A comprehensive perspective on local drivers in community-based health tourism industry development: a qualitative study of Mazandaran Province, Iran

Abstract

Background

Health tourism is an important component that may influence the direction of development in a region. Mazandarn, Iran, is recognized as a highly sustainable market in the region because of its abundant natural resources, temperate temperature, and strategic geographical location. Therefore, considering the importance of health tourism and its existing potential in Mazandaran, Iran, this study was conducted with the aim of exploring a comprehensive perspective on local drivers in community-based health tourism industry development and factors affecting the attraction of health tourism.

Methods

We conducted this study in Mazandarn, Iran, using a qualitative approach. Participants included a sample of Iranian people, aged 34–54 years, with previous history of health tourism or expert in it. Participants were selected from three different categories of the community: academic professionals in health tourism, managers in health tourism, and health tourists. Data were obtained via semi-structured in-depth interviews and focus group discussions. Inductive qualitative content analysis was used to converge and compare themes through participant data. The interviews kept going until data saturation was achieved.

Results

Based on our findings, we distilled local drivers in community-based health tourism industry development into five main categories and 30 subcategories: (Sharifabadi AM, Ardakani FA. A model for health tourism development using fuzzy TOPSIS and interpretive structural modeling in Yazd province. J Health Adm (JHA). 2014;17:55.) infrastructure and resources; (Hemmati F, Dabbaghi F, Mahmoudi G. Investigating the impact of Information Technology on the status of Health Tourism in Mashhad, Iran. Revista Publicando. 2018;5(15):54–65.) tourist attractions; (Sarabi Asiabar A, Rezapour A, Raei B, Tahernezhad A, Alipour V, Behzadifar M. Economic, Cultural, and Political Requirements for Medical Tourism Development in Iran: Insights from a Fuzzy Analytical Hierarchy Process Method. Med J Islamic Repub Iran. 2022;35:199.) socio-cultural contexts; (Mosadeghrad AM, Sadeghi M. Medical tourism: Reasons for choosing Iran. Payesh (Health Monitor). 2021;20(2):145–66.) economic-financial factors; and (Manna R, Cavallone M, Ciasullo MV, Palumbo R. Beyond the rhetoric of health tourism: shedding light on the reality of health tourism in Italy. Curr Issues Tourism. 2020;23(14):1805–19.) political-communicative factors. The findings of the study showed that, from the participants’ point of view, although there are several strategies, such as the development of public service and tourism infrastructure, increasing tourist attractions, and formulating appropriate policies and procedures for the development of health tourism, they are also faced with many challenges, especially political, economic, and cultural challenges.

Conclusion

This study showed that improving infrastructure and resources, promoting tourist attractions, informing socio-cultural contexts, improving economic and financial capacity, and developing political and communicative contexts might increase the attraction of health tourists. The suggested components are not contextually driven, although empirical outcomes may differ based on the level of service offerings in health tourism locations.

Introduction

The tourism industry is the third largest industry in the world after the oil industry and the automobile industry, and it has a great impact on the foreign exchange earnings of countries. It will most likely become the first industry in the world in the near future [1]. The growth of the tourism industry, in addition to its impact on the national identity of a country, has an impact on improving economic aspects such as income generation, creating job opportunities, reducing the level of poverty, and increasing social justice and community welfare. With the expansion of tourism, this industry has been divided into specialized sub-branches such as religious tourism, cultural tourism, adventure tourism, sports tourism, and health tourism based on the main intention of the tourist [2].

Health tourism discusses the national and international trips of people for the improvement of their health. Any trip with the main goal of treating people and maintaining their well-being is considered health tourism. According to the definition of the United Nations World Tourism Organization (UNWTO), health tourism is the use of services and facilities that lead to improving or improving the health level and increasing a person’s spirit (using weather, mineral waters, or medical procedures) in a place outside the person’s place of residence that lasts more than 24 h [3]. Health tourism includes medical tourism, therapeutic tourism, preventive tourism, and wellness tourism. Getting healthy is one of the main reasons tourists travel—the goal that has created health tourism. In fact, the main motivation in health tourism is to help improve the level of physical, mental, or spiritual health through medical and health-oriented activities. This is despite the fact that health tourism is an important part of social tourism and emphasizes care that increases the well-being of a person. Health tourism has two preventive and curative goals [4].

Health tourism is one of the most important and profitable branches in many destinations around the world, as well as in Iran. Several factors play a role in the increase in the number of health tourists, including the rapid growth of medical technology, the high cost of health services in developed countries compared to developing countries, the improvement of health care standards, the increase in the quantity and quality of international travel routes, and the formation of new intermediary companies to provide health services without medical expertise [5, 6]. Attracting health tourists, in addition to improving the reputation of countries’ health levels, causes capital to enter that country. However, there is no accurate information on the number of tourists who obtain health services in tourism destinations [7].

Due to the low costs and high income of the health tourism industry, countries interested in the development of the industry focus on the growth of this industry and plan in this direction [8]. Due to its cultural, natural, and historical attractions, Iran is considered one of the first 10 countries in the world in the tourism industry. According to the 20-year vision document for the tourism industry, Iran must attract 20 million foreign tourists by 2025. On the other hand, Iran’s share of the income of the world’s tourism industry should be increased from 0.07% in 2004 to 2% in 2025, so that in 2025, Iran should earn about 25 billion dollars annually from the arrival of tourists to the country. However, Iran’s tourism industry has not grown as necessary and appropriate [9].

Numerous studies show that several factors and variables influence the development of the health tourism industry. These include socio-cultural aspects, facilities and infrastructure, policymaking and planning, effective marketing, political-legal considerations, and economic components [10,11,12,13,14,15,16]. For instance, Zarei and Maleki [16] reported that the main elements iattracting health tourists are the understanding the quality of facilities and satisfaction with them. They also identified the key barriers to medical tourism as the lack of management among medical market stakeholders, lack of insurance coverage, insufficient regulations, and the quality of medical facilities. Medhekar et al. [14] recognized several critical factors infuencing tourists’ decisions to travel to other countries for treatment or surgery. Thes factors include shorter waiting times for surgery, higher quality of healthcare and validation grades, expertise of workforce/doctors, healthcare data and evidence, hospital services and amenities, patient security, travel risks, medical prices, and vacation opportunities. Similarly, Goodarzi et al. [12] identified that the cost, high quality of facilities, culture and values, amenities, and information and communication technology impact the development of health tourism.

Globalization and commercial freedom in the health services sector have enabled this kind of tourism to grow quickly [17]. If health tourism is prioritized nationally, Iran may be able to prevent the potential outflow of skilled personnel and foreign exchange to other nations and even attract foreigners. Over the last several years, there has been a rise in the number of individuals leaving their home countries to find suitable health care on a global scale. Several factors contribute to this increase, including the high cost of healthcare in developed countries, the ease of traveling abroad, favorable exchange rates, the rapid development of medical technology, the strengthening of patient protection standards in many states, tourist access to the Internet, and the emergence of new businesses that facilitates connections between patients and healthcare systems [5]. With the development of worldwide guidelines and standardization now applying to various regions globally, individuals are searching everywhere for the best care at the most affordable prices [18]. Meanwhile, Iran’s healthcare system offers an excellent cost-to-quality ratio. The major benefit of health tourism in Iran is the low cost of care compared to foreign countries, particularly those in Europe and America. Due to its improved facilities and access to skilled medical professionals, Iran will be able to attract more tourists in the health tourism sector. Iran’s health tourism industry offers a broad variety of medical and health services that meet international standards and incorporate the latest advancements in medicine. This will support the growth of Iran’s medical tourism industry [16].

Health tourism services in Iran are delivered in various cities, with Teheran, Yazd, Mazandaran, Shiraz, and Mashhad being the main destinations for health tourists. Some of the competences of health tourism in Iran, along with its scientific potential and other factors, include a skilled and renowned international medical workforce, well-resourced and advanced clinics and hospitals in the region, diagnostic facilities, check-up facilities, surgery and hospital facilities, post-treatment follow-up, rehabilitation facilities, and supplementary treatment facilities (such as mineral water and mud therapy). Additionally, Iran offers competitive prices for health and medical services compared to other countries and boasts significant achievements in medical specialties such as infertility treatment, plastic surgery, cardiovascular surgery, and eye surgery. Iran’s unique geographical place and climate diversity, presence of hot springs, and freshwater lakes, cultural, historic, natural and touristic attractions, strong culture of hospitality, and traditional medicine knowledge further enhance its appeal as a health tourism destination [19, 20].

Mazandaran, one of the northern provinces of Iran, has significant potential to become a health tourism center both nationally and regionally. It boasts high medical capacities, including well-known doctors, reasonable expenses, and high quality of health facilities. Additionally, its proximity to four, its proximity to four neighboring countries - Turkmenistan, Kazakhstan, Russia and the Republic of Azerbaijan- and its cultural similarities with many of these countries further enhance its appeal. These factors collectively position Mazandaran attract health tourists from all over the world. Due to its mild climate, this province is a suitable destination for health tourism. Pleasant weather in spring and summer, pristine nature, a peaceful environment from a cultural-social point of view, and hot and cold mineral water springs attract domestic and foreign tourists. The development of the health tourism industry, in addition to the treatment of destination tourists, improves the social, cultural, and economic well-being of the residents of the tourism area [21]. However, the development of this industry in Mazandaran province has not received the attention and welcome of the responsible organizations, which is one of the reasons for the low growth of entrepreneurship in Mazandaran province [22]. Therefore, it is very important to provide a strategic plan and basic management of health tourism in line with the well-being of tourists and residents of the region. Additionally, it is very important to identify native and local components that increase the growth and development of the health tourism industry.

Considering the potential of Mazandaran province in the field of health tourism, this research, in its first step, identified the factors influencing the development of health tourism in Mazandaran province in order to arrive at a comprehensive perspective on local drivers in community-based health tourism industry development. It is hoped that the obtained results will lead to the economic growth of Mazandaran province through the promotion of the health tourism industry in this province.

Methods

The purpose of our qualitative study is to identify the drivers and local factors affecting the development of the community-oriented health tourism industry and increasing the attraction of health tourism in Mazandaran, Iran.

Study design and participants

A qualitative method was used in this project. Participants for the present study were recruited from three levels of the community: academic experts in the field of health tourism, managers in the field of health tourism, and also health tourists. To acquire different viewpoints, participants were selected by both snowball and purposeful sampling (with maximum variation) because of the requirement of sample diversity in terms of demographic features and expertise [23]. Though most contributors were employed through purposeful sampling, In this regard, first an interview was conducted with one of the experts familiar with health tourism in Mazandaran province who had the necessary criteria (including being key, recognized by others, theoretical understanding of the subject, diversity and agreement to participate, useful work experience, and relevant education). Then, he or she was asked to introduce the experts who might be suitable for the interview. Therefore, except for the first few people who were directly selected by the main researcher based on the above criteria, other experts were included in the study in addition to the criteria of expertise. In choosing participants, the maximum variation, or “heterogeneous procedure,” was performed to attain varying levels of socioeconomic position, age, gender, work experience, education level, and aim of trip. The snowball sampling method was applied on a case-by-case basis by encouraging engaged applicants to request others to contribute to the interview. At the beginning of the project, the purpose of the interview was described to each applicant. Interviews with participants continued until data saturation was reached, and the answers to the interview questions were repeated. That is, no new code was displayed in the data.

Data collection

This study consists of in-depth interviews and focus group discussions. Data was derived from the sum of secondary analysis from a qualitative study directed by Khazaee-Pool [in Persian] in which 17 participants from Mazandaran [Iran] explored the concept of health tourism and its effective components [13], and interviewed eight new volunteered [health tourism experts] from Mazandaran. The interviewer (MK) has received professional training from qualitative method experts in several workshop and is experienced in designing and conducting quality in-depth interviews and focus group discussions. This includes proper guide development and interviewing/moderating skills and techniques with various group and subjects. To collect more detailed data, interviews were conducted with participants using an interview guide. The guide was developed based on a literature review [10, 11, 13, 18, 24, 25] and insights from some professors in related fields, and it was piloted with four interviews. The interviewer followed a guide designed to encourage participants to explore and discuss their perspectives and experiences regarding the factors affecting the development of health tourism. The interview guide included the following sections: (1) demographic characteristics of participants; (2) components involved in attracting health tourists; (3) the function of these components in attracting health tourists; (4) the role of social, economic, and cultural factors in the attraction and development of health tourism; (5) participant’ experiences; (6) identifying factors related to the development of health tourism; (7) facilitators of health tourism development; and (8) obstacles to the attraction and development of health tourism. We conducted this study in the tourist-friendly Mazandaran province of Iran, which reflects the diverse cultural and linguistic features of Iranian society. The interview guides are presented in Appendices 1–4.

Semi-structured in-depth interviews (IDIs)

Overall, the 17 participants in three levels of the community—academic experts in the field of health tourism (n = 3), managers in the field of health tourism (n = 9), and also health tourists (n = 5)—volunteered to participate in semi-structured interviews. Sampling was continued until data saturation was reached, that is, no new codes were found in the data. At the beginning of each interview, all participants were asked about demographic information. They were also questioned about social, cultural, and environmental factors that might have influenced this subject.

After the preliminary acquaintance of the interviewer and the interviewee, each interview started with a general question: “What is the main process of developing and attracting health tourism in Mazandaran province?” According to the answer provided by each interviewee, depending on the case and if necessary, in-depth questions were used to clarify the answers of the participants and redirect the discussions, and more exploratory questions were asked based on the answers of the participants. According to the replies to the questions, follow-up questions were requested. After each question, contributors were requested to clarify more about what they had stated. For instance, they were questioned, “Can you explain more about this?” or “What do you mean?” for a deeper reflection of the participant’s experiences concerning the subject.

To maintain the privacy of the participants’ data, the interviews were numbered from 1 to 17. The data reached theoretical saturation after 13 interviews, and for more certainty, the interview continued until the 17th participant, and the analysis was completed with the 17th participant. All interviews were recorded with the consent of the participants. The interviews were recorded and transcribed word-for-word in Persian. The transcripts and digital recordings were cross-checked. The time and place of the interviews were considered according to the opinions of the participants. All interviews were conducted by the first author of the study, who is familiar with qualitative research methods. The duration of the interview was a maximum of 45 min, according to the conditions of the participants, their busy schedules, and their willingness to be interviewed.

Focus group discussions

Following the semi-structured interviews, the main researcher [Mk] conducted an FGD to validate the themes that had previously emerged and gain a deeper understanding of the themes related to the subjective experiences of health tourism experts on the issue. The FGD was held in a convenient and accessible location for the participants, with eight new volunteers [health tourism experts] attending. The discussion lasted for 120 min. All themes that emerged from the IDIs were confirmed, no new information was obtained, and as no additional coding was possible, data collection was concluded.

Data analysis

Content analysis with a conventional method was applied to explore the data according to Graneheim and Landman’s method, recognize key themes, and compare patterns among numerous people [23]. All interviews were audio-recorded after obtaining informed consent, and the audio-recordings were attended to cautiously numerous times. Data analysis started throughout the data-gathering process. The FGD and individual interview were transcribed literally and analyzed before the next interview was accomplished.

First, the investigators spent time with the data, which included listening to recordings, transcribing them verbatim, and reviewing and rereading the transcripts. Each interview was listened to several times before starting the next interview, and then it was transcribed word for word. A separate number was assigned to each lined of the transcribed interview to facilitate returning to specific parts of the textual data during coding. The transcript was compared with the recorded interview to ensure the accuracy of the written data. Key quotes related to the studied phenomenon were extracted. In the next stage, the meanings of the extracted key quotes were written. All recorded transcripts were converted into meaning units. Concepts related to keywords and phrases about the interview setting were identified. These concepts were shown as codes once all interviews were finalized. The codes were then assigned to these meanings. The investigators read the interviews several times and discussed the best coding techniques. Double coding was implemented, with investigators separately assigning pre-specified codes to the data. Each text was read word for word, and initial codes were obtained. The initial code was created, the meaning unit was condensed into a “condensed meaning unit,” and the extracted codes were generated during the next stage. The study continued by coding the remaining transcripts once the coding structure was clearly established. This stage included both manual and electronic coding techniques, with manual coding being used during the initial coding stage. The first researcher [MK] entered the transcripts into the MAXQDA software (version 12) once the coding structure was well defined. This enabled the text to be coded and retrieved easily for interpretation. At that time, the codes were organized systematically. This process reduce the number of initial and redundant codes. In the next step, the primary codes obtained were categorized based on their similarity, resulting in the formation of the subcategories. Subcategories with similar subjects were grouped to form more general categories, and main with similar content create the main themes. Subcategories, categories, and themes emerged at this stage. When latent themes developed, the investigators refined them by removing unclear themes and concepts, including some pertinent ones, and separating general concepts and themes into distinct ones. The names of each subcategory, category, and main theme were chosen based on the coverage of the extracted codes. Once a number of fully-developed themes emerged, an effort was made to present the findings as follows.

Ethics

Participants provided informed written consent. All interviews were audiotaped and transcribed with the participant’s consent. Each participant received a gift card of 1,000,000 Rial for the time involved as study participant.

Rigor

The rigor of the data gathering was set by analyzing its credibility, transferability, confirmability, and dependability [26]. In the present project, multiple attributes of trustworthiness were recognized. Credibility was obtained via long-term engagement with data, member checking, and peer checking. We asked another coder skilled in qualitative studies. We invited six of our contributors to review the transcripts, a brief of the interviews, and the emerging results (member check); these contributors were chosen through the interviews. Conformability was attained by sending content codes and themes to five investigators acquainted with qualitative content analysis approaches (peer checks). The transferability was confirmed by presenting a rich and full description and a comprehensive report of the study method. The transferability was established by applying the maximum variation sampling technique [27]. The dependability and credibility of the current information were established by the clear coding technique and inter-coder approval [26]. Furthermore, the data were analyzed by a thematic analysis technique in Persian, and the codes and study data were transcribed in English.

Result

In total, 25 Iranian people aged 34–54 years (41.8 ± 4.88 years) took part in the study. The characteristics of the participants are reported in Table 1. Due to the large number of extracted concepts, only the concepts related to all the interviews, which included 289 codes, were considered. In the coding process in the open stage, the keywords of the study were identified. Overall, five major themes emerged from the analysis: (1) infrastructure and resources; (2) tourist attractions; (3) socio-cultural contexts; (4) economic-financial factors; and (5) political-communicative factors. More information on themes and categories can be found in Table 2. In the following section, we describe participants’ experiences. More information on the themes and categories is accessible in Tables 3, 4, 5, 6 and 7. Additionally, in the following section, we reveal the participants’ experiences of the major themes. [Supplementary file: Tables 3, 4, 5, 6 and 7].

Table 1 Socio demographic characteristics of participants (n = 25)

Table 2 Factors related to the development of the health tourism industry

Theme 1: Infrastructure and resources

This main theme shows the concepts and factors related to the structural component affecting the health tourism industry, which consists of five categories: infrastructure and information technology, public service infrastructures, infrastructure of health and medical services, communication and transportation equipment, and expert human resources. (Table 3).

Infrastructure and information technology (IIT)

From the viewpoint of the interviewees, strengthening the health tourism infrastructure and information technology (IIT) accelerates the entry into the health tourism industry and the achievement of the expected results. According to the interviewees, the level of health tourism will improve when the required platforms for providing information-communication services, public services, and health services are developed. In this regard, one of the participants stated that:

The existence of informational infrastructure, such as the development of comprehensive health tourism maps and brochures, is essential for increasing success in this industry (P8).

Also, some participants believed that the existence of internet infrastructure and social networks would increase the attraction of health tourists, which indicates the importance of paying attention to information and communication infrastructure.

The existence of high-speed internet is very necessary for easy access for health tourists. Today’s world is the world of communication (P9).

All the contents mentioned above indicate the importance of paying attention to the infrastructure for providing public services. Most of the participants emphasized the need to pay attention to the facilities of hospitals and health service centers. In this regard, three participants stated that:

Hospitals that receive foreign patients must prepare all their facilities and treatment facilities in the best way. The lack of some equipment or the absence of some medicines is not pleasant and acceptable for a foreign patient (P1 and P6).

All the above cases reflect the importance of the infrastructure for providing health services, which should be considered in the tourism destination in order to promote this industry.

Public service infrastructures

Many participants described the positive effects of public service infrastructures like standard hotels in the closest distance to the health service center on tourism’s attention to visit the health tourism destination. Some believed that the existence of a bathroom, shower room, and dressing room next to the hot springs was equal to an increase in health tourism. A participant said:

Tourism development needs to provide proper infrastructure. In order to increase the capacity of tourism, proper infrastructure, and standard hotels in the closest distance to the health service center, safe roads, safe residences, tourism agencies and tours, etc. should be built. Until we can solve the deficiencies in this sector, we will not achieve results in health tourism. (P22).

Infrastructure of health/medical services

According to most participants’ points of view, the provision of health and medical infrastructure is the most important prerequisite for the development of health tourism in a region. In this regard, one of them said:

Health tourism in Iran has a very small share in the world, and if it is valued and the necessary infrastructure is created, we can hope to attract more health tourists. This is despite the fact that in most provinces of Iran, steps have been taken to realize such an important task, but there is still a long way to go before reaching the ideal distance, and many basic facilities and infrastructures have not been provided in most of Iran’s tourism areas… (P20).

Another participant said:

When a foreign tourist travels to Iran for treatment, other plans for greater productivity, such as economic issues, should also be considered, and these issues are of particular importance. Considering the natural attractions in most cities of Iran, the Iran Tourism Organization, in cooperation with the Ministry of Health, can do proper planning, for example, the development of health farms and traditional medicine centers/medicinal plants, separate sun baths and salt rooms, the presence of health facilities [such as bathrooms, shower rooms, and dressing rooms] next to tourist places, and flower therapy near the beach for both genders… (P25).

Communication and transportation equipment

According to most of the participants, transportation is one of the most important components of tourism, and creating a connection between the tourist and the travel destination is an important issue. Air and rail transportation to the city should be easy, accessible, and of good quality and price. The transportation industry, as one of the basic requirements for the development of the tourism industry, enables access to attractions for tourists. The availability of suitable, safe, comfortable, fast, and cheap transportation facilities is a prerequisite for the development of mass tourism. Because tourists consider the two factors of cost and time in their decisions, choosing the type of transportation system or the availability of a suitable system to access tourist destinations affects these two factors. One of the participants explained in this regard:

Health tourism needs to strengthen transportation infrastructure. The transfer of passengers for one-day and multi-day tours for Iranian guests, as well as the transfer of foreign tourists who enter Iran to visit historical, cultural, natural, religious centers, etc., requires a fast and high-quality transportation system [with a reasonable price]. (P19).

Expert Human resources

Manpower is very important in managing and providing services. Tourism is a type of service activity. Manpower is a main factor in the development of the tourism sector. Expertise, effective skills, efficiency, and respecting respect when providing services are among the important things in the health tourism industry, and they are the result of investments made in the field of education and training of people. Most of the participants admitted that the existence of specialized human resources with sufficient knowledge and skills and appropriate personal characteristics leads to an improvement in the level of health tourism. One of the participants stated that:

Choosing employees with scientific and social qualifications to work in this field is very important, and officials should choose employees with good communication and social skills for the development of the health tourism industry (P1).

The tourism industry has a service nature, and its main product is the experience that tourists and guests get from being in the destination. Therefore, the knowledge and skills of the industry’s employees and suppliers will play a very important role in the quality of the experience, creating satisfaction, and finally developing tourism in that destination. An interviewee stated that:

Access to employees specializing in cultural heritage as well as the field of health and the use of forces familiar with health tourism who have communication skills and foreign languages are effective in the development of this industry in tourism destinations. (P4).

The special nature of the tourism industry requires employees who are concerned about the development of the culture of the tourism industry and are capable of acquiring knowledge, communicating effectively, showing benevolence and love to others, meeting the needs of others, and solving problems in times of crisis. Therefore, targeted and correct training of human resources, both in the public sector and in the private sector, is very important in the development of the health tourism industry of the destination.

Theme 2: Tourist attractions

One of the elicited themes in the present study was tourist attractions, including eight different categories: historical, cultural, and religious attractions; natural-environmental attractions and resources; security of tourists; variety of services; availability of services; quality of services; ease of travel and geographical proximity; and advertising and marketing. Participants also expressed different views about destination attractions and their effect on increasing the number of tourists in different destinations (Table 5).

Historical, cultural, and religious attractions

The majority of participants agreed that palaces and museums, historical monuments, cultural-religious buildings, spiritual residences in tourist destinations, and centers and cultural products [such as handicrafts, local music, and dance in tourist destinations] in the tourist destination could attract health tourists. One of the participants stated:

For a health-conscious tourist, the beauty of the environment is very important. The tourist goes to the areas where nature or conditions have chosen to treat and heal the disease. In addition to using nature conditions while traveling, we can do activities such as yoga in religious and spiritual places as well as in nature and healing places, which improve the health of the human mind and body, strengthen the soul and spirit, release the fatigue of life, and intercede for human illness. (P21).

Natural-environmental attractions and resources

Natural attractions were the main concept that was related to different views on health tourism destinations and willingness to travel. Most of the participants formulated emotional responses in which they associated the attractiveness and natural beauty of the destination with the intention to travel to those destinations. These included beautiful and unique views with green spaces and beaches for both genders, mountainous areas, caves, ski slopes, waterfalls, marshes, and wetlands, hot and mineral water springs, and forest. Some of the participants stated that the mild climate, along with the hot springs and medicinal plants, is an important motivation for doing health tourism. One of the participants stated:

In my opinion, one of the attractions and privileges of Iran for medical and health tourism is in the field of hydrotherapy, where there are many mineral water springs. There is a lot of medicinal vegetation in most regions of Iran. All these things are a high point that makes us able to treat our physical and mental problems at a lower cost and at a cheaper price. (P18).

The diversity of food culture, along with other natural resources, was one of the factors that could be effective in the development of this industry from the point of view of the participants. Participant number 14 believed that:

The diverse and delicious foods of the northern provinces, along with their beautiful nature, are very important in attracting the attention of tourists, especially from neighboring countries. (P14).

Security of tourists

Since many participants believed that the security of tourists and tourist destinations could increase tourist attraction and develop the health tourism industry, they emphasized the planning of different levels of safety for health tourists in health tourism destination (HTD). The direct presence of visitors and tourists in a country, in addition to the development of the economy and cultural exchanges, introduces that country to the world as a safe tourism hub. Security, in a broad sense, is one of the most important issues that affects the amount of demand from foreign tourists to travel to any other country. According to one participant:

Security can be the most reliable tourist attraction in Iran. What is called “tourism security” is not only the protection of tourists from thieves and criminals but also includes several factors, including road casualties, plane crashes, bureaucracy in visa and insurance procedures, the way the police force deals, and limited store opening hours. (P24).

Another participant said:

One of the most important concerns for us tourists is maintaining mental security, privacy, and personal information. I believe that deploying special police to ensure the safety and security of tourists will yield significant benefits and encourage more tourists to visit these tourist areas. Because the security of mind has been created for them, the anxiety and fear of negative events in the tourist are reduced… (P13).

Variety of services

From the point of view of many participants, one of the ways to attract health tourism is to provide various products (health, medical, accommodation, entertainment, food, transportation, etc.) along with easy access to them. One expert in this field has expressed the following opinion:

To attract visitors and grow this business in tourism areas, a variety of goods and services must be available, in addition to an abundance of easily accessible amenities. Some of the cases include different lodging options with a wide range of amenities and prices, different tourism-nature tourism-antiquities tours, helping the patient and doctor communicate before the patient gets to the destination, different medical services that are necessary for traditional medicine, the availability of accompanying translators, etc. (P20).

Availability of services

The growth of the health tourism business and the rise in the number of health tourists are largely due to the availability and ease of access to tourism services and facilities, in addition to the wide range of services offered. Several individuals highlighted the need for classifying various age cohorts, such as youngsters, pregnant women, and the elderly, to ensure they get the services that are suitable for their specific needs. To enhance the quality of health tourism services, it is essential to accurately classify visitors based on their health status, including the specific illnesses they may have. One of the attendees stated:

A crucial aspect of the development of the health tourism sector is the provision of health tourism services catering to individuals of all age groups, genders, and vulnerable populations, including children, pregnant women, individuals with terminal conditions, and the elderly. The crucial factor for achieving success in the growth of this business is the presence of customized services that cater to individuals’ specific requirements. (P10).

Easy access to the transportation system and adherence to international tourism standards, together with the presence of lodging and food supply centers, as well as suitable furniture and urban space, may significantly contribute to attracting health tourists. An essential criterion in standardizing health services is to provide comprehensive and integrated care to international customers and ensure a systematic approach to treatment procedures, starting from patient admission to their release. Many participants believed that the availability and distribution of health tourism information had a significant role in the growth of health tourism. According to several interviewees, using media communication, information technology, and focusing on global markets in international health tourism may be advantageous. One of the participants expressed:

In order to successfully share experiences and promote hospitals to others via existing patients, it is crucial that we be able to provide or enable the implementation of electronic and telecommunication communication for patients and their companions in hospitals. (P3).

Quality of services

The majority of participants said that standardizing the quality of tourism services will help draw more health tourists to popular tourist destination. Service quality, as defined by the majority, encompasses the provision of standardized infrastructure, relevant media information, customer-centricity, and personalized attention to tourists. It also involves establishing trust and confidence among tourists, delivering services promptly and efficiently, treating all tourists equally, and promptly addressing their needs. Creating contentment and a positive experience for tourists throughout their therapeutic travel to the location is of utmost importance. Thus, it is essential that we consider ourselves from the perspective of a health tourist and ascertain the kinds of medical and non-medical services that the visitor expects from us. Regarding this matter, one of the participants expressed the following:

From my perspective, information has to be disseminated in different languages using various communication channels, social media platforms, and media outlets in order to boost health tourism and visitor satisfaction. Conducting surveys using various methods and analyzing the elements that influence the satisfaction of health tourists might be beneficial. In order to successfully increase the number of health tourists visiting tourist sites, efforts must be made to raise the bar for medical care, equipment, and hospital facilities to the highest international standards. Offering high-quality services also entails putting the needs of health tourists first in all aspects, including their health, treatment, welfare, post-treatment follow-up, and continuous contact with the health-care team. (P19).

To attract and accommodate tourists in Iran, it is essential to have suitable infrastructure, including accommodation, transportation, and catering facilities. However, it is important to note that tourists prefer staying in close proximity to their chosen tourist destinations. Hence, the quantity and quality of hotels near health tourism destinations play a crucial role in the success of health tourism.

Ease of travel and geographical proximity

Geographic closeness and ease of travel are significant considerations when selecting a tourism location, as stated by several interviewers. Numerous factors were highlighted, including the short travel time between the origin and the tourist destination, the residence’s proximity to the tourist attractions and medical facilities, the ease of access to a variety of secure transportation options, and the layout of walking routes within the destination. A participant expressed:

The short distance between the origin and the tourist destination is a crucial factor, particularly for the elderly or those with knee and spine pain issues who want to go by vehicle (since plane tickets are expensive). The accommodation’s closeness to tourist attractions and medical facilities is crucial for those who are traveling for skeletal-muscular difficulty and want to take advantage of hot springs. (P8).

Advertising and marketing

The participants believed that using strategies and appropriate and effective advertising methods in the direction of marketing the health tourism industry is one of the most important, effective, and efficient ways to create a positive image and favorable perception in the minds of potential tourists about tourist destinations and tourism products, and as a result, it can lead to the proper development of tourism.

Tailored marketing is essential for attracting tourists to the most significant tourist destinations. The unknown quality of Iran’s tourism attractions poses a significant hindrance to the development of nature therapy and the attraction of health tourists. Given the significance of naturopathy in the growth of health tourism, it is crucial to keep in mind that nature therapy is only attractive to tourists if we effectively introduce attractions related to nature therapy to health tourists.

Despite the current organizational and institutional infrastructure, health tourism in Iran faces significant challenges when compared to its neighborhood competitors. These challenges include the absence of a comprehensive health tourism management system, insufficient investment and allocation of funds to upgrade infrastructure and facilities, and a lack of domestic and international advertising to promote health tourism attractions in Iran. This field needs more public-private sector collaboration in addition to a comprehensive evaluation. (P24).

The media plays a vital role in the tourism business by providing information and advertising on a national and worldwide scale. Additionally, presenting cultural and artistic events both domestically and abroad, together with the use of media like radio, television, the phone, and email, helps to improve visitors’ perceptions of the nation and increase demand for travel to various tourist destinations. Utilizing contemporary methodologies and strategies in advertising to entice tourists and subsequently augment the influx of visitors contributes to the advancement of the tourism sector in the given location. Several participants believe that the absence of information has impeded the sector’s progress and that this significant barrier has to be addressed in order for the industry to continue growing. One of the respondents provided an explanation:

Lack of appropriate information on the opportunities for health tourism in Iran is one of the main shortcomings of the country’s health tourism industry, which keeps both foreign and domestic medical tourists in the dark about the country’s health tourism potential. To substantiate this assertion, one needs to just peruse the websites of many foreign hospitals inside our nation to ascertain the insufficiency of the information they present, despite their state-of-the-art facilities. Alternatively, explore the websites of hospitals in the Philippines, Korea, or Japan to ascertain the distinctions. These contrasts exclude the extensive hours of radio and television production programs that expose these locations, as well as the frequent commercial teasers that are shown on satellite channels. Because of this, not even a large number of people in Iran’s major cities—Isfahan, Sari, Rasht, Tehran, etc.—are aware that there is a hospital with this level of equipment. This basic weakness is present in almost all well-equipped medical facilities that are susceptible to attracting medical tourists, as well as in locations such as natural springs, etc., in Iran. (P24).

Theme 3: Socio-cultural contexts

One of the elicited themes in the current study was the concept of socio-cultural contexts, including four different categories, namely cultural similarity, religious similarity, cultural exchanges, hospitality ethics, and interaction with tourists.

Cultural similarity

An important topic that was often discussed in the interviews was the relationship between tourism and cultural similarities. The cultural aspect is a significant determinant in the attraction of tourists. Prior to being seen as an economic phenomena, tourism is fundamentally a cultural concern, giving rise to several cultural ramifications. During the interviews, individuals consistently emphasized the significance of subcultural similarity, linguistic closeness, and the absence of cultural alienation in the tourist location. Most participants stated that the following factors are effective in drawing health tourists: similarity between the origin and the destination in terms of cultural rituals and subcultures; similarity between the tourist destination and the origin in terms of customs and cuisine; and even similarity between the values and norms governing the tourism destination. A participant expressed:

When it comes to developing health tourism, the key infrastructure that must be prioritized is the provision and enhancement of cultural platforms. To get started in this industry, it is essential to identify and assess the cultural impacts and subcultures of the destination on the origin, as well as vice versa, taking into account both positive and negative aspects. Consequently, it is critical to understand the local culture in order to fully guide the development of health tourism in a given area. Before implementation, all health tourism initiatives must be integrated into and consistent with the local culture as well as the target market. Put simply, many visitors have a tendency to visit areas that have cultural similarities with their place of birth, such as language, cuisine, values, and so on. (P23).

Religious similarity

One aspect that was raised in many interviews was the similarity of religious beliefs and the role of religion in the development of health tourism. From the point of view of most of the interviewees, paying attention to the religious aspects and the closeness of the religious aspects of the origin and the destination is effective in the development of this industry. Participants mentioned suitable facilities for both genders, respect for religious customs, separate recreational facilities for both genders, and compliance with local values. One of the participants said:

Religion and cultural beliefs play a significant role in all forms of tourism and travel, regardless of the goal. Travel introduces people to different cultures and religions and connects them to each other despite their differences. Religious places and pilgrimage destinations are present in the majority of cities in Iran. In addition to going to hot springs and nature tourism, going to these places also improves the mental state of a person. It is better for the government to prepare its proper infrastructure and offer attractive programs and products for those interested and applicants. (P7).

Cultural exchanges

Based on the majority of participants, travel and tourism within communities may enhance understanding, expand knowledge, and foster a deeper appreciation for the surrounding environment and cultural similarities with various ethnic groups and diverse perspectives. Another consequence of tourism is the exchange of cultures and subcultures. Cultural-religious events, goods, or activities are a source of inspiration for visitors and travelers to a city or a nation. An in-depth understanding of cultures in connection to the tourist sector is crucial. Even though tourism is an industry, the majority of religious and cultural exchanges occur there, and in some cases, one of the reasons it is developing so much is to ensure economic growth and the ability to showcase a nation’s culture to other nations. Regarding this matter, one of the participants provided an explanation:

Travel and tourism include the acceptance of new habits, the mobility of subcultures, the transfer of languages, and the sharing of civilization and culture. Hence, possessing socio-cultural adaptability might be advantageous in attracting tourists. Whatever the reason for trips, the destination’s tourism agency may make a cultural draw by introducing tourists to the native culture and customs. Simultaneously, it is necessary to plan and establish effective executive methods to mitigate cultural conflicts. (P3).

Furthermore, other participants also stated that:

Organizing international exhibits that focus on cultural and social aspects of health may broaden global perspectives on the culture and civilization of the tourist destination. Additionally, these exhibitions may provide the perfect context and platform for activities linked to health tourism. (P1, P13).

Hospitality ethics and interaction with tourists

Another factor that many participants highlighted as influential in attracting health tourists is interaction and hospitality behavior. The participants’ viewpoint suggests that the hospitable behavior towards tourists, and the level of tolerance towards tourists may contribute to the promotion of public knowledge and cultural understanding about the advantages of health tourism. As reported by one of the participants:

The involvement of the local population is a crucial element for the sustainable development of health tourism. This collaboration will not only bring economic benefits to the local community but also foster a deeper appreciation for the positive impacts of tourism development. It will improve their attitude towards tourism and support more health tourism. As a result, the local community’s tolerance threshold will increase, leading to greater compatibility with tourists. (P18).

The interviews revealed that the residents’ support and hospitable behavior towards tourists have an impact on several variables: the destination’s image, tourist satisfaction, tourist loyalty, positive word-of-mouth advertising, perceived service quality, emotional solidarity and connection between tourists and residents, and the level of dependence of tourists on the destination.

According to the opinion of one of the interviewees:

Implementing compensation strategies is an important component of attracting health tourists to mitigate their discontent with the inadequate care provided by the local community. Furthermore, encouraging tourists to share their pleasant experiences engaging with the local community might be a successful strategy for attracting health tourists to tourism destinations. (P6).

Theme 4: Economic-financial factors

According to the participants’ opinions, economic-financial issues were considered a significant aspect of attracting health tourism. This issue encompasses five distinct categories: appropriate pricing and service rates, inflation, degree of competitiveness, investment and privatization of tourism, and coverage of insurance services (Table 6).

Reasonable price and service rate

The majority of participants highlighted the significance of product pricing and noted that one crucial aspect contributing to the rise in health tourism to tourist destinations is the affordability of medical, recreational, and general products and services available in such places. One of the participants stated:

I highly recommend this place to anybody seeking health-treatment services. It is my top preference on my list due to its affordability in both health services and tourism. Urban transportation expenses are exempt, and the cost of guided tours is readily apparent. (P15).

According to the majority of participants, one of the most effective strategies for attracting tourists is offering competitive pricing for services. The participants held the belief that our approach should be such that the cost and fee of healthcare services serve as a competitive advantage for us. Regarding this particular issue, participants 3 and 9 remarked that:

The set-up of health service prices based on the health tourism destination and the cost-effectiveness of health services in Iran compared to other countries, together with the accessibility of high-quality services, are crucial factors for successfully attracting health tourists. (P3, P9).

Inflation

Although the health tourism industry is seeing growth, it is important not to ignore the obstacles it faces. The biggest challenge in this industry is the rising inflation levels in tourism destinations. The widely held opinion is that the pricing of products and services in tourist cities and destinations tends to be higher compared to places with fewer tourists or non-touristic regions. Furthermore, it is worth noting that in public resorts, the costs for tourist services see an increase during the peak travel season compared to the pricing throughout the remainder of the year. Price fluctuations are expected to be larger in economically disadvantaged regions compared to affluent regions. Based on the majority of respondents, tourists possess the financial capacity to afford greater costs. Consequently, businesses raise the prices of their products and provide a wider range of costly goods. As per the participants, all the factors stated may contribute to a rise in inflation in destinations for tourists. One of the attendees explained that:

Regardless of the reason for their visit, the entrance of visitors causes a notable increase in the price of various goods and services, which contributes to inflation. There are two consequences arising from this. First, the people living there have to spend more money in order to meet their needs; second, vendors that sell goods to tourists may have to pay more in rent and taxes, which ultimately transfer all costs to the final customer. (P17).

Level of competitiveness

The participants identified the competitiveness of tourist destinations as another influential component in attracting health tourism. Based on the responses of most interviewees, various factors contribute to the competitiveness of health tourism destinations. These factors include the expenses associated with visas and travel, the costs of health services and tours, the quality of hospitality, the availability of attractions and facilities, the strength of the information technology infrastructure, and the level of economic, political, and social security. Additionally, the provision of information about the destination’s attractions and amenities is also important. One of the attendees explained that:

The competition among tourism places is a significant factor in attracting tourists. The greater the tourism destination’s capacity to provide better facilities and lower the expenses associated with healthcare services, the higher the influx of health tourists into this region. (P4).

Based on the other participant:

One of the factors that influenced my decision to choose Mazandaran province over other places for my vacation was the abundance of advertisements on Instagram highlighting the hot springs in Mazandaran province… Additionally, the accommodation and transportation expenses associated with this trip were comparatively cheaper than those of other tours. Conversely, a substantial amount of information on the natural and therapeutic attractions of Mazandaran province was provided by this tour… (P15).

Investment and privatization of tourism

A significant proportion of participants expressed the need for cooperation among several executive agencies, including the Ministry of Cultural Heritage, Tourism, and Handicrafts and the Ministry of Health, in order to promote the development of health tourism. They emphasized the urgent need for investment and increased activity. As reported by one participant:

The government should provide a conducive environment for investors to join the health tourism business by encouraging and supporting them in various ways. Actions such as identifying potential opportunities and enhancing their conditions, maintaining updated information, promoting the growth of medical scientific knowledge among doctors, nurses, and medical staff involved in the health tourism industry, providing low-interest loans to individuals active in this field, and overall enhancing the environment to attract and convince investors can be beneficial. (P1).

Another said that:

Allocating an adequate budget for infrastructure projects and establishing a comprehensive transportation network are crucial. Additionally, preserving the natural appeal of the destination, promoting the private sector, and investing in the infrastructure and superstructure of the health tourism destination are also essential. (P13).

Coverage of insurance services

Another aspect that the majority of participants highlighted was the level of coverage provided by health tourism insurance providers. Participants emphasized the significance of insurance coverage and insurance savings in attracting health tourists. Regarding this matter, a participant said the following:

For a health tourist to visit another country, it is necessary to have both travel insurance and health insurance. Insurance companies should provide a discounted insurance package in relation to this issue… However, it is necessary to provide post-discharge follow-up care after the tourist has received medical treatment. We should monitor the patient after his release from the hospital to ensure he has no issues following therapy. Upon departing from the health care facilities, the patient is required to remain in Iran, as the medical tourist may want to extend their stay for a few more days. As a result, we need to understand its workings, as well as the services that follow discharge. Since this is a cooperative effort, coordination across all groups is required. Throughout all of these phases, the presence of various insurance options may simultaneously decrease the expenses associated with a patient’s medical care and enhance their level of contentment. (P19).

Theme 5: Political-communicative factors

Participants highlighted many political and communicative factors that contribute to attracting health tourism to a destination. These factors included government regulatory regulations, health tourism policy, political stability, government assistance, and inter-organizational and departmental collaboration.

Government regulatory policies

The participants emphasized the crucial role of the government in supporting this industry by enacting legislation and implementing regulatory rules. As stated by one of the participants:

The government’s implementation of trans-sectoral and inter-sectoral policies to establish an open market for health services in the nation contributes to the development of this business. To achieve this objective, implementing economic liberalization and enhancing political contacts with other nations, as well as revising visa requirements, are useful measures. The health sector’s unique policies, such as privatization and the provision of comprehensive regional or supplemental insurance coverage, have a direct impact on the development of the market for healthcare services. (P18).

Health tourism policy

One of the important points that most participants emphasized was health tourism policy. The policy-making process in the tourism sector varies greatly depending on the political, economic, and cultural structures of each country. This reflects the level of government involvement in shaping tourism policies, including the political nature of policy-making, the selection of managers in political environments, the extent of public participation in tourism planning, the analysis of power sources in tourism policy, the effectiveness of tourism policies, and the role of governments in the formation and growth of the tourism industry. The participants listed a number of elements for this area, including the establishment and growth of health tourism organizations, the development of a national health tourism program, local, federal, and international rules and regulations, the attention given to international standards in health facilities, etc. One of the participants expressed:

The price of a visa and leaving the country are expensive for a short trip. The government may effectively contribute to the growth of this sector by passing legislation that lowers the cost of obtaining visas and makes it easier for visitors to get them. The government should establish a framework for the harmonization of health tourism regulations and provide realistic measures to attract consumers and health tourists, particularly those from foreign countries. I believe that developing health tourism training programs, drawing in both domestic and international investment to construct infrastructure (such as hotels and restaurants), and approving regulations that support the growth of health tourism infrastructure may all be beneficial. (P21).

Regarding this, some respondents said that government support initiatives, inter-sectoral collaboration, health tourism information management, and policymaking in the field may all help to develop and expand the health tourism sector in a given location. Some individuals emphasized the need for establishing comprehensive legislation to attract health tourism and adopting a strategic approach towards the long-term growth of this industry. According to the participant’s statement:

…Furthermore, the government needs to provide guidelines for tourists to enter the area or nation, including online visa applications and foreigner entrance procedures, among other laws and regulations. (P12).

Political stability

The participants highlighted the importance of security in tourist locations and the implementation of policies to combat global terrorism. Several participants have identified various challenges that hinder the entry of health tourists, including the outbreak of war, the rise of terrorism, the increase in insecurity, the implementation of demanding border controls, the enforcement of strict visa regulations, and the instability in political security. As a result, in order to overcome the aforementioned challenges, the government should provide political stability and create rules and regulations pertaining to tourism that would help grow this sector. One interviewee expressed the following:

Due to the growth of Daesh [ISIS] and the heightened insecurity at certain borders, there has been a decline in the presence of health tourists, despite the significant potential in this industry. This decline can be attributed to the implementation of stringent border control measures and visa regulations. The government’s cooperation in maintaining peace and stability at the borders and implementing suitable legislation to permit the admission of health tourists seems to be beneficial… (P21).

Government support

Government support and funding have a significant role in promoting health tourism, as demonstrated by the participants. They believed that the government’s extensive support for marketing this industry, enhancing communication channels, utilizing Iran’s free zones, and providing specialized internet facilities for tourists could significantly contribute to attracting health tourists. Others believed that when the government created and approved a program, it should also set up the necessary executive mechanisms for its implementation in order to help in the more effective realization of policies. These programs should be based on the health tourism competitiveness model and appropriate to the characteristics of the destination. As per the viewpoint expressed by one of the interviewees:

To promote health tourism, the government should enhance and establish a competitive framework. To accomplish this objective, the government must establish the requisite programs and executive procedures for their execution… (P3, P2, P11).

Some also thought that the government could help this industry grow by compiling data on health tourists, compiling a list of facilities and attractions relevant to health tourism, and assessing how competitive the destination’s tourism market is in order to increase the number of health tourists. Some of the interviewees stated:

Investing in the improvement of health accommodation facilities and the establishment of medical centers that prioritize the provision of top-notch treatments at affordable rates will stimulate growth in the health tourism sector, resulting in job creation and financial gains. (P10 and P17).

The aforementioned reasons highlight the significance of health tourism information management as a standard practice within institutions for the advancement of health tourism.

Inter-organizational/departmental partnership

Several participants highlighted the significance of the tourism organization’s collaboration with various entities, including the University of Medical Sciences, the Ministry of Science, Cultural Heritage, the Food and Drug Organization, insurance companies, the Ministry of Sports, and the Chamber of Commerce. One of the interviewees expressed the following viewpoint:

…Setting policies to enhance the partnership and collaboration between the tourist organization and other entities, such as the insurance organization, the University of Medical Sciences, cultural heritage, food and drug organizations, etc., may also provide positive results. (P20, P11).

Like other health-related fields, health tourism depends on collaboration with other industries and organizations to succeed and grow. According to the participants’ perspectives, the government should provide practical measures to build this collaboration. A number of participants emphasized that establishing connections with other global health tourism providers is a very successful and crucial aspect of industry growth. To capitalize on the target market and establish a strong position in this industry, according to laws and norms for growing interactions is crucial for the advancement of this profession. One of the participants expressed the following:

The growth of health tourism via the marketing of health-focused goods may serve as a significant draw for many nations, particularly those with a Muslim population. (P13).

Discussion

This research was to explore the role of local factors in the development of a community-based health tourism industry in Iran. This discussion addresses the existing situation from the viewpoints of community leaders, residents, academic experts in health tourism, managers in health tourism, and health tourists. Consequently, five primary themes emerged, including infrastructure and resources, tourist attractions, socio-cultural contexts, economic-financial factors, and political-communicative factors.

There is evidence that having strong infrastructure and information technology in destinations may encourage health tourists to visit those destinations [11]. Therefore, we think it was inevitable that concepts related to infrastructure would come to light throughout the investigation. The infrastructure of tourism serves as the foundation for tourism and the extraction of the destination’s resources. A wide range of services constitute the infrastructure for tourism, all of which are necessary to satisfy tourists’ demands and enhance their stay. Tourism infrastructure refers to the tangible components specifically constructed and developed to accommodate and cater to tourists. Researchers have demonstrated a strong correlation between the growth of tourism and infrastructure [28,29,30,31].

The study’s findings highlighted the importance of establishing an effective health tourism infrastructure to attract tourists to this region. For example, Siregar et al. (2019) found that public amenities and infrastructure need to be updated to support the development of tourism. Supporting variables such as socio-cultural factors, political conditions, and relationship networks impact the infrastructure and amenities available for growing tourist industry. Conversely, deterrent factors in de development of health tourism include insufficient knowledge, inadequate planning, and limited financial resources [31]. Mandić et al. (2018) report that recreational facilities are a crucial component of physical infrastructure necessary to support both general economic and tourism growth, [29]. Similarly, Ebrahimi et al. (2016) found that key components of this industry’s infrastructure for drawing tourists include the presence of skilled physicians, medical and monitoring infrastructures, medical and health facilities like hospitals and standard clinics, and modern medical equipment. In addition, the provision of lodging options and amenities for patients’ companions, such as hospital hotels, suitable nursing and care services, and prompt monitoring, significantly contributes to the attraction of health tourists [32]. Those who offer services believe that Iran’s health tourism is competitive because of tourist attractions including shopping, and/or sightseeing [18]. Each of these components increases a destination’s competitiveness and appeal, which promotes tourist development.

According to our research, participants believed that human resources had an impact on health tourism and that if a destination had qualified professionals in the field, the tourism industry would grow there. Similarly, Ebrahimzadeh et al.‘s study’s findings demonstrated that interactions between workers in the health tourism industry and possessing communication skills and fluency in another language were crucial in drawing in health tourists to Iran and India [33]. Similarly, Jung et al. emphasized the role of culture and government in attracting health tourists and selecting tourism destinations in the Philippines [34]. Nikraftar and colleagues (2015) highlighted the significance of rules, service availability, and human resources as determining factors for medical tourists selecting Iran as their destination. They also claimed that the financial and economic resources provided by the government, as well as their support, had an impact on tourists’ decisions to revisit tourist destinations [35]. Study conducted by Shafapey et al., identified that two of the most fundamental issues in accepting foreign patients are a Lack of communication skills between the patient and medical personnel, and a lack of availability of a translator [36]. Disparities in capacity, service infrastructure, and human resources may account for the variation in findings across different research, thereby influencing the development of this industry in specific destinations.

Infrastructure for the tourist industry is crucial because it may boost the productivity of production and distribution of tourism services and, in some situations, even lead to an increase in services in remote locations. It is important to remember that the inadequate quality and insufficient infrastructure of the domestic health system prompt health tourists to seek medical care overseas [11, 36]. Because of this, tourists want extra services to help them feel better during their trip, and infrastructure services like communication and waste management are always anticipated as necessary components of a more comfortable location. Tourists also need infrastructure such as public security, transportation services, medical systems, financial systems, educational systems, and other services that are accessible in all cultures and nations [37]. If we view health tourism as a service, infrastructure plays a crucial role as a component of this product and service. The sustained growth and development of health tourism in a particular location relies on the availability of the services these tourists require. A well-planned tourist destination with facilities can lay the foundation for the growth of health tourism. The presence of adequate infrastructure, together with government support, plays a crucial role in offering services and accommodations for health tourists in tourism destinations. This feature is a significant determinant when selecting a tourism destination that has received positive evaluations.

The research revealed that tourism attractions in a place have a significant impact on the rise in the number of health tourists. Prior research has also shown similar findings, indicating that cultural, historical, and natural resources and attractions significantly influence the growth and competitiveness of health tourism destinations [3, 8, 25, 35, 38,39,40,41,42]. In line with the findings of the study by Nikraftar and colleagues (2015), the participants believe that historical, cultural, and religious attractions, natural-environmental resources, security of tourists, variety of services, availability of services, quality of services, ease of travel and geographical proximity, and advertising and marketing have important roles in developing health tourism in tourism destinations. They highlighted the need to access the potential and natural resources of the tourist destination, as well as the presence of medical and general services, in the context of health tourism. A key reason for the slow growth of health tourism in the aforementioned study was a lack of knowledge and an inadequate infrastructure for communication, promotion, and tourist amenities [35]. Furthermore, Hajinejad and colleagues (2015) highlighted in their research the importance of diverse infrastructure and knowledge, supporting the non-governmental sector, and fostering international contact as being crucial to the growth of health tourism in Mashhad [41]. Mahdavi et al. [25] and Mirfakhraldini et al. [42] emphasized the significance of comfort and recreational amenities in the advancement of essential therapeutic tourism. The study by Izadi et al. (2012) mentioned the development of fundamental medical infrastructure, the supply of skilled human resources, securing international credit in health tourism service centers, and effective marketing as contributing factors to the growth of medical tourism [43]. Providing accurate and timely information on health tourism attractions in a place may contribute to a rise in the number of health tourists. The spa and vacation facilities in Mazandaran are renowned and have received both national and international recognition [21]. Destinations catering to health and medical tourism create medical services and initiatives aimed at providing enjoyable and rejuvenating vacations. The main objective of health tourism is to improve one’s health, necessitating service providers to offer supplementary activities that health tourists can engage in to further enhance their health. Furthermore, establishing a robust infrastructure in Mazandaran includes a diverse range of health care programs, such as spas, fitness centers, and meditation centers.

According to the study’s results, the quantity and quality of services supplied, as well as tourists’ sense of security, may all have an impact on the growth of this industry. Prior research has also shown that the amount and quality of treatment impact the growth of health tourism destinations [9, 18, 44,45,46,47]. For example, Heydarzadeh et al. (2017) reported that the quality of tourism services influences both tourist satisfaction and their perception of the destination. This perception, in turn, impacts loyalty towards the destination [46]. As a result, it is advised to provide more high-quality services (in addition to more quantity) to improve health tourists’ trust as well as loyalty to the travel location. In addition, providing a wider range of attractive services increases interest among health tourists in comparison to other locations.

Similar to findings other studies, safety and security emerged as crucial concerns among participants [47,48,49,50,51,52,53]. Ensuring safety and security is fundamental for travel and tourism. Modern tourist destinations must address a spectrum of issues including public safety, political stability, health and sanitation standards, personal data security, legal protection for travelers, consumer rights, communication safety, disaster preparedness, environmental sustainability, access to accurate information, and assurance of service quality [48, 51, 54, 55]. For instance, Rittichainuwat et al. (2018) found that perceptions of a destination’s security directly influence travel decisions, with some travelers opting to delay or cancel trips if they perceive a location to be unsafe [47]. Similarly, Zhang et al., (2018) found that destinations exceeding safety expectations, tend to foster return visits positive word-of-mouth recommendations, and referrals to others [53]. In the study of Andrewik et al. found that security for tourists was a major factor in selecting Japan as a health tourism destination [56]. Zahmatkesh et al. (2020) [55] and Shao et al. (2021) [57] underscored the critical importance of health tourist safety, promoting social and moral security, and providing hospitality. According to Kazemi et al., (2015) social security and adherence to global medical standards are key drivers of health tourism [58]. Tourists’ perceptions are significantly influenced by their recollections of the safety and security they experienced during their trip. They often remember notable safety advantages or services provided at destinations [59]. Travelers’ feedback are likewise a source of information into public perceptions of security before traveling. Research suggests that perceptions of destination security among visitors are dynamic, influenced by various factors such as time-space dimensions, interpersonal communication, and social relationships, rather than being fixed. Engaging with feedback from medical tourists plays a crucial role in enhancing the quality of treatments. In order to achieve success, tourism locations that focus on health tourism must provide superior services to health tourists compared to their competitors. Travel information and security information have an impact on tourist’s choices of destinations and travel behaviors Therefore, tourism entities must remain mindful of these factors influencing visitor behavior.

Similarly to previous research, a number of people highlighted the importance of having accessible services in tourist destinations [10, 18, 25, 28, 60]. This includes making sure that tourism attractions, services, and products are accessible to everyone, regardless of their age, physical barriers, or disability. The goal of accessible tourism is to provide everyone the same opportunity. In this regard, Dias et al., (2022) states that people are more likely to utilize a facility, equipment, service, or resource if it is easily accessible. Customers must actively participate in this, putting themselves at the center and taking responsibility for their own choices [60]. The current study’s findings indicate that the quantity of health tourism services, the utilization of different service types, and the ease of accessing those services all contribute to an increased motivation for tourists to revisit the tourist destination. Additionally, these factors also play a role in promoting to others the desired destination. Accessibility is more than just a tool or technical method; it embodies cultural and attitudinal dimensions that encompass and enhance all aspects of customer convenience. It enhances each tourist’s experience and provides additional benefits across the entire tourism industry [61]. They considered that convenient access to the transportation system, adherence to international tourism standards, the presence of lodging and food supply centers, and the availability of furniture and urban space may significantly contribute to attracting health tourists. These beliefs seem to be consistent among travelers across the globe. A tourist destination must ensure that all visitor can access and enjoy its services and amenities in an equitable, non-discriminatory way to be considered accessible in the broadest sense of the term [62].

The findings also demonstrate the significant influence of tourist destination marketing. This research has highlighted the role of media and different strategies in promoting health tourism destination attractions to tourists, which is similar to previous studies [7, 10, 63]. Growing health tourism skills in tourist destinations via media advertising may effectively attract more tourists. Crooks et al. (2011) found that effectively promoting and delivering accurate information to tourists about health care options, facilities, tourism possibilities, trip planning, and destination nations significantly influences the attraction of health tourists [63]. Hen and Hian (2015) also introduced factors such as quality, satisfaction, trust, and price of health tourism services that are effective in maintaining and returning medical tourists. In their study, they reported that internet advertising has an important effect on the trust in the destination and travel intentions of medical tourists [64]. Therefore, planning and focusing on internal facilities in the field of new information and communication technologies in the field of medicine, as well as improving situational factors, can play a significant role in expanding the health tourism industry and attracting domestic and foreign tourists in this field.

Health tourism is promoted by introducing historical places, hot springs, therapeutic mud, and other natural attractions and establishing informative and promotional infrastructures [25]. According to most of the participants, the historical and natural attractions of Mazandaran are effective to attract health tourists. Similarly, kazemi et al. (2015) reported that tourist attractions are the second most important factor to promote the health tourism industry. [58]. Highlighting the area’s cultural connections would draw tourists, raise foreign funds, and support healthcare infrastructure. Any health tourism marketing plan must convince clients to pick one product or service over another [13, 37]. Thus, health tourism companies must develop clear social media advertisement and employ standards to support the sector’s growth. To attract health tourists, venues must advertise their potential and recreational well-being offerings. Virtual networks, provincial networks, embassies, poster placement on important routes entering and departing the province, and pamphlets and infographics for foreign health tourists may provide this information. Marketing helps all sectors evaluate product features, pricing, strategy, and promotional channels [41]. Additionally, we should implement the chosen strategy based on the prevailing environmental circumstances and the capabilities of specific market segments that are more likely to succeed. We can implement these approaches by clearly defining service pricing, enhancing service quality, strengthening social-cultural capabilities, addressing legal and management factors, adhering to global standards in health tourism facilities, and employing health tourism information technology.

In the present study, we found that socio-cultural contexts [such as cultural similarity and religious similarity] could affect the development of health tourism in destinations, and these factors could result in reactions such as cultural exchanges, hospitality, interaction with health tourists, and even seeking correct information about the nature of health tourism. Furthermore, having various levels of similarity in cultural, religious, values, norms, customs, and language between the origin and the destination in different countries or cities encouraged tourists to visit destinations, develop this industry, and attract health tourists. In fact, culture is the most important factor in developing health tourism [65]. Research has also shown that elements such as similarity in languages, art, cultures, food, and hospitality laws contributed positively to the growth of tourism [12, 66]. According to the findings of Ranjan Debta et al.‘s study, social and cultural variables have been highlighted as significant determinants of health tourists’ destination destinations [67]. Consistent with the findings of research by Nemati et al. [66], Lee et al. [68], and Asaadi et al., [61] the present study addressed cultural, historical, and climatic circumstances and capabilities as effective variables in the development of destination health tourism. As a result, if tourism is properly organized, it can lead to opportunities for socio-cultural interaction since socio-cultural components have different impacts on drawing tourists to a destination. On the other hand, administrators of health tourism must keep in mind that different individuals see various components and subcultures differently. Customs, subcultures, and ethnic-religious similarities all have a significant influence on attracting health tourists [67].

According to research, tourism enhances people’s awareness of diverse cultures through cultural exchange. Tourism also contributes to the survival of local culture by conserving traditional art forms and cultural identity, as well as transmitting cultural values and customs to future generations. The aforementioned themes are essential to the host community; the host community values these subjects, and they enjoy introducing their local culture and traditions to others via the tourist industry, therefore helping to maintain and promote their culture. Tourists’ cultural benefits contribute to the welfare and social belonging of the local community, resulting in the development of the tourist sector in society [3, 18, 25, 69]. The study’s findings highlighted that customer behavior in the health tourism industry is shaped by cultural, social, individual, and psychological factors. therefore, tourists within the social context of the health tourism destinations are not passive but play pivotal roles [36, 57]. As a result, health tourists’ subjective perceptions of the socio-cultural dynamics of a tourism destination significantly influence their decisions to choose, stay, or return to the destination, as well as their likelihood to recommend it to others.

The majority of participants said that economic and financial difficulties are important for developing the health tourism industry in the destination. They stated that having an acceptable service price, a low inflation rate, a high degree of competition, strong investment and privatization of tourism, and convergent insurance services would help them choose a place for their vacation. Several factors influence the competitiveness of health tourism destinations, such as visa costs, travel expenses, health service fees, tour prices, hospitality, the diversity of attractions and facilities, information technology infrastructure, and economic, political and social security, along with comprehensive information about destination attractions [16]. The disparity in the cost of health services between the host city or province and other tourist destinations raises demand for health care. This difference might be attributed to the reduced cost of medical facilities (diagnostic-therapeutic services), which will boost the number of tourists who visit that health-medical service facility. Other research has shown similar findings [3, 6, 18, 21, 24, 30, 39, 43, 70,71,72]. Similarly, the findings of the Forgeon and Smik (2007) research revealed that pricing, accreditation of medical facilities, quality of medical services, and training of hospital personnel, particularly physicians, all influence the choice of health care location [73]. Suess and colleagues (2018) showed in their research that the greater the value of the economic performance of medical tourism, the more they perceived the impacts of medical tourism on the welfare of society. The welfare of society improves as citizens are prepared to pay more taxes and support the growth of medical tourism. Furthermore, the attitude towards medical tourism and the general satisfaction of society play an important part in the influence of medical tourism on the welfare of society [74]. According to Heung et al. (2010), the growth of medical tourism is constrained if there is limited access to financial markets, low confidence on the part of local and foreign investors, complicated tax regulations and procedures, and limited budget allocation [34].

A tourism destination can capitalize on its advantages in health tourism, which include infrastructure for service delivery, affordable costs, high-quality health services, physicians with scientific credentials, and natural attractions [31, 36]. We should conduct ourselves in such a manner that the fees of medical services provide a competitive advantage. We perceive these are good issues since tourists are becoming more aware of the aspects that enhance the health tourism industry and are willing to plan around these key features and components if health tourism trustees discover such critical factors for health tourism growth. In order to establish an efficient health tourism industry, it is critical to create environments for tourists that meet or exceed their expectations while also providing more advantages to locals than charges. This should be linked to the country’s macroeconomic policy via carefully chosen economic and financial plans, as well as proper labor market rules and the government’s external economic performance.

Similar to some studies [3, 10, 11, 22, 25, 75,76,77,78], our findings indicated that the establishment of laws and regulatory policies, health tourism strategies and policies, political stability, inter-organizational and departmental collaboration, the creation of national programs for health tourism, and local, national, and international laws and standards are critical to developing health tourism. Participants indicated various variables for this category, including the establishment and strengthening of health tourism organizations, the development of a national health tourism program, local, national, and international laws and standards, adhering to international standards in health infrastructure, and so on. Furthermore, the current study found that political stability, health tourism policymaking, government support programs, inter-sectoral cooperation, health tourism information management, and interactions with other sources of health tourism from around the world can all help to strengthen and grow the health tourism. For instance, Zhang et al., (2021) reported that socio-political conformity and health consciousness could jointly influence tourists’ health-directed travel choice through changes in their attitudes, subjective norm, and perceived behavioral control [76]. It was also mentioned that using privatization, extensive regional or supplementary insurance coverage, which also affects the formation of the market for such services. According to a study of Sarabi et al., (2021), health tourism-related policies are one of the most important factors in the development of the tourism industry. They believed that in order to ensure that policy decisions are appropriately informed by the most recent scientific and clinical developments in the field and are properly and effectively implemented, regulatory organizations in the setting of health tourism should collaborate significantly with the Ministry of Cultural Heritage, Tourism, and Handicraft Organization of Iran [3]. According to Gonzalez, establishing legislative frameworks for ensuring consumer care and the enjoyment of excellent care services are critical components in the growth of the health tourism industry [62]. According to Forjion and Smik (2007), a country’s unique characteristics, such as economic, political, and legislative policies, have a significant impact on the choice of tourism destination [73].

Study limitations

This study has several limitations. Firstly, the statistical population was limited to residents of Mazandaran Province, potentially limiting the generalizability of their perspectives to other regions and cultures. In future research, it may be useful to conduct qualitative interviews along with quantitative data to explore a broader range of experiences and perspectives across diverse locations and cultures. Additionally, the study’s scope encompassed all forms of health tourism simultaneously. Conducting separate studies on specific categories like medical or preventative tourism, could provide more precise insights into the growth of the health tourism industry in Mazandaran province. Given that our findings stem from a qualitative case study approach, they may not be readily applicable to all segments of health tourism. While qualitative studies aim for transferability rather than generalizability, the concepts and themes identified herein are intended to inform further research rather than serve as a prescriptive model.

Conclusion

The study’s findings revealed that the health tourism industry in Mazandaran, Iran, is influenced by five components: infrastructure and resources, tourist attractions, socio-cultural contexts, economic-financial factors, and political-communication factors. Therefore, it is suggested that tourism destinations, which have different potential capabilities in health tourism, abandon the one-dimensional view of the health issue as the only effective criterion for the development of this industry. Despite the key role of the quantity and quality of health services, which is a necessary condition in attracting health tourists, nowadays even health tourists prefer to pay attention to other facilities in the tourist destination.

Given that the five components identified in the current study were not directly related to the issue of health, it is suggested that managers in this industry focus on infrastructure and resources, tourist attractions, socio-cultural contexts, economic-financial factors, and political-communicative factors. The increasing growth of the number of health tourism service providers has prompted the market to pay greater attention to all aspects of the industry. The interdepartmental structure of the aforementioned components raises interaction and collaboration across executive departments in the development of health tourism. As a result, the present study’s most significant recommendation is to focus on the constructive synergy between health tourism administrators, as well as their engagement, collaboration, and coordination in addressing the diverse demands and needs of health tourists.

We believe that future studies on health services and health tourism should play a crucial role in adapting local drivers for the development of community-based health tourism industries. This can be achieved by identifying additional implications and elements that emerge from the sector’s development processes in nations and states not previously considered. Furthermore, future research can enhance our understanding of of community-based health tourism development through comparative analyses of the specific themes and framework areas. These analyses will shed light on how local contexts influence the unique ways in which these events unfold in different places. Simultaneously, such studies will deepen our understanding of trends that drive the growth of health tourism and their impact on health systems, spite regional variations. Additionally, conducting quantitative studies to validate the consistency of identified dimensions and sub-dimensions, and to assess their significance in motivating demand within this tourist segment, could substantially advance knowledge in this field.

Practical implications

This study explored the perspectives and experiences of three distinct groups within the community: academic professionals in health tourism, managers in health tourism, and health tourist’s .It focused on local drivers in the development of community-based health tourism industries and factors influencing the attraction of health tourism. The five main themes of experiences were (1) infrastructure and resources; (2) tourist attractions; (3) socio-cultural contexts; (4) economic-financial factors; and (5) political-communicative factors. To develop community-based health tourism industry, these themes should be regarded as key components. Therefore, strategic planning for health tourism development should prioritize improvements in these components. Implementing a socio-cultural platform, organizing and training personnel, offering language courses (such as English, Arabic, and Russian), and enhancing economic capacity (such as job creation and regulating service prices) are effective strategies for fostering intermediate levels and influencing growth of the destination’s health tourism sector. Providing timely and high-quality services, improving service delivery efficiency, and appropriate responses to tourists are also vital solutions for enhancing destination attractiveness and advancing health tourism. This study underscores the significant role that these five factors play in the decision-making process of health tourists and the overall growth of the sector. The findings can aid policymakers in developing and implementing policies that enhance health tourism practices. It is crucial to recognize that ensuring safety and security in the tourism industry requires collaboration among various private and public sector stakeholders, each with specific responsibilities and obligations. Further comprehensive studies are needed to pinpoint the root causes of these issues, involving stakeholders such as the local community and tourism provides. Tourists consistently prioritize security and personal safety when selecting travel destinations. By adopting a coordinated approach, the tourism sector can effectively address safety concerns and provide international tourists with a positive and secure experience.”