Diasporic medical tourism: where tourism meets migration and healthcare. Understanding its antecedents, behavioural intention and potential.

doi:10.21203/rs.3.rs-2377045/v1

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Diasporic medical tourism: where tourism meets migration and healthcare. Understanding its antecedents, behavioural intention and potential.

https://doi.org/10.21203/rs.3.rs-2377045/v1

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published 11 Apr, 2024

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This study focuses on diasporic medical tourism (DMT), an offshoot of migration-led tourism. There has been growing recognition of the significance of a diasporic dimension of medical tourism worldwide, yet little is known about these travellers, especially quantitatively. This paper examines the antecedents and behavioural intention of the DMT by applying the extended Theory of Planned Behaviour. A cross-sectional survey was conducted in three European countries (Belgium, the Netherlands, and Luxembourg) among the Polish diaspora (n = 1,288), constituting one of the largest migrant populations in Europe. Structural Equation Modeling was applied, and the model explained 53% of the variance in behavioural intention (R²= .527, Q²= .392). All exogenous variables were statistically significant. The intention to undertake DMT was influenced by complex commercial and noncommercial motivational factors, mostly related to uncertainty avoidance and reliance on heuristics to overcome acculturative stress. “Committed” and “Contended” travellers accounted for 70%, indicating the significant potential of those “hidden” consumers. A profile of diasporic medical tourists was presented and compared to foreign medical tourists. This research explores practical implications and contributes to the research on diaspora tourism, medical tourism and the interrelation between tourism and migration, specifically in the European context, but also globally.

Health Economics & Outcomes Research

Health Policy

Hospitality and Tourism

Management

diasporic medical tourism

medical tourism

transnational healthcare

patient mobility

migration-led tourism

diaspora tourism

visiting friends and relatives (VFR)

theory of planned behaviour (TPB) tourism

structural equation modelling in tourism

migrant health

trasnantionalism and health

healcare policy Europe

Polish diaspora

Migration-led tourism has become increasingly important in a globalised world due to the growing number of migrants across the globe. In 2021, there were 281 million international migrants worldwide, three times more than in 1970. They account for 3.6% of the global population (McAuliffe & Triandafyllidou, 2021). For the first time in history, the number of international migrants outpaced the growth rate of the world's population (United Nations Department of Economic and Social Affairs, 2019). Europe hosted the most significant number of international immigrants (82 million).

The two most significant manifestations of globalisation have been tourism and migration, and both phenomena have become interconnected (Griffin & Dimanche, 2017; Williams & Hall, 2000) owing to the increasing demand for travel among dispersed family members and friends. Travelling migrants have been classified in international statistics under the category of Visiting Friends and Relatives (VFR) or as Migration-led Tourism (MLT) (World Tourism Organisation (UNWTO), 2009). Well-respected international organisations refer to this as “diaspora tourism” (International Organisation for Migration (IOM), 2020) or “expat tourism” (as “ex-patria”; in UNWTO, 2019). Yin et al. (2022), in Tourism Management Perspectives, contextualised migration-led tourism as “immigrant tourism”, Mathijsen (2019) in Tourism Management as “diasporic tourism”, and Moon et al. (2019) in the Journal of Tourism and Cultural Change as “immigrant VFR tourism”.

In 2019, “VFR, health, religion and other” constituted the second largest category of international inbound tourism (UNWTO 2009) and accounted for 28% of international tourist arrivals (UNWTO, 2021), up from 20% in 1998 (World Tourism Organisation WTO, 2000). This segment accounted for 25% of all inbound travel to Europe, while in non-EU destinations, it represented a much larger share (43%) (UNWTO, 2016). However, despite the global growth in the number of travelling migrants and dispersed families and friends, research on the subject is scarce, and governmental institutions, tourism organisations, and academia often misunderstand the phenomenon. The IOM (2020) clearly stated that “measuring all of these economic investments at all levels and in all communities of your country is crucial.”

The dynamic environment of changing migration and tourism flows needs to be acknowledged and, even more importantly, understood in its interconnectedness (King & Dwyer, 2015). We have chosen the medical tourism (MT) field to obtain insights into this interconnectedness. The literature has denoted the existence of diasporic medical tourism (DMT) in various countries across the globe (in-depth review of Mathijsen & Mathijsen, 2020; Villa-Torres et al., 2017). Nevertheless, the DMT category has been underresearched, most likely given its complexity-to-document VFR nature. Connell (2013: 45) called DMT tourists “hidden tourists” because they were “largely undocumented and ignored in publicity, yet they have effectively pioneered MT in some countries”. Furthermore, little is known about the characteristics and behaviours of diasporic medical tourists (Morrison et al. 2000). It was assumed that DMT was driven mainly by cultural factors (Connell, 2011). The explanation might lie in the observation that DMT is impacted by the VFR, which in turn is caused by a goal of strengthening social networks and cultural values and norms (Duval, 2004). Therefore, targeting foreign travellers in MT seemed to be a dominant option. However, over 60 countries are actively promoting MT (Edelheit, 2019), and competition has become fierce; therefore, tapping the potential of diasporic patients may offer a competitive advantage.

Accordingly, this paper has two objectives. First, we seek to understand how vital the segment of DMT is and whether it could be promoted by marketing activities and adequate policies, in juxtaposition to the opinion that DMT happens spontaneously. That would undoubtedly contribute to pursuing new avenues for the medical tourism market, which has become very competitive over the past years. Second, we aim to understand how these travellers are different or similar to foreign medical tourists in their motivations and behavioural intention. Specifically, are they solely driven by cultural motivation factors or a much more complex set of motivational factors? Therefore, we propose to test a motivational framework based on the well-established theory of planned behaviour (TPB). This research was conducted on the Polish diaspora in Europe, given that Polish migrants are among the most mobile citizens in the European Union (Eurostat, 2021).

2.1. Migration-led tourism (MLT)

The interdependencies between tourism and migration are not new, but their scale, intensity, and geographical scope have increased significantly over the decades. Migration is a precondition for migration-led/VFR tourism. It can be direct or indirect (dependent on earlier generations of immigrants, e.g. “roots tourism”) or bidirectional (migration-led tourism vs tourism-led migration). VFR is the outgrowth of migration, which is a prerequisite for VFR based on friendship and kinship networks. Three mechanisms can be differentiated in the link between tourism and migration: migration leading to tourism (MLT) by stimulating VFR, the relationship running from tourism to migration (tourism-led migration, TLM), and finally, a bidirectional causal link (Williams & Hall, 2002). In our analysis, we will concentrate solely on the first mechanism. We define return visits after Duval (2004:51) as “periodic, but temporary sojourns of members of diasporic communities to their external homelands”. Duval (2004) suggests that return visits are characterised by three elements: 1) the existence of extensive social and cultural foundations in the country of origin, 2) return visits function as a means to renew, restate, and solidify familial and social networks, and 3) the involvement of individuals who are part of a larger (self-described) diasporic community formed from past migration.

The UNWTO (2009) has suggested that migration might be behind the most significant tourism flows in the world; MLT has made a significant economic contribution and led to development and poverty reduction worldwide. According to UNWTO (2019) estimates, 20% of the tourism economy was related to migration, and between 15% and 25% of international tourist arrivals were migration-driven (between 210 million and 350 million international tourist arrivals). Parr et al. (2000) demonstrated that the growth of the VFR travel market was strongly correlated with the increase in migrant families dispersed across countries. The UNWTO (2009) has estimated that in countries with net emigration, “home visits” by non-resident migrants represent at least 15% and, in some cases, even 70% of total inbound tourism. To name a few examples: 1) British expat tourists made up the most significant proportion of nationalities visiting the United Kingdom in 2007 (UNWTO, 2009); 2) in Australia, VFR accounted for approximately 48% of the total overnight tourism market (Backer, 2012); 3) in Mexico, VFR accounted for 28% (Damián & Ramírez, 2020); 4) 61% of New Zealand-resident Koreans’ overseas trips were to Korea (primarily for VFR; Kang & Page, 2000); and 5) 40 to 45% of New Zealand visitors to Samoa were VFR (Hall & Duval, 2004). Migrants travel to their countries of origin for many reasons, the most critical being to enhance kinship relationships, maintain social and cultural ties, and fulfil family and societal obligations (King & Dwyer, 2015). Nevertheless, while conducting VFR travel, they pursue an array of additional activities, such as entertainment, sightseeing, shopping, and access to healthcare (Mathijsen, 2019).

Information and communication technologies (ICT) and easily accessible and cost-effective networks have turned the diaspora market into one of the most flourishing tourism target markets (UNWTO, 2009). However, despite its substantial volume and activity, the VFR tourism market has received little attention from academia and business (comprehensive analysis in Backer & King, 2015). Reasons for that lie certainly in the inconsistency of definitions and data and diversity of situations. All these gaps make it challenging to quantify the links between tourism and migration (UNWTO, 2009; Williams and Hall, 2002). Additionally, a division of institutional responsibilities – tourism and migration managed by different governmental bodies – makes the management of migration-led tourism challenging but not impossible.

2.2. Diasporic medical tourism: the intersection of medical tourism and migration

Medical tourism (MT), the most significant component of trade in health services, has generated income that benefits domestic economies and improves countries' balance of payments (Cattaneo, 2009). At the beginning of 2020, Allied Market Research (2020) valued the size of the global medical tourism market at USD 104.68 billion and its growth at 12.8%. The Medical Tourism Association (Edelheit, 2019) estimated that fourteen million people travel abroad to obtain healthcare services worldwide. In 2006, there were 10 to 15 medical tourism facilitators worldwide, while currently, there are over 1000 in China alone (Edelheit, 2019). Over 60 countries actively promote MT, and competition has become fierce. Multiple countries saw in MT the opportunity for income generation to benefit domestic economies, improve the balance of payments and support the development of healthcare services.

Diasporic medical tourism has become a recognised subsegment of medical tourism (Connell, 2013), yet there is scant research on this migration-led tourism behaviour. Given the multidisciplinary nature of DMT, scientists have researched it from the perspective of various scientific disciplines, such as tourism, management, migration, global health, sociology, and anthropology. Sometimes, a broader context of transnationalism and tourism, or transnationalism and migration, has been applied (Jang, 2017; Lunt et al., 2016; Wang & Kwak, 2015). For our research, we define DMT as the “travel of migrants to their countries of origin with the intention to use healthcare services and access them through their own volition” (Mathijsen, 2019).

The empirical research suggests that the diaspora may even account for the majority of medical travellers in certain countries, such as Colombia, Guatemala, India, Iran, Jordan, Lebanon, Malta, Mexico, Poland, the Philippines, Turkey, or given regions, e.g. Taiwan (Connell, 2011; Glinos et al., 2010; Horsfall, 2019; Snyder et al., 2016). Countries such as Cuba, India, Korea, Puerto Rico, the Philippines, and Taiwan have expressly included diaspora populations in their medical tourism promotional strategies (Connell, 2013). As a result, those countries have benefited from diasporic patients, investment, philanthropy, and volunteerism (Newland & Taylor, 2010). Surprisingly and counterintuitively, DMT occurs frequently from countries considered to have well-performing healthcare systems to countries whose healthcare systems are categorised as underresourced and underperforming. For example, in Horsfall (2019), Polish diasporic medical consumers travelled from the UK to Poland; in Şekercan et al. (2014), Moroccan immigrants travelled from the Netherlands to Morocco, or in Nielsen et al. (2012), Turkish immigrants went from Denmark to Turkey. Esiyok et al. (2017) confirm that the diaspora population is the largest group of medical tourists in Turkey, something which has been referred to as the 'diaspora effect'.

The marketing of medical services to this segment has proven beneficial for certain countries. For example, Croatia actively promoted medical tourism to its diaspora in the USA via the Association of Croatian American Professionals (Total Croatia News, 2019). Trinidad and Tobago promoted MT amongst its diaspora by advertising and diaspora events (Hellyer, 2012). Other promotional activities targeted Filipinos living in the USA (Porter et al., 2008). South Koreans living in the USA and Canada benefited from ethnic networks and community media (Jun & Oh, 2015, Wang & Kwak, 2015). Guatemala also targeted this subsegment to promote its medical services (Snyder et al., 2016).

In the current COVID-19-impacted environment, VFR and domestic travel will likely lead the demand in the immediate travel recovery phase (Global Data, 2021; OECD, 2020; World Travel & Tourism Council, 2020). For the tourism sector, severely impacted by the COVID-19 pandemic, familiar, predictable or trusted tourism seems to be emerging as one of the latest trends. Wolff and Larsen (2016) described the recovery trend for domestic, home-like travel as the “home-is-safer-than-abroad” bias. In the context of the MT market, the diasporic segment might play a particular role in recovery. It should also be noted that VFR “extends the season”, curbing the issue of seasonality, and contributes to repeat visits (Ramachandran, 2006).

2.3. European immigration and Polish diaspora

Polish migrants constitute one of the largest migrant populations in the world (12th position according to the IOM (McAuliffe & Triandafyllidou, 2021)). Europe was the top destination for international migrants (87 million), followed closely by Asia (86 million) (IOM, 2021). Among European populations, in 2020, Poland, Ukraine and Romania were the leading countries of origin for international migration. These three European countries were the most migration-intense countries in Europe: the first had an estimated 4.82 million emigrants (11.3% of the total population), the second had 6.05 million (12.2% of the total population; before the war), and the third had 3.98 million (17.1% of the total population).

For Poland and Romania, those movements increased significantly after accession to the European Union (in 2004 for Poland and in 2007 for Romania). The number of Polish migrants to the OECD has risen by 79% in the past 15 years, and that of Romanian migrants has more than tripled (OECD/French Development Agency (AFD), 2019). Currently, the Polish diaspora constitutes the most significant number of emigrants in the European Union and the 4th largest in OECD countries (after India, Mexico, and China) (OECD/AFD, 2019). Since joining the European Union (May 1, 2004), Poles have benefited from the right to free movement and residence of persons across Schengen member countries (Treaty of Maastricht, 1992). For stays over three months, they must demonstrate sufficient resources and access to health insurance, and after five years of uninterrupted legal residence, they acquire the right to permanent residency. Hence, they can travel freely between their countries of residence and origin. The EU-specific cross-border healthcare directive (Directive 2011/24/EU) entered into force in October 2013 and enabled EU citizens to access healthcare in any European Union country and be reimbursed by the home country's healthcare system. Patients can choose public or private healthcare in another country of the EU, and nearly 200,000 people a year use cross-border healthcare via institutional channels (European Patients’ Forum, 2021).

The healthcare landscape in Europe has been very diverse. Among the latest attempts to define healthcare system typologies in Europe, Reibling et al. (2019) grouped Belgium and Luxembourg (with Austria, France, and Germany) into a cluster defined by a “certain type of Western European social insurance” (high degree of doctors' autonomy resulting in high supply- and choice-oriented systems). The Netherlands, with Canada, Denmark, and Great Britain, belonged to the “second cluster” (strong gatekeeping, regulation-oriented, and modest supply). Finally, Poland formed a cluster with Estonia, Hungary, and Slovakia (low-supply and low-performance mixed systems). The above data indicate that diasporic medical tourists travelled from countries evaluated as well-performing to nations categorised as underresourced and with low-performance levels.

This research was conducted among the population of the Polish diaspora residing in three European countries: Belgium, Luxembourg, and the Netherlands (Table 1). The Polish Statistical Office (GUS, 2020) estimated that the Netherlands was the third most popular European country to which Poles emigrated (after the UK and Germany). We use Constant and Zimmermann's (2016) definition of diaspora as a “well-defined group of migrants and their offspring (hence 1st and potentially consecutive generations), who exhibit a joined cultural identity, and who identify themselves (inactive or dormant way) with the culture or country of origin (the way they envision it)”.

Table 1

Permanent and temporary Polish emigrants in the three researched countries (GUS, 2020).
Country of residence of Polish emigrants (CoR)	Permanent residents (more than 12 months)	Temporary residents*
Netherlands	144,000	123,000
Belgium	70,000	54,000
Luxembourg	4,700
TOTAL	285,700

*Polish citizens who kept their residency in Poland but resided abroad.

2.4. Motivations for diasporic medical tourism: theoretical background and hypothesis development

Many scholars have attempted to explore salient motivational factors in the overarching medical tourism market; however, no theoretical framework has yet been agreed upon. Therefore, the researchers applied various existing theoretical frameworks, which serve as a starting point for exploration and experimentation. The universal 'Push-Pull' theoretical framework (Crompton, 1979) has been a popular framework to explain why patients-consumers decide to leave their countries and undertake international medical trips (Hanefeld et al., 2014). Motivational theories transposed from tourism or health-behaviour research were applied to MT. The former is represented by, for example, the Iso-Ahola theory (Adams et al., 2015), while the latter is represented by the Health Belief Model (Ban & Kim, 2020). In recent years, we have seen increased application of the Theory of Planned Behaviour (TPB) in medical tourism related to foreign patients. The TPB has been tested in its basic form, extended form, mixed with protection motivation theory, decomposed (DTPB, Taylor & Todd, 1995), and for testing MT-related scales (MEDTOUR scale; Ramamonjiarivelo, Martin & Martin, 2015). Research on MT with TPB application was conducted solely in Asia: in China (Ming, 2019), South Korea (Lee et al., 2012), and Malaysia (Saragih & Jonathan, 2019). The researchers also explored the extended TPB framework in India, Iran, Malaysia, South Korea, and Taiwan. However, none of the research has been conducted in Europe thus far.

Regarding the segment of diasporic medical tourism, motivational factors have frequently been compiled into an overarching category of 'cultural proximity' (i.e., Ormond & Lunt, 2019; Vargas Bustamante, 2019). Hall (2017) referred to them as 'noncommercial' behavioural dimensions. Glinos et al. (2010) called it 'familiarity with the system' combined with ‘affordability’. Our previously published scoping review (Mathijsen & Mathijsen, 2020, which intended to better understand DMT motivational factors from broadly published papers across various scientific domains) enumerated eight motivational drivers present in various research conducted on DMT across the globe. They turned out to be 'commercial' and 'noncommercial': medical culture, time availability (by-the-way of being back at home), communication, dissatisfaction with the current system in the country of residence (CoR), healthcare insurance status (accessibility), quality of healthcare (swiftness of services, treatments available), desire for a second opinion and relative cost (value for money). Nevertheless, none of the researchers analysed them in their interdependence.

To our knowledge, no quantitative research has investigated the motivational factors of DMT in its complexity in an attempt to test it in a theoretical framework or explore a new theoretical avenue. Therefore, we propose to model DMT based on the Theory of Planned Behaviour (TPB), which has demonstrated its predictive value in tourism (meta-analysis of Yuzhanin & Fisher, 2016). The meta-analysis of McEachan et al. (2011) summarised that TPB is also an appropriate predictor of health-related intention and behaviour, explaining 40–49% of the variance in intention. According to the authors of the TPB (Fishbein & Ajzen, 2010), behavioural intentions indicate a person's readiness to perform a behaviour; the more potent the intention, the more likely it is that the behaviour will be performed.

Three significant factors guide behavioural intentions, namely, attitudes towards behaviour (AT), subjective norms related to behaviour (SN), and perceived behavioural control (PBC), leading to the formation of behavioural intention (BI). Therefore, behavioural intention (BI) has been a linear regression function of AT, SN and PBC, as follows:

BI = w₁A + w₂SN + w₃PBC (where w₁ to w₃ are empirical weights)

In the current formulation of the TPB, favourable AT and SN motivate engagement in the behaviour, yet concrete action is taken when PBC is sufficiently strong (Ajzen, 2020). Furthermore, the founders of TPB argued that people tend to approach different kinds of behaviour in much the same way, with the same limited set of constructs (Fishbein & Ajzen, 2010).

2.4.1. Attitudes towards diasporic medical tourism

Fishbein and Ajzen (2010:76) understood Attitude as a tendency to respond to the behaviour with a certain degree of favourableness or unfavourableness (whether the person favours doing it). Hence, it is a function of readily accessible (salient) beliefs about the consequences of the behaviour, termed “behavioural beliefs”. The following equation represents Attitude in the expectancy-value model:

AT α Σbᵢeᵢ

The strength of each accessible belief (b) is multiplied by the subjective evaluation (e) of the outcome or experience, and the resulting products are summed. A person's attitude (AT) is expected to be directly proportional (α) to this composite belief index.

Previous research on MT concerning foreign patients has found significant positive results between attitudes and intention to undertake MT, and AT was identified as the most vital determinant of intention (Lee et al., 2012, Ming, 2019; Saragih and Jonathan, 2019). Lee et al. (2012) demonstrated that AT was a positive determinant in predicting Japanese tourists' intention to undertake MT for i) health treatment and ii) beautification treatment. Japanese tourists believed that MT for health treatment in Korea would enable them to receive immediate treatment, with extra care, using the latest technology, by a highly professional team, at significant cost savings, and all that with the additional benefit of food tourism. Martin, Ramamonjiarivelo, and Martin (2011), creators of the MEDTOUR scale, concluded that while cost may be a significant factor in MT, attitude determines which alternatives to consider. Without a positive attitude, this option of MT abroad would not be considered. Following those results, we postulate the following hypothesis:

Attitude (AT) toward DMT is positively associated with behavioural intention (BI) to undertake DMT.

2.4.2. Subjective norms about diasporic medical tourism

Fishbein and Ajzen (2010) saw Norms as perceived social pressure to perform (engage in or not) a given behaviour. It refers to a person's perception that “important others” expect a behaviour performance (or nonperformance). The injunctive normative beliefs (perceptions of what should be done) and descriptive normative beliefs (perceptions of whether others were/weren’t performing a given behaviour) lead to the formation of norms. However, it is not enough to know the above if the person is not motivated to comply with the referent. Therefore, Fishbein and Ajzen (2010) recommend integrating the motivation to comply. They assumed that normative beliefs and the motivation to comply determined the prevailing subjective norm, as follows:

SN α Σnᵢmᵢ

The strength of each subjective norm (n) is multiplied by the motivation to comply (m) with the subjective norm, and the resulting products are summed.

The subjective norm was statistically significant in most of the research related to the medical tourism of foreign patients (Chaulagain et al., 2021, Lee et al., 2012; Liang et al., 2019; Na et al., 2016, Saragih and Jonathan, 2019; Seow et al. 2017). Moreover, in two instances (Lee et al., 2012; Saragih & Jonathan, 2019), SN presented a more significant direct effect on BI than AT and PBC. In Lee et al.’s (2012) research on Japanese MT travellers, SN (of friends, family, acquaintances, and doctors) was the most important predictor for health treatment MT. The authors attributed this to Japan’s collectivist culture. Saragih and Jonathan (2019) argued that Indonesian patients travelled to Malaysia for medical treatment based on their friends' recommendations. Only in Ming’s research (2019) was SN relatively weak. Following previous learning drawn from MT, we stipulate the following:

A subjective norm (SN) related to DMT is positively associated with a behavioural intention (BI) to undertake DMT.

2.4.3. Perceived behavioural control over diasporic medical tourism

Last, Perceived Behavioural Control (PBC) refers to people's perceptions of their ability to perform a given behaviour and their control over its performance. Fishbein and Ajzen (2010) conceptualised it as a comprehensive set of accessible control beliefs pointing to the factors that may facilitate or impede the performance and the perceived power of each control belief, as follows:

PBC α Σcᵢpᵢ

The strength of each perception of the ability to perform (c) is multiplied by the perceived power of the control over it (p), and the resulting products are summed.

In our research, we were more inclined to follow the direction of Trafimow et al. (2002), who proposed a distinction between items that assess the perceived ease/difficulty of performing a behaviour and perceived control over its performance. People usually act on their intentions when the AT and SN are favourable and when they have sufficient control over performance. Salient control beliefs might also be influenced by observations of other people's experiences and second-hand information: the more information we think we possess, the greater our perceived control over performance. Due to the difficulty of measuring actual behavioural control, PBC works as a proxy in most studies.

In most research on MT in foreign patients, PBC was the weakest, yet still statistically significant, determinant (Chaulagain et al., 2021; Lee et al., 2012; Liang et al., 2019; Saragih and Jonathan, 2019). However, in Seow et al. (2017) and Na et al. (2016), PBC was not statistically significant. The latter was explained by a great number of intangible factors associated with MT. Following the above and given that diasporic tourists travel to familiar environments, we posit the following hypothesis:

H 3

Perceived behavioural control (PBC) over DMT is positively associated with a behavioural intention (BI) to undertake DMT.

2.4.4. Past behaviour with diasporic medical tourism

Additionally, the results of some studies demonstrated that Past Behaviour (PB) was the best predictor of future behaviour. Three meta-analyses and a handful of single studies showed that an additional per cent of variance was explained by PB, varying between 9.6% and 13% (Fishbein & Ajzen, 2010). The research showed that intentions and past behaviour had some variance in common that is not explained by the three predictors in TPB (AT, SN, and PBC). Lee et al. (2012) pointed to PB in the form of experience and familiarity, which strengthened the intention via positive experiences of Japanese MT who had previously travelled to Korea. Based on the above, we extended the TPB model to include the Past Behaviour construct and postulated the following hypothesis (Fig. 1):

Past behaviour (PB) related to DMT is positively associated with a behavioural intention (BI) to undertake DMT.

3.1. Measurement and questionnaire development

We applied the TPB survey development guidelines to design the questionnaire (Ajzen, 2019, 2020; Conner & Sparks, 2005) and a 7-point Likert scale (unipolar and bipolar) to assess all items. Each predictor variable was measured directly and indirectly. Both measures uncover the same construct and should be included (Francis et al., 2004).

All items were DMT-specific and adopted from previous validating research discussed in a scoping review of Mathijsen and Mathijsen (2020). Specifically, the authors evaluated AT to ten behavioural beliefs (from strongly disagree to strongly agree) and corresponding outcome valuations (from Not important at all to Very important). Three normative beliefs related to 1) the closest people (wife/husband/partner/close friend, 2) friends, 3) extended family were applied on a semantic differential (Extremely Unlikely – Extremely Likely) and estimated in terms of the respondents' motivation to comply (Definitely yes – Definitely not). Control beliefs were composed of five facilitators, two barriers to DMT (Definitely not - Definitely yes), and respective power of control beliefs (Strongly Disagree - Strongly Agree). Last, past behaviour was evaluated indirectly by subjective evaluation of DMT: How would you rate your frequency of DMT? (Never – Every time), and directly (number of times DMT was undertaken).

Three items measured behavioural intention: 1) I plan to use, 2) I will definitely use, and 3) If I have such a health need, I will first seek healthcare services (HCS) in the country of origin (CoO) (Extremely unlikely - Extremely likely).

Ajzen (2021) and Ajzen and Fishbein (2008) suggested using bipolar (from − 3 to + 3) as well as unipolar scaling (from 1 to 7) and using the optimal scaling approach, which gives a more robust correlation with the direct measure of the construct. Following this approach, we obtained the following results: AT (bipolar x unipolar), SN (bipolar x unipolar), and PBC (unipolar x unipolar).

The questionnaire was translated from Polish to English and back to Polish. The translations were rigorously checked and compared by two independent consultants fluent in both languages. Subsequently, one medical tourism expert, one expert in psychological scales, and two doctoral students reviewed the content validity of the survey instrument. Furthermore, face validity was applied in a pretest of the questionnaire (n = 33). Finally, we applied several corrections related to wording, presentation, and scales and retested the questionnaire again.

3.2. Research population, sampling method, and data collection

The research was conducted in three European countries: Belgium, the Netherlands, and Luxembourg (the so-called Benelux countries). The target population of this research was as follows: 1) Polish diaspora, 2) had resided in the country of residence for at least the past 12 months (had a residence/accommodation), and 3) had, within the past two years, used some kind of healthcare service in the country of origin (had personal experience of DMT, hence a minimum understanding of the problem, not just speculative responses). The research was carried out from April 2020 until the end of July 2020.

We applied respondent-driven and snowball (nonprobability) samplings. Immigrant populations were frequently qualified as hard-to-reach (or hidden) populations due to the difficulty of using standard probability methods. In addition, as migrants were mobile, population registers were often approximative, and accurate sampling frames were missing. Additionally, personal health is considered a sensitive subject, and respondents were reluctant to respond via standard sampling methods. Previously, snowball sampling had been used in the ethnic minority entrepreneurship literature when working with Polish, Indian, Bangladeshi, and Somali immigrants (Ram et al., 2008; Vershinina & Rodionova, 2011).

We aimed to obtain responses from a heterogeneous population (in terms of age, profession, and residency location). The authors distributed call-to-respond, tailored messages via various channels: email, outdoor adverts (in Polish shops), European Commission and European Parliament intranet websites, Polish Tourism Organisation local offices, Polish Embassies in the Netherlands and Luxembourg, Polish diaspora organisations, and via social media (diaspora groups on Facebook, LinkedIn, and WhatsApp). Many studies have successfully recruited hard-to-reach populations via social media, e.g. Vershinina & Rodionova (2011) on ethnic minority entrepreneurs who run their businesses illegally and Loxton et al. (2015) on young women for a health survey.

The authors used a web-based, self-administered questionnaire to collect the data with the support of Survio (professional online software). Subsequently, the data was cleaned, removing responses from other countries of residence, wordy descriptions, and failure to pass screening questions. Finally, we ran an analysis to detect the outliers and removed 53 with 'z scores' of 2.78 (above the acceptable level of 2.68). Thus, the total number of respondents retained for subsequent analysis was n = 1,288.

3.3. Data characteristics

G*Power software was used to measure the statistical power of our sample (the probability of rejecting false null hypotheses). We tested it for the Linear Multiple Regression statistical tests (R² deviation from zero) with a Post hoc type of power analysis. Most of our analyses were conducted for the entire Benelux. However, it is worth noting that country-specific data still represented a significant power (Table 2).

Table 2

Post hoc power analysis (using *G*Power 3.1.9.7).*
Country	Total sample size	α err probability	Number of predictors	Power*	Effect size f²
Belgium	695	0,05	4	0,80	0.017
Netherlands	483	0,05	4	0,80	0.024
Luxembourg	110	0,05	4	0,80	0.113
All together	1,288	0,05	4	0,80	0.009

For our analysis, we used structural equation modelling (SEM). It belongs to so-called second-generation statistical techniques that followed the first-generation methods of regression-based approaches (i.e. multiple regression, logistic regression; analysis of variance; techniques such as exploratory and confirmatory factor analysis, cluster analysis, and multidimensional scaling) (Hair et al., 2017). Structural equation modelling is a multivariate statistical analysis technique used to analyse structural relationships. We chose the partial least squares SEM (PLS-SEM) method, which is appropriate for exploratory and confirmatory research (Hair et al., 2019) and conducted our analyses with SmartPLS3 software

Before analysing the data, we examined data normality. There was high skewness (from − 2.424 to 2.855) in some instances, going beyond an acceptable range (-1.96, 1.96). Our data also presented a leptokurtic curve with items ranging from − 1.126 to 12.372. A Kolmogorov–Smirnov test indicated that most of our items did not follow a normal distribution, D(1,288) = < 0.128–0.254>, p < .001, which was one of the reasons we chose to conduct partial least squares structural equation modelling (PLS-SEM).

Our data contained responses from three countries: Belgium (BE: 54%), the Netherlands (NL: 37.5%), and Luxembourg (LUX: 8.5%).

Women were significantly overrepresented in our research (in all three countries). As guidance, StatBelgium data reported that Polish female immigrants in Belgium accounted for 53% of all immigrants (Derwae, 2020). Therefore, we applied poststratification weights (% stratum in population / % stratum in a sample). Survey weights were essential to avoid bias when estimating population means and to correct the results, following Bollen et al.’s (2016) recommendation that this is always a reasonable option if weighting is at no cost. After poststratification, new weights were 52.5% for women and 47.5% for men (Table 3).

Table 3

Poststratification weights with GENDER as an auxiliary variable (based on statistical data from Belgium).
Auxiliary variable	Population N	Population %	Sample n	Sample %	Weight (% stratum in population / % stratum in a sample)	SPSS Weighted data %
Female	37,501	52.57%	1,140	88.50%	0.59	52.5
Male	33,830	47.42%	148	11.49%	4.12	47.5
Σ	71,331		1,288

4.1. Socioeconomic characteristics of respondents

The descriptive statistics from the sample profile (Table 4) revealed that they primarily represented a post-accession (EU) migration wave, with an average length of residency in the CoR of 9.5 years. Around 30% of the sample population lived in the CoR between one and five years, 34.3% lived there for more than five to 10 years, and 31.8% - lived for more than ten years but less than 20. The results also demonstrated that diaspora members kept strong ties with the CoO, and three-quarters of the DMT travellers visited their CoO either frequently or very frequently in the past two years. The former accounted for 44% and travelled between 4–6 times, and the latter for 32% and travelled between 7 and 20 times. Twenty-two per cent returned to the CoO occasionally (1–3 times), and around 2% extremely frequently (over 20 times).

Age-wise, the Millennials (26–35 years old) and Pre-Millennials (36–45 years old) represented the most significant groups, 38.5% and 31.8%, respectively, accounting for almost three-fourths of the sample. They were followed by Generation X (46–59 years old; 20.6%), Generation Z (18–25 years old; 6.2%) and a small number of Baby Boomers (above 60 years old; 3%). The results were in line with the data from StatBelgium, which reported in a similar fashion that the Poles population in Belgium aged 18–64 accounted for 97.3% (Derwae, 2020). Furthermore, the data revealed that DMT households were relatively small, with 40% declaring as having no children and 50% having one or two children. Yet, the majority of DMT was in some marriage/partnership (over 70%), 19.8% were single, and 9.6% were divorced/widowed/separated.

Regarding education, 53.5% of respondents had secondary education, and 45.8% had higher education. Those findings indicate that our sample data represented the latest trends of Polish emigration in the Netherlands. It was in line with The National Bank of Poland report (NBP, 2019) conducted on the Poles working abroad, which noted that new immigrants were much better educated than overall Polish immigrants in the Netherlands.

The data showed that our respondents were in the most significant part ‘Employed’ (76%), followed by ‘Self-employed’ (13.4%), ‘Unable to work/retired’ (4.7%), ‘Unemployed’ (4.1%) and ‘Students’ (1.8%). This data was also in line with the report of NBP (2019), which revealed that Polish immigrants in terms of employment status were mostly ‘Employed’ (83%), followed by ‘Unable to work’ (9%), ‘Self-employed’ (5%), and ‘Unemployed’ (5%). The results also demonstrated that DMT travellers did not have financial difficulties. The respondents’ financial situation was self-evaluated as ‘Very good’ (12.3%), ‘Quite Good’ (57.7%), or ‘Average’ (28.9%).

Table 4

Sample characteristics (n = 1,288 respondents).
	Frequency	(%)		Frequency	(%)
Country of residence			Employment status
Belgium	695	54.0	Student	23	1.7
Netherlands	483	37.5	Unable to work/retired/other	71	5.5
Luxembourg	110	8.5	Unemployed	77	6.0
Gender			Self-employed	118	9.2
Female	1140	88.5	Employed	999	77.6
Male	148	11.5	Financial situation (self-assessed)
Age group			Very badly/badly	20	1.6
18–25 (Generation Z)	92	7.1	Doing average/well	376	29.2
26–35 (Millennials)	550	42.7	Doing quite well	751	58.3
36–45 (Pre-Millennials)	397	30.8	Doing very well	141	10.9
46–59 (Generation X)	220	17.1	Marital status
above 60 (Baby Boom)	29	2.3	Divorce/separated/widow	143	11.1
Education			Married/partnership	913	70.9
Primary/lower secondary	16	1.2	Single	232	18.0
Vocational/High school	642	49.9	Number of children
Higher education (BA, MA, PhD)	630	48.9	None	528	41.0
Number of years living abroad			From 1 to 2	661	51.3
From 1 to 3	196	15.2	Three and more	99	7.7
From 3.5 to 5	197	15.3	No. of travels to Poland P2Y
From 5.5. to 10	459	35.6	From 1 to 3	285	22.2
From 10.5–15	250	19.4	From 4 to 6	566	44.0
From 15–20	122	9.4	From 7 to 10	327	25.0
Over 20	64	4.9	From 11 to 20	80	6.0
			Over 20	25	2.0

4.2. Diasporic medical tourism service characteristics

In the past two years, 76% of respondents used healthcare services between one and four times, and 21% used them between five and ten times. The average DMT was 3.5 times. In addition, data showed that they had travelled to Poland in the past two years: very frequently (31% of respondents between 7 and 20 times), frequently (44% 4–6 times), and occasionally (22% 1–3 times).

The healthcare service most frequently sought was dental care (63.6%). This category included the most commonly requested dentistry procedures, namely, conservative dentistry (caries removal), surgical dentistry (implant or tooth removal), orthodontics (appliance), and endodontics (root canal treatment). Fifty per cent of respondents had used Medical procedures/medical visits/treatments (i.e., general practitioners, specialists, oncological treatment, infertility treatment). Thirty-nine per cent of respondents had used diagnostics/tests (scans, tests, examinations). A smaller group of diasporic medical tourists (11%) was interested in aesthetic medicine (hair, skin, breast, laser eye surgery, aesthetic surgery, teeth whitening, facials, and aesthetic gynaecology). Only 2% of the diasporic medical tourists used other services, such as complementary and alternative medicine (CAM, e.g. massage), ophthalmology (e.g. for glasses), giving birth, and psychological therapies. There was no significant difference in perceptions of the quality of healthcare services in the CoO and CoR (for the former Mdn = 4, and the latter Mdn = 5 on the scale from very negative (1) to very positive (7)).

Respondents obtained healthcare services primarily in private clinics (86.3%). Nevertheless, over 20% also used state clinics, and 12.3% used state hospitals. Only a tiny fraction (3.7%) used private hospitals. DMT consumers paid for the expenses out of pocket (76%). A certain number of respondents used the European Health Insurance Cards of their CoR (10%) or obtained reimbursement from health insurance policies of the European Institutions (8.5%). Notably, 96% of respondents had health insurance in their country of residence, and 18% had insurance in their country of origin. Surprisingly, 15% (n = 190) of respondents had health insurance in both countries. Only 0.7% (n = 10) were not insured at all.

4.3. Evaluation of the measurement model

The model assessment was based on Hair et al.'s (2019) recommendations. We retained all factor loadings higher than 0.600, resulting in five items for AT, four for SN, three for PBC, and two for PB (Table 5). The composite reliability values (CR) were above 0.800, indicating a good measure. We also looked at Cronbach's alphas for internal consistency reliability, even though it has been less precise as a measure (Hair et al., 2019). According to Garson (2016), the 0.708 standard was relatively high, and for exploratory research, the accepted limit could have been 0.400 for the central factors (PB was 0.558, and PBC was 0.654).

Table 5

Measurement model assessment results with retained items.
Variables	Loadings	Cronbach's α	Rho A¹	CR	AVE
ATTITUDE		0.760	0.777	0.840	0.515
Trust x Outcome evaluation	0.823
Doctors x Outcome evaluation	0.752
System x Outcome evaluation	0.611
2nd opinion x Outcome evaluation	0.745
Lower costs x Outcome evaluation	0.635
SUBJECTIVE NORMS		0.781	0.780	0.860	0.609
Injunctive Norms Close x Importance	0.880
Injunctive Norms Friends x Importance	0.794
Injunctive Norms Extended x Importance	0.788
Descriptive Norms Close x Importance	0.639
PERCEIVED BEHAVIOURAL CONTROL		0.654	0.700	0.809	0.588
By-the-by x Perceived power	0.647
Affordability x Perceived power	0.800
Convenient transport x Perceived power	0.839
PAST BEHAVIOUR		0.558	0.645	0.811	0.684
Evaluative Frequency	0.736
Subjective estimation	0.909

¹ Dijkstra and Henseler (2015) stipulate that the Rho A coefficient should have values greater than 0.60

The convergent validity (average variance extracted, AVE) was higher than the recommended 0.50 for all constructs. The heterotrait-monotrait (HTMT) ratio of correlations indicated discriminant validity. All values were below a threshold of 0.85. Additionally, the square root of each construct's AVE was higher than its correlation with another construct (the Fornell-Larcker Criterion), and each item loaded highest on its associated construct (Table 6).

Table 6

Discriminant Validity with Fornell-Larcker Criterion
Constructs	Attitude	Control	Past Behaviour	Norms
Attitude	0.717
Control	0.251	0.767
Past Behaviour	0.349	0.175	0.827
Norms	0.488	0.166	0.233	0.780

4.4. Assessment of the structural model

First, we verified the variance inflation factor (VIF) to assess the structural model. There was no multicollinearity problem, as all values were lower than 3. Then, we examined the R² (measure of the model's explanatory power) value of the endogenous variables. In our model, four independent variables explained 53% of the variation in the dependent variable: the in-sample predictive power was R² =.527, representing moderate power. Through the blindfolding procedure (D = 10), Q² = .392 of Stone-Geisser was obtained, which depicted a sizeable predictive relevance for an endogenous construct. We also looked at the standardised root mean square residual (SRMR), an absolute fit measure. It was 0.08 at the cut-off value defined by Hu and Bentler (1999).

The structural model was assessed through a bootstrapping procedure. All hypotheses 1, 2, 3, and 4 were supported (Fig. 2). The results indicated that the Polish diaspora’s attitude towards DMT (β = .329, p < .001), their subjective norms (β = .277, p < .001), perceived behavioural control (β = .112, p < .001) and past behaviour (β = .302, p < .001) were significant predictors of DMT. We also verified the effect size (f²) to evaluate the constructs' effects (Table 7). The Attitude and Past Behaviour in undertaking DMT had moderate effects; Subjective Norms had a small/close to moderate effect, and PBC had only a small effect.

The data span three different countries, although similar in terms of HCS characteristics. Therefore, we conducted a multigroup analysis (MGA, complete bootstrapping 5000, significance level p˂.05) to test whether predefined data groups (BE, NL, and LU) had significant differences in their group-specific parameter estimates (e.g., outer loadings and path coefficients). The differences between the countries and the main constructs were not significant at the statistical level for all three countries.

Table 7

Assessment of the structural model with a complete bootstrapping procedure (bias-corrected, resampling of 5000, sign. level.05, two-tailed test).
Hypotheses	Std. Beta	Std. Dev.	t-value	p-value¹	BC CI 2.5%	BC CI 97.5%	VIF	f²	f² effect²
R² = .527, Q² = .392
H1) AT -> DMT Intention	0.329	0.037	8.949	***	0.258	0.402	1.462	0.157	moderate
H2) SN -> DMT Intention	0.277	0.031	8.961	***	0.218	0.338	1.323	0.122	small/moderate
H3) PBC -> DMT Intention	0.112	0.029	3.870	***	0.054	0.165	1.079	0.024	small
H4) PB -> DMT Intention	0.302	0.029	10.355	***	0.245	0.360	1.155	0.167	moderate
¹β: Standardized Regression Weights * p < .05, *** p < .001*
²f² for various proposed models: f² ≥ 0.02 small, f² ≥ 0.15 medium, f² ≥ 0.35 large

5.1. Antecedents of Diasporic Medical Tourism

The attitude was the most vital determinant of an intention to undertake diasporic medical travel. Previous research on DMT demonstrated that affective healthcare was as crucial as effective healthcare (Lee et al., 2010; Mathijsen, 2019; Osipovič, 2013). The findings show that three affective aspects of AT had the highest item scores: trust, doctor's approach, and second opinion (confirmed by previous results of Lokdam et al., 2016; Kemppainen et al., 2018; Mathijsen, 2019; Şekercan et al., 2014). Nevertheless, the instrumental dimension of AT was not negligible. Two items – much lower costs and better knowledge/ability to navigate the healthcare system in the CoO – came out as significant. Of two cost-related items we tested – comparable and substantially different costs – only the second appeared substantial. Therefore, we can presume that price also matters, but is not a major driving factor. AT showed that having confidence in doctors (‘Intentional Trust’ in Calnan & Calovski, 2015) and in the system (‘Institutional Trust’ in idem), together with costs, shaped a positive attitude toward DMT.

The second exogenous variable that demonstrated a statistically significant contribution was Past Behaviour. Research on immigrants suggests that they are exposed to information overload once in the new country (Ndumu, 2020), which might be a barrier to social inclusion. When coping with uncertainty, people often rely on heuristics (simple, intuitive decisions; Kahneman, 2011): they resort to what they know as familiar. Alternatively, Hofstede's cultural dimensions theory (Hofstede, 2011) may provide another explanation. In this cross-cultural framework (which shows the effects of a society's culture on the members' values and how these values relate to behaviour), Poland scored very highly on the uncertainty avoidance dimension (93 out of 100) (Hofstede Insight, 2021). People from countries that score highly for this dimension avoid uncertainty and minimise the unknown. Interestingly, other countries cited in the literature on DMT also scored highly for this dimension, e.g. Guatemala (98), Mexico (82), South Korea (85), and Turkey (85). Lastly, the third hypothesis explanation is that diaspora members are satisfied with the HCS they received in the CoO and continue to return.

Subjective Norm also emerged as a significant determinant, indicating that referents significantly influenced the intention to undertake DMT (via encouragement or pressure). Specifically, injunctive norms were dominant and vital to each category of the referent group. Additionally, the descriptive norms of people closest to the respondents impacted DMT behaviour. A few explanations may apply to these results. According to Zou and Savani's (2019) research, people are more likely to follow injunctive norms when they require cognitive elaboration in decision-making. When this is not required, they tend to follow descriptive norms. Additionally, the focus theory of normative conduct (Cialdini et al. 1991) explains that social norms provide people with decisional shortcuts in their behaviour. We also tested two additional referents – 'local doctor in the CoR' and social media contacts (Facebook, blogs, forums, chats)' – but respondents judged them nonessential in the pretest.

Lastly, Perceived Behavioural Control contributed the least to forming a behavioural intention. Among control beliefs, three items appeared particularly important: prompt/convenient transport (flights, distance), by-the-by (by-the-way of VFR), and affordability. Understandably, ease of travel significantly impacted DMT. Before the COVID-19 pandemic, there were multiple flight connections between the CoR and CoO (daily flights, many operated by low-cost airlines). Additionally, road transport functioned very well, with numerous mini-bus companies frequently travelling to Poland. Geographical proximity (two-hour flights between main cities) contributed to diasporic travel, in line with previous findings (Jaapar et al., 2017; Lee et al., 2010; Musa et al., 2012; Vargas Bustamante, 2019). Specifically, low-cost travel and relative geographic proximity – the so-called spatial capital – made DMT possible (Osipovič, 2013; Şekercan et al., 2014). In many instances, diasporic travellers used HCS in the CoO while undertaking their VFR travel, which authors have referred to either as the “by-the-by factor” (Mathijsen, 2019; Snyder et al., 2016) or “aprovechar” (meaning “take advantage of”) (Bergmark et al., 2010;) or “add-on treatments” (Hanefeld et al., 2015). Additionally, the affordability control factor (as per previous research by Mathijsen, 2019; Stan, 2015; Vargas Bustamante, 2019) highlighted the ability to select the best value for money. Due to price differences, respondents could choose the best value for money, which increased their social status in the CoO and mitigated their uncertain status in the CoR. Nieswand (2011) documents it in the status paradox of migration. Frequently, migrants are forced to accept positions in low-income segments (e.g. domestic help, construction). As a result, they lose status in the CoR but gain status in the CoO by building symbolic representations of a middle-class lifestyle (e.g. frequent flights, access to private medical healthcare, and good medical facilities; Şekercan et al., 2018; Stan, 2015).

5.2. Diasporic versus foreign medical tourists

The present study aimed to understand the concordance and discordance between diasporic and foreign medical tourists. Most of the research on foreign patients' MT applying TPB has been conducted in Asia; therefore, a strict comparison with our European results would have to be cautious. Nevertheless, the results showed that the main constructs influenced foreign and diasporic MT similarly. In line with our research, AT was the most vital determinant in Ming (2019 - China) and Na et al. (2016 – Malaysia). However, in Lee et al. (2012, South Korea), SN was the most vital determinant. PBC was the weakest determinant in all instances, as this research shows. Our study also demonstrated that Past Behaviour played an essential role in the behavioural intention of undertaking DMT. Additionally, the Polish diaspora was driven by similar constructs across three countries (BE, NL, LUX) with no statistically significant differences.

The detailed analysis revealed that different underlying factors fashioned the main constructs. They were not solely culture-related but were both commercial and noncommercial. First, trust in doctors and the system (often termed ‘medical culture’) played a significant role, something which has not been emphasised or researched much in foreign MT travellers (there is a good overview of the research gap related to trust in MT in Calnan & Calovski, 2015). Secondly, the quality of HCS, waiting times, and the language barrier (as presented in Snyder et al., 2016; Van den Broek, 2021) did not seem to be essential factors (also confirmed by Şekercan et al., 2018). Thirdly, while cost savings played a crucial role for MT foreign patients (Jaapar et al., 2017; Vargas Bustamante, 2019), diasporic travellers expected the best value for money. Fourth, while diasporic medical tourists sought a second opinion, foreign medical tourists looked for treatments based on opinions already received. Lastly, the trip was intentional and well-planned for foreign travellers, often as a “vacationing patient” (as in Calnan & Calovski, 2015). For diasporic travellers, the DMT was also planned and complementary to the VFR purpose (Mathijsen, 2019). Additionally, in foreign MT, word-of-mouth (WOM, and especially e-WOM) is highlighted (Connell, 2013; Musa et al., 2012). In diasporic MT, social norms—which are much broader concepts specifying the rules (primarily unwritten and informal) of acceptability, appropriateness, or obligation in a given group or culture—drive the behavioural intention of travellers guided by their social network (Şekercan et al., 2018).

The research data suggest that factors related to uncertainty avoidance – such as reliance on Past Behaviour, Affective Attitudes, and Subjective Norms – influenced the intention to undertake DMT. Therefore, we presume that DMT might be a form of acculturative integration via bicultural identity. Following this logic, diasporic travel and DMT might diminish with the length of residence in the CoR; Van den Broek (2021) confirmed that hypothesis. When people are subject to uncertainty, and in a state of information overload, they rely on heuristics, resorting to what is known to overcome acculturative stress. In addition, the instrumental AT and the facilitating factors of PBC rendered the DMT actionable in terms of time, value, and organisation.

In our research, two groups of diasporic medical tourists – Committed (every time/frequent/usual travel – 19%) and Contended (sometimes travel – 53.4%) – constituted over 70% of all DMT (segmentation borrowed from Rowley, 2005). The remaining 26% – a Captive group undertook DMT occasionally/rarely. Previous research shows that DMT has been correlated with the frequency of travel to the CoO and the length of stay in the CoR (Van den Broek, 2021). DMT travellers use the HCS in an organised manner (Mathijsen, 2019) and in a complementary way rather than as an alternative to the CoR (demonstrated by Kemppainen et al., 2018; Troccoli et al., 2021).

Diasporic medical travellers mainly used primary and secondary health care. Dentistry and medical visits/procedures were diasporic travellers' most sought healthcare services. Additionally, over one-third used diagnostic medicine. On the other hand, tertiary and quaternary care (aesthetic medicine) did not attract DMT, which differs from foreign medical tourists seeking specialised or highly specialised healthcare. In summary, DMT was applied to elective, routine healthcare for noncritical conditions, mostly in private settings and with out-of-pocket financing.

Our research did not intend to quantify the percentage of DMT within the total immigrant population. However, there are specific estimations of DMT volume in previously published papers, which could give a hint. For example, the data from Troccoli et al. (2022) stipulates that 57% of Polish immigrants have used HCR in Poland since becoming resident in the UK, while Horsfall (2019) estimates that medical tourists from the UK to Poland were primarily nationals of the country, with the number rarely under 75% (in the period 2008–2016). According to Van den Broek (2021), one in four emigrants of Polish origin in the Netherlands used HCS in Poland.

All constructs of the TPB model were significantly important – Attitude, Subjective Norms, Perceived Behavioural Control, and Past Behaviour. However, the underlying items were not solely cultural; therefore, commercial and noncommercial motivational factors need to be stressed in promoting medical tourism to diaspora members.

The caring/affective/trusting relationship with doctors/systems, the possibility of a second opinion, encouragement from referents (close 'entourage' and extended family), and facilitating factors (accessibility, affordability, availability) influence the decision to undertake DMT much more than just cheap costs of medical services (in line with Thuy et al., 2019). In contrast to foreign MT, the quality of HCS, waiting times, and the lack of a language barrier in the CoO do not seem to play a crucial role, most likely because DMT was accessed via private clinics and paid for out of pocket.

The ‘affinity marketing/cultural affinity’ approach (see Serrano-Arcos et al., 2022, for a good overview) would be recommended for this segment. Since DMT relies strongly on SN, affinity and kinship relationships are increasingly important in marketing to the countries of origin (UNWTO, 2009). The encouragement from trusted contacts – close/extended family and friends – is much more critical than e-WOM and virtual connections on social media (extensively used in foreign MT). Importantly, encouragement from peers (i.e. compatriots) and sharing of experiences might be very impactful in the context of acculturative stress. When information overload appears, information from trusted and familiar sources will be accepted quicker and more straightforwardly. Kemppainen et al. (2020) demonstrated that the community of one's nationality (83%) and having friends/relatives in the CoO (70%) were essential for immigrants. Therefore, in promoting DMT, it is crucial to communicate to diasporic networks (nostalgia goods shops, associations, cultural and religious communities, diaspora media outlets, and border crossings).

An additional route for DMT promotion may be the formation of the country's 'health ambassadors’' leading to the recommendation of the MT in their CoO among foreign patients. Furthermore, DMT travellers act as 'early adopters' who pass their experiences on to their contacts in their CoO (Ormond, 2014; Snyder et al., 2016). The Irish example is quite instructive regarding marketing targeting diaspora members: the Minister of State for the Diaspora and International Development of Ireland runs the Global Irish digital newsletter and website targeting its diaspora.

Additionally, the digitalisation of health services – such as e-health and telehealth - could bring about substantial improvements. Benbassat (2019) argued that patients had a right to obtain a second opinion and advocated creating programs to help patients seek it. Various doctors could consult the health data, assuming the results are accessible in an understandable format and language (for example, a proposed European Health Data Space). Additionally, digital access to healthcare can facilitate DMT via easy-to-access offers such as “medical Groupon”, telehealth or the availability of diagnostic websites, where everyone can sign up for any kind of test close to their stay and at a convenient time (e.g. ‘Alab Laboratoria’ with 180 testing points across Poland).

Management in the case of migration-led tourism requires special government competence (UNWTO, 2009). National Tourism Administrations are not responsible for policies and measures regarding migration. Nevertheless, UNWTO (2009) suggests they might indirectly help through coordination mechanisms, research funding, and consultation. Governments are encouraged to expand their promotional activities via tourism offices with diaspora-related activities in collaboration with ministries for diasporas. National tourism offices could serve as points of contact for diaspora members.

Countries targeting diasporic medical tourists might benefit from strategic planning around specialisation and targeting subpopulations of patients (Snyder et al., 2016). There is also the question of how health ministries could be involved, for example, through schemes to obtain compensation for medical expenses in the CoO (Turkey, in Esiyok et al., 2017). The rising prices of deductible insurance plans in certain countries may lead to the formal organisation of cross-border communication between healthcare providers (Esiyok et al., 2017). The results of the above research and literature indicate that DMT expenses are substantial and contribute to sustaining the healthcare services of the CoO. Therefore, governments should reasonably be stirring up interest in supporting DMT instead of acknowledging that it just happens organically.

It is also worth emphasising that DMT is a worldwide phenomenon and depends on the level of migration and its VFR visits (and in this case, also on convenient travel options). Therefore the results apply to all countries with migration-intensive populations and those with a high number of migration populations in their countries. The research confirmed that the Polish diaspora is a potentially significant medical tourism segment. Furthermore, assuming the applicability of the scarce results of the DMT estimates (between 25 and 75%) and given that there are 4.8 million Polish emigrants in Europe, the most restrictive number points to over 1.2 million potential customers for DMT, which is a substantial group of consumers.

Diasporic medical tourists were 'Committed' and 'Contended' travellers (70%). They consciously and deliberately participated in both healthcare systems, acting as transnational patients-consumers-travellers. Specifically for the European Union context, where DMT travellers do have access to the healthcare systems of the CoRs and still choose to use them in the CoOs, it is an indication that those ‘hidden’ consumers might exist in significant numbers, but they remain understudied. In a way, they could be perceived as precursors of so much aspired European Health Union, where patients treat their health needs across the entire European Union, according to their needs, capacity, and accessibility. Simply, with the European ‘public goods in health’ approach in mind.

Lastly, it is important to note that diasporic social ties may fade away over time. Therefore, encouraging DMT is recommended as long as relations with the CoO are strong. DMT might be pursued over time with continued migration. The literature on migration specifies that both the pace of migrant assimilation and the endpoint of acculturation remain unknown due to the complex nature of acculturation dynamics and the limited research in this field. Schluter et al., 2011 pointed to 12 years (66% of the respondents had lived in the CoR less than ten years at the time of research). Additionally, Van den Broek (2021) documented that migrants who stayed longer in the CoR were less likely to undertake DMT (the correlation between length of stay in the CoR and DMT was attributable to improvements in proficiency in the language of the CoR).

This research aimed to understand the importance, specificity, and distinctiveness of diasporic medical tourism as a part of the phenomenon of migration-led tourism. This study allowed us to understand better diasporic medical tourism, a worldwide phenomenon on which “little has been written on such travellers because they are (…) not easy to distinguish and even harder to document” (Connell, 2015: 399).

The results of this research contributed to motivational theory building in the field of medical tourism, and particularly for the first time, towards the theory building in diasporic medical tourism. Until today, no frameworks were proposed for this tourist/patient/consumer behaviour sub-segment. It is also worth noting that the research contributes to the academic field of migration and ‘transnationality’ (i.e. transnational healthcare-seeking behaviour’), in which high-quality quantitative studies are scarce, particularly in Europe (Schunck, 2014).

Contrary to previous indications suggesting that DMT mostly responded to cultural factors, this study confirmed the assumption that both commercial and noncommercial factors were important for behavioural intention. The intention to undertake the DMT was influenced by the factors related to uncertainty avoidance, such as reliance on Past Behaviour, Affective Attitudes and Subjective Norms. The Instrumental Attitudes and the facilitating factors of the Perceived Behavioural Control made the DMT possible in terms of time, value and organization. Diasporic members resorted to their comparative knowledge (Instrumental Attitudes) and sources/relationships (Injunctive Norms) to find the best solutions to their health-related demands.

Therefore, the DMT could be seen as a form of acculturative integration via bicultural identity. When people are under uncertainty and in a state of information overload, they tend to rely on heuristics, resorting to what is known to overcome acculturative stress.

There were some limitations to the present study. Due to the COVID-19 pandemic and lockdowns, we were forced to abandon the previously selected TSL (time-space-location) sampling method in favour of RDS (respondent-driven sampling) and SBS (snowball sampling), and carry it out via digital channels. Strategies such as SBS and RDS involve referral chains of sampling, which may lead to selection bias and gatekeeper bias influencing the validity of the sample. Whenever possible, we compared our sociodemographic characteristics with the general data and reported that the data reflected the general population quite well.

Additionally, the research was conducted in European Union countries within a specific cultural context; hence, marketing programs should be sensitive to cultural specificity. Future cross-cultural studies would contribute to testing the generalisability of the instrument and could exclude/add country-specific factors if necessary (e.g. religious rituals or travel time/distance). Additionally, the typical application of the TPB devotes little attention to the role of emotion (Fishbein & Ajzen, 2010), which might be significant in medical travel and VFR travel.

Further research would be very welcome to quantify the volume of diasporic medical tourists, given the challenging nature of immigrants who belong to hard-to-reach populations, for which complete sampling frames rarely exist. In addition, there is an urgent need for more data regarding the diaspora's contributions through tourism (its frequency, time spent, travel patterns, and the amounts paid while in the CoO). Additionally, applying another theoretical framework, such as the Health Belief Model or Conservation of Resources Theory, could yield interesting results for comparison. Finally, it would be beneficial to conduct a similar study in other geographical areas and with more traditional sampling methods to confirm the generalisability of the above findings.

attitude

BE Belgium

behavioural intention

CoO

country of origin

CoR

country of residence

DMT

diasporic medical tourism

GPs

General Practitioners

HCS

healthcare services

LUX

Luxembourg

medical tourism

the Netherlands

past behaviour

PBC

perceived behavioural control

P2Y

past two years

subjective norms

TPB

theory of planned behaviour.

Consent to participate: All participants received written information about the study, highlighting participants’ rights to withdraw, ask any questions, and that (non)participation had no consequences for the individual and gave informed consent to participate. It was underlined that all participants would remain anonymous in the data sets and publications, and that the data be processed in full compliance with the General Data Protection Regulation (EU) (GDPR, 2016/679) and other rules concerning the protection of personal data (encryption of data, anonymisation, data minimisation). Statistical analyses were performed via a secure person-encrypted database, which comprised both the questionnaire and the registry data (paid services of www.Survio.com). The research was presented to the IRB on 13.11.2019 and approved.

Competing interests: The authors declare that they have no competing interests.

Availability of data and material: The data that support the findings of this study are available from the authors upon reasonable request (only in the coded form).

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Diasporic Medical Tourism (DMT) (Mathijsen & Dziedzic, 2022)

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published 11 Apr, 2024

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Diasporic medical tourism: where tourism meets migration and healthcare. Understanding its antecedents, behavioural intention and potential.

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1. Introduction

2. Research Context

2.1. Migration-led tourism (MLT)

2.2. Diasporic medical tourism: the intersection of medical tourism and migration

2.3. European immigration and Polish diaspora

2.4. Motivations for diasporic medical tourism: theoretical background and hypothesis development

2.4.1. Attitudes towards diasporic medical tourism

2.4.2. Subjective norms about diasporic medical tourism

2.4.3. Perceived behavioural control over diasporic medical tourism

2.4.4. Past behaviour with diasporic medical tourism

3. Methodology

3.1. Measurement and questionnaire development

3.2. Research population, sampling method, and data collection

3.3. Data characteristics

4. Results

4.1. Socioeconomic characteristics of respondents

4.2. Diasporic medical tourism service characteristics

4.3. Evaluation of the measurement model

4.4. Assessment of the structural model

5. Discussion

5.1. Antecedents of Diasporic Medical Tourism

5.2. Diasporic versus foreign medical tourists

6. Implications

7. Conclusions

8. Research Limitations And Future Research Recommendations

Abbreviations

Declarations

References

Supplementary Files

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