56 and 65 would love to have Chinese Kong-Fu or Taiji with a mean score at 4.25, but the people above 65 did not think that would be important.
To identify the underlying development dimensions for destinations, factor analysis was employed for the nineteen items. Principle rotation and varimax rotation were used to clarify the structure of the factors. First, three factor groups with an Eigenvalue greater than 1 were elicited that accounted for 66.723%, then try to add one more group the cumulative percent variance (CPV) raised to 72.03%. In all the factors, there are some dominant variables. Bartlett's test of sphericity yields a value of 4216.924 with a statistical signi cance (ρ=0.000). KMO shows a value of 0.921, which indicated the suitability of the data for structure detection. All three factor groups possess Cronbach's alpha value greater than 0.7, which showed acceptable consistency within the factor group. Table 3 reveals that the factors could be categorized into the four groups: basic services, health services, religious services, and social services.

Method for promotion
Based on the previous study, a set of promotion methods were adapted into the questionnaire (9). The respondents rated agreement level of effectiveness of each attribute on ve-point Likert-scale (from 1 = Strongly Disagree, to 5 = Strongly Agree). Table 4 shows the results of the descriptive statistics. The chisquare test (all signi cant at the level of 0.01) indicated that all the items had in uences on promoting. Nationwide/International event (i.e. Olympics), mass media advertising, special destination event (i.e. Marathon, Yoga congregation) and government campaign were rated as the four most effective ways of promoting with mean values above 3.81.
To examine the effective way of promoting to a different market segment, we performed the ANOVA analysis. The ANOVA test showed differences on levels of promotion preferences according to participants' gender, age, monthly income, and marital status. Further, correlation analysis was performed to nd the direction and degree of association. Table 5 presents the corresponding results. Regarding gender, cooperation with a geriatric nursing center and rehabilitation appealed to female more, with a mean score of 3.96 for female and 3.53 for male. Holding nationwide/International events or special destination events works effectively towards young people (with mean scores of 4.15 and 4.09 respectively), but not so convincingly for people over 65 (with mean scores of 2.33). The correlation between education background and promotion methods revealed that higher educated people were more likely to accept online advertising and advertisements on health magazines. To do marketing in the highincome segment is not an easy job. We could only nd they have the least interest in government campaign, but no exist way could effectively encourage this group into health tourism. The Marital status also in uenced promotion preferences. Event planning would be the best way to attract single, in-love people and even families (married and live with child) to the destinations.

Health tourism experience and expectations
To explore tourists' experience and expectations, more questions were added, including "I am very familiar with health tourism"," I have several health travel experiences", "I am satis ed with my health travel experience", "Health travel is worthwhile" and "I would like to participate again in health tourism activity". Respondents were asked to rate each statement based on their agreement level using a vepoint Likert scale (from 1 = Strongly disagree, to 5 = Strongly agree). Table 6 shows the frequency statistic and the chi-square test results. Overall, the respondents were lack of participation and understanding of health tourism (with a mean value below 3). Then the ANOVA analysis discloses that most of the population are in lack of health tourism awareness in China, as shown in Table 7. Only the aging people had a bearing on the re-travel intention. People aged between 56 and 55 (mean score of 4.08) had a comparatively higher willingness for participating in health tourism again than other age groups. This age group was considered more likely to be wealthy and leisure with the intention for better life quality.

Dream destinations and property buying
As for the choice of health destinations in the future, 49.32% of respondents chose international destinations, while 50.68% prefer domestic. An open-end question was added to analyze what is the difference when the tourists think of the health destinations in the east and west. Table 10 recorded the most representative opinions of from186 responders. We could see that in most tourists' mind, there are better-developed health tourism industry in the west with better service, facilities, and natural environment. But the expenditure is much higher than in the east. Meanwhile, the concerns of health tourism are different. Spiritual health is very important in east health destinations, while physical health is very important in the west. Also, culture and food are different between east and west. When talking about property purchasing in health destinations, 22.51% of respondents showed their willingness within the price range of 500,000 RMB (about $73500) to 1,000,000 RMB (about $14700).

Travel pattern
To understand the health travel pattern, respondents lled out two multiple-choice questions asking the traveling companion, types of traveling. A single-choice question was added requesting the length of stay. Table 10 shows the frequency analysis results. Majority of the respondents would like to travel with friends and families and mates when they do health tourism (61.0%, 77.2%, and 43.3% respectively). The respondents also showed great interest in independent traveling and semi-independent traveling (67.2% and 46.4% respectively); while traveling with professional health institution was viewed as the fourth favorable health travel type (22.8%). In terms of the length of stay, most of the respondents would like to take a health trip of 3-7 days (57.8%), which is pretty high compared to the 21.6% from all tourist sample survey of the government (China National Tourism Administration, 2016). Traveling for two to four weeks was also a favorable option (32.5%), which achieved a signi cantly high score by comparing 2.4% to the all type of tourist census data.

Discussion
Findings of the present study represents the uniqueness of the Chinese outbound market, particularity in terms of the size of Chinese outbound market as it is expanding rapidly. In addition, the market that the present study investigates is different from the market that was investigated by previous studies, which are re ected in the travel pattern of Chinese tourists. Speci cally, respondents showed a great interest in both travelling with their mates and travel independently for health tourism. Furthermore, since health tourism is expected to continue to grow globally, knowing the perceived attributes of health tourism from the perspective of Chinese tourists provide the necessary information and enlightenments for other countries of marketing health tourism to Chinese tourists. Last but not least, the present study takes the initiative to understand the key elements so as to better market health tourism in the future.

Conclusion
Embracing great opportunities, health tourism in China is still in its infancy. It is important to understand the health tourism market in China and provide practical information to the academics and the health tourism industry. In this research, from a well-designed and social network distributed questionnaire, attributes of health tourism and effective methods for promoting health tourism in China were discovered. Major ndings indicate that regarding the favorable attributes of health destinations, safety was considered to be the top priority. In addition, all these attributes identi ed were categorized four factors which could be used to improve the supply of health destinations. In terms of marketing China's health tourism, the most effective way to do marketing of health tourism in China is events. which is more interesting is that tourists with different demographics were very diverse when choosing effective marketing ways. Particular attention should be paid on the market segment. Finally, the present study discloses that Chinese tourists were not familiar with health tourism. Even for those who had participated in some, they were not be familiar and satis ed by the situation.
China is the biggest outbound tourism market at present and in the coming future [16]. Detailed understanding and research of this market would increase the knowledge of the hospitality industry. The market investigation and implications for health tourism are useful not only in China but also in other potential destinations. Further studies could focus on the marketing sector more closely, which should be valuable information for all health tourism developers. Closer research on speci c domestic health destinations could also be informative towards the industry. The present study has one limitation. Since it is a pilot study, the sample size is not big enough. Hence, future studies may explore this topic with a larger sample so as to gain more comprehensive understanding.

Declarations Acknowledgements
We wish to thank our patient research partners for their involvement in the manuscript.
Authors' contributions LZ is the lead author of this paper. She made substantial contributions on the research idea, research design, data acquisition, and responded to the comments for revision. BD contributed to this paper in drafting, writing and revising manuscript. SS contributed to this paper structure and direction of this paper, edited the manuscript, and responded to the comments for revision.

Funding
The author disclosed receipt of the following nancial support for the research: