1. HEALTH TOURISM, CUSTOMER SATISFACTION AND QUALITY OF LIFE: THE ROLE OF SPECIALTY HOSPITALS Dina Lončarić, PhD Faculty of Tourism and Hospitality Management, Opatija Damir Lončarić, M. A. Thallassotherapia, Crikvenica Suzana Marković, PhD Faculty of Tourism and Hospitality Management, Opatija

2. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija CONTENTS  Purpose of the study  Theoretical background  Research objectives and hypotheses  Methodology  Research results  Conclusion  Limitations and suggestions

3. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija PURPOSE OF THE STUDY To assess the impact of health services on physical quality of life and customer satisfaction in the health tourism sector with special emphasis on the role of specialty hospitals which are part of the health system of the Republic of Croatia.

4. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija THEORETICAL BACKGROUND HEALTH TOURISM  … "the provision of health facilities utilizing the natural resources of the country, in particular mineral water and climate“ (IUOTO, 1973)  … “tourism that is linked with travel to health resorts or other destinations, the primary purpose of which is to improve the physical condition of tourists through a regime of physical exercises and therapy, and controlled nutritional and medicinal services relevant to health maintenance” (National Strategy of Health Care Development, 2012)

5. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija THEORETICAL BACKGROUND HEALTH TOURISM  4 segments of health tourism in Croatia (Kesar and Rimac, 2011) : sanatorium/hospital "tourism" spa/thermal/thalassotherapy tourism wellness tourism medical tourism SPECIALTY HOSPITAL  … “is a health care institution engaged in the specialist-consiliary and hospital treatment of specific diseases and specific age-groups and possessing the facilities, in terms of beds, diagnostics, etc., required to carry out such treatment (Health Protection Act, 2008).

6. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija THEORETICAL BACKGROUND QUALITY OF LIFE (QOL)  … “an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns”, (WHOQOL Group, 1994) LIFE SATISFACTION (LS)  … “is the degree to which a person positively evaluates the overall quality of his/her life as a whole. In other words, how much the person likes the life he/she leads”, (Veenhoven, 1996) LIFE DOMAIN  The domain of health is one of the most important determinants of QOL and LS (Andrews and Withey, 1976 ; Cummins, 1996; Alber and Fahey, 2004)

7. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija THEORETICAL BACKGROUND CUSTOMERS  … patients of medical institutions (Altsech, 2012; Han, 2013; Zaim, Bayyurt and Zaim, 2010) CUSTOMER SATISFACTION  … the customer's evaluation of a product or service in terms of whether that product or service has met their needs and expectations (Zeithaml and Bitner, 2003) CUSTOMER LOYALTY  … “commitment to re-buy or re-patronize a preferred product or service consistently in the future… “ (Oliver, 1997)

8. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija RESEARCH OBJECTIVES  to study the correlation between the perception of physical quality of life and the life satisfaction of patients who have stayed in a specialty hospital for medical rehabilitation;  to establish the correlation between the perception of physical quality of life after staying in a hospital and customer satisfaction;  to study the correlation between customer satisfaction and life satisfaction after using the hospital’s services;  to establish the correlation between customer satisfaction and customer loyalty.

9. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija HYPOTHESES H1H1 Physical quality of life is positively related to life satisfaction. H2H2 Physical quality of life is positively related to customer satisfaction in a specialty hospital. H3H3 Customer satisfaction is positively related to life satisfaction. H4:H4: There is a positive relationship between customer satisfaction and customer loyalty in a specialty hospital.

10. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija HYPOTHESES Figure 1. The conceptual model H1H1 H2H2 H3H3 H4H4 LIFE SATISFACTION CUSTOMER LOYALTY PHYSICAL QOL CUSTOMER SATISFACTION

11. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija METHODOLOGY Research instrumentQuestionairre, 7-point Likert-type scale, 15 items: Physical Quality of life, 7 items (WHOQOL-BREF quality of life assessment, Skevington, S. et al., 2004) Life satisfaction, 3 items Customer satisfaction, 3 items Customer loyalty, 2 items Demographics characteristics SampleConvenient sample of patients of a specialty hospital for medical rehabilitation N = 82 Response rate68.33 % ( N=120, n=82) Data collectionJuly and August of 2014 Data analysisDescriptive statistics Partial Least Squares Structural Equations Modelling (PLS-SEM)

12. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija RESEARCH RESULTS CHARACTERISTICSRESPONDENTS Gender53.7% females, 46.3% males Age62.1% more than 56 years old Occupation50.0 % retired, 30.5 % employed Level of education63.4 % secondary school Purpose of visit92.7 % medical and health programs Previous hospital stays 15.9% first time visitors Table 1. Socio-demographic profile of respondents (N=82) Source: Research results

13. CONSTRUCTSITEMSMEANSD PHYSICAL QUALITY OF LIFE Reduced physical pain 5.931.54 Reduced addiction to medication 5.361.99 Increased energy levels 5.891.56 Increased ability to relax and sleep 5.831.61 Increased ability to carry out everyday activities 5.911.55 Increased ability to work 5.701.71 Enhanced mobility 6.021.42 LIFE SATISFACTION Satisfaction with health 5.191.89 Satisfaction with quality of life 5.401.79 General life satisfaction 5.661.67 CUSTOMER SATISFACTION Satisfaction with overall hospital services 6.291.20 Satisfaction with health care services 5.811.67 Satisfaction with accommodation and food and beverage services 5.571.81 CUSTOMER LOYALTY Intention to recommend to friends 6.351.24 Intention to repeat hospital stay 6.481.09 Source: Research results Table 2: Constructs, measurement items and results of descriptive analysis (N=82)

14. Figure 2. PLS-SEM model with indicator loadings and structural coefficients Source: Research results

15. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija RESEARCH RESULTS Path Path coefficients t valuesp valuesEffect sizeHypotheses PQOL  LS 0.4223.1690.002* 0.224Supported PQOL  CSAT 0.4995.1040.000* 0.332 Supported CSAT  LS 0.3072.494 0.013** 0.119 Supported CSAT  CLOY 0.4032.9430.003* 0.194 Supported * p<0.01 ** p<0.05 Source: Research results Table 3. Significance testing of the structural model path coefficients

16. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija CONCLUSION  The patients using the services of the specialty hospital expressed a positive attitude towards hospital services.  Medical rehabilitation services helped to improve the physical quality of their lives.  A positive effect on their life satisfaction.  A postive effect on the customer satisfaction and loyalty.

17. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija CONTRIBUTION THEORETHICAL CONTRIBUTION  the WHOQOL-BREF quality of life assessment scale (Skevington, Lotfy and O’connell, 2004) previously used to study the impact of tourism on quality of life (Carneiro and Eusébio, 2012), and in the field of health care (Skevington, Lotfy and O’connell, 2004), can be successfully applied in the area of health tourism. PRACTICAL CONTRIBUTION  is evident in proving the connection between the perception of the influence of health services on the improvement of health and satisfaction with hospital services, and their influence on the patients’ satisfaction and loyalty to the hospital.

18. ToSEE - Tourism in South East Europe 3rd International Scientific Conference Sustainable Tourism, Economic Development and Quality of Life University of Rijeka, Faculty of Tourism and Hospitality Management Opatija LIMITATIONS AND SUGGESTIONS LIMITATION OF THE RESEARCH  A small convinient sample of patients in only a single specialty hospital.  Only the construct of physical quality of life was applied, while social, psychological and environmental quality of life constructs were not studied. SUGGESTIONS FOR FUTURE RESEARCH  To conduct the research on representative sample of patients in larger number of speciality hospitals.  Social, psychological and environmental quality of life constructs should be included.  This study - a platform for similar research in the field of health tourism and quality of life.

19. Thank you for your attention! Dina Lončarić Faculty of Tourism and Hospitality Management, Opatija E-mail: dinal@fthm.hr