Journal of Hospitality and Tourism Management 31 (2017) 220e227 Contents lists available at ScienceDirect Journal of Hospitality and Tourism Management journal homepage: http://www.journals.elsevier.com/journal-of-hospitalityand-tourism-management eWOM, revisit intention, destination trust and gender A. Mohammed Abubakar a, *, Mustafa Ilkan b, Raad Meshall Al-Tal c, e, Kayode Kolawole Eluwole d a Department of Management Information System, Aksaray University, Turkey School of Computing and Technology, Eastern Mediterranean University, P.O Box 95, Famagusta North Cyprus via Mersin 10, Turkey c Northern Border University, Saudi Arabia d Faculty of Tourism, Eastern Mediterranean University, North Cyprus, via Mersin 10, Turkey e Jadara University, Jordan b a r t i c l e i n f o a b s t r a c t Article history: Received 6 June 2016 Received in revised form 30 November 2016 Accepted 16 December 2016 This article investigates the impact of eWOM on intention to revisit and destination trust, and the moderating role of gender in medical tourism industry. Result from structural equation modeling (n ¼ 240) suggests the following: (1) that eWOM influences intention to revisit and destination trust; (2) that destination trust influences intention to revisit; (3) that the impact of eWOM on intention to revisit is about 1.3 times higher in men; (4) that the impact of eWOM on destination trust is about 1.2 times higher in men; and (5) the impact of destination trust on the intention to revisit is about 2.3 times higher in women. Implications and future research directions are discussed. © 2017 The Authors. Keywords: eWOM Destination trust Intention to revisit Gender 1. Introduction The med-tour industry is reported to be a multi-billion dollar one, it is expected to generate a market value of US$32.5 billion by the end of 2019; and the current global med-tour market value was estimated to be around US$10.5 billion (Globenewswire.com, 2015). Med-tourists engage in med-tour for several reasons, but the primary factor is the significant cost saving in the medical treatment. A substantial number of reports and empirical evidence have shown that med-tourists cost saving can range from 30 to 80 percent; but cautioned that these savings are contingent on the procedure and the country (Hall, 2011; Marlowe & Sullivan, 2007; Nicolaides, 2012; Taylor, 2007; Yeoh, Othman, & Ahmad, 2015). Furthermore, the presence of qualified medical personnel's in developing countries, long waiting list in home countries, availability in host countries, and the illegality of certain medical procedure contributes to the growth of med-tour (Keckley, 2008; Woodman, 2008). The number of medical complications experienced by patients is * Corresponding author. E-mail addresses: me@mohammedabubakar.com (A.M. Abubakar), mustafa. ilkan@emu.edu.tr (M. Ilkan), altall1985@yahoo.com (R. Meshall Al-Tal), kayode. eluwole@emu.edu.tr (K.K. Eluwole). http://dx.doi.org/10.1016/j.jhtm.2016.12.005 1447-6770/© 2017 The Authors. underreported (Imison & Schweinsberg, 2013), and the lack of reliable data related to the risk faced by med-tourists is critical (Whittaker, 2011; Woo, 2009). More specifically, this has led medtourists to rely on personal information sources e.g., word-ofmouth (WOM) from friends, doctors, colleagues and the internet. Electronic word-of-mouth (eWOM) is a form written memo on the web usually posted by an experienced or previous consumer (Abubakar & Ilkan, 2014); this memo may influence the behavioral actions of a potential consumer (Abubakar & Ilkan, 2013). The empirical evidence provided above suggest that eWOM may influence med-tourists intention to revisit and destination trust; this is primarily due to the intangible nature of med-tour services (Lin, Jones, & Westwood, 2009). Potential tourists consult their inner
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n, Guinalíu, & circles for travel related information (Casalo Ekinci, 2015); which reduces the uncertainty and ambiguity (Bickart & Schindler, 2001) associated with a med-tour destination. Turkey has an estimated med-tour revenue of $1 billion in 2015 (Anadolu Agency, 2015); and is the second largest country in the Eurasia in terms of med-tour revenue and arrivals (Beladi, Chao, Shan Ee, & Hollas, 2015). The country has about 32 hospitals accredited by the Joint Commission International which are mostly located in Istanbul. About half a million med-tourists visits Turkey every year (Anadolu Agency, 2015; Ministry of Health, 2012). These figures show that Turkey is an important player in the industry, and A.M. Abubakar et al. / Journal of Hospitality and Tourism Management 31 (2017) 220e227 also highlight the importance and reputation of the sector in the country. Policy makers in key med-tour hubs (e.g., Turkey) are interested in increasing revenues. For instance, Turkey's Ministry of Health plans to increase the number of med-tourists to about 2 million by 2023, by introducing tax-free health care zones specifically tailored for foreign patients (Anadolu Agency, 2015). This can be achieved by delivering top-notch services and the assurance of patient safety. Empirical evidence showed that online reviews have significant influence on destination image (e.g., Govers & Go, 2004; Mridula, 2009), destination choice (Jalilvand & Samiei, 2012b) and revisit intention (e.g., Kim, Hallab, & Kim, 2012; Quintal & Polczynski, 2010) of tourists. The impact of gender on shopping intents has been a subject of special interest to researchers for a long time. A handful of studies noted that men and women have different attitudes toward online messages and shopping (Chen, Yan, Fan, &
langer, Johnson, & Hightower, 2010). With Gordon, 2015; Slyke, Be the exception of Abubakar (2016) and Abubakar and Ilkan (2016), empirical work that investigates the impact of eWOM on revisit intention and destination trust coupled with gender in the medtour industry is sparse. Moreover, the aforementioned studies were with potential tourists at home country. In contrast to the ideal-typical approach, we propose that revisit intention should be captured at destination point with actual tourists. This approach has been adopted by prior revisit intention studies (Guntoro & Hui, 2013; Marinkovic, Senic, Ivkov, Dimitrovski, & Bjelic, 2014). To bridge the gap in the eWOM, intention to revisit, destination trust and gender literature, this study offers an integrated approach to examine the interplay of the aforementioned variables. It is important to say that this is the first study that integrates these four variables together in a unique model of tourism behavior in the virtual world. Fig. 1 presents the conceptual model of the study. 2. Literature review Much has been debated, written and published about the reason med-tourists travel over international borders, these motives varies significantly by country or region. For instance Indonesians often travel to Singapore for improved healthcare services (Gan & Frederick, 2011), high cost for Americans (Horowitz & Rosensweig, 2008), and long waiting list for Europeans (Bies & Zacharia, 2007). According to Westbrook (1987) WOM is “informal communications directed at other consumers about the ownership, usage, or characteristics of particular goods and services and/or their sellers”. WOM has now taken a different form known as the eWOM, which resides in the virtual server (Minxue, Fengyan, Alex, & Nan, 2011). Abubakar (2012) noted that eWOM is an addendum to the classic interpersonal communications in the contemporary world. eWOM's are positive or negative statements made by consumers concerning products or services that are scripted and posted on the internet for individuals and institutions (Hennig-Thurau, Gwinner, Walsh, & Gremler, 2004, p. 39). The increased literacy on the use of computer and the internet has made modern consumers savvy since they can collect, gather, analyze, interpret, and disseminate information related to a product or service (Chevalier & Mayzlin, 2006). Besides, traditional advertisement is losing its place in the eyes of consumers, because they view it as a medium by which companies exploit them. As such, they have little regard for the classic advertisement approach. This development has called for more research and modification to marketing strategies of various firms (Rowley, 2001). Research has shown that the Internet has facilitates web-based searches for med-tour related information (Frederick & Gan, 2015). 221 Fig. 1. Conceptual model. For instance, empirical evidence has shown that 80% of American internet users had searched for medical related information, 56% had searched for information relating to treatment; 44% and 36% of them had searched for information regarding physicians and healthcare centers respectively (Pew Research Center, 2011). In addition, websites and online communities are the main channel used by the med-tour marketers to attract med-tourist (Frederick & Gan, 2015; Lunt, Hardey, & Mannion, 2010). 2.1. eWOM Park and Lee (2009) suggested that eWOM has higher effect when a good is consumed than when it is searched, fundamentally suggesting that the impact of eWOM becomes stronger after service encounter, this position was shared by Gruen, Osmonbekov, and Czaplewski (2006) as they suggested that eWOM leads to postpurchase customer loyalty. As against the traditional WOM communication, eWOM eliminate the negativity associated with bias information dissemination among friends, relatives and family because the identity of the reviewer cannot be identified (Abubakar, Ilkan, & Sahin, 2016). Different motivations has been found to be responsible for generating eWOM, pre-purchase expectations, customer delight, satisfaction or dissatisfaction and general consumer behaviors. The credibility and reliability of eWOM has also be studied. eWOM being a form of online reviews serves as medium to help other consumer; vacationer make good decision(Bronner & de Hoog, 2011). These characteristics of eWOM present a desirable purpose to investigate how eWOM impacts med-tourists’ destination trust and intention to revisit. 2.2. Destination trust Due to the simultaneous nature of production and consumption of tourism products, destination marketers must ensure delivery of promised service during advertisement and promotion. The integrity and transparency of service offerings of a destination results in the trust that tourist develops for such destinations. Evidence from Kim and Oh (2002) provide support for trust as an antecedent of repeat visit. Yet while research across the tourism industry recognize that destination image and trust operates through WOM and eWOM to constitute travel intention (Abubakar & Ilkan, 2016), the details of this argument in respect to revisit intention remain underdeveloped. 2.3. Intention to visit/intention to revisit Consumer of tourism services are often made up of two classes. The initial consumer and the returning consumer(Huang & Hsu, 2009). Decision making for first time consumer are mostly based on information gathered from various source which results in an expectation of a desired encounter from a tourism service provider. 222 A.M. Abubakar et al. / Journal of Hospitality and Tourism Management 31 (2017) 220e227 This expectation has been studied in the hospitality literature as intention to visit. The literature target prospective consumer behavior and investigate the effect of different predictors in their decision making process. Revisit intention however, target repeat consumers of tourism services whom had previously encounter the actual delivery of the service. Most studied has predicted revisit intention has an extension of satisfaction derived from initial encounter (Huang & Hsu, 2009; Um, Chon, & Ro, 2006). This study intend to extend the literature by established the predictive effect of eWOM on revisit intention. 3. Research hypotheses 3.1. eWOM and intention to revisit Intention to revisit is the willingness to visit a destination again. Destination marketers are interested in understanding the drivers of tourist intention to revisit, because the cost of retaining revisitors is much less than the cost of attracting new visitors (Um et al., 2006). eWOM communication has received huge attention in the recent years, due to its impact on marketing strategy (Smith, Coyle, Lightfoot, & Schott, 2007). Moreover, patients are now more proactive and the main sources of their marketing intelligence include personal experience, eWOM, and advertisements (Yang, 2011). Research has shown that favorable online reviews concerning a hotel increase the likelihood of booking and room sales (e.g., Duverger, 2013; Mauri & Minazzi, 2013; Ogut & Tas, 2012; Ye, Law, Gu, & Chen, 2011). Whereas minimizing negative eWOM is expected to ensure re-patronage of the establishment (Ko & Kim, 2011). More specifically, empirical evidence in hotel and travel industry suggested that eWOM can influence tourists travel and/or revisit intention (e.g., Arsal, Backman, & Baldwin, 2008; Filieri & McLeay, 2014; Filieri, 2015; Sparks & Browning, 2011; Vermeulen & Seegers, 2009; Ye, Law, & Gu, 2009). This article argues that eWOM should equally have influence on revisit intention in the med-tour industry. Thus, the following hypothesis was proposed. H1. eWOM has a significant impact on the intention to revisit in the medical tourism context. 3.2. eWOM and destination trust Destination trust refers to a visitor's willingness to rely on the ability of a destination to perform its advertised functions. In other words assuring tourists that service provision will be transparent, reliable, risk, and hassle free (Abubakar & Ilkan, 2016). Potential tourists were more likely to seek information about a destination from friends, colleagues and relatives who had experience with the destination (Lee, Soutar, & Daly, 2007). This is because WOM messages comfort customers, reduce fear and uncertainty, and enact assurance (Martilla, 1971). Settle and Alreck (1989) and Murray’s (1991) added that WOM messages are primary uncertainty eliminator for risks and uncertainty accrued from the potential purchase of a product or service. The inherent impact of eWOM on consumers' behavioral intentions can be more powerful than the traditional WOM (Eunha & Soocheong, 2011). Because eWOM communication is more reliable than WOM due to its anonymous nature, and the absence of incentives. Wu and Wang (2011) suggested that there is a linkage between eWOM, brand trust and purchase intention, thus the direction of eWOM will increase or decrease the impact of trust on purchase intents (Long-Yi & Ching-Yuh, 2010). A careful examination of the above findings reveal that there is a potential relationship between eWOM and destination trust. This paper posits that positive eWOM messages will eliminate uncertainty, and enhance destination trust. Thus, the following hypothesis was proposed. H2. eWOM has a significant impact on destination trust in the medical tourism context. 3.3. Destination trust and intention to revisit Brand trust evoke consumers' emotional attachment toward a brand (Esch, Langner, Schmitt, & Geus, 2006). Lin and Lu (2010) suggested that trust has a significant impact on purchase intention when positive WOM is high. There is a broad consensus among scholars that trust serve as an effective means for minimizing uncertainty (e.g., Han & Hyun, 2013; Pavlou, Liang, & Xue, 2007). For instance, Chiu, Hsu, Lai, and Chang (2012) revealed that customer levels of trust can influence repurchase intention. Similarly, destination trust may evoke med-tourist's emotional attachment toward a destination, and such attachment can predict the willingness of consumers to make financial sacrifices in order to obtain it (Thomson, McInnis, & Park, 2005). Research has shown that tourists are more likely to visit destinations that they perceive as trustworthy and dependable (Ekinci & Hosany, 2006; Roodurmun & Juwaheer, 2010). Furthermore, Han (2013) indicated that trust is particularly significant in a med-tour context such that malpractice, low-quality medical care, and medical accidents are increasingly fretted-over risks. Med-tourists are more likely to revisit when they trust the healthcare establishment as noted by Han and Hyun (2015). Thus, the following hypothesis was proposed. H3. Destination trust has a significant impact on the intention to revisit in the medical tourism context. 3.4. Gender role A substantial body of researches have supported the hypothesis that women and men respond to and express risk differently (e.g., Brindley, 2005; Eckel & Grossman, 2008; Palich & Bagby, 1995; Simon, Houghton, & Aquino, 2000). Social role theory posits that gender differences in social behaviors originate from shared expectations about what is appropriate behavior for men and women (Karakowsky & Elangovan, 2001). Risk expression varies across genders, primarily due to gender identity, which is isomorphic. For example, most men holds a masculine agnatic identity, and most females holds a feminine communal identity (Meyers-Levy & Loken, 2015). While risk perception is the manner people of the same gender assess risk in a rational way, and weighing information before making a decision. A number of studies have supported the notion that women have higher risk perception and/or are riskaverse than men (e.g., Byrnes, Miller, & Schafer, 1999; Hudgens & Fatkins, 1985; Pascual-Miguel, Agudo-Peregrina & Chaparro
ez, 2015; Van Slyke et al., 2002). While others asserted that Pela women are more trusting than men (Feingold, 1994). The traditional role in taking responsibility for the family in that “putting the family's resources in danger, especially in a situation of necessity, tends to increase women's risk perception and tolerance” (Langowitz & Minniti, 2007, p. 356). Men and women differs on several dimensions in the cyber world; and these differences may arise from social, cultural, psychological, and other environmental factors (Meyers-Levy & Loken, 2015). Men differ from women with respect to eWOM messages and shopping behaviors (e.g., Dittmar, Long, & Meek, 2004; Rodgers & Harris, 2003). For instance, Olsen and Cox (2001) stated that in the presences of social and technological hazards, women are more risk-averse (i.e. less risk-taking) than men, even when the level of expertise and experience is the A.M. Abubakar et al. / Journal of Hospitality and Tourism Management 31 (2017) 220e227 same (e.g., Dwyer, Gilkeson, & List, 2002; Harris, Jenkins, & Glaser, 2006; Powell & Ansic, 1997). Thus, the following hypothesis was proposed. H4. The strength of the relationship between eWOM, destination trust, and revisit intention will differ by gender in the medical tourism context. 4. Methodology Turkey as a medical destination has about 32 international accredited hospitals; the country offers top-notch medical services in various areas e.g., cardiology, endocrinology, nephrology, oncology, neurology, dermatology, gynecology/obstetrics, orthopedics, hair transplantation and others (Skylife, 2011). Some hospitals have partnerships with top American hospitals such as Harvard Medical Center and Johns Hopkins, and are staffed with many highly skilled, English speaking, and western trained doctor (Foreign Economic Relation Board, 2012; Organization of Medical Tourism, 2015). One of these hospitals (Acibadem Health Group) is declared among “ten hospitals worth to trip” in the world forbes. com (Van Dusen, 2007). Cultural factors, language and social ties may influence med-tourist decision but referral is the most important factor (Hanefeld, Lunt, Smith, & Horsfall, 2015); and referral is a form of eWOM. 223 (17%); Germany (15%); Bulgaria (14%); Iraq (13%); Libya (12%); Romania (11.6%); England (8%); Holland (4%); USA (3%); Russia (2%) and (1%) from Northern Cyprus. 4.2. Measures Although Turkish is the official language in Turkey, we administered the survey in English and Turkish. This is because the respondents are foreigners visiting Turkey for purpose of medical tourism. 4.2.1. eWOM We adapted 6- item scale used by prior studies (Abubakar et al., 2016; Jalilvand & Samiei, 2012a). A sample item for eWOM was: “If I don't read tourists' online travel reviews when I travel to a medical destination, I worry about my decision”. For this measure, response range from 5 (strongly agree) to 1 (strongly disagree). All factor loadings for this construct were beyond the threshold level of 0.5. 4.2.2. Destination trust We measured destination trust with 8-item scale used by prior study in med-tourism context (Abubakar & Ilkan, 2016). A sample item was: “Turkish hospitals would be honest and sincere in addressing my concerns”. For this measure, response range from 5 (strongly agree) to 1 (strongly disagree). All factor loadings for this construct were beyond the threshold level of 0.5. 4.1. Sampling and procedure Data were obtained from med-tourists in Istanbul, using a convenient sampling technique. This sampling technique was employed because of subjects’ accessibility and proximity to the researchers. Data obtained were analyzed using SPSS and AMOS version 21 to estimate the proposed structural model. We initially contacted the 10 certified Med-tour hospitals and establishment for permission to conduct the study. These hospitals were selected for the study due to their high participating in medical tourism and high number of Med-tourist participation. Four out of ten agreed and granted permission to conduct the study. We then proceed by sending 100 questionnaires to each of the 4 participating hospitals together with cover letter detailing the purpose of the study, assurance of anonymity, confidentiality and return envelope for each respondent (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). The questionnaires were administered to the Med-tourists through their attending nurses whom have been briefed about the study through the Human resource unit of the participating hospitals; 350 questionnaires were initially returned accounting for 87.5% response rate. However, after careful screening using the five inclusion criteria of: (1) 18 years of age or older; (2) fluent in English and/or Turkish; (3) foreign nationals; (4) A member of any online community; (5) read or post online reviews, we have 240 final useable sample. The screening was done to allow the selection of med-tourists who have used online reviews to make travel decisions following Abubakar and Ilkan (2016)’s procedures. All data were collected in total of 8 weeks. 59% of our final sample were married. 38% were between 31 and 40 years old, 37% were between 41 and 50 years old, 14% were above 50 years old and the rest were between 21 and 30 years old. Forty one percent of the respondents have monthly income over 4000 Turkish Lira; (37%) have monthly between 3000 and 3999 Turkish Lira, and (16%) have monthly income between 2000 and 2999 Turkish Lira; and the rest have less than 2000 Turkish Lira. In terms of education, (34%) of the respondents have attended some college; (33%) have bachelor degrees; (22%) have higher degrees; and the rest have high school diplomas. The demographic breakdown of the med-tourists nationality is as follows: From Azerbaijan 4.2.3. Intention to revisit We used 3-item scale developed by Blodgett, Hill, and Tax (1997) and used in prior study by (Kim, Park, Kim, & Ryu, 2013). A sample item was: “It is very likely that I will revisit a hospital in Turkey”. All factor loadings for this construct were beyond the threshold level of 0.5. 4.2.4. Gender The moderating effect of gender on the predictive capability of eWOM of the mediated relationship of destination trust on medtourists’ intention to revisit was studied in this research, hence we report that 53% of our final sample (240) were female and the others male. 5. Findings Because we used self-reported data collection design, we perform confirmatory factor analysis to validate the discriminant nature of our construct. The model fit indices were assessed twice, similar to the approach carried out by Morgan, Kaleka, and Katsikeas (2004). First, a single factor model was tested, in this model all the research variables were loaded into a single factor. The single factor model failed to fit the data satisfactorily, the goodness-of-fit for the model yielded (X2 ¼ 3213.07, df ¼ 104, p ¼ 0.000), (GFI ¼ 0.40, 1 ¼ maximum fit), (NFI ¼ 0.59, 1 ¼ maximum fit), (CFI ¼ 0.60, 1 ¼ maximum fit), (RMSEA ¼ 0.35, values < 0.08 indicating good fit), (CMIN/DF ¼ 30.89, values > 1 and < 3 are accepted). Next, a three factor (proposed) model was tested, the model fit the data satisfactory, and the goodness-of-fit for the model yielded (X2 ¼ 131.7, df ¼ 110, p ¼ 0.08), (GFI ¼ 0.90, 1 ¼ maximum fit), (NFI ¼ 0.94, 1 ¼ maximum fit), (CFI ¼ 0.99, 1 ¼ maximum fit), (RMSEA ¼ 0.040, values < 0.08 indicating good fit), (CMIN/DF ¼ 1.20, values > 1 and < 3 are accepted). The result showed that the proposed model fits were reasonable and acceptable. All factors and items load significantly on designated constructs, and there is no evidence of any cross loading except one item for destination trust (Fornell & Larcker, 1981). The 224 A.M. Abubakar et al. / Journal of Hospitality and Tourism Management 31 (2017) 220e227 factor loadings were all above the benchmark value 0.50, composite reliability (CR) were above the benchmark value 0.60; similarly average variance extracted (AVE) values were also above cutoff point 0.50 (Hair, Anderson, Tatham, & Black, 1998). Overall, this provide evidence of internal consistency, convergent and discriminant validity (Bentler & Bonett, 1980; Bollen, 1989a, 1989b; €reskog & So €rbom, 1984; Tanaka & Huba, 1985). In addition, the Jo outcome provided collateral evidence to that common method bias seems not to be a problem. See Tables 1 and 2. The empirical results from the structural model suggests that eWOM positively influences intention to revisit (r ¼ 0.338, p ¼ 0.000) (b ¼ 0.296, t ¼ 4.42, p ¼ 0.000); and eWOM explains R2 (intention to revisit) ¼ 10% of the variance [H1 gained support]. eWOM positively influences destination trust (r ¼ 0.312, p ¼ 0.000). (b ¼ 0.332, t ¼ 5.08, p ¼ 0.000); and eWOM explains R2 (destination trust) ¼ 11.4% of the variance [H2 gained support]. Destination trust influences intention to revisit (r ¼ 0.277, p ¼ 0.000) (b ¼ 0.190, t ¼ 3.02, p ¼ 0.000); and destination trust explains R2 (intention to revisit) ¼ 8% of the variance [H3 gained support]. See Tables 2 and 3. Table 4 present total, direct and indirect estimates of the study variables. Although not hypothesized, this paper evaluated the mediating effect of destination trust with the aid of bootstrapping analysis (n ¼ 2000) as suggested by (Preacher & Hayes, 2004). A bias-corrected bootstrap indicated that the indirect effect of eWOM on intention to revisit through destination trust was significant 0.059 (p ¼ 0.010, 95% confidence interval: 0.020e0.121). See Table 4. The paper hypothesized that the strength of the relationship between eWOM, destination trust, and revisit intention will differ by gender in the med-tour context. The dataset was split into two, and the hypothesized relationships were assessed gender wise. Table 5 suggests that the impact of eWOM on intention to revisit is about 1.3 times higher in men; the impact of eWOM on destination trust is about 1.2 times higher in men; and the impact of destination trust on the intention to revisit is about 2.3 times higher in women. [H4 gained support]. 6. Discussion and conclusion This paper builds on previous research by exploring the contribution of social influence on destination trust and intention to revisit from med-tour angle. This study investigated how eWOM may enhance destination trust and intention to revisit a medical hub. The structural equation modeling suggests that eWOM positively influences intention to revisit, consistent with prior studies in travel and leisure tourism (Filieri & McLeay, 2014; Vermeulen & Seegers, 2009). This outcome underlined the significant influence of eWOM on important variable in the tourism industry, more specifically med-tour industry. Second, eWOM positively influences destination trust; this also complement other scholars who asserted that eWOM has significant influence on destination image (Jalilvand, Samiei, Dini, & Manzari, 2012), and destination choice (Jalilvand & Samiei, 2012b). The result provide a deeper and richer portrait of the relationship between eWOM and destination trust. Third, destination trust influences intention to revisit, this findings is also consistent with the research prediction. Similarly, prior studies have also shown that destination image has an impact on the intention to revisit (Jalilvand et al., 2012; Kim et al., 2012). As such, the present study is thus a compelling extension of the previous research concerning the antecedents of intention to revisit. The core practical and theoretical contribution of the present study is the extension of the above said variables to med-tour industry. Consistent with prior research, this study found that men are more trusting than women; the result revealed significant variance between men and women. The impact of eWOM on intention to revisit is about 1.3 times higher in men; in line with social role theory proposition which classified men as agnatic and competent (Eagly & Wood, 1991; Eagly, 1987). The theory and the current finding suggests that men are more likely to revisit a destination when the volume of positive eWOM is high. The impact of eWOM on destination trust is about 1.2 times higher in men; this is because men use online information to explore and discover new things (Taylor, Lewin, & Strutton, 2011). This finding suggests that logically, travel is an inclusive category. Finally, the impact of destination trust on the intention to revisit is about 2.3 times higher in women, which also conforms to the existing hypothesis: women are more risk-averse. This outcome shows that when women trust a particular destination, their intention to revisit tends to be higher than men; this is primarily due to their communal nature, in line with social role theory (Eagly & Wood, 1991; Karakowsky & Elangovan, 2001). The context of this research has important implications for med- Table 1 Psychometrics properties of the measures (n¼240). Scale items eWOM I often read other medical tourists' online travel reviews to know what destinations make good impressions on others. To make sure I choose the right medical destination, I often read other medical tourists' online travel reviews. I often consult other medical tourists' online travel reviews to help me choose a good medical destination. I frequently gather information from tourists' online travel reviews before I travel to a certain medical destination. If I don't read tourists' online travel reviews when I travel to a medical destination,I worry about my decision When I travel to a medical destination, tourists' online travel reviews make me confident in travelling to the destination. Destination trust Turkey as a medical destination meets my expectations. I feel confidence with Turkish hospitals. I will not be disappointed with Turkey's healthcare services. Turkish hospitals guarantee satisfaction. Turkish hospitals would be honest and sincere in addressing my concerns I could rely on Turkish hospitals to solve my medical problems. Turkish hospitals would make any effort to satisfy me. Turkish hospitals would compensate me in some way in case of injuries after service Intention to revisit I intend to revisit Turkey for medical attention in the near future. It is very likely that I will revisit a hospital in Turkey. I would like to visit Turkish hospitals more often. Loadings Mean (S.D) 0.53 0.69 0.99 0.64 0.96 0.97 3.40(1.26) 3.47(1.22) 3.39(1.18) 3.54(1.21) 3.43(1.19) 3.41(1.18) 0.97 0.94 _* 0.99 0.99 0.98 0.95 0.96 3.96(1.12) 3.91(1.11) _* 4.00(1.13) 3.99(1.13) 3.98(1.12) 3.92(1.12) 3.95(1.11) 0.94 0.81 0.85 3.49(1.16) 3.58(1.18) 3.57(1.21) Notes: CR, construct reliability; AVE, average variance extracted; a, Cronbach's alpha; -* dropped items during confirmatory factor analysis. KMO Measure of Sampling Adequacy ¼ .88; Bartlett's‘Test of Sphericity ¼ 7718, df ¼ 120, p ¼ .000. 225 A.M. Abubakar et al. / Journal of Hospitality and Tourism Management 31 (2017) 220e227 Table 2 Means, standard deviations (SD), and correlations of study variables. Variables Mean SD Mean (Male) Mean (Female) AVE CR a 1 2 3 1. eWOM 2. Destination trust 3. Revisit intention 3.44 3.96 3.55 1.04 1.10 1.10 3.32 3.89 3.49 3.54 4.03 3.59 0.67 0.95 0.83 0.92 0.99 0.93 0.93 0.99 0.92 e 0.312a 0.338a e 0.277a e Note: Composite scores for each variable were computed by averaging respective item scores. a Correlations are significant at the .01 level. Table 3 Maximum likelihood estimates for the research model (n¼240). Exogenous variables Endogenous variables Coefficient estimates Standard error t- statistics p eWOM eWOM Destination trust Intention to revisit Destination trust Intention to revisit 0.296 0.332 0.190 0.067 0.065 0.063 4.42 5.08 3.02 *** Notes: * **Significant at the p < 0.05 level (two-tailed); *** *** *** significant at the p < 0.01 level (two-tailed). Table 4 Standardized break down of the total effect of the research model (n¼240). Exogenous variables Endogenous variables Total Effect Direct Effect Indirect Effect P EWOM EWOM Destination Trust Intention to revisit Destination trust Intention to revisit 0.338 0.312 0.190 0.278 0.312 0.190 0.059 0.000 0.000 ** Notes: ** Significant at the p < 0.05 level (two-tailed); *** *** *** significant at the p < 0.01 level (two-tailed). Table 5 Multi-group moderation analysis (n¼240). Exogenous variables Endogenous variables Male (n ¼ 112) b(t) Female (n¼128) b(t) Decision eWOM eWOM Destination Trust Intention to revisit Destination trust Intention to revisit 0.363(3.56***) 0.372(3.86***) 0.120(1.28) 0.245(2.75) 0.293(3.25**) 0.244(2.89**) Accepted Accepted Accepted Notes: ** Significant at the p < 0.05 level (two-tailed); t  1.960; *** significant at the p < 0.001 level (two-tailed); t  3.291. tour destination marketers, the results suggest that practitioners have a lot to gain from computerized information tools. Segmenting med-tourists on gender basis may produce a more sensitive instrument which destination marketers can use to increase destination trust and intention to revisit through eWOM messages. Practitioners at medical clinics and destination countries must recognize the intricate and essential role of eWOM; and utilize it in developing strategies to acquire and retain med-tourists, and to maximize revenue. This paper recommends that med-tour hubs should improve their amenities and services such that they will resemble excellent hotels (Bernstein, 2012; Hume & DeMicco, 2007). Due to the fact that top-notch service experience can induce positive eWOM, which in turn facilitates indirect destination branding co-creation due to the interactive and diffusive nature of eWOM. Two, this paper recommends that med-tour hubs should furnish their websites to have interactive features, such as real-time interaction with previous med-tourists who agree to respond to and share their contact details with potential med-tourists. This may be a good strategy to penetrate other untapped markets. Third, the paper advises med-tour hubs to change their business orientation from transaction to relationship, from tourists into partners, and from long-term relationship into commitments as suggested by (Raju, Lonial, & Gupta, 1995). On the negative front, theory of negativity suggests that negative eWOM is easily absorb by tourists than positive eWOM; therefore, negative eWOM can have a stronger negative influence on travel and revisit intention. On the positive front, the cost of attracting new tourists is five times higher than retaining existing tourists (Yeoh et al., 2015) and “a 5% decrease in the customer defection rate can boost profits from 25% to 95%” (Jacob, 1994). Marketers should develop diverse benefits that encourage the spread of positive eWOM to acquire new medtourists and for repeat med-tourists to re-patronage their services. 6.1. Limitation and future study While this paper has shed some light on eWOM literature, it has some limitations. The nature of the research design e.g. sample size, data collection method, potentiality of causal inference, and the absences of experimental control establish causality. The response rate was somewhat low, which may limit the generalizability of the model. 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