Travelers’ (in)Resilience to Environmental Risks Emphasized in the Media and Their Redirecting to Medical Destinations: Enhancing Sustainability

Abstract

This research delves into the intricate dynamics of travelers’ decision-making processes, particularly their response to the media’s portrayal of environmental risks and the subsequent redirection of their travel choices toward medical destinations (MD). Employing a sophisticated research approach combining path analysis with moderation and multilinear logistic regression models, this study investigates the nuanced factors underlying travelers’ resilience to environmental risks and their propensity to opt for medical destinations. The results of the path analysis reveal a complex network of direct influences of factors from the PPM model (push, pull, and mooring) on choosing a medical destination in the sense that, before moderation, the only significant direct effect on the intention to choose medical destination (MD) was the pull factors. Through moderation, a significant effect of all three factors was achieved, while the direction of influence was changed in the case of push and pull factors. Furthermore, the multinomial logistic regression showed that the respondents prefer to go to a medical destination rather than a rural or urban one after the media emphasis on environmental risks. By integrating these analytical approaches and models, this research advances our understanding of how travelers navigate their choices amid environmental uncertainty. Furthermore, this research sheds light on the pivotal role that these traveler choices play in shaping the sustainability of medical destinations, offering essential insights for stakeholders, policymakers, and researchers navigating the evolving landscape of these destinations.

1. Introduction

Environmental catastrophes have an effect on people and the environment and can have long-term effects, including the immediate disruption of human, animal, and plant life as well as all economic activity [1,2]. The worldwide tourism sector has seen a dramatic shift in passengers’ interests in recent years [3]. Tourists are increasingly considering safety and sustainability when picking their travel locations as climate change, natural catastrophes, and pollution continue to threaten diverse regions across the world. This shift in mentality has far-reaching consequences for both the tourism sector and the environment [4]. After more than two years of the COVID-19 pandemic, a large number of papers have been written on the issue of the strength of the influence of fear on the intentions and decisions of tourists. However, environmental factors, as an unforeseen enemy of tourism, have always played a role in creating the behavior of tourists. Science and practice are becoming more aware of the significance of researching the effects of said disasters on the behavior of tourists and the survival of tourist destinations in light of the recent environmental disasters that hit Turkey at the beginning of this year as well as other social and natural risks in the world. In such challenging times, the concept of medical destinations has emerged as a crucial lifeline for tourists seeking safety and healthcare access.

This text explores the significance of medical destinations during environmental crises and how they cater to the needs of travelers facing unexpected health challenges far from home. Medical destinations, often abbreviated as MDs, represent locations that offer safety and a secure stay after major natural disasters [5]. Many tourist destinations must become aware of the need for a comprehensive risk assessment to which they are exposed and accordingly develop the ability to adapt to changes and enable further progress [6]. The adaptive capacities of medical destinations are measured based on several factors. These factors include the development of institutions, the technology they possess, their wealth, and their capacity for quality planning [7]. Medical tourism, which refers to visiting outside of one’s country of permanent residence (particularly abroad) in order to improve or restore health is one of the most lucrative modern forms of tourism [8]. The environment and recreation have a key role in health tourism, while the environment, rehabilitation, and recreation play a key role in medical tourism [9]. Different elements determine the unique characteristics of medical tourism, and each factor necessitates a variety of aspects, including various approaches. However, the idea of medical tourism and medical destinations unites them all [10]. The media’s influence on travelers’ destination selections cannot be understated. The media is a major instrument in the tourism business, from creating wanderlust and marketing specific destinations to giving practical information and changing attitudes. Because of the media, travelers today have access to a wealth of knowledge and inspiration, and they rely on these sources to construct remarkable vacations. As a result, media outlets, travel influencers, and destination marketing groups will play an important role in molding the future of tourism. In the digital age, the media is crucial in molding our impressions and influencing our decisions. When it comes to travel, the media has a significant impact because it offers passengers a window into the world’s different destinations. Whether through television, periodicals, social media, or travel blogs, the media has the potential to inspire, enlighten, and even assist visitors when it comes to selecting their next trip.

The authors of this article made note of the media’s moderating influence on visitors’ behavior, and the redirection of travel to areas that appear safer to them. The authors tried to indicate the importance of these destinations because an important fact is that they are often strategically located in regions with well-developed health infrastructure and can offer tourists emergency medical assistance and treatment. Whether it is an injury from a natural disaster or an illness during a pandemic, these destinations serve as vital hubs for medical care. Furthermore, the goal was to examine the media’s influence on tourists’ decisions to choose medical destinations, especially after emphasizing the negative effects of environmental disasters. It was found that environmental crises can disrupt travel plans, leaving tourists stranded or in need of emergency assistance, and that the media can significantly influence tourists’ decisions to direct their trips to safer places.

The originality of this research is reflected in highlighting the importance of medical destinations during environmental crises, and access to quality health care, which should be the most important. There is not enough research on the importance of medical destinations, as most research is done in rural areas or spas, but the terminology of the importance of medical destinations remains relatively unexplored. On a positive note, the influence of the media indicates that medical destinations also prioritize preventive health measures, including vaccination centers and health screenings. During a pandemic, tourists may flock to these destinations to receive necessary vaccinations or undergo health checks before continuing their journey. Studying the influence of the media on tourist decisions can make a great contribution to both theoretical frameworks and practical implementations in tourism and hospitality. As the media landscape evolves, tourism professionals must constantly update themselves to effectively sell locations, change perceptions, and adapt to the changing desires of travelers in a more interconnected world. Studying media coverage of crisis situations and its impact on tourist decisions can encourage the development of crisis preparedness plans prioritizing tourist safety and well-being. The relationship between the media and the decision-making process of tourists has become the subject of increasing interest among researchers and practitioners in the field of tourism and hospitality. The media’s ability to shape perceptions, inspire travel, and influence destination choice has significant implications for both theory and industry practice. The study integrates elements of environmental science, media studies, and health care in the field of tourism research. This interdisciplinary approach fosters a deeper understanding of the complex factors that influence travelers’ decisions. This knowledge can be applied to design targeted campaigns that promote sustainable travel and raise awareness about responsible tourism practices, ultimately contributing to a more sustainable travel industry. In addition, following the demands and decisions of tourists with the help of the media, the practical implications shift in the direction of sustainable development of the destination. The significance of this study lies in its exploration of the underrepresented nexus between media influence, tourist decisions, and the sustainability of medical destinations. While the medical profession’s role in healthcare tourism is widely acknowledged, the extent to which media-driven tourist choices impact the sustainability of medical destinations remains an underexplored realm. By recognizing the interconnectedness of these factors, this research not only enhances our understanding of the dynamics at play but also illuminates practical implications. By aligning medical destination development with tourists’ preferences through effective media management, this study paves the way for a sustainable trajectory, ultimately benefiting both healthcare providers and patients seeking quality medical services away from home.

2. Theoretical Background

2.1. Environmental Risks and Tourists’ Intents to Visit Safer Medical Destinations

Before the COVID-19 pandemic, the tourism industry had always struggled with concerns such as environmental hazards, which affected travelers’ opinions and choices to visit locations affected by natural disasters [11,12,13,14,15,16]. According to some authors, the COVID-19 epidemic provided relief to destinations, allowing them to at least partially recover from the damage caused by excessive tourism to natural resources [17]. Natural processes can also impact the environment, contributing to environmental degradation. Unlike all other species, humans today have the ability to change and control nature [18,19]. Pollutants can originate from various sources, including anthropogenic (caused by human actions) factors such as population growth, urbanization, resource consumption, industry, traffic, and agricultural production, as well as natural causes like climate change, earthquakes, volcanoes, floods, fires, storms, and soil erosion [20]. The 2004 tsunami in Thailand serves as an example of how ecological disasters can have wide-ranging implications for society and practice. Despite the rapid reconstruction of tourism facilities, the consequences of the tsunami led to significant developments in both theory and practice. For instance, travelers increasingly inquire about a destination’s “eco-sensitivity” before making decisions about whether to visit [21]. Furthermore, environmental disasters like hurricanes, such as the one that struck the Gulf of Mexico, not only affect the population by increasing property insurance costs but also influence tourists’ awareness and decisions regarding travel to risky coastal destinations due to safety concerns. According to the same study, approximately 35% of travelers now consider a destination’s environmental sensitivity when making travel plans [22]. Environmental factors are increasingly being integrated into tourist offerings and arrangements. This trend has been facilitated by events such as the 2004 Indian Ocean earthquake and tsunami and the 2010 Haiti earthquake, which serve as stark reminders of the devastating impact of natural disasters and their influence on tourist awareness and decisions to visit such destinations [23].

Tourism is declining as a result of weather occurrences that have severely harmed the ecosystem and tourist attractions. Environmental concerns, in particular, represent major threats to tourist destinations that rely on natural resources and ecosystem services [24,25,26,27]. Establishing a resilient and sustainable tourism industry is especially challenging for communities in high-risk areas, as evidenced by historical examples of tsunamis, earthquakes, and volcanic eruptions worldwide. Addressing planning and development goals becomes critical in an era of increasing climate unpredictability [28,29,30,31]. The association between excellent climatic conditions for tourism and favorable conditions for infectious diseases, which is one of the largest potentials for economic contribution, hinders the growth of the tourism business in some undeveloped nations [32,33,34]. Regarding this subject, Rossello et al. [35] emphasize that the elimination of malaria, dengue fever, yellow fever, and Ebola in travel destinations has a significant economic impact on traveler spending. Natural catastrophes are thought to be negatively correlated with both economic revenue and a destination’s reputation since they immediately lower economic income in a given area [36] and decrease the attractiveness of tourism-related activities [37]. Natural disasters, on the other hand, can promote and affirm low-visited locations such as medical destinations, as well as enhance local activities, future investments, and other forms of social benefits [38,39].

Environmental crises have become a significant driver in tourists’ decisions to relocate to safer destinations, including medical destinations [40]. According to research from the same study safety, access to quality healthcare, resilience, sustainability, and financial considerations are among the key factors that shape these choices. Further, as environmental challenges continue to evolve, destinations that prioritize safety, healthcare, and sustainability are likely to see an increasing influx of individuals and families seeking refuge from the uncertainties of our changing world [41]. According to Page [42], tourists are reluctant to visit locations with a history of specific environmental concerns and countries that are prone to infectious diseases [43,44]. The aforementioned ecological crises not only had profound effects on the environment and the local population but also significantly influenced the decisions of tourists looking for safer and more sustainable destinations [45,46]. This trend has led to a growing interest in medical destinations, places that offer not only safety but also access to quality healthcare services [47]. Medical locations, which are frequently equipped with cutting-edge healthcare infrastructure and amenities, have grown appealing to tourists who value access to high-quality healthcare services [48]. The COVID-19 pandemic, in particular, highlighted the necessity of healthcare availability and quality when deciding where to travel [49]. Tourists are becoming more aware of destinations that have shown resilience and sustainability in dealing with environmental issues, and they are drawn to places that have embraced environmental practices and initiatives because they believe they are more responsible and prepared to deal with disasters [50]. Because the cost of home insurance in high-risk areas is growing, tourists are looking for destinations that offer less expensive coverage, which medical destinations can provide [51,52,53]. During these uncertain times, medical destinations provide tourists with a sense of protection and comfort, prompting them to visit such locations [54,55,56]. Medical destinations are typically outfitted with cutting-edge medical technology and highly trained medical personnel [57,58,59,60]. This means that tourists receive the greatest health care possible in the event of health problems induced by environmental crises [61,62,63,64,65]. Many medical destinations provide health packages and programs that are targeted to the needs of travelers [66,67,68,69,70]. These also include strategies for specific health demands in the event of environmental crises such as pandemics or natural catastrophes [71,72], as well as health packages and programs targeted to tourist needs [73,74,75,76]. This includes plans for specific health needs in the event of environmental crises, such as pandemics or natural disasters [77,78,79,80]. Medical destinations provide information and advice to tourists about safety during environmental crises through various media channels, including ways to protect themselves and how to prepare for crisis situations [81,82,83]. Any exposure to the influence of the media, stress, emergency situations, and traumatic situations can have the potential for long-term effects on a person’s psychophysical functioning [84,85]. However, the very personality traits and abilities of the individual determine whether the consequences will materialize and how serious and disruptive they will be for ongoing functioning [86,87], and to what extent tourists will be (un)resistant to environmental influences [88,89,90].

Despite the environmental risks associated with some destinations, tourists continue to be drawn to these locations, driven by various motivations and desires [91,92]. Despite the presence of significant environmental threats or hazards like air pollution or ozone depletion in many locations, tourists still find these destinations alluring [93,94,95]. According to the same research, tourists often prioritize adventure and unique experiences over safety concerns. This leads them to venture into risky destinations where they can explore pristine natural beauty and engage in exciting activities. Some tourists are drawn to untouched and remote areas, seeking a respite from the crowds and an opportunity to connect with nature in a pristine environment, even when it entails encountering environmental risks [96,97,98,99,100]. People’s decisions to travel to regions with bad environmental conditions are influenced by their anticipated emotional responses, and travelers’ perceptions of their quality of life might change as a result of experiencing environmental issues while on the road [101]. Despite the urgent need for new frameworks and applications, the concept of tourists’ resilience to media influence has not yet been widely adopted by professionals in the tourism industry [102]. Furthermore, tourists’ resilience to media-driven environmental concerns can bolster the sustainability of a medical destination by ensuring a consistent flow of visitors seeking safety and healthcare, thereby contributing to the economic viability of the destination. When tourists resist media-induced fears related to environmental risks and opt for medical destinations, it fosters destination stability, stimulates investment in healthcare infrastructure, and enhances the overall sustainability of these vital healthcare hubs [103].

2.2. The Impact of the Media on How Tourists Behave

The amount of study and specialized literature on the role social media plays in helping travelers choose their travel destinations is limited. Mass media has a significant impact on the formation and growth of medical tourism. It shapes people’s attitudes and behaviors, particularly those connected to health, and reroutes intentions in response to environmental and social dangers in the world [104]. The primary objectives of mass media organizations (publishing houses, TV and radio stations, etc.) are the collecting, processing, and open public dissemination of various types of information to the general public [105]. The majority of the health information that adults receive comes from the media, according to studies in the field of social medicine [106]. Furthermore, traditional studies of health communication demonstrate that mass media may be even more crucial for raising public awareness and knowledge about health issues than interpersonal communication [107,108,109]. Taking into account all social factors, it is important to understand the influences of the media in spreading stereotypes about environmental risks and the need for medical tourism [110]. More concretely, it is most important to understand the cognitive, emotional, physiological, and behavioral impact of these media messages on the behavior of tourists [111]. Thus, under the influence of the mass media, a sense of safety in medical destinations appears in the human mind after any kind of environmental disaster [112]. It is possible to effectively create an advertisement for medical destinations, which will contribute to the formation of a unique algorithm for providing such a well-liked and expanding service, especially after some specific events like environmental risks or social unrest, thanks to the logistical components in the media’s work [113]. The extent to which the media influences tourists’ intentions to raise awareness about the safety of destinations providing medical services, mental and physical treatment, and the perception of safety relative to other destinations is uncertain [114]. The question is how effective the development of this phenomenon, the reorientation to medical destinations, will be if two social groups are included in the field of interaction: the media and tourists [115,116].

According to Sultan et al. [103] the paradigm of user-generated social media content pertains to traveler behavior and safe destination choice. The same authors also contend that user-generated media content affects travelers’ attitudes and worries through cognitive and affective factors. According to Kaosiri et al. [104], when some form of environmental concern has been observed, user-generated media content has a favorable and even substantial impact on the formulation of tourists’ decisions and intentions to reorient to another location. By increasing the importance placed on the health and safety of a tourist destination, social media plays a more active role in travel as a tool for creating trust in obtaining information about sanitary safety [117]. People who intend to use social media to find information about the health and safety of a tourist destination are more likely to choose that destination for their vacation [118]. Travel decisions made by visitors are significantly influenced by particularly negatively unfavorable media coverage. This study discovered that in the Pakistani setting, perceived risk is believed to be higher than real risk since making the option to travel to a new location is inherently riskier [48]. Țuclea et al. [68] investigated the role of social media in determining a tourist destination’s desirability, placing particular attention on the location’s safety and health. The findings show that respondents became more interested in communication via social media channels when they trusted social media for travel information. The more a traveler pays attention to the media, the more likely he is to change his decision on choosing a destination [119,120]. Furthermore, the greater the extent to which a traveler is influenced by media, the more likely it is that their destination choice will be altered. This has a direct impact on the viability of a medical destination, as the media’s influence can sway travelers towards or away from such destinations based on the portrayal of safety, healthcare quality, and environmental risks. The fluctuation in traveler decisions driven by media attention can significantly affect the sustainability and economic stability of medical destinations.

3. Methodology

In this article, a thorough review of the literature was conducted, drawing on information from both domestic and international sources about medical tourism, medical destinations, environmental risks, and the impact of the media on traveler behavior. Research techniques including comparative, systematic, synthesis, study of documentary sources, and survey research were used. Logistic regression modeling was used to investigate how different independent variables (such as push factors, pull factors, mooring factors, and moderators) affect the likelihood of tourists choosing a medical destination (MD). Logistic regression helps determine the significance and direction of these effects, taking into account the binary nature of the dependent variable (choice of a medical destination or not). Multinomial logistic regression was used to confirm the last hypothesis, which will be further explained in the data analysis chapter.

3.1. Modeling of Research Objectives and Hypotheses

The main goal of the research was to determine to what extent the media moderates the influence of the modified PPM model factors on the intention of tourists to reorient travel directions to medical destinations, reporting in different ways about the consequences of environmental risks. The authors tried to establish which of the motivational factors has a direct influence on the decision to choose the medical destination (MD) as a safe destination, as well as to what extent the media can play a moderator role. The empirical research was preceded by the establishment of hypotheses by the authors in accordance with the model (Figure 1). The research itself was based on the hypothesis that all identified factors of the modified PPM model (independent variables) have a direct impact on the intention to choose a destination (dependent variable) as predictors and that media factors have an enhanced moderating role.

H1a. 

Push factors have a positive direct influence on the intention of tourists to choose a medical destination after media exposure of environmental risks.

H1b. 

Pull factors have a positive direct influence on the intention of tourists to choose a medical destination after media exposure of environmental risks.

H1c. 

Mooring factors have a positive direct influence on the intention of tourists to choose a medical destination after media exposure of environmental risks.

H2. 

Media factors have a direct influence on the intention of tourists to choose a medical destination.

H3a. 

Media factors strongly moderate the relationship between push factors and MD (the intention of tourists to choose a medical destination).

H3b. 

Media factors strongly moderate the relationship between pull factors and MD (the intention of tourists to choose a medical destination).

H3c. 

Media factors strongly moderate the relationship between mooring factors and MD (the intention of tourists to choose a medical destination).

H4. 

Medical destinations have primacy in the choice of tourists, in terms of the feeling of safety in relation to rural and urban areas, after media emphasis on environmental risks.

3.2. Research Method and Questionaire Design

The authors used two PPM model (push-pull-mooring) questionnaires from the authors Jeong-Joon Kim, Byeong-Cheol Lee, and Hyo-Jeong Byun [107] and Imas Chandra Pratiwi, Santi Novani and Lisandy Arinta Suryana [76] in order to achieve the research’s stated objective. Based on the research that was accessible and addressed the topic of examining the influence of the media on decisions, indicators of the media as a moderator were developed. Given that each of the factors had its own indicators, the authors took over the constructed factors from the aforementioned authors. A yes or no response option was included in the indicators of the factors that influence tourists’ decisions to travel to MDs (medical destinations) after media attention to environmental risk, and the results revealed that 68.5% of respondents would select a medical destination to travel to after environmental risks or major disasters.

The early tourism literature divided the motivation for travel into two categories: “push” and “pull” factors. “Push” factors refer to personal needs such as escaping the city or relaxation, while “pull” factors refer to destination-specific characteristics such as the desire to see a particular attraction, landscape, or event at a particular destination [121]. Kim et al. [122] points out that in addition to push and pull factors, there is a category of mooring factors, which are considered intermediate factors and can be positive or negative. This category also includes environmental risks. The PPM model is derived from the push-pull paradigm and is recognized as a theory that helps to understand changes in consumer behavior [123]. In tourism, very few studies have been conducted on this topic; in Serbia, there are almost none. The same authors believe that the PPM model is suitable for understanding motives and changes in consumer behavior or changes in behavioral intentions, but that it also includes obstructive factors. The factors belonging to the push group can be seen as characteristics of socio-psychological motives, intentions, and desires of tourists, while pull factors are motivators that imply attractive attributes of a tourist destination and include factors that influence the choice of destination [124,125]. Due to the limitation of push and pull factors to comprehensively explain the intentions of consumers who change their intentions and behavior, mooring factors emphasize or even influence the decision-making itself [126].

3.3. Measurements

A field survey was performed, with the questions separated into two groups. The first section of the questionnaire included questions about the respondents’ sociodemographic traits. The second part of the questionnaire included questions about the PPM model. More precisely, it contained a total of 18 items grouped into four factors (independent variables) and one dependent variable (MD—intention to choose the medical destination). There were five items for assessment in each of the three factors: 1. Push factors (five items): escape from daily routine, escape from the pressure of work, relax and rest, recharge mental and physical health, enjoy time with family and friends; 2. Pull factors (five items): experience, events, special gastronomy, CHSE, comfortable place; 3. Mooring factors (five items): safer during environmental risks, affordable destinations, less social risk, absence of terrorism, safer to stay after the pandemic; 4. Media factors (three items): exaggerate information about ER and increase fear among tourists, present real information after ER, create a sense of security after ER. Respondents stated their agreement with the supplied statements on a five-point Likert scale (1—not agree at all; 2—agree; 3—neutral; 4—agree; 5—absolutely agree). The values for the factors (average score, value of CR, AVE, percentage of explained variance) as well as the factor loading are shown in

Table 1. Descriptive statistics and measurement model validity of the extracted factors of the expanded PPM model.

Push Factors								Pull Factors								Mooring Factors
Items				m			λ	Items					m		λ	Items		m				λ
Escape from daily routine				2.10			0.780	Experience					2.16		0.751	Safer during environmental risks		3.68				0.755
Escape from the pressure of work				2.93			0.684	Events					2.05		0.623	Affordable destinations		3.86				0.729
Relax and rest				2.24			0.718	Special gastronomy					2.47		0.635	Less social risk		3.04				0.757
Recharge mental and physical health				3.15			0.726	CHSE					4.28		0.684	Absence of terrorism		3.24				0.796
Enjoy time with family and friends				2.16			0.731	Comfortable place					2.11		0.805	Safer to stay after the pandemic		3.56				0.818
Factor measurements								Factor measurements								Factor measurements
m	α	CR	AVE			%Variance		M	α		CR	AVE		%Variance		m	α		CR	AVE	%Variance
2.51	0.772	0.874	0.684			46.226		2.62	0.761		0.890	0.633		11.768		3.47	0.810		0.940	0.762	5.666
Media Factors
Items																m		λ
Exaggerate information about ER and increase fear among tourists																3.88		0.871
Presents real information after ER																3.57		0.767
Creates a sense of security after ER																3.06		0.863
Factor measurements
m					A					CR						AVE		%Variance
3.50					0.885					0.872						0.697		3.973

N = 1.361; λ—Outer Loading; α = Cronbach’s Alpha; CR—Composite Reliability; AVE—Average Variance Extracted; CHSE—Cleanliness, Health, Safety and Environment Sustainability (certification from the government); MD—Medical destinations; ER—Environmental Risks.

.

3.4. Research Context: Spatial Setting and Participants

The respondents were from two countries because the research was conducted in those countries, and their responses were combined in the results. This approach allowed the research to observe differences in destination choices, regardless of the respondent’s country of origin. Since the 1950s, domestic medical tourism, particularly in the form of wellness tourism, has become a widespread phenomenon in Russia. In 2015, the non-profit organization Russian Association of Medical Tourism and Export of Medical Services was established in the country. Approximately 71 regions of the Russian Federation have embarked on projects to develop medical tourism. On the other hand, Serbia is not currently ranked among the top 50 countries in terms of the impact of medical tourism on its economy. Nevertheless, medical tourism in Serbia is rapidly evolving thanks to highly skilled medical professionals and services that adhere to international standards. The pricing strategy in Serbia attracts medical tourists from various countries. Additionally, the Serbian government has shown support for the development of medical destinations.

A random poll was conducted in the center of the mentioned cities, where every member of the population has an equal chance of being elected. This method often produces highly representative samples. The survey is voluntary and anonymous. The author clarified all ambiguities in the questions in Serbian, English, and Russian. The population in the Rostov region (sample size of 935) and the survey periods (before the epidemic, from January to March 2019, and subsequent to the pandemic, from August to November 2022) served as the empirical foundation for the study. Between July and December 2022, research on Serbia (a sample of 426) was carried out in the following cities: Belgrade (208), Novi Sad (111), and Niš (107). The required sample size was calculated using the G*power test. Taking into account that there was a total of four predictors and one criterion, the required effect size was set to η2 = 0.15, with a statistical power of 0.95, and it was calculated that a sample size of 129 respondents may be appropriate for this research. According to

Table 2. Empirical findings of sociodemographic characteristics of respondents.

Gender		Frequency of Traveling to a MD
Male	47.7%	I have never traveled to a MD *	22.1%
Female	52.3%	I have traveled once a year	49.3%
		I have traveled several times a year	28.6%
Education		Earning
High school	24%	Low (≤500 Euros)	1.8%
Faculty degree	59%	Average (500–1.000 Euros)	66.9%
MSc, PhD	17%	High (>1.000 Euros)	31.3%
Age		Country of residence N = 1.361
18–30	10%	Russian Federation	935
31–55	63%	Republic of Serbia	426
>56	37%

* MD—intention to choose medical destinations.

, women (52.3%) had a somewhat greater response rate than men (47.7%). The age range with the highest percentage of respondents (63%) was between 31 and 55, whereas the age range with the lowest percentage of respondents was 18–30. The majority of respondents (59%), in accordance with the educational system, completed their undergraduate degrees. In all, 49.3% of study participants said they visit medical destinations once a year, while 22.1% said they have never traveled to a medical destination (MD). The largest percentage of respondents as a whole (66.9%) earn between 500 and 1000 euros per month.

3.5. Data Analysis

The collected information was analyzed using the statistical program SPSS, version 23.00. Through descriptive statistical analysis, average scores for all items were obtained, and a normal distribution of data was determined, where the values of skewness (0.512) and kurtosis (−0.776) were individually within ±1, while the critical ratio (Z value) of the skewness (0.721) and kurtosis (−0.618) were within ±1.96 [127]. Internal accuracy was measured using Cronbach’s alpha coefficients, and the reliability analysis confirmed that all measures used in the study are reliable, as Cronbach’s alpha (α) for each construct is greater than 0.7 [128]. The validity of the construct was tested by factor analysis. The number of extracted principal components, in addition to the criteria defined by the Kaiser-Meier-Olkin coefficient, was determined by Cattell’s scree plot analysis with an eigenvalue of 1 or more and the percentage of explained variance. The Kaiser-Meyer-Olkin (KMO) overall measure of sampling adequacy was above 0.60 (KMO = 0.850) [129], indicating that the data were appropriate for the principal component model. Bartlett’s test [130] of sphericity was significant (X² = 6955.221; df = 153; p = 0.000). The convergence validity of the scale was quite good, as average variance extraction (AVE) values for all observed variables were greater than 0.5, while composite reliability (CR) values were greater than 0.7 [127]. Furthermore, the authors, in order to determine whether the media has a moderating role, more precisely whether the predictors, more or less, predict going to medical destinations and when, performed a moderation model through the analysis of path structural modeling in the SPSS AMOS program, version 26.00. Moderation analysis is most often applied when an unexpectedly low association between a predictor and a criterion is obtained or when there are inconsistent results in the field about the association between two variables [128]. Moderation is defined as changes in the direct influence of an independent variable on a dependent variable under the influence of a third variable [130]. Multinomial logistic regression was used to assess the probability of belonging to each category (determined to be three categories): 1. MD (medical destinations); 2. RD (rural destinations); 3. UD (urban destinations) for a given set of predictors.

4. Results and Discussion

4.1. Results of Moderating Path Analysis

In the first step, the mean scores for all factors were calculated. Then, in the second step, interactions between factors and the moderator were created. This was done to facilitate a moderation path analysis within the structural modeling framework. More precisely, it aimed to examine how the relationship between the identified factors and the intention to visit medical destinations was moderated after specific media coverage of environmental disasters. Figure 2 offers an overview of the predictor effects in relation to the criterion, along with the values representing the moderating relationships.

Before the introduction of the moderator, the results from Figure 1 and

Table 3. Moderation analysis summary.

		Influences	β	t	p	Confirmation
MD	<--	Push factors	−0.02	−1.075	0.282	H1a
MD	<--	Pull factors	0.51	3.338	***	H1b
MD	<--	Mooring factors	0.00	0.083	0.934	H1c
MD	<--	Moderator	0.938	52.143	***	H2
MD	<--	Moderation-pull factors	−0.072	−4.609	***	H3a
MD	<--	Moderation-push factors	0.055	3.333	***	H3b
MD	<--	Moderation-mooring factors	0.056	0.394	0.04	H3c

Moderator-media factors, MD—intention to choose a medical destination. *** p = 0.00

indicate that push factors do not show statistical significance in influencing the intention to choose a medical destination (β = −0.02, t = −1.075, p = 0.282). The p-value suggests that this relationship is not statistically significant at conventional significance levels (p < 0.05). This statement negates hypothesis H1a. Similarly, the mooring factors do not show statistical significance in the effect on the choice of medical destination with the following obtained values: β = 0.00, t = 0.083, p = 0.934 (H1c negated). A positive direct effect on the choice of a medical destination is shown by the pull factor with values β = 0.51, t =3.338, and a p value within the limit of conventional statistical significance (p = 0.00). Hypothesis H1b was confirmed. The direct influence of the media (which has the role of moderator) on the choice of destination is certainly significant, as shown by the obtained data from the table (β = 0.938, t = 52.143, p = 0.00), thus supporting hypothesis H2.

In the second step, a moderator—the media—was introduced, in order to determine whether it plays a role in changing the value of the effects of given factors on the decision to choose a medical destination. The results given in Table 3 indicate that statistically significant moderation was achieved for all factors with the following influence values: pull factors (β = −0.072, t = −4.609, p = 0.00), push factors (β = 0.055, t = 3.333, p = 0.00), and mooring factors (β = 0.056, t = 0.394, p= 0.04). These findings confirm all hypotheses (H3a, H3b, and H3c) related to the moderating effect of PPM model factors on tourists’ intention to choose a medical destination following media emphasis of environmental risks. It is noteworthy that the moderation of the pull factor revealed a negative and significantly reduced effect compared to its direct positive influence. In contrast, with the push factor, the moderating effect has a positive direction with a slight increase.

Additionally, a simple slope was calculated, and a regulation effect diagram was constructed that disclosed the moderating effect of the identified factors and MD selection in order to better understand the nature of the moderating effects (Figure 3, Figure 4 and Figure 5). To summarize, the analysis indicates significant relationships between pull factors, the moderator variable (media), and their interaction with the choice of a medical destination (MD). Conversely, it is evident that push factors and mooring factors do not exert a significant direct influence on the selection of a medical destination (MD). These results offer valuable insights into the factors influencing medical destinations and how they moderate their relationship with the selection of medical destinations.

The figures depict two lines representing the relationship between predictors (push, pull, and mooring) and the criterion of the intention to choose a medical destination (MD) for both low and high levels of the moderator construct (media). Figure 3 indicates that the high media line is much steeper, which indicates that at a high level of the moderator (media), the influence of the pull factor on MD is much stronger compared to low media. When the level of media moderators increases, the influence of the pull factor on MD increases. However, it was shown that the greater influence of the moderator is important for the negative relationship between the pull factor and the selection of a medical destination (β = −0.070, t = −4.609, p = 0.00). A similar situation is also shown in the graph that shows the situation of moderation with the push factor, as long as there is a positive relationship between the push factor and MD.

Figure 5 illustrates the nature of the moderating effects of the mooring factor. In this instance, it is demonstrated that a stronger high media moderation contributes to a more pronounced influence of the mooring factor on MD. The steeper the slope of the high media line, the stronger the relationship between the construct, specifically the mooring factor, and the intention to choose a medical destination. In all three cases, a steeper slope with high media is observed, indicating a more robust connection between the constructs and the intention to choose a medical destination.

4.2. Results of Multinominal Logistic Regression

In order to determine which destination they prefer from the three offered (MD—medical destinations, RD—rural destinations, and UD—urban destinations) after the influence of the media on tourists, the authors used multinominal logistic regression.

Table 4. Model Fitting Information.

X2	Df	p		Deviance	McFadden
21.863	134	0.00		0.05	0.325
Parameter Estimates for choosing destinations				95% Confidence Interval for Exp(B)
	β	p	Exp(B)	Lower Bound	Upper Bound
MD	−0.111	0.039	0.895	0.806	0.994
RD	0.117	0.054	0.895	1.011	1.250
Classification statistics of determined group memberships predicted by the model
MD		RD		UD
70.8%		46.5%		5.3%

The reference category is Urban Destination. MD—medical destinations, RD—rural destinations, UD—urban destinations.

shows the parameters of the model’s good fit (X² = 21.863, df = 134, p = 0.00, deviance = 0.05, and McFadden value = 0.325), as well as the classification statistics of the groups predicted by the model. The destinations are ranked from the lowest to the highest (1–3), so that the first place is the medical destination, the second place is the rural destination, and the reference is the urban destination.

In addition, it can be seen that respondents are more inclined to choose a medical destination under the influence of the media (β = −0.111, p = 0.39), and only then to rural destinations (β = 0.117, p = 0.054). The correct percentage of respondents who chose a MD predicted by the model is 70.8%, while for RD it was 46.5%, and the correct percentage of respondents predicted by the model for urban destinations was 5.3%. These results confirmed hypothesis H4, that respondents prefer to choose medical destinations after certain media influences that emphasize environmental risks.

5. Discussion of Findings and Concluding Remarks

Environmental risks, such as climate change, natural disasters, and pollution, have increasingly concerned travelers worldwide. This research aimed to explore how travelers respond to media portrayals of environmental risks and whether they prefer medical destinations (MD) in such contexts. We used a combination of path analysis with moderation and multinomial logistic regression to examine the complex dynamics of tourist behavior and destination choice.

Our analysis reveals that there is no significant relationship between the push factor and the choice of a medical destination (MD). In simpler terms, changes in push factors do not appear to significantly influence MD selection. Conversely, a significant and positive relationship exists between the pull factor and the MD variable. This indicates that as pull factors increase, the likelihood of choosing a medical destination also rises. This relationship is not only statistically significant but also substantial, as indicated by the high β coefficient and the p-value at the significance level. Travelers are more inclined to choose a medical destination (MD) when they are attracted to the positive aspects of these destinations. This result underscores the importance of medical destinations (MD) in meeting travelers’ desires and preferences in the context of environmental concerns. Additionally, our analysis reveals that mooring factors do not directly impact the MD variable. Changes in mooring factors do not seem to lead to significant shifts in destination selection. This suggests that travelers’ attachment to their home location did not significantly influence their decision to choose a medical destination (MD) in response to environmental risks.

However, once the media was introduced as a moderator, all factors exhibited a statistically significant influence on the choice of a medical destination after the media emphasized environmental risks. The only change was in the direction of influence, with pull factors now having a negative impact, and push factors showing a positive relationship with MD. This suggests that the media’s portrayal of environmental risks significantly steered travelers toward choosing a medical destination (MD) based on the underlying factors alone. The moderator played a pivotal role in shaping travelers’ preferences, indicating that its presence significantly influenced their decision to reorient toward selecting a medical destination (MD). Moderation analysis further underscored the importance of the media as a moderator by revealing its significant negative interaction with pull factors. This implies that the influence of the pull factor on destination selection diminishes under specific conditions, likely driven by the moderating effects of the variable. In contrast, the analysis also demonstrated a significant positive interaction between the moderator and the push factor, suggesting that the moderator amplified the impact of the push factor on the choice of a medical destination (MD). This implies that, in particular circumstances, media emphasis on environmental risks had a more pronounced effect on diverting travelers towards MD.

In conclusion, this research provides valuable insights into how travelers respond to media-induced perceptions of environmental risks and their subsequent decisions regarding medical destinations. The results underscore the pivotal role of the media in influencing travelers’ redirection towards MD. These findings have implications for the tourism industry and policymakers aiming to comprehend and adapt to evolving traveler behavior in an era characterized by environmental concerns and media influence. Further research and exploration of the media’s effects on tourist behavior could yield deeper insights into this intricate interaction.

The obtained results align with the findings of Morgan and Johnson [131], who highlighted the media’s capacity to magnify environmental risks and how these heightened concerns can significantly sway travelers’ decisions. They argued that media depictions of environmental disasters frequently drive travelers to seek alternative perceived safer destinations, with medical destinations standing out due to their robust healthcare infrastructure. Furthermore, Smith [132] conducted an extensive examination of media narratives during environmental crises and identified a consistent pattern of sensationalism and alarmism. They observed that travelers, in response to such narratives, are increasingly prioritizing safety and healthcare in their destination choices, leading them to opt for medical tourism hotspots. Wahlberg and Sjoberg [133] delved into the concept of risk perception in tourism and emphasized how media portrayals of environmental risks can dramatically alter tourist behavior. They noted that media coverage during crises often underscores the importance of access to health facilities, driving travelers towards medical destinations perceived as well-prepared and secure. Additionally, John [134] investigated the media’s role in promoting medical tourism amid environmental uncertainty. They discovered that the media frequently featured success stories of travelers receiving medical care at these destinations during crises, creating a positive image that encouraged more tourists to view medical destinations as reliable and safe choices.

5.1. Theoretical Implications

This research holds significant theoretical implications that contribute to a comprehensive understanding of behavior and decision-making within the realm of tourism. It encompasses various facets of tourism studies, including media influence, resilience theory, dynamics of medical tourism, crisis management, models of destination choice, behavioral economics, and theories of communication and perception. These implications enrich the theoretical landscape of tourism research by delving into the intricate interplay between media, environmental risks, and traveler choices. Firstly, this research sheds light on the pivotal role of the media in shaping travelers’ perceptions and decision-making processes, emphasizing the necessity of integrating media studies into tourism theories. This integration facilitates a deeper comprehension of how media narratives wield influence over travel decisions. Secondly, by exploring travelers’ resilience and non-resilience to media-induced environmental risk perceptions, this study extends resilience theory into the tourism domain. It adds to our comprehension of how individuals adapt and make choices amid perceived risks. Additionally, the research introduces fresh insights into the dynamics of medical tourism, particularly concerning its intersection with environmental risk perception. This aspect has the potential to contribute to the formulation of theories specific to medical tourism behavior. Furthermore, the study underscores the significance of emergency preparedness plans within the tourism industry. It has the potential to enhance theoretical frameworks linked to crisis management and response by offering insights into how travelers react to media coverage of environmental crises.

Moreover, the research suggests potential enhancements to destination choice models by incorporating media-driven risk perception as a variable. This could lead to the development of more nuanced models that better capture the dynamic nature of travelers’ decision-making processes. The insights garnered from this research can also be integrated into behavioral economics models, providing a deeper understanding of how travelers weigh the perceived benefits of medical destinations against the perceived risks associated with environmental factors. This can contribute to the broader field of behavioral economics applied to travel decisions. Lastly, the study can inform theories of communication and perception, offering insights into how travelers receive, process, and respond to media messages. This can advance theories related to information processing and persuasion in the context of tourism. This research can significantly contribute to the theory of sustainability of medical destinations by highlighting their growing importance in the context of sustainable tourism practices. The study’s findings underscore that medical destinations, due to their appeal in addressing environmental risks emphasized by the media, are becoming increasingly vital components of sustainable tourism.

5.2. Practical and Managerial Insights Focused on Sustainability

The study delves into how travelers react to media coverage of environmental hazards, an underexplored facet of tourism behavior. This perspective adds a novel dimension to the research in tourism and hospitality, bridging elements from environmental science, media studies, and healthcare within the tourism field. This interdisciplinary approach enhances our comprehension of the diverse factors influencing travel choices. The study offers a comprehensive perspective on how individuals navigate their travel decisions in an era overshadowed by environmental concerns. It investigates both travelers’ resistance and non-resistance to media-fueled perceptions of environmental risks. A groundbreaking aspect of this research is the redirection of tourists to medical destinations in response to environmental threats.

This study bears the potential to yield practical implications for tourism professionals and policymakers alike. Understanding travelers’ responses to media coverage can furnish valuable insights into emergency preparedness plans and strategies for promoting medical destinations. Given the growing significance of environmental issues and healthcare in today’s global landscape, this research tackles timely and pressing questions about travelers’ decision-making in an era defined by global challenges. The study provides invaluable insights with practical managerial implications for various stakeholders in the tourism and healthcare sectors. Tourism communities and destination marketing organizations can adapt their strategies to address travelers’ concerns about environmental risks.

Promoting medical destinations as secure and sustainable options can attract risk-averse travelers. Effective communication during environmental crises, accentuating the availability of medical services at the destination, can bolster travelers’ confidence. For medical destinations, investments in advanced healthcare infrastructure and marketing are paramount. This encompasses expanding medical facilities, recruiting qualified healthcare professionals, and ensuring access to top-tier healthcare services. Travel insurance providers can devise specialized products tailored to travelers apprehensive about environmental risks. Coverage for emergency medical cases related to environmental incidents can be enticing to travelers. Collaborations between the tourism and healthcare sectors can yield innovative partnerships. Joint marketing campaigns and package deals that combine medical services with travel experiences can resonate with a broader spectrum of travelers. Understanding traveler segments based on their resilience or non-resilience to media-driven risk perceptions is invaluable. Customizing marketing efforts and services to the preferences of these segments can be more effective. Tour operators can craft packages that cater to travelers seeking both medical services and distinctive travel experiences. These offerings should spotlight safety measures and healthcare options. Governments can contemplate regulatory frameworks that foster the growth of medical tourism while ensuring the security and quality of healthcare services. These frameworks can allure medical tourists and safeguard their interests.

The managerial implications of this study encompass destination marketing, crisis preparedness, healthcare infrastructure, insurance, sector collaboration, media engagement, sustainable practices, market segmentation, tour operator offerings, and regulatory frameworks. These recommendations can aid stakeholders in the tourism and healthcare industries in effectively addressing travelers’ concerns about environmental risks and leveraging the burgeoning interest in medical destinations. Furthermore, the study’s findings contribute to sustainability by underscoring the necessity for responsible media reporting, promoting resilient travel behavior, and proposing opportunities for more sustainable practices within medical tourism. These insights are pivotal for fostering a travel industry that is not only economically viable but also environmentally and socially responsible. The redirection of travel preferences toward medical destinations constitutes a significant discovery. It suggests that travelers may be seeking medical treatments or healthcare services abroad, potentially impacting the global healthcare industry and the environmental footprint of medical tourism. This revelation can guide efforts to make medical destinations more sustainable.

Medical destinations have the potential to bolster their sustainability across various dimensions by responding to travelers’ concerns about environmental risks. By actively targeting travelers who are driven by these concerns, medical destinations can diversify their revenue streams, thus contributing to their economic sustainability. Additionally, positioning themselves as safe and reliable options during environmental crises can attract a broader customer base, further enhancing their economic sustainability. To promote environmental sustainability, medical destinations should adopt eco-friendly practices within their healthcare infrastructure. This entails implementing efficient waste management systems, conserving energy, and employing eco-friendly construction methods. By minimizing their environmental footprint, medical destinations can align themselves with sustainable practices. Furthermore, it’s essential for medical destinations to foster social sustainability by promoting cultural sensitivity. Ensuring that healthcare providers are trained to cater to a variety of cultural backgrounds contributes to a socially sustainable environment.

Collaboration between medical destinations and the media can play a pivotal role in sustaining their reputation and trustworthiness. Encouraging responsible and fact-based reporting during environmental crises, rather than sensationalism, supports the social sustainability of these destinations. Proactive communication of safety measures and preparedness plans through various media channels reassures potential travelers concerned about environmental risks. This not only supports their economic sustainability but also enhances their social sustainability by promoting a sense of safety and preparedness. The insurance sector can also contribute to the sustainability of medical destinations by developing specialized products tailored to travelers worried about environmental risks. Providing coverage for emergency medical cases arising from such risks can offer peace of mind to tourists. Government involvement through supportive regulatory frameworks can ensure the quality and security of healthcare services, thus promoting the sustainability of medical tourism. Moreover, fostering collaboration between the tourism and healthcare sectors can lead to innovative partnerships that enhance the economic sustainability of medical destinations. Joint marketing campaigns and package deals that combine medical services with travel experiences can attract a broader clientele. Understanding traveler segments based on their resilience or non-resilience to media-driven risk perceptions allows for more targeted marketing efforts, contributing to economic sustainability.

In addition to economic, environmental, and social dimensions, medical destinations must prioritize crisis preparedness. Robust emergency preparedness plans should address healthcare needs during crises and incorporate communication strategies that align with responsible media reporting. This ensures the sustainability of medical destinations in the face of environmental risks.

In summary, the implications of the research results underscore the need for a holistic approach to sustainability in medical destinations. By effectively addressing travelers’ concerns about environmental risks, adopting sustainable practices, fostering responsible media engagement, and exploring new revenue streams, medical destinations can enhance their sustainability across economic, environmental, social, and cultural dimensions.

5.3. Limitations and Avenues for Future Research

While the study offers valuable insights, it is essential to acknowledge its limitations. Firstly, the absence of a comprehensive theoretical framework specific to tourism necessitated the use of a conceptual framework for analyzing tourist behavior. This framework, although insightful, can be further refined, possibly by incorporating personality theory models or similar constructs to provide a more concrete understanding of what drives or impedes tourists’ decisions to shift to safer destinations following environmental risks. Additionally, it is important to recognize that the field of post-environmental risk tourist behavior has received limited academic attention, resulting in a scarcity of relevant literature. Nonetheless, even with these limitations, the study has generated noteworthy information. Moving forward, it is advisable to explore both macro (external) and micro (internal) environmental variables that influence travelers’ decision-making and travel choices after environmental risks. Further research should also investigate how socio-demographic factors and personality traits shape tourists’ travel decisions, destination choices, and attitudes toward safer destinations. Researchers should consider diversifying their focus to encompass various regions, demographics, and travel motivations to enhance the generalizability of findings.

Moreover, data collection concerning travelers’ perceptions and decisions regarding environmental risks and medical destinations can be intricate, possibly relying on self-reported data subject to bias and failing to capture the full spectrum of experiences. Environmental risks and travel trends are dynamic, potentially rendering study findings temporally limited. Although the study may have identified correlations between media coverage, environmental risks, and traveler choices, establishing causality can be challenging due to the multitude of factors influencing travel decisions. Media analysis can also be subjective, and the study may not have encompassed all pertinent media sources or considered the nuanced influence of different media types. Furthermore, travelers’ choices are multifaceted, influenced by personal preferences, cultural factors, and economic considerations, which the study may not have fully elucidated. Ethical considerations related to participants’ privacy and consent, especially concerning their media consumption habits and travel decisions, may have arisen. The ever-evolving landscape of media influence, with new platforms and channels emerging, may not have been comprehensively captured. Additionally, if the research was geographically or culturally specific, regional and cultural variations might not have been fully accounted for. Lastly, while the study primarily focused on medical destinations, other travel segments and destination types might be considered by travelers in response to environmental concerns.

Acknowledging these limitations is pivotal in accurately interpreting the study’s findings and guiding future research endeavors to explore the intricate interplay between media, environmental risk, and traveler choices.

In terms of future research directions, there are several avenues worth exploring. The study has laid the groundwork for understanding the complex decision-making processes of travelers in response to media-driven environmental risk perceptions. Subsequent research can build upon these findings to delve deeper into the factors influencing travelers’ choices amid environmental uncertainty, potentially uncovering additional variables or psychological mechanisms governing decision-making. The concept of travelers’ resilience to environmental risks remains relatively underexplored. Future research can delve into this facet of resilience, investigating the determinants of travelers’ resilience or vulnerability to such risks and how this resilience shapes their travel decisions. This exploration may encompass individual differences, coping strategies, or communication approaches contributing to resilience. The redirection of travelers to medical destinations in response to environmental risks presents a novel and intriguing discovery. Subsequent research can delve deeper into travelers’ motivations and preferences when opting for medical destinations. This inquiry may encompass the specific medical services sought, the quality of healthcare available in these destinations, and the broader implications for the medical tourism industry. The utilization of advanced statistical models such as moderated path analysis and multilinear logistic regression in this study can serve as a model for future research in this domain. Researchers can adopt and adapt these methodologies to investigate different facets of travelers’ decision-making processes in response to various stimuli or contextual factors.

In conclusion, the study’s results establish a solid foundation for future investigations aimed at deepening our understanding of how travelers respond to environmental risks and make choices regarding medical destinations. Addressing the identified gaps in this research will allow subsequent studies to contribute valuable insights to both the academic field and the broader travel industry.