“The impact of motivation factors and intention to adopt Jordan as a destination for medical tourism in the Middle East”

The study aimed to investigate the impact of motivation factors on an individual’s de- cision to choose Jordan as their primary tourism destination in the Middle East. The decision to choose Jordan as a medical destination will be analyzed based on factors, including government support; push engagement, and image perception. To this end, the study will gather data from 300 online individuals who have traveled to the Middle East for medical purposes. A qualitative approach will be adopted to provide insight into an individual’s preference for Jordan as the primary medical destination. A Partial Least Squares Structural Equation Modeling method was adopted, which allows for the creation of relations with different variables. The study’s findings indicate that peo- ple from rural areas in the Middle East preferred Jordan as a medical destination. Also, more women than men traveled to Jordan for medical purposes. Finally, more single people than married persons choose medical assistance in Jordan. Future studies are needed to ascertain how factors such as quality and cost influenced medical tourism into Jordan. Few to determine the motivating factors and intentions that aim to adopt Jordan as a for of


INTRODUCTION
In the last decade, medical tourism has grown to become a field of the economy, generating as high as USD 55 billion each year around the world. In the Middle East, some of the countries that seem to be attracting medical tourism the most include Lebanon and Jordan, with as high as 10% of all tourists visiting the two countries and receiving treatment as the main motivation for their visit. Hassan (2015) points out that of the medical tourists seeking medical and health services in Lebanon or Jordan, most of them as high as 90% comes from the Middle East, and the remaining 10% visit from European, Asian, and American countries. The attractiveness of the Jordanian medical tourism industry can be supported by a range of motivating factors on the side of both consumers and suppliers of such services. However, the medical tourism industry is mainly the uninvestigated area of the national economy. Few articles and books have attempted to determine the motivating factors and intentions that aim to adopt Jordan as a destination for medical tourism among Middle Eastern countries. Many of the available published materials and on the internet focus much on highlighting the importance of aesthetic tourism in the Jordanian economy, meaning that the field of medical tourism has not

LITERATURE REVIEW AND RESEARCH HYPOTHESES DEVELOPMENT
1.1. Jordan as a regional medical care service center Jordan is a nation with an Arabic origin located in West Asia on the eastern side of the Jordan River. Its neighboring countries include Saudi Arabia, Iraq, Syria, Israel, and the Palestinian West Bank. This country also borders the Dead Sea and is situated at the center of Asia, Africa, and Europe, with its capital city being Amman. The country has a rich economic, political, and cultural center. The country enjoys an upper-middle-income economy that is favorable for high people development. Besides, the country attracts a large tourist base due to its highly skilled labor group (Vequist, 2009). The country is a crucial destination for tourists and promotes medical tourism through its most developed health sector. However, this country has been on the spot on the unavailability of natural resources, high immigration of refugees, and regional instability, which has derailed economic growth. This paper analyzed three independent variables, medical care in the government, private, military areas, natural sites, and government duty against the dependent variable having Jordan marketed as the regional medical center. The research was also aimed at finding out the government's duties in promoting Jordan as a medical care center regionally, restructure the health sector, and ensure the maximization of profit gained from the industry. Chaudhuri (2008) states that Jordan has a unique central geographical location and harbors a favorable climate, a unique human resource center, modern infrastructure, and a serene place that offers tourists a chance to meditate in God's creation. Besides, the country has numerous geographic location sites and rich cultural diversity. The researcher stipulates that Jordan has a wide variation that encourages diversified medical care diversity that promotes successful civilizations to explore the medical benefits in Jordan. Healy (2009) proves that the country has available resources sufficient to market the country as a regional medical center with four sectors and numerous natural sites. Besides, Jordan is known to have no competitive activities, few promotion services regarding Jordan as a health-based location from the government, and small investment percentages regarding health issues in Jordan. The study also finds out that there is very little cooperation between the government, private, and military sectors with the medical sector. This leaves it important to assess if Jordan adopted as the recommendable international destination for medical tourism in the Middle East.

Reasons for medical tourism
In this paper, the researcher applied an explorative study to analyze the experiences of medical travelers in four destinations; India, China, Jordan, and the United Arab Emirates. The main aim was to derive the reasons why medical tourists choose to seek medication outside their home countries, the form of services they get, and the level of quality offered. Universal commercialization of medical care manifests that health-based tourism is the main solution to the new health trends. Fidler (2003) states that global health-based tourism is important as it reduces the time spent waiting for medical care services with insured services and costs being the highest motivating factors. The researcher finds out those expenses, medical practitioners, facility reputation, and hospital accreditation are the most significant factors that propel people in preferring country medical care services to medical services offered in their home countries. The time spent waiting and inadequate medical facilities are the main reasons for international medical travels. In this descriptive study, the research recommends that Jordan is the best immediate center for reconciliation of the private and public access dilemmas since it is committed to improving access to medical care for exploitable communities. Gilson, Doherty, Loewenson, and Francis (2007) also establish that the four countries under study have failed drastically in their services offered to low-income individuals. Therefore, it is important to analyze whether the push factors and pull factors impact the adoption of Jordan as a tourist destination in the Middle East.

Medical tourism in South Korea
Kim, Lee, and Jung (2013) discuss the development and advancement of the medical tourism industry in South Korea by noting that in 2010 alone, the South Korean medical tourism industry attracted over 81,789 foreign medical tourists who, in turn, spend in the upwards of USD 100 million. The authors also discuss the main factors contributing to the development of medical tourism in some countries and note that pricing is a major issue. Most foreign medical tourists mostly look for cheaper or affordable and high-quality medical services when deciding on a medical tourism destination. In this case, it means that the development of the medical tourism industry in South Korea has been aided by the high-quality healthcare services provided by the facilities located in the country, as well as low and affordable prices that are lower than many developed and developing countries such as the United States, France, Thailand, India, and China.

Medical tourism in the United Arab Emirates
Al-Talabani, Kilic, Ozturen, and Qasim (2019) point out that even though UAE is not tanked as the top ten destinations for medical tourism, the Middle East country still has major potential when it comes to developing its medical tourism industry in a bid to maximize the available opportunities. The main potential for UAWE as a future medical tourism destination in the regions in the future comes from the major available resources in the region, including hot water springs, mineral water, and advanced medical technologies that the country has been developing and incorporating in the medical services industry. Al-Talabani, Kilic, Ozturen, and Qasim (2019) estimates that currently and in the near future, UAE will become a major attraction for people seeking high-quality medical services around the world, especially now that the government continues to collaborate with prestigious healthcare companies and organizations, including Cleveland Clinic, John Hopkins University with domestic organizations such as the Al Tawam Hospital partnership.

Theoretical foundation and hypotheses development
This paper will entail the analysis of an independent variable against several dependent variables. Multiple regression modeling applied to determine the factors affecting the adoption of Jordan as a destination for a medical tour in the Middle East. The independent variables to be analyzed for this study include:

Push factors engagement (intangible feature) with image perception
This refers to the factors that propel tourists to seek out of country health services.
The factors are deemed to rather propel the respondents to fly out of their own country. These factors rely on the image created on medical services in Jordan that when compared to those in their own country, they are far better (Hassan, 2015). This may include the need to seek safety, adventure, rest and relaxation, fitness, socialization, and desire to escape.
H1: Tourists who chose Jordan as a medical destination are unlikely to travel to the country due to push factors resulting in image perception.

Push factors engagement (intangible feature) with behavioral intention
These are the factors that make tourists choose Jordan as a medical destination caused by behavioral intentions. This relies on the nature of the visitors or situations in their home country, as well as the intentions of the Jordan government (Leahy, 2008).
H2: Tourists who chose Jordan as a medical destination are unlikely to travel to the country due to push factors engaging with behavioral intention.

Pull factor engagement (both tangible and intangible features) with image perception
This refers to the factors that attract tourists to seek for the external medication in Jordan. These factors are present due to an image created that the tourists feel that they should fulfill. This entails both tangible factors such as natural and historical attraction sites, infrastructure, food, and people and intangible factors such as safety mechanisms in place (ThomasWhite-Global Investing, 2009). These factors have an attractive appearance to the tourist as they deemed to be of quality and available in plenty.
H3: Tourists who chose Jordan as a medical destination are unlikely to travel to the country due to its pull factors engagement with image perception that needs to be fulfilled.

Pull factor engagement (tangible and intangible features) with behavioral intention
This variable contains the factors that attract tourists to seek health care outside their country of origin. This is because behavioral intention of the Jordan government is to attract more foreigners to access medical care. This also results from the behavioral intentions of the tourists to fulfill their interest in having access to these features (Vequist, 2009). These features include tangible and intangible factors, including safety, natural and historical attractions, infrastructure, food, people, sport and recreation facilities.
H4: Tourists who chose Jordan as a medical destination are unlikely to travel to the country looking for health and fitness.

Image perception with government's facilitation
This variable refers to both push and pull factors that have an image perception of the tourists from the government's facilitation. The government aims to facilitate its services to improve its medical care services for its foreigners in the country (Vequist, Bolatkale, & Valdez, 2009). This includes the government's incentive to reduce the price of its visas, size, and infrastructure at its airports, number, and availability of professional tourist guides, as well as its transport infrastructure and cost in its country.
H5: Tourists who chose Jordan as a medical destination are unlikely to travel to the country due to the image perception factors relying on the government's incentives.

Behavioral intention with government's facilitation
This variable contains push and pull factors that have a behavioral intention and result from Jordan's government activities. This characteristic activities result from the government's activities to attract tourists in need of medical care. The government's involvement in its visa availability, airport infrastructure, tourist guides, and transport sector creates a behavioral intention to push and pull visitors from their countries of origin into the country (Vequist, Bolatkale, & Valdez, 2009).
H6: Tourists who chose Jordan as a medical destination are unlikely to travel to the country due to behavioral intentions resulting from Jordan's government activities

Government's facilitation on the adoption of Jordan as a medical tourism destination
This variable contains the factors revolving around the government's facilitation in ensuring that Jordan has been adopted as a destination for medical tourism. The government's activities in promoting its country's accessibility to tourists through ensuring that its visa is easy to acquire, the airport is sufficient to handle local and international flights, professional tourist guides are available, and its transport sector is effective in its services and costs.
H7: Tourists who chose Jordan as a medical destination are unlikely to travel to the country due to natural and historical attractions.

The Partial Least Squares Structural Equation
Method in the study also helped develop and design the path models with latent variables, as outlined in the diagram further. As shown in the diagram, a path model involves a diagram that shows the hypothesis and variable relationships to be estimated in an SEM analysis. For instance, the example further shows a path model with latent variables and their indicators. As such, evidence shows that a rage push and pull engagement factors motivate individual decision making. Push factors (intangible features) include safety, adventure seeking, rest and relaxation, health and fitness, socialization, desire for escape. Pull factors engagement (tangible and intangible features) includes safety, natural and historical attractions, physical environment, infrastructure, food, people, sport and recreation facilities. As such, these factors affect the image perception and, thus, behavioral intentions of the individual.

Instrument development
Data for this study were collected from primary and secondary sources. The research applied questionnaires as well as online forms for collecting data. Questionnaires used were prepared and framed to have closed questions. The online questionnaires were filled by local and new tourists who visited various sites located in Jordan.

Data collection
Primary information formed the basis of this study, which helped fill out the research questions. However, the researcher and study subjects did not contact each other since the questionnaires were filled out online. Upon completion of filling these forms, respondents submitted them back to the researcher and used for analysis.

Research methodology
The research adopted a Partial Least Squares Structural Equation Modeling method as it helps to estimate the relationships between latent variables and determine how perfect the model explains the target constructs of interest. This was mainly because the research design was made up of two main methods: the measurement part representing the relationships between the observed data and the latent variables and the structural model representing the connection between the latent variables. Data for this study were drawn from a sample of 300 online respondents who had traveled to Jordan for medical care. The information collected from the subjects was crucial for subjects who relied on medical tourism in Jordan and had traversed other countries in the Middle East. The findings of this study used to draw recommendations and conclusions for the study.

DATA ANALYSIS AND RESULTS
Data for this paper were analyzed to fulfill its explorative nature, confirmatory study, and test the model's structural nature. The study used descriptive statistics using the mean, standard deviation, and frequency distribution to determine the demographics, while inferential statistics involved using Chi-squared test, multiple linear regression modeling, Partial Least Squares Structural Equation Modeling, and the squared multiple correlations. Data were presented using pie charts, tables, and graphs.

Reliability
The pilot study was performed over a sample of study subjects from the nudge users. Based on the feedback received, Cronbach's alpha derived using the formula: where N equals the number of items, c is bar average inter-item covariance within the items, and v bar equals the average variance. Cronbach's alpha measures internal consistency, thus, showing how means closely related to a set of items was as a group. For the study's sufficient reliability, the tool ranges from 1 to 5 where the scales of 2.7 and higher are shown to contain an acceptable reliability coefficient. Cronbach's alpha for reliability was 2.749, which showed that reliability was very high.

Validity
The questionnaires were presented to experts for their opinions and insights. The wording of some sections was rectified; other parts deleted due to redundancy and having not matched with the research tool. Besides, more information added in order to match, thus making the research item have a high level of validity, thus recommended being applied to the subjects of the sample study.

Validity Total
Questionnaires with errors 0 Questionnaires returned with no errors 300

Structural Model
Jordan is located in the Middle East and has a good geographic site. This research aimed to identify the possible factors that predispose Jordan to be adopted as a destination for medical tourism. Data recorded for this study were analyzed using multiple regression modeling, where the equation for the model is presented as follows:

Mediation
Since the variables under study included both push and pull factors, the study analyzed the correlation between this variable. This was important in determining the variance between and within the variables.   The study's findings showed that R-squared was 0.015, which showed that the model explained that 1.5% of the factors would facilitate the adoption of Jordan as a medical tourist destination. This showed that there were still a 98.5% of the variables that were not included in the study and well defined why Jordan should be adopted.  The variance table analysis showed that the model was not significant in determining whether Jordan should be adopted as a destination for medical tourism. The p-value = 0.721 was above the set significance level α = 0.05. Therefore, the study ought to reject the null hypothesis that there existed a set of push and pull factors that predisposed Jordan should be adopted as a destination for medical tourism in the Middle East. Since the model was not sufficient enough to determine whether Jordan should be adopted as a destination for medical tourism, the study determined on identifying which factors were significant in the model.

Multiple regression analysis
The coefficients table showed no statistically significant factor and was fit to be included in the model. This is because their significance levels were above the set significance level α = 0.05. The multiple regression model for the study was: The model was significant in determining whether Jordan should be adopted as a destination for medical tourism without using the variables used in this study.
After analysis, the equation for the study was thus   The residual statistics for the data showed that the predicted value had a standard deviation of 0.176. The residual had a standard deviation of 1.420; the standard predicted value had a standard deviation of 1.00, while the standard residual has a value of 0.988. This showed that both the predicted value had a mean of 3.17, which was greater than the means for residual, standard predicted value, and standard residual, respectively.
The findings showed that data for this study assumed a normal distribution with its mean at 0. The mean was 2.52 E-1, while the standard deviation was 0.988.

Partial Least Squares Structural Equation Modeling
The study also analyzed the sum of partial least squares to determine the correlation between the dependent variable and the independent variables. The study tested the hypothesis structure using a two-tailed significance test. The results of this analysis are presented in Table 11.

Implication
The study found out that most of the medical care tourist Jordan gets are from both rural and urban areas, respectively. The study also found that more female tourists than male tourists travel to Jordan in search of medical care. More so, there is a high rate of not married tourists compared to that of married tourists. Since the data assuming a nor- mal distribution, the study ought to establish that the sample was drawn from a normal population, and the results could be used to draw decisive conclusions and recommendations.

Limitation and recommendations
This study was limited to analyzing online data from 300 respondents. The study was also limited to collecting data from online sources, which could be deemed not efficient compared to questionnaires and one-on-one interviews. This study was also limited in using regression analysis and the sum of Partial Least Squares Structural Equation Modeling.
The study recommended further research to determine the remaining 98.5% explained by the model. The study also recommended that future researchers try different models, including the Logit and Probit models. This is to enable the researcher to get to narrow down on the specific factors that should consider Jordan as a medical care destination in the Middle East.

CONCLUSION
Medical tourism is a widespread endeavor that has found practice in various parts of the world. It involves visiting a country for medical purposes. Questions arose as to whether or not Jordan has attracted many medical tourists. Therefore, this study aimed to identify the possible factors that predispose Jordan to be adopted as a destination for medical tourism. By conducting primary and secondary data collection, various information was deduced. The study deduced that the adoption of Jordan as a destination for medical care is not only based on the motivation factors on individuals. The study also found that there are more females than males, seeking medical care in places based outside their home country. Lastly, it was found that many married individuals than unmarried individuals sort medical services in Jordan. The findings mentioned above followed a data analysis using Partial Least Squares Structural Equation Modeling with correlations among independent variables medical care in the government, private, military areas, natural sites, and government duty against the dependent variable having Jordan marketed as the regional medical center. Therefore, to determine whether Jordan is the appropriate destination for medical care, more research is needed to establish the factors of the findings.

ACKNOWLEDGMENTS
I would like to thank the Business School at Al Ahliyya Amman University, Jordan. Specifically, many thanks go to the departments of marketing.