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Tourism and Hospitality Research

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Investigating healthcare hotel travelers’ ! The Author(s) 2016
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DOI: 10.1177/1467358416670936

cognition, affect, and conation thr.sagepub.com

Heesup Han
College of Hospitality and Tourism Management, Sejong University, Seoul, Korea

Jinsoo Hwang
College of Hospitality and Tourism Management, Sejong University, Seoul, Korea

Abstract
Since there has been little empirical research on the phenomenon of healthcare hotels, this study examined
them in order to provide a clear understanding of these facilities and international medical/healthcare tour-
ists’ overall perspectives on them. A model was developed and tested that integrated conation into an existing
theoretical framework related to image. A field survey was conducted to collect data. A confirmatory factor
analysis was used to evaluate measurement quality, and a structural equation modeling was utilized to test
research hypotheses and achieve study objectives. A series of modeling comparisons using a structural
analysis were conducted. The test results verified the completeness of the proposed model and demonstrated
the superiority of the proposed research framework, which comprises conative image factors as the most
proximal determinants of overall image, over alternative models. In addition, the results of the structural
analysis suggested that cognitive image involving perceived quality and value has a positive impact on affect-
ive image; affective image forms conative images involving visit intention and commitment, and conative
image exerts a positive impact on overall image. Moreover, an examination of the indirect impact of study
variables suggested that affective image and conative image components are necessary mediators in the
model. Theoretical implications and the advertising and marketing implications for practitioners are
discussed.

Keywords
Healthcare hotel, medical tourism, overall image, medical treatment, intention to visit

of accommodations, and food and beverage (F&B)

Introduction
The medical tourism industry is nearly $60 billion-
plus annually, primarily involves international trav-
elers, and has experienced growth of approximately
20% each year (Heung et al., 2011; Yu and Ko,
2012). While medical travel is becoming more and
more popular, medical/healthcare tourists who
engage in it express concerns relating to conveni-
ences (e.g., access to a variety of medical treat-
ment/healthcare clinics from the hotel, language
issues), privacy/confidentiality, medical safety (e.g.,
follow-up care, malpractice), quality of care, quality
for themselves as well as accompanying family/
friends/others (Gan and Frederick, 2011; Reddy
et al., 2010). The healthcare hotel, which is also
known as a medical hotel or Meditel, can be a
great facilitator of international medical tourism
(Han, 2013).
Corresponding author:
Jinsoo Hwang, Faculty of College of Hospitality and Tourism
Management, Sejong University, 98 Gunja, Gwanjin, Seoul
143-747, Korea.
Email: jinsoohwang@hanmail.net
2 Tourism and Hospitality Research 0(0)
Although the phenomenon of the healthcare hotel is
not well documented in the academic literature, it has
made inroads into the popular press. Accounts in these
publications report that this destination is believed to
significantly increase patient travelers’ physical and
psychological conveniences, feelings of privacy/confi-
dentiality, safety, quality of care, comfort, and services
(Han, 2013; Han and Hyun, 2014; Hwang, 2011).
The notion of the healthcare hotel is not yet a heavily
studied topic in the academic literature and, to the best
of our knowledge, little empirical study has appeared
in the hospitality and tourism literature.
It is generally believed that a firm’s overall image is
one of the vital elements in increasing a firm’s com-
petitiveness and encouraging continuous repurchase
(Lee et al., 2010; Lin et al., 2007). Therefore, a
number of studies have dealt with customers’ percep-
tions and images of a product or service. Previous stu-
dies have generally indicated that overall image forms
through two major stages: cognitive and affective
image (Baloglu and McCleary, 1999; Lee et al.,
2010; Lin et al., 2007). That is, the perceptual, cog-
nitive, and affective steps taken by customers in eval-
uating a product or service are essential to shaping
their overall beliefs, ideas, and impressions. However,
it has been argued that overall image formation ignores
individuals’ conative process by mainly involving
intention/commitment (Oliver, 1997), which is a
vital/valuable concept in consumer behavior, and that
conation is occasionally believed to be an outcome
rather than a contributor/predictor of conation. In
addition, in the hospitality industry, even though the
significance of image and conation in explaining cus-
tomer behaviors is well recognized, few studies have
examined overall image formation. For this reason,
there are no detailed explications of how conation pro-
duces customers’ overall image of a product/service.
Further, while previous studies have identified compo-
nents of cognition and conation, cognition and con-
ation were normally utilized in the hospitality/tourism
literature as uni-dimensional constructs in explaining
consumer behaviors.
Considering the points outlined above, in the pre-
sent study, the main purpose was to develop a robust
model that provided a deeper understanding of inter-
national medical travelers’ overall image formation of a
healthcare hotel. In particularly, the present study
attempted to: (1) integrate the conative stage into an
existing socio-psychological theory about overall image
formation, which mainly consists of cognitive and
affective stages; (2) compare the proposed model
with alternative models only involving the original
phases of the existing theory (i.e., cognitive and affect-
ive) and theorizing conation as a function of overall
image; (3) examine the detailed relationships among
components of cognition, affect, and conation, and the
impact of such associations on overall image forma-
tion; and (4) investigate mediating roles of study vari-
ables in generating customers’ overall image of a
healthcare hotel.
Overview of the literature
Healthcare hotels
A healthcare hotel refers to a lodging establishment
that contains a variety of medical/healthcare/aesthetic
facilities and hospitals (Han, 2013). In the increasingly
competitive lodging industry, simply changing a
hotel’s accommodations to make them more appealing
and improving services cannot be the ultimate strate-
gies followed to ensure continued customer attraction
and retention. In recent years, the healthcare hotel has
emerged as a niche market in the lodging industry,
mainly targeting international visitors who want to
obtain medical treatment and healthcare/aesthetic ser-
vices along with traveling opportunities (Han, 2013;
Han and Hyun, 2014). Although the perfect health-
care hotel rarely exists, an increasing number of hotels,
particularly in developing/less developed countries, are
eager to integrate healthcare/medical facilities and ser-
vices into their operations as well as to improve exist-
ing facilities with advanced technology to actively
attract more international medical tourists (Han,
2013; Han and Hyun, 2014). A healthcare hotel pro-
vides not only diverse types of rooms—just like a con-
ventional hotel—but a variety of medical treatment,
healthcare, or aesthetic services for international tour-
ists (KTMA, 2011; Han, 2013; Han and Hyun, 2014).
Overall image formation and its components
Retaining existing customers and attracting new cus-
tomers are hospitality/tourism marketers’ goals since
customer retention and attraction are directly asso-
ciated with a firm’s profit and success (Lee et al.,
2010; Han and Hyun, 2012; Han et al., 2011).
Researchers agree that overall image can have a
major impact on attaining this goal. The topic of over-
all image is, therefore, often preferred in many
researchers. For example, Baloglu and McCleary
(1999) found that, in the tourism context, the percep-
tual/cognitive stage and affective phase, which are the
outcomes of the perceptual/cognitive stage, generate
individuals’ overall conception of image. Lin et al.
(2007) have consistently shown that cognitive and
affective components of image influence travelers’
overall images and their association with a product
preference in natural, developed, and theme park des-
tination settings. In a hotel setting, Lee et al. (2010)
Han and Hwang
reported that cognitive factors of image and affective
image impact customers’ overall image of a hotel prod-
uct/service. These studies all centered on previous
knowledge/information and pleasurable feelings of ful-
fillment about a product/service in shaping overall
notions of image. Many researchers in diverse fields
have agreed that such perceptual/cognition stage
mainly comprises the functional and psychological
aspects of perceived value and quality (Back, 2005;
Han and Hyun, 2012; Han et al., 2011), and affect
mainly involves one’s emotional responses that contain
feelings or pleasurable fulfillments of a specific prod-
uct/service (Bagozzi, 1978; Oliver, 1997, 1999).
However, the common agreement among many
researchers in diverse fields is that the conative
aspect is also critical in shaping individuals’ psycho-
logical processes—this includes decision/image forma-
tion (Evanschitzky and Wunderlich, 2006; Han and
Hyun, 2012; Han et al., 2011; Oliver, 1997, 1999).
Conation can be described as ‘‘intention or commit-
ment to behave toward a goal in a particular manner’’
(Oliver, 1997: 393). Such conation contains two major
factors (i.e., commitment and intention) (Han et al.,
2011; Oliver, 1997, 1999). Researchers have verified
that employment of three phases, including cognitive,
affective, and conative, is essential to understanding
customers’ psychological process/decision/behavior
related to various products/services. These researchers
have insisted that conation is a direct function of affect
in shaping attitudes and individuals’ purchasing-
related psychological processes. Specifically, in exam-
ining customers’ attitude development structure,
Oliver (1997, 1999) theorized that one’s attitude
toward a product/service develops through cognitive,
affective, and conative manners. This conative phase,
which is mainly comprised of intentions/commitment,
is a vital element in attitudinal structure along with
cognitive and affective phases. His finding was sup-
ported by many recent studies. For instance,
Evanschitzky and Wunderlich (2006) and Han et al.
(2011) stated that considering cognition and affect as
well as conation are vital to explicitly comprehending
customers’ psychological processes related to a prod-
uct/service. Their findings implied the conceptual ade-
quacy of comprehensively integrating conation into an
existing bi-dimensional image model that involves cog-
nitive and affective components.
Cognitive dimension and its impact
The term, cognition, refers to one’s perceptions/know-
ledge/beliefs about a particular product, its attributes,
and its performances (Baloglu and McCleary, 1999;
Oliver, 1997). This cognition mainly comprises such fac-
tors as functional and psychological facets of value and
3
perceived quality (Back, 2005; Han et al., 2011).
Zeithaml (1988) indicated this value as one’s comprehen-
sive evaluation of the utility of a product/service rooted in
the perceptions of what is obtained and given; Bitner and
Hubbert (1994) described this perceived quality as one’s
overall perception of the relative superiority or inferiority
of a product and the performances of its attributes. The
criticality of cognition and its constituents in product/ser-
vice consumers’ psychological process is often stressed by
researchers. For instance, Baloglu and McCleary (1999)
asserted that cognitive factor and its components are
direct drivers of affective image. Lee et al. (2010) also
indicated that cognition exerted a significant influence
on affective image playing a vital role in generating hotel
customers’ eco-friendly purchasing behaviors.
Consequently, it was hypothesized that:
H1: Increases in perceived value lead to increased
affective image.
H2: Increases in perceived quality lead to increased
affective image.
Affective factor and its impact
Affect is another crucial construct in one’s image for-
mation. According to Lee et al. (2010) and Lin et al.
(2007), affective image is central in building one’s
favorable overall image and decision for a firm.
Affect comprises individuals’ emotional responses,
which include pleasurable fulfillments/feelings when
using a specific product/service (Bagozzi, 1978;
Oliver, 1999). Lin et al. (2007) demonstrated that
affect generates overall image and contributes to
better predicting travelers’ choice/preference across
natural, developed, and theme-park destinations. In a
green lodging sector, Lee et al. (2010) also verified
that affect, which is a significant function of cognitive
image, has a key role in triggering patrons’ overall
image and behavioral intentions. Moreover, in a res-
taurant sector, Han et al. (2011) demonstrated that
affective process exerted a significant influence on
patrons’ commitment and revisit intention. These
researchers’ general agreement is that conative image
constituents (e.g., intention, commitment, choice, and
preference) in the overall image (or decision) forma-
tion for a product/service are often induced by affect.
It was therefore hypothesized that:
H3: Increases in affective image lead to increased visit
intention.
H4: Increases in affective image lead to increased
commitment.
4 Tourism and Hospitality Research 0(0)
Conative dimension and its impact
The term, conation, is also an essential concept in explain-
ing one’s psychological decision-making process related to
consumption (e.g., Han and Hyun, 2012; Oliver, 1999).
Oliver (1997) defined conation as one’s commitment or
intention to act toward a goal in a specific manner. As this
definition indicates, intention and commitment are two
core components of conation (Han et al., 2011; Oliver,
1999). While some researchers utilized conation as a uni-
dimensional construct (Back and Parks, 2003), a two-
dimensional view of conation comprising commitment,
and intention is believed to capture the construct more
explicitly (Han et al., 2011). The conative process con-
taining both commitment and intention is often found to
be influenced by affect (Han et al., 2011). According to
Han and Hyun (2012), conation is a significant and posi-
tive function of affect in one’s decision-making process
related to consumption. Their finding also indicated
that cognition also significantly influences conation indir-
ectly through affect. Similarly, in building a theoretical
framework explicating tourists’ behavioral intention,
Baloglu (1999) identified that cognitive evaluation deter-
mines tourists’ affective evaluation (e.g., feelings-related
evaluation) about travel destination, and this affective
factor increases their intention to travel to the place,
which is a vital constituent of conative image. Therefore,
it was hypothesized that:
H5: Increases in visit intention lead to increased over-
all image.
H6: Increases in commitment lead to increased overall
image.
Cognitive Image
Perceived
Value
H1 H3
Affective
Image
H4
H2
Perceived
Quality
Figure 1. Proposed model.
Conceptual model
According to the view in the literature discussed above,
individuals’ psychological decision-making process or
thought development process related to consumption
proceeds through cognitive stage, affective phase, and
conative stage in a sequential manner. Hence, we put
forth that the overall image forms through cognitive,
affective, and conative processes. The proposed model
is exhibited in Figure 1. This model comprises a total
of six hypotheses.
Methods
Measures and questionnaire development
The initial questionnaire comprised an introductory
cover letter, definition of the concept of a healthcare
hotel, questions relating to the variables to be studied,
and questions for a demographic profile of each par-
ticipant. The questionnaire was based on the existing
literature (e.g., Baloglu and McCleary, 1999; Han
et al., 2010; Kim and Han, 2008; Lee et al., 2010;
Morgan and Hunt, 1994; Oh, 2000; Varki and
Colgate, 2001) and refined to be adequate in a health-
care hotel setting. Multi-item scales were consistently
used to measure study variables. In addition, a seven-
point Likert-type scale from ‘‘Extremely disagree’’ (1)
to ‘‘Extremely agree’’ (7) was used for cognitive com-
ponents of image, conative image components, and
overall image. For affective image, four bipolar scales
were used (e.g., ‘‘Arousing’’ – ‘‘Sleepy’’). The initial
questionnaire was altered and perfected through a hos-
pitality and tourism expert review and a pre-test. As a
Conative Image
Intention to
Visit
H5
Overall Image
about a
Healthcare Hotel
H6
Commitment
Han and Hwang
next step, the original English version of the survey
questionnaire was translated into Chinese, Japanese,
and Korean employing a blind translation-back-trans-
lation method (Brislin, 1976) in that a majority of
international travelers using an international airport
in Busan, Korea spoke one of these languages. The
content validity of the translated questionnaires was
ensured in a review by hospitality and tourism experts
who use one of these as a native language. Measures
used in the present study are shown in Appendix 1.
Data collection
The sample population consisted of international trav-
elers who had had previous medical/healthcare tourism
experiences abroad. These travelers were expected to
provide more pragmatic judgments and opinions on
the survey, as their likelihood of international travel
for medical treatment/healthcare and staying at a
healthcare hotel would be higher than that of traditional
tourists. The data were collected at an international air-
port located in a metropolitan city, South Korea.
Potential respondents were initially screened by asking
if they had had any previous experience traveling abroad
for medical treatment or healthcare/aesthetic services.
Only travelers who had experienced medical/healthcare
tourism were invited to fill out the questionnaire. Well-
trained students provided a brief explanation about the
objectives of the study to international travelers who
were in the rest areas near the boarding gates. These
travelers were approached during their waiting times for
flights. The survey questionnaires were collected onsite
to enhance return and usable rates. About 700 ques-
tionnaires were distributed. Among them, a total of 423
completed and usable questionnaires were returned
through this process (the response rate ¼ 60.4%).
After removing five extreme multivariate outliers
(Mahalanobis’ D (17) > 40.790, p < .001), 418
responses remained for data analysis. A common
method bias was checked by using Harmon’s single-
factor test (Podsakoff and Organ, 1986). Our results
indicated that the total variance explained by common
factor was about 40.1%, which was lower than the
problematic level of .50.0% (Podsakoff and Organ,
1986). This finding implied that the common method
variance was not a critical issue in the present study.
Sample characteristics
Among the 418 survey participants, 59.0% were
female. Their mean age, which ranged from 20 to 65,
was 31.8 years old. While about 60.5% of the partici-
pants reported that their annual household incomes
were under $40,000, about 39.5% described their
household incomes as being over $40,001. The greatest
5
proportion of the participants (31.9%) reported that
their purpose in traveling at this time was pleasure
(39.5%), followed by business (20.5%), study
(13.7%), medical treatment/healthcare (12.9%), other
(12.7%), and conference (.7%). Of the respondents, a
total of 74.5% were Asians; 16.9% were Caucasian/
White; 3.4% were Polynesian/Pacific Islander; 2.9%
were Black; and 2.4% were others. The respondents
were from 22 different countries. The largest group
was Koreans (29.4%), followed by Japanese (24.9%),
Chinese (22.6%), Americans (11.6%), Filipinos
(2.8%), Singaporeans (1.5%), Russians (1.3%), etc.
The highest frequency of medical/healthcare tourism
experiences within the last five years was two times
(38.5%), followed by once (34.7%), three times
(23.9%), etc. In addition, 43.8% said that their latest
medical/healthcare travel was within the last six months,
74.9% reported that it had been within two years.
Lastly, about 34.4% of the participants indicated ever
having heard of a healthcare hotel, and only 17.2%
reported ever having stayed at a healthcare hotel.
Results and findings
Measurement model and validity testing
This study utilized SPSS and AMOS 5 to analyze the
data. A measurement model using the confirmatory
factor analysis (CFA) was estimated to test the overall
fit of the proposed measurement structure and to assess
reliability and validity. Table 1 presents the findings
from the measurement model. The results demon-
strated acceptable overall fit (2 ¼ 198.657, df ¼ 87,
p < .001, RMSEA ¼ .055, CFI ¼ 0.982, NFI ¼ .968,
GFI ¼ .944). Composite reliability was evaluated to
ascertain the consistency of the multi-items for each
construct. All reliability values ranging from .890 to
.930 were acceptable. In the next step, construct valid-
ity (i.e., convergent and discriminant) was evaluated for
all constructs in the measurement model. As shown in
Table 1, average variance extracted (AVE) ranging from
.734 to .816 exceeded the minimum suggestion of .500
found in the literature (Fornell and Larcker, 1981; Hair
et al., 1988). Thus, convergent validity was wholly
established. Next, also as seen in Table 1, the squared
correlation values between constructs were less than the
AVE of each variable, providing evidence for the dis-
criminant validity of the study constructs (Fornell and
Larcker, 1981; Hair et al., 1988).
Structural model and modeling
comparisons
Since the utilization of structural equation modeling
(SEM) is effective for the simultaneous assessment of
6 Tourism and Hospitality Research 0(0)

Table 1. Summary of the confirmatory factor analysis.

Perceived Perceived Affective Intention Overall image about

Constructs value quality image to visit Commitment a healthcare hotel

Perceived value 1.00

Perceived quality .789 (.623) 1.00
Affective image .579 (.335) .561 (.315) 1.00
Intention to visit .651 (.424) .630 (.397) .571 (.326) 1.00
Commitment .737 (.543) .762 (.581) .574 (.329) .634 (.402) 1.00
Overall image about a .670 (.449) .646 (.417) .624 (.389) .687 (.472) .624 (.389) 1.00
healthcare hotel
Mean 4.061 4.057 4.143 3.865 4.025 4.139
Composite reliability .892 .890 .928 .904 .895 .930
AVE .734 .801 .811 .759 .810 .816
Goodness-of-fit statistics:
2 ¼ 198.657 (df ¼ 87, p < .001), RMSEA ¼ .055, CFI ¼ .982, NFI ¼ .968, GFI ¼ .944.
Note. Squared correlations are in the parentheses.

the entire theoretical framework (Hair et al., 1998;
Tabachnick and Fidell, 2007), our proposed model
was estimated using the SEM. In particular, a covar-
iance-based SEM was utilized. The use of the covar-
iance-based SEM is adequate for theory testing (or
theoretical framework development) and comparison
of alternative models/theories (Hair et al., 2011) like
the present study. The results indicated that the model
satisfactorily fit the data (2 ¼ 277.175, df ¼ 94,
p < .001, RMSEA ¼ .068, CFI ¼ 0.970, NFI ¼ .966).
Prior to testing the hypothesized associations among
study variables, this model was compared with two
alternative models to determine the best model with
the most excellent model fit and predictive ability. As
discussed earlier, previous studies indicated that over-
all image formation is mainly a function of cognition
and affect (e.g., Baloglu and McCleary, 1999; Lin
et al., 2007). In addition, unlike our proposed frame-
work, some researchers indicated that overall image is
a direct predictor of such conative components as
behavioral intentions (e.g., Han et al., 2009; Lee
et al., 2010). Thus, the first alternative model only
involves perceived value, perceived quality, affective
image, and overall image, and the second alternative
model locates overall image as an antecedent of cona-
tive components. These models are presented in
Figure 2. The fit of both alternative models was
acceptable (Alternative model 1: 2 ¼ 172.502,
df ¼ 37, p < .001, RMSEA ¼ .074, CFI ¼ 0.968,
NFI ¼ .960; Alternative model 2: 2 ¼ 449.557,
df ¼ 95, p < .001, RMSEA ¼ .078, CFI ¼ 0.943,
NFI ¼ .929). In comparing three models, the proposed
model had better explanatory power for overall image
(R2 ¼ .630) than alternative models (Model 1:
R2 ¼ .521; Model 2: R2 ¼ .574). In addition, as
shown in Table 2, the fit statistics of the proposed
model were superior to the alternative models. The
Chi-square differences between the proposed model
and the alternative model 1 (
2 (57) ¼ 104.673,
p < .01) and between the proposed model and the
alternative model 2 (
2 (1) ¼ 172.382, p < .01)
were significant. That is, the proposed model, which
involves conative components and uses them as direct
predictors of overall image, is also statistically and sig-
nificantly better than the alternative models.
As a next step, the proposed relationships were
assessed. First, Hypotheses 1 and 2, in which the
direct impact of perceived value and quality on affect-
ive image were hypothesized, were tested. Both path
coefficients were positive and significant (H1:
b ¼ .478, p < .01; H2: b ¼ .466, p < .01), thus support-
ing Hypotheses 1 and 2. Hypotheses 3 and 4 were
tested to determine if affective image has a positive
influence on conative components. The path coeffi-
cients from affective image to visit intention and com-
mitment were positive and significant (H3: b ¼ .803,
p < .01; H4: b ¼ .898, p < .01), supporting Hypotheses
3 and 4. Hypotheses 5 and 6 were assessed. As
expected, the linkages from visit intention and com-
mitment to overall image about a healthcare hotel were
positive and significant (H5: b ¼ .528, p < .01; H6:
b ¼ .320, p < .01). Cognitive image components
explained about 80.3% of the variance in affective
image, and this affective image accounted for 64.4%
and 84.2% of the total variance in visit intention and
commitment, respectively. The model involving cogni-
tive, affective, and conative image well predicted an
overall image of a healthcare hotel (R2 ¼ .630).
Lastly, the indirect impacts of study variables were
examined. In particular, bootstrapping was utilized to
Han and Hwang 7

Cognitive Image Conative Image

FIGURE 2.1
Perceived Intention to
Value
Proposed Model Visit
.478** .528**
..803**
R2 = .863 R2 = .630
R2 = .644
Affective Overall Image
Image about a
Healthcare Hotel
R2 = .842

.466** .898** .320**

Perceived Commitment
Quality ** p < .01

Goodness-of-fit statistics: χ2 = 277.175 (df = 94, p <

.001), RMSEA = .068, CFI = .970, NFI = .966
Cognitive Image
FIGURE 2.2
Perceived Alternative Model 1
Value
.662**

R2 = .496 R2 = .521

Affective .875** Overall Image

Image about a
Healthcare Hotel
** p < .01
Perceived .178**
Quality Goodness-of-fit statistics: χ2 = 172.502 (df = 37, p <
.001), RMSEA = .074, CFI = .968, NFI = 0.960

Cognitive Image FIGURE 2.3 Conative Image

Alternative Model 2
Perceived Intention to
Value Visit
.634**
R2 = .496 R2 = .574
.794** R2 = .631
.735**
Affective Overall Image
Image about a
Healthcare Hotel
R2 = .562
.750**
.221**
Perceived Commitment
Quality
** p < .01
Goodness-of-fit statistics: χ2 = 449.557 (df = 95, p <
.001), RMSEA = .078, CFI = .943, NFI = .929

Figure 2. Results of the proposed and alternative models.

identify the mediating effect of research variables. This

method is a widely accepted way to test the mediating
role of constructs. As shown in Table 3, our findings
from bootstrapping revealed that perceived value
and quality had a significant impact on a healthcare
hotel’s overall image through affective image and cona-
tive image components (p < .01). In addition, affective
image had a significant indirect impact on overall
image (p < .01). Overall, these results indicated that
both affective and conative image components acted
as significant mediators in the proposed theoretical
model.
Discussion
According to the existing conceptual frameworks/the-
ories, overall image forms through cognitive and affect-
ive evaluation processes. In particular, many image
studies focused mainly on cognition and affect as
direct indicators of overall image (e.g., Baloglu and
McCleary, 1999; Lin et al., 2007). In addition, many
theoretical frameworks in the previous literature con-
sider overall image as a predictor of conation mainly
involving behavioral intentions (e.g., Lee et al., 2010;
Lin et al., 2007). However, researchers from various
8 Tourism and Hospitality Research 0(0)

Table 2. Modeling comparisons and goodness-of-fit statistics.

Fit indices Suggested Proposed Alternative Alternative

and R2 value model model 1 model 2

2 277.175 172.502 449.557

Df 94 37 95
2/df  5 2.949 4.662 4.732
RMSEA  .08 .068 .074 .078
CFI  .90 .970 .968 .943
NFI  .90 .966 .960 .929
Adjusted R2:
Overall Image about .630 .521 .574
a Healthcare Hotel
Note. Suggested values were based on Hair et al. (1998).

Table 3. Final model – Hypotheses testing and structural model results.

Independent variable ! Standardized

Hypothesis Dependent variable coefficient t-value

H1 Perceived value ! Affective image .478 3.144**

H2 Perceived quality ! Affective image .466 3.070**
H3 Affective image ! Intention to visit .803 11.594**
H4 Affective image ! Commitment .898 12.913**
H5 Intention to visit ! Overall image .528 8.203**
H6 Commitment ! Overall image .320 5.203**
Goodness-of-fit statistics: 2 ¼ 277.175 (df ¼ 94, p < .001), RMSEA ¼ .068, CFI ¼ .970, NFI ¼ .966
Total variance explained: Standardized indirect impact of variables:
R2 of affective image ¼ .863 b perceived value ! affective image ! visit intention and
commitment ! overall image ¼ .343**
R2 of intention to visit ¼ .644 b perceived quality ! affective image ! visit intention and
commitment ! overall image ¼ .334**
R2 of Commitment ¼ .842 b affective image ! visit intention & commitment ! overall
R2 of overall image ¼ .630 image ¼ .417**
**p < .01.

fields have indicated that customers’ psychological pro-
cess can be better explicated when the conative phase is
involved (e.g., Evanschitzky and Wunderlich, 2006;
Han et al., 2011; Oliver, 1997, 1999). Findings of the
present research were of great importance since it pro-
vided a clue for such theoretical conflict. In particular,
our empirical demonstration contributes to the litera-
ture by successfully theorizing that conation is essential
in explaining consumers’ psychological process, and the
effectiveness of this variable is maximized when utilizing
it as an outcome of cognition/affect and as a direct pre-
dictor of overall image.
The previous approach can be criticized in that the
complicated procedure of image formation cannot be
solely explained by the use of a single dimensional
approach that combines components of cognition/con-
ation into one comprehensive construct (Han et al.,
2011; Lee et al., 2010). To avoid such criticism of a
single dimensional approach, the present study exam-
ined the independent role of each component of the
cognitive and conative images. As indicated by the
excellent fit of the proposed model (2 ¼ 277.175,
df ¼ 94, p < . 001, RMSEA ¼ .068, CFI ¼ 0.970,
NFI ¼ .966) and path coefficients relating components
of cognitive and conative images to other study vari-
ables, this study verified the adequacy of the utilization
of a bi-dimensional model involving cognitive and
conative image components in explaining overall
image formation. Researchers should consider utiliz-
ing a bi-dimensional (or even multi-dimensional)
Han and Hwang
approach in the cognitive and conative phases of over-
all image formation and using possible associations
between the components of these phases and other
critical variables when developing a model/theoretical
framework for overall image.
In our theoretical framework, a prominent role of
affective image was identified. In particular, the impact
of affective image on outcome variable(s) was substantial
not only in the proposed model but also in alternative
models. As demonstrated in this study, affective image
significantly triggers such conative image factors as visit
intention and commitment, which are most proximal
determinants of overall image. On the whole, our
result informs industry practitioners that providing
favorable affective experiences to patient travelers is an
essential process to build strong commitment and inten-
tion and to form a positive overall image about a health-
care hotel. Given this, diverse endeavors should be made
for the enhancement of healthcare hotel travelers’ affect-
ive experiences. According to Han et al. (2015), one of
the important benefits that medical travelers are likely to
expect from healthcare/medical lodging accommoda-
tions is that they can receive medical treatment and
healthcare/aesthetic services within a hotel. Offering
high quality encounter services and physical environ-
ments (décor, music, lighting, colors, plants, quality of
furniture, aroma, overall layout, air quality, paintings,
etc.) would be an effectual way to elicit travelers’ positive
affective experiences, which ultimately contributes to
enhancing conative and overall images regarding health-
care hotels.
In the proposed theoretical model, the important
role of perceived value and perceived quality was
empirically identified. In other words, the enhance-
ment of these constructs is essential to building a posi-
tive overall image of a healthcare hotel. From the
managerial aspect, it is indispensable to increase and
offer diverse benefits or advantages that are not easily
available in other healthcare or medical clinics.
Providing an inclusive value package containing
choices for various healthcare/medical/aesthetic treat-
ments, airline ticket, meals, and hotel room, and meals
within one property and offering hotel-style services/
products comprising upscale F&Bs and hotel rooms
for overseas patient customers and their accompanying
friends/family can be the good examples of such bene-
fits or advantages. Moreover, the existing benefits or
advantages of a healthcare lodging firm should be
extensively advertised for the enhancement of cogni-
tive image of a firm. In particular, such advertising
endeavors may help overseas patient travelers believe
that experiencing diverse healthcare/aesthetic services
and receiving medical treatments at a healthcare hotel
facility are valuable, which eventually contributes to
improving the firm’s overall image.
9
The present study identified a significant mediating
impact of affective image and conative image compo-
nents. This result is consistent with previous studies
that emphasized the significance of affect and conation
as mediators (Evanschitzky and Wunderlich, 2006;
Han et al., 2011; Oliver, 1997, 1999). Our findings
implied that the enhancement of these variables is
essential to magnifying the role of cognitive image
components in international travelers’ favorable over-
all image of a healthcare hotel. Hospitality and tourism
researchers should carefully develop a conceptual
framework about overall image formation that includes
this result. For practitioners in the healthcare hotel
industry, a simultaneous effort to increase perceived
value and quality as well as to enhance affective
image and conative image is recommended for the
effective improvement of their hotel’s image.
Conclusion
This study was designed to advance earlier conceptual
frameworks related to overall image by developing and
testing a theoretical model comprising cognitive,
affective, and conative image as these influence health-
care hotel residents’ perceptions of this location. A
series of modeling comparisons verified the superior
ability of our proposed theoretical model to predict
overall image, compared with alternative models.
The hypothesized associations were all supported. In
particular, cognitive image components (perceived
value and quality), affective image, and conative
image components (visit intention and commitment)
in the formation of overall image for a healthcare hotel
were all significantly and highly associated.
Overall, our findings suggested the following
sequence of psychological processes in forming overall
image: Briefly, international medical/healthcare tour-
ists initially form a cognitive image of a healthcare
hotel based on their general perception of its quality
and value; this image shapes their emotional states
about this hotel; they then form a certain level of behav-
ioral intention and commitment based on these affect-
ive states; and lastly, such intention and commitment
eventually result in a favorable/unfavorable image of a
healthcare hotel as a place to obtain medical treatment,
healthcare, or aesthetic services. Although medical
tourism is in rapid growth (Heung et al., 2011;
Jackson and Barber, 2015), the phenomenon of health-
care hotels is not sufficiently examined in previous stu-
dies. The proposed model is theoretically and
practically meaningful since the framework provides a
new insight to existing theories about overall image for-
mation. In reflecting on study findings relating to the
development or extension of a theoretical/conceptual
framework, it can be concluded that the employment
10
of the consecutive overall image formation through cog-
nitive, affective, and conative processes is critical and
effective when conducting image-related research in a
medical tourism sector.
Limitations and future research
This study had several limitations. None of the correl-
ations among constructs exceeded Hair et al.’s (1998)
cut-off of .80. However, some correlations were com-
paratively high (e.g., correlation between value and
quality ¼.789). A thorough study design in future
research is necessary to completely avoid the multicol-
linearity issue. All study variables were assessed using
measures designed to be adequate in a healthcare hotel
setting. Hospitality and tourism researchers who
employ and directly apply our conceptual framework
to other situations should do so carefully. As discussed
earlier, one of the greatest advantages of a healthcare
hotel for customers is conveniences. Identification of
the detailed components of conveniences (e.g., physical
convenience, time and effort saving, language/commu-
nication) through a qualitative approach would be
meaningful in future studies. In addition, examining
the possible associations between such convenience fac-
tors and conceptual variables in the proposed model
would be an interesting extension of this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
Back K (2005) The effects of image congruence on customers’
brand loyalty in the upper middle-class hotel industry. Journal
of Hospitality and Tourism Research 29(4): 448–467.
Back K and Parks SC (2003) A brand loyalty model involving cog-
nitive, affective, and conative brand loyalty and customer satis-
faction. Journal of Hospitality and Tourism Research 27(4):
419–435.
Bagozzi RP (1978) The construct validity of the affective, behav-
ioral, and cognitive components of attitude by analysis of covari-
ance structures. Multivariate Behavioral Research 13: 9–31.
Baloglu S (1999) A path analytic model of visitation information
involving information sources, socio-psychological motivations,
and destination image. Journal of Travel and Tourism Marketing
8(3): 81–90.
Baloglu S and McCleary KW (1999) A model of destination image
formation. Annals of Tourism Research 32(2): 94–104.
Bitner MJ and Hubbert AR (1994) Encounter satisfaction versus
overall satisfaction versus quality. In: Rust RT and Oliver RL
(eds) Service Quality: New Directions in Theory and Practice.
London, UK: Sage, pp. 72–94.
Tourism and Hospitality Research 0(0)
Brislin RW (1976) Comparative research methodology: Cross-cul-
tural studies. International Journal of Psychology 11(3):
215–229.
Evanschitzky H and Wunderlich M (2006) An examination of mod-
erator effects: The four stage loyalty model. Journal of Service
Research 8(4): 330–345.
Fornell C and Larcker DF (1981) Evaluating structural equation
models with unobservable variables and measurement error.
Journal of Marketing Research 18: 39–50.
Gan LL and Frederick JR (2011) Medical tourism facilitators:
Patterns of service differentiation. Journal of Vacation Marketing
17(3): 165–183.
Hair JF, Anderson RE, Tatham RL, et al. (1998) Multivariate Data
Analysis, 8th ed. Upper Saddle River, NJ: Prentice-Hall.
Hair JF, Ringle CM and Sarstedt M (2011) PLS-SEM: Indeed a silver
bullet. Journal of Marketing Theory and Practice 19(2): 139–151.
Han H (2013) The healthcare hotel: Distinctive attributes for inter-
national medical travelers. Tourism Management 36: 257–268.
Han H, Hsu L and Lee J (2009) Empirical investigation of the roles
of attitudes toward green behaviors, overall image, gender, and
age in hotel customers’ eco-friendly decision-making process.
International Journal of Hospitality Management 28: 519–528.
Han H, Hsu L and Sheu C (2010) Application of the theory of
planned behavior to green hotel choice: Testing the effect of envir-
onmental friendly activities. Tourism Management 31: 325–334.
Han H and Hyun S (2012) An extension of the four-stage loyalty
model: The critical role of positive switching barriers. Journal of
Travel and Tourism Marketing 29: 40–56.
Han H and Hyun S (2014) Medical hotel in the growth of global med-
ical tourism. Journal of Travel and Tourism Marketing 31: 366–380.
Han H, Kim Y, Kim C, et al. (2015) Medical hotels in the growing
healthcare business industry: Impact of international travelers’
perceived outcomes. Journal of Business Research 68: 1869–1877.
Han H, Kim Y and Kim E (2011) Cognitive, affective, conative, and
action loyalty: Testing the impact of inertia. International Journal
of Hospitality Management 30: 1008–1019.
Heung VCS, Kucukusta D and Song H (2011) Medical tourism
development in Hong Kong: An assessment of the barriers.
Tourism Management 32: 995–1005.
Hwang T (2011) The first ‘‘hospital + hotel’’ in Busan. Medipana.
Available at: https://ibis.ambatel.com/frontsite/busan/Default.aspx?
HC ¼ 20andlanguage ¼ KR (accessed 10 September 10 2015).
Jackson LA and Barber DS (2015) Ethical and sustainable health-
care tourism development: A primer. Tourism and Hospitality
Research 15(1): 19–26.
Kim W and Han H (2008) Determinants of restaurant customers’
loyalty intentions: A mediating effect of relationship quality.
Journal of Quality Assurance in Hospitality and Tourism 9(3):
218–238.
KTMA (2011, December) Anti-aging clinic for rich Chinese visitors
in Ritz-Carlton, Seoul. Meditimes, Korea Medical Tourism
Association. Available at: www.meditimes.kr/news (accessed 10
September 2015).
Lee J, Hsu L, Han H, et al. (2010) Understanding how consumers view
green hotels: How a hotel’s green image can influence behavioral
intentions. Journal of Sustainable Tourism 18(7): 901–914.
Lin C, Morais DB, Kerstetter DL, et al. (2007) Examining the role
of cognitive and affective image in predicting choice across nat-
ural, developed, and theme-park destinations. Journal of Travel
Research 46: 183–194.
Morgan RM and Hunt SD (1994) The commitment-trust theory of
relationship marketing. Journal of Marketing 58: 20–38.
Oh H (2000) The effect of brand class, brand awareness, and price
on customer value and behavioral intentions. Journal of
Hospitality and Tourism Research 24(2): 136–162.
Han and Hwang 11

Oliver RL (1997) Satisfaction: A Behavioral Perspective on the

Consumer. New York, NY: McGraw-Hill.
Oliver RL (1999) Whence consumer loyalty? Journal of Marketing
63: 33–34.
Podsakoff PM and Organ DW (1986) Self-reports in organizational
research: Problems and prospects. Journal of Management 12(4):
531–544.
Reddy SG, York VK and Brannon LA (2010) Travel for treatment:
Students’ perspective on medical tourism. International Journal of
Tourism Research 12: 510–522.
Tabachnick BG and Fidell LS (2007) Using Multivariate Statistics.
Boston, MA: Pearson.
Varki S and Colgate M (2001) The role of price perceptions in an
integrated model of behavioral intentions. Journal of Service
Research 3(3): 232–240.
Yu J and Ko T (2012) A cross-cultural study of perceptions of med-
ical tourism among Chinese, Japanese and Korean tourists in
Korea. Tourism Management 33: 80–88.
Zeithaml VA (1988) Consumer perceptions of price, quality, and
value: A means-end model and synthesis of evidence. Journal
of Marketing 52: 2–22.
Author Biographies
Heesup Han is a Professor in the College of
Hospitality and Tourism Management at Sejong
University, Korea. His research interests include air-
line, medical tourism, green hotels, and hospitality and
tourism marketing. His papers have been selected as
the most downloaded and read articles in many top-
tier hospitality and tourism journals.
Jinsoo Hwang is an assistant professor in the College
of Hospitality and Tourism Management at Sejong
University, Korea. He received his Ph.D. degree in
Hospitality Management from Kansas State
University. Dr. Hwang has published in various pro-
fessional journals in hospitality and tourism. He spe-
cializes in hospitality and tourism marketing and
research methods.

Appendix 1

Perceived value (Oh, 2000; Varki and Colgate, 2001)

Extremely disagree (1)/Extremely agree (7)
The medical treatment/healthcare service in a healthcare hotel would be worth the price I paid.
I think a healthcare hotel would provide a good deal.
I think a healthcare hotel would provide me great value compared to other medical treatment/healthcare clinics.
Perceived quality (Oh, 2000; Varki and Colgate, 2001)
Extremely disagree (1)/Extremely agree (7)
I think the aspects of a healthcare hotel would be excellent.
I believe the overall quality of a healthcare hotel would be great.
Affective Image (Baloglu and McCleary, 1999; Lee et al., 2010)
Staying at a healthcare hotel will be

– Arousing (1)/Sleepy (7).

– Pleasant (1)/Unpleasant (7).
– Exciting (1)/Gloomy (7).
– Relaxing (1)/Distressing (7).

Intention to visit (Kim and Han, 2008; Han et al., 2010)

Extremely disagree (1)/Extremely agree (7)
I am willing to stay at a healthcare hotel when traveling abroad for medical treatment/healthcare.
I plan to stay at a healthcare hotel when traveling abroad for medical treatment/healthcare.
I will try to stay at a healthcare hotel when traveling abroad for medical treatment/healthcare.
Commitment (Morgan and Hunt, 1994)
Extremely disagree (1)/ Extremely agree (7)
I believe a healthcare hotel deserves my maximum effort to have a relationship with.
I am committed with a healthcare hotel.
Overall image about a healthcare hotel (Han et al., 2009; Baloglu and McCleary, 1999)
Extremely disagree (1)/Extremely agree (7)
My overall image of a healthcare hotel is positive.
The overall image I have of a healthcare hotel is favorable.
Overall, I have a good image about healthcare hotels as places to receive medical treatment/healthcare service.