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between, perceived destination image, perceived
value and perceived behavior control.
2.3
Theory of planned behavior
The TPB was developed by Ajzen (1985), and
it provides a well-documented and rigorously
tested framework for investigating goal-oriented
behaviors. In brief, this theory states that attitude
towards the act; subjective norm and perceived
behavioral control are indirectly linked to behavior
via intention.
According to the TPB, attitude refers to evalua-
tions of both favorable and unfavorable behavior.
Subjective norm describes the perceived pressure
from others to commit such behavior. Perceived
behavioral control refers to how easy or difficult it
would be to carry out the act. Although the TPB
has been used extensively in social psychological
research to explain a variety of human behaviors,
this model has received only limited attention in the
destination behavior in medical tourism sector.
Martin, Ramamonjiarivelo and Martin (2011) on
the other hand, has used TPB model in developing a
scale of medical tourism, and the result shows that
all the three variables of TPB, i.e. attitude, subjective
norms and control, has shown positive significant
impacts on intention to participate in medical tour-
ism. Hence, the proposed study intends to minimize
the gap by drawing on TPB in the adoption of desti-
nation choice behavior in medical tourism.
2 LITERATURE REVIEW
2.1
Medical tourism
Tourism has become one of the major industries
that could contribute to country's development.
Melanie (2009) refers tourism as the activities of
visiting or travelling to a destination that exceeds
fifty miles from the residence for no more than a
year due to recreational purposes or fulfilling other
non-formal agendas. Middleton and Clarke (2012)
suggest the main tourism offering are destination
attractions; destination facilities and services;
accessibility of the destination; images, brands and
perceptions; and price to the visitor.
Sen Gupta (2004) view medical tourism as a
provision of cost-effective medical care to patients
in collaboration with the tourism industry. Connell
(2006) further defined medical tourism as consti-
tuting a form of popular mass culture, to which
individuals travel long distances to obtain medi-
cal, dental, or surgical services while being holi-
daymakers in a more conventional sense. Recently,
medical tourism is viewed as the process of patients
travelling abroad for medical care and procedures
as a result of unavailability or unaffordability of
certain medical procedures in their own respective
countries (Voigt et al., 2010). The plausible reasons
for tourist searching out medical care in another
country include cost, access, expertise, quality and
service (Hume & Demicco, 2007).
3
RESEARCH MODEL AND HYPOTHESIS
3.1
Attitude
Ajzen (1991) stated that attitude can be considered
as a sum of beliefs. Person will have an attitude
toward that phenomenon based on the overall
evaluation of his or her beliefs (Ajzen, 1991). The
author also states that people can simultaneously
hold two different attitudes categorized as implicit
and explicit attitudes. The explicit attitudes are
retrieved in favor of an implicit evaluative response
by means of motivation and capacity. In medical
tourism, attitude is developed based on the motiva-
tional belief to travel to seek for medical treatment.
In this study, attitude towards behavior generally
reflect a consumer's overall affective evaluation
of the outcomes of adopting destination choice
behavior in medical tourism.
Putit (2008) stated that attitude has a posi-
tive and significant relationship with intention to
transact online for travel services.
Similar results was also found by Reza Jalilvand,
Samiei, Dini, and Yaghoubi Manzari (2012) found
significant relationship of electronic word of mouth,
destination image, tourist attitude toward destina-
tion and travel intention using TPB approach. In
this proposed study, it is also posited that attitude
significantly influences medical tourists' intention
2.2
Intention
Ajzen (1991) stated that intentions refer to the
motivational factors that influence a person's
behavior. Thus, it indicates how willing a person
is to attempt a behavior, and how much effort he
is likely to exert toward that behavior. Individual
intentions are an indication of the readiness to
undertake a given behavior, and are assumed to
precede actual behavior (Ajzen, 2002).
Diverse models of consumer behavior are build-
ing upon the theory of reasoned action which
emphasizes intention as an immediate antecedent
to actual behavior (Fishbein & Ajzen, 1975). Ale-
gre and Cladera (2009) have pointed out that sev-
eral studies of consumer intentions, for instance,
to make repeat purchases or visit a destination
have focused on the factors that determine this
intention. These suggested determinants are tour-
ist motivations, a satisfactory prior experience,
perceived quality and a previous repeat visit to a
destination.
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