Journal of Modern Medical

Introduction
Medical tourism is travel for the purpose of treating illness and performing surgery under the supervision of physicians in medical centers. It provides opportunities for physicians to use their potential to provide services to patients in other countries. This has become a multi-billion-dollar business in the world. In addition to providing medical services, medical tourism promotes the prosperity of other areas of tourism such as hoteling and transportation sector. Factors such as providing advanced facilities and high-quality and cost-effective treatments are the most important factors for attracting patients from other countries. Unfortunately, compared to other countries in the Middle East region, Iran does not have a good position in this industry in spite of significant potentials for the development of medical tourism, including the four-season nature, high natural resources, low cost of medical services, good physicians, and successful performance in surgeries at the international level. Countries can achieve more success in medical tourism by providing services with higher quality according to the tourists’ expectations. Sistan and Baluchistan province of Iran has a lot of natural, historical and cultural diversities. The proximity of this province to the countries surround the Persian Gulf, the presence of beautiful beaches in its southern area, and having a prestigious medical university in Zahedan city are among the potentials of this province to attract tourists and become a medical tourism destination, especially in the specialized field of ophthalmology. This study aims to survey the attitudes of the employees towards the status of an ophthalmology hospital in Zahedan in attracting medical tourists.
Methods
This descriptive-analytical cross-sectional study was conducted in 2019 in Al-Zahra Ophthalmology Hospital in Zahedan, Iran. The study population consists of all administrative and clinical staff of the mentioned hospital who had a diploma or higher and were previously in contact with medical tourists. Due to the limited number of the study population, sampling was not done and the census method was used. Finally, 75 people voluntarily participated. The data collection tool was a researcher-made questionnaire that was designed according to previous studies and its validity and reliability were measured. To measure validity, the questionnaire was given to four experts in the field of tourism. After applying corrections based on their comments, the validity was confirmed. The reliability of the questionnaire was measured and a Cronbach’s alpha of 0.83 was obtained. According to the opinion of the experts who participated in the preparation of this questionnaire, a mean score of 1-2.5 shows unfavorable status, a score 2.6-3.5 indicates moderate status, and a score 3.6-5 represents favorable status. The collected data were analyzed in SPSS software, version 22 using Mean±SD, and independent t-test. P<0.05 was considered statistically significant.
Results
Most of the participants in this study (62.7%) were women. The Mean age and Mean work experience of participants were 33.77±7.28 and 11.16±8.42 years, respectively. Most of them (60%) had a bachelor’s degree. The mean score of the possibility of attracting medical tourists by the Ophthalmology hospital was 3.5±0.6. Among the domains, the general condition and the quality of equipment and infrastructure had the highest score, while its geographical condition had the lowest score according to the hospital staff. Moreover, nurses had a more positive perspective than physicians and administrative staff (P=0.01) (Table 1).


Discussion
The status of the ophthalmology hospital in Zahedan in attracting medical tourists was moderate. The general condition of the hospital and its equipment and infrastructure were favorable while its geographical condition was unfavorable. The good reputation of physicians, the quality of medical services, the healthy and clean environment, the quality of medical equipment, having up-to-date medical equipment, and the introduction of specialist doctors and their resume on the website obtained the highest scores, which are important for attracting medical tourists. Therefore, it can be said that the studied hospital has good potential to attract medical tourists in ophthalmology. On the other hand, the lowest scores were related to the recreational facilities to spend leisure time, climate, a restaurant with a food menu, and advertisements for attracting tourists. The hospital managers should try to improve these conditions. Introduction of historical and scenic places as well as tourist attractions of the province on the website of the hospital, coordination with tourism companies to organize recreational tours according to the climate of the province, creating a food menu and improving the quality level of patients’ foods in accordance with their cultures, as well as improving the hospital’s website, both in terms of content and technical issues, and making it trilingual (Persian, English and Arabic) can be effective in improving the status of the hospital in attracting more medical tourists.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Zahedan University of Medical Sciences. (Code: IR.ZAUMS.REC.1395.283).

Funding
This study was extracted from a research project (Code: 8097) in Zahedan University of Medical Sciences and with the financial support of the Research and Technology Vice-Chancellor ofZahedan University of Medical Sciences.

Authors' contributions
Conceptualization: Afsaneh Karimi; Methodology: Yousef Mehdipour; Investigation: Saeid Ebrahimi, Jahanpour Alipour; Writing-original draft: Afsaneh Karimi; Writing-review & editing: all authors; Supervision: Afsaneh Karimi. 

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the managers and staff of Al-Zahra Ophthalmology Hospital in Zahedan who helped us in collecting the required data and information.


References

1. Adrom M, Anvary M, Bostani M. Evaluation of social security sense in tourism development case study; Zahedan city. Res J Agric Biol Sci. 2015; 11(1):5-10. [Link]
2. Hadian M, Jabbari A, Mousavi SH, Sheikhbardsiri H. Medical tourism development: A systematic review of economic aspects. Int J Healthc Manag. 2021; 14(2):576-82. [DOI:10.1080/20479700.2019.1677977]
3. Jabbari A, Gholami M, Kavosi Z, Chamanpara P. [The role of demographic variables on medical tourists’ viewpoints about service quality of hospitals (Persian)]. Hospital. 2016; 15(3):95-102. [Link]
4. Raoofi S, Khodayari-Zarnaq R, Ghasemyani S, Hamidi H, Vatankhah S. Barriers of medical tourism development in Iran. Anatolia. 2022; 33(1):91-103. [DOI:10.1080/13032917.2021.1907760]
5. Soofi S, Aligholi M. [The effect of website promotion three times in increasing the rate of increase between nations and revenue In Bina Ophthalmology Hospital, Tehran (Persian)]. J New Approach Educ Sci. 2022; 4(1):85-94. [Link]
6. Asadi M, Boroumandzad Y, Derakhsh S. [Boosting the presence of foreign health tourists in Yazd, Iran; challenges and solutions (Persian)]. Health Inform Manage. 2019; 16(4):161-7. [Link]
7. Masoud F, Alireza J, Mahmoud K, Zahra A. A systematic review of publications studies on medical tourism. J Educ Health Promot. 2013; 2:51. [PMID] [PMCID]
8. Taghvaei M, Goodarzi M. [Developing and prioritizing the formation of strategies in medical tourism (Case Study: Shiraz Metropolis) (Persian)]. Res Urban Plan. 2016; 7(24):1-22. [Link]
9. Shokohyar S, Kavyani H. [The evaluation of medical tourism centers’ service quality in Tehran city by using fuzzy SERVQUAL approach (Persian)]. Hospital. 2015; 14(2):127-37. [Link]
10. Mosadeghrad AM, Sadeghi M. [Medical tourism: Reasons for choosing Iran (Persian)]. Payesh (Health Monitor). 2021; 20(2):145-66. [DOI:10.52547/payesh.20.2.145]
11. Delgoshaei B, Ravaghi H, Abolhassani N. [Performance analysis of medical tourism in Tehran province from medical tourists and medical services providers’ perspective (Persian)]. Hospital. 2012; 11(1):63-72. [Link]
12. Mosavi-Negad SM, Adeli O, Hariri T, Vali-pour N, Moshkani Z. [The potential of medical tourist’s attraction in hospitals (A case study of a military hospitals in Tehran) (Persian)]. Hospital. 2016; 15(3):63-71. [Link]
13. Snyder J, Crooks V, Turner L. Issues and challenges in research on the ethics of medical tourism: Reflections from a conference. J Bioeth Inq. 2011; 8(1):3-6. [DOI:10.1007/s11673-010-9272-0]
14. Shafiee M, Ghafoori MH, Aboee F, Forootan S, Arab M. [ Evaluation of delivered services among selected hospital wards: A case study using multiple criteria decision making methods (MCDM) (Persian)]. J Hospital. 2017; 15(4):95-102. [Link]
15. Ebrahimzadeh I, Esmaelnejad M. [Analysis of climatic comfort and tourism planning; case study: Sistan and Baluchestan (Persian)]. J Geogr Reg Dev. 2012; 10(1):123-45. [Link]
16. Mir M, Tajzadehnamin AA. Assessing preparation level of medical tourism in Zahedan City. Glob J Manag Bus Res. 2014; 14(F1):27-34. [Link]  
17. Moghadam FN, Masoudi Asl I, Hessam S, Farahani MM. In search a medical tourism marketing pattern in Iran: The case of cultural sensitivities. Int J Healthc Manag. 2021; 14(4):1081-6. [DOI:10.1080/20479700.2020.1732647]
18. Ghasemi M, Nejad MG, Aghaei I. Knowledge management orientation and operational performance relationship in medical tourism (overview of the model performance in the COVID-19 pandemic and post-pandemic era). Health Serv Manage Res. 2021; 34(4):208-22. [PMID]
19. Heydari M, Yousefi M, Derakhshani N, Khodayari-Zarnaq R. Factors affecting the satisfaction of medical tourists: A systematic review. Health Scope. 2019; 8(3):e80359. [DOI:10.5812/jhealthscope.80359]
20. Mahmoudifar Y, Tabibi SJ, Nasiripour AA, Riahi L. Effective factors on the development of medical tourism industry in the West Azerbaijan Province, Iran: Pattern presentation. Int J Med Res Health Sci. 2016; 5(7):620-30. [Link]
21. Naami A, Chatrooz A. [Systematic review of medical tourism in Iran and case study of Tehran University of Medical Sciences (Persian)]. J Payavard Salamat. 2018; 11(5):598-609. [Link]
22. Baghbanian A, Safdari R, Erfannia L, Zokaee M. The medical tourism industry in Iran: A review of websites designed for cross-border patients. Health Scope. 2021; 10(1):e108482. [DOI:10.5812/jhealthscope.108482]
23. Naghipour M, Langarizadeh M, Razzazi M. Identification of the requirements for designing medical tourism information system of Iran. J Educ Health Promot. 2019; 8:118. [PMID]
24. Koyama T, Takahashi K, Takahashi A, Takeda Y. How does a hospital website branding have positive effects of patients visiting and hospital recruitment. J Hosp Manag Heal Policy. 2019; 3(20):1-8. [DOI:10.21037/jhmhp.2019.07.02]
25. Samadbeik M, Asadi H, Mohseni M, Takbiri A, Moosavi A, Garavand A. Designing a medical tourism website: A qualitative study. Iran J Public Health. 2017; 46(2):249-57. [PMID]
26. Hanefeld J, Lunt N, Smith R, Horsfall D. Why do medical tourists travel to where they do? The role of networks in determining medical travel. Soc Sci Med. 2015; 124:356-63. [PMID]
27. Madariaga L, Nussbaum M, Marañón F, Alarcón C, Naranjo MA. User experience of government documents: A framework for informing design decisions. Gov Inf Q. 2019; 36(2):179-95. [DOI:10.1016/j.giq.2018.12.005]
28. Rokni L, Pourahmad A, Moteiey Langroudi MH, Rezaeiy Mahmoudi M, Heidarzadeh N. Appraisal the potential of central Iran, in the context of health tourism. Iran J Public Health. 2013; 42(3):272-9. [PMID]
29. Momeni K, Janati A, Imani A, Khodayari-Zarnaq R, Arab-Zozani M. An analysis of competitive situation medical tourism industry: A case study in northwest Iran. Bali Med J. 2014; 6(2):279-88. [Link]