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Exploring Service Needs and Development Strategies for the Healthcare Tourism Industry Through the APA-NRM Technique

Sustainability 2025, 17(15), 7068; https://doi.org/10.3390/su17157068

by Chung-Ling Kuo¹ and Chia-Li Lin^2,*

Reviewer 1:

Liping Gao

Reviewer 2:

Andrii Dovhopolov

Reviewer 3: Anonymous

Reviewer 4:

Conceição Ilda Da Silva Gomes

Reviewer 5: Anonymous

Sustainability 2025, 17(15), 7068; https://doi.org/10.3390/su17157068

Submission received: 14 April 2025 / Revised: 7 July 2025 / Accepted: 21 July 2025 / Published: 4 August 2025

(This article belongs to the Special Issue Inclusive Tourism and Its Place in Sustainable Development Concepts)

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Authors performed an interesting work to explore the service needs and development strategies for the healthcare tourism industry through the APA-NRM technique. This work is a comprehensive and innovation study using APA to evaluate aspects/criteria and NRM to determine network relationships. And the research combined the APA and NRM techniques to develop the APA-NRM technique to assess the adoption strategies and suitable paths for health tourism services. However, some concern needs to address before accept to publication.

“DEMATEL” in the key words section didn’t show in the abstract, please check.
There is blank before the number of references in the text, please check the reference 15, 17, 18 and others, because there are no blank. What’s more, it is strange that there is no reference in the discussion and conclusion section.
Please optimize article structure format. Abstract, Introduction, Methods, Results, Discussion and Conclusion may be better?
Many tables are in the text. I think authors should embellish and standardize the formatting of the table, such as the three-line grid formatting.
Figures with two diagrams should be labeled, such as A and B, and should explain what each diagram represents.
I think the Method section can be improved.
The conclusions are consistent with the evidence and arguments presented, but I think the authors should simplify this section.

Author Response

Comment 1:

The authors performed interesting work exploring the service needs and development strategies for the healthcare tourism industry through the APA-NRM technique. This work is a comprehensive and innovative study using APA to evaluate aspects/criteria and NRM to determine work relationships. And the research combined the APA and NRM techniques to develop the APA-NRM technique to assess the adoption strategies and suitable paths for health tourism services. However, some concerns need to be addressed before acceptance for publication.

Response 1:

Thank you very much for the detailed and profound reading of the manuscript, as well as for your time and willingness to improve the quality and clarity of the paper.

Comment 2:

“DEMATEL” in the keywords section wasn’t shown in the abstract. Please check.

Response 2:

Thank you very much for the detailed and profound reading of the manuscript, as well as for your time and willingness to improve the quality and clarity of the paper. The study has already modified the abstract on page 1.

Abstract: With the advent of an aging society, people are living longer, but their quality of life is not necessarily improving. The demand for happiness and health is increasing. As a result, a combination of tourism and medical services—health tourism—has emerged. This growing demand has prompted many service providers to see it as a business opportunity and enter the market. Tourism enables tourists to release stress related to work and restore their physical and mental balance, while health checks and disease treatments help them regain their health. Health and healthcare tourism have always been popular with consumers because they can alleviate stress and restore health. As some consumers age, their physical functions gradually deteriorate, and it is challenging to participate in the travel services provided by regular travel agencies. Therefore, personalized medical services should be considered for health tourism development. This study identified four critical driving forces for healthcare tourism services: medical services, medical facilities, tour planning, and hospitality facilities. The study used APA (attention and performance analysis) to evaluate aspects/criteria, and NRM (network relationship map) to determine network relationships based on the DEMATEL approach. The research combined the APA and NRM techniques to develop the APA-NRM technique to assess the adoption strategies and suitable paths for health tourism services. This study provides suitable development strategies and suggestions to help providers customize health tourism services and improve the service experience.

Comment 3:

There is a blank before the number of references in the text; please check references 15, 17, 18, and others, because there is no blank. Moreover, it is strange that there is no reference in the discussion and conclusion sections.

Response 3:

4.2 Discussion

In recent years, the attractiveness of medical tourism destinations has increasingly drawn the attention of travelers/patients. Some studies explored the factors influencing patient flow to Austria and proposed a comprehensive framework for future comparison analyses. The researchers used literature reviews, secondary data, site analysis, and interviews with patients and health professionals. The study revealed that outbound medical travel from Austria is mainly due to access, affordability, and proximity. In contrast, inbound medical travel is driven by insufficient medical infrastructure and medical and service quality in source countries. Health care providers differ based on the extent of their participation in medical tourism. Although specific to Austria, these findings contributed to understanding Europe’s current medical travel patterns. Unlike other studies, the study looked at Austrian and international medical travel and provides crucial insights into the development of European health policy [50]. Recent research investigated the key determinants of service satisfaction and evaluation processes among Bangladeshi medical tourists in India. The researchers conducted a cross-sectional study involving 388 Bangladeshi patients who sought medical treatment in India. The study revealed several critical findings through comprehensive surveys gathering data on medical tourism experiences, health conditions, and demographic profiles. Statistical analysis identified health care facilities and services as the primary factors influencing patient satisfaction, with location, cost considerations, and rural settings also playing significant roles. The study highlighted that most participants were self-referred patients, with cardiac conditions and cancer being the predominant medical concerns. The researchers recommended interventions to enhance medical tourism satisfaction, including improving health care provider training, addressing language barriers, and reducing travel and treatment expenses [51].

Based on research findings from Austria, patient flows in medical tourism are influenced by accessibility, medical costs, and proximity. Outbound medical travel is mainly driven by the accessibility and affordability of domestic healthcare, while inbound travel is due to inadequate medical infrastructure and service quality in source countries. Improving accessibility, rationalizing medical costs, and enhancing transport convenience are crucial for advancing medical services. Additionally, the study of 388 Bangladeshi patients seeking treatment in India found that medical facilities and services are the most critical factors affecting satisfaction, with location, cost, and environment also influencing choices. Recommendations include strengthening healthcare training, reducing language barriers, and lowering costs to improve satisfaction further. This study identified four dimensions (medical services, medical facilities, tour planning, and hospitality facilities) and 16 evaluation criteria for medical tourism assessment based on expert interviews and a literature review. The APA-NRM approach can be proposed by integrating APA (attention and performance analysis) and NRM (network relation map). APA results showed that medical facilities (MF) are in the first quadrant (high attention, high performance) and should be continuously strengthened (Adoption strategy A). Tour planning (TP) is in the second quadrant (low attention, high performance) and should be status-keeping (Adoption strategy B). Medical services (MS) and hospitality facilities (HF) are in the third quadrant (low attention, low performance). They should adopt progressive development (Adoption strategy C) to enhance Taiwan's international competitiveness in medical tourism services. In conclusion, to improve its global competitiveness in medical tourism, Taiwan should strengthen medical facilities, optimize tour planning, and improve medical services and hospitality facilities. At the same time, improving healthcare service training, reducing language and communication barriers, and rationalizing medical costs are critical to increasing overall service satisfaction and international appeal.

A study of cultural differences in healthcare service explores the perception of foreign patients' cultural differences in South Korea. The study establishes a 41-item evaluation framework to measure the healthcare perceived cultural differences based on the 256 foreign patients of three tertiary hospitals in Seoul, South Korea. Besides, two physicians and eight nurses in an international healthcare department evaluated the framework of perceived cultural differences for content validity. It establishes the structural validity through the exploratory factor analysis. The researchers also compare the perceived cultural differences between foreign patients' home countries and the South Korean healthcare system using the one-sample t-test and evaluate the cultural differences among language groups using variance analysis. The research result indicates that the evaluation framework's content validity index was 0.97. The exploratory factor analysis determined the seven critical factors (cultural values, communication, religion, food, hospital care & services, the healthcare system, and the healthcare facility). The study considers that the foreign patients have a perceived healthcare culture that differs between the South Korean hospitals and their home country, and the perceived cultural differences were influenced significantly by language. The proposed evaluation framework can aid in measuring the cultural differences of foreign patients and provide various culturally competent nursing care services [52].

Comment 4:

Please optimize the article structure format. Would an abstract, Introduction, Methods, Results, Discussion, and Conclusion be better?

Response 4:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper. The study has already modified the article structure for the introduction and literature review on page 3.

The present study consists of five sections. Section 2 explores the driving forces behind the healthcare tourism evaluation system. Section 3 introduces the APA-NRM technique (attention and performance analysis—network relation map) and proposes suitable adoption paths. Section 4 describes case-based studies on healthcare tourism to explain the adoption strategies and suitable paths based on the APA-NRM technique. Finally, section 5 provides future research directions and some valuable recommendations.

Comment 5:

There are many tables in the text. I think authors should embellish and standardize the formatting of the tables, such as the three-line grid formatting.

Response 5:

Comment 6:

Figures with two diagrams should be labeled, such as A and B, and should explain what each diagram represents.

Response 6:

Comment 7:

I think the Method section can be improved.

Response 7:

Comment 8:

The conclusions are consistent with the evidence and arguments, but the authors should simplify this section.

Response 8:

Conclusions and recommendations

With advancements in medical technology and improvements in quality of life, life expectancy is increasing year by year. For the silver generation, longevity is no longer a challenge; a happy and healthy life is their ultimate goal. The emerging healthcare tourism industry focuses on helping the elderly recover from illnesses and discover the joys of life through travel. This technique improves older adults’ health and enriches their later years, helping them rediscover the meaning and joy of life. The study identified four aspects of the healthcare tourism evaluation system (medical services, medical facilities, tour planning, and hospitality facilities) and 16 evaluation criteria through expert interviews and literature reviews. The study combines APA (attention and performance analysis) and NRM (network relation map) methods and proposes APA-NRM methods. APA (attention and performance analysis) evaluates the status of the attention and performance indicators for healthcare tourism evaluation systems. Based on APA analysis, the MF (medical facilities) aspect is located in the first quadrant (H, H), and the TP (tour planning) aspect is located in the second quadrant (L, H). In addition, MS (medical services) and HF (hospital facilities) are located in the third quadrant (L, L). Adoption strategy A (continuous strengthening) can be adapted to the MF (medical facilities), and Adoption strategy B (status keeping) can be used for the TP (tour planning) aspect. Adoption strategy C (progressive development) can be used in the areas of MS (medical services) and HF (hospitality facilities). Some development directions and valuable recommendations for the service providers of healthcare tourism include:

(1) In the APA analysis, travelers/patients pay more attention to MF (medical facilities) than MS (medical services), and MF (medical facilities) have a higher performance than MS (medical services), which also means that travelers and patients pay attention and choose a comprehensive and excellent healthcare tourism itinerary with nice medical facilities/services. Furthermore, travelers/patients pay more attention to TP (tour planning) than HF (hospitality facilities), and TP (tour planning) performs better. The result means that travelers/patients will pay attention and choose medical sightseeing tours (city tours/international tours) with comprehensive transport services and friendly guide receptions. In the MF (medical facilities), travelers/patients pay more attention to the criteria of surgical equipment (MF1), diagnosis facility (MF2), medical equipment (MF3), and medical examination facilities (MF4). However, the performance of the MF4 criterion was less than the average level. Furthermore, MF4 (medical examination facilities) is the dominant criterion in the NRM (network relation map) analysis, while MF2 (diagnostic facility) is the subordinate aspect. Therefore, service providers must consider the needs of travelers and patients and cooperate further with medical hospitals that have complete medical examination facilities. By collaborating with health screening and early treatment centers, service providers can provide early warning and treatment for travelers and patients with medical tests and examination equipment.

(2) In the NRM analysis, TP (tour planning) is the dominant aspect of healthcare tourism evaluation systems, while MF (medical facilities) is the subordinate aspect. The TP (tour planning) aspect can enhance the HF aspect. Then, the HF aspect can improve the MS (medical services) aspect, and the MS (medical services) aspect can enhance the MF (medical facilities) aspect. Therefore, we need to improve the overall satisfaction with healthcare tourism services. Let’s start with TP (tour planning), then improve HF (hospitality facilities), and finally strengthen MS (medical services) and MF (medical facilities). In other words, most customers’ primary healthcare tourism needs are travel. After relieving stress and relaxing, they can understand their current physical condition through a full-body checkup and finally carry out early prevention and treatment of diseases. Therefore, increasing travelers’/patients’ interest through itinerary planning will be attractive, which is also why they become healthcare tourism customers. Besides, healthcare tourism service providers need to consider the accommodation and dining needs of different travelers and patients during the trips and customize the arrangements according to their needs, such as the accommodation regulations for the elderly and the design and auxiliary facilities for them. However, some healthcare tourism service providers can offer meal arrangements for travelers/patients before special medical examinations; these special services can reduce the inconvenience of travelers/patients during their trip. In addition, for medical services (MS) and medical facilities (MF), although travelers/patients attach more importance to medical facilities (MF), without good medical services, it is difficult for travelers/patients to trust that service providers are truly standing on the needs of travelers/patients and arranging best suitable medical services and treatments for them.

(3) In the TP (tour planning), travelers/patients pay more attention to the TP1 (intercity sightseeing) criterion than the TP2 (city tour), TP3 (reception service), and TP4 (traffic connection) criteria. However, the performance of the TP2 (city tour) criterion was less than the average for the performance indicator. Furthermore, the TP1 (intercity sightseeing) criterion is the dominant criterion in the NRM (network relation map) analysis, while TP3 (reception service) is the subordinate aspect. Therefore, healthcare tourism service providers should start by considering the travel arrangements. Planning the trip and travel arrangements includes arranging health check-ups, routes, and options for medical treatment for tourists and patients because high-end health checks and medical treatment hospitals are more suitable for them. However, most high-end health checks and medical treatment hospitals are concentrated in cities and urban areas. At the same time, those with a particular geographical landscape and unique historical and cultural characteristics are mainly located in the surrounding towns and far from the cities. Consequently, integrating tourist and city tours in the city has become a service provider’s challenge. Intercity sightseeing can increase the diversity of the itinerary, while fixed-point tourism can increase the depth of the itinerary and integrate it into local life. Therefore, according to the flexibility of travel time and budgetary arrangements of travelers and patients, it is recommended to provide a variety of itineraries. Those with more time can arrange long-term leisure and wellness trips to a specific place. They can arrange in-depth travel routes to each city for one or more weeks. For those still working, you can arrange a health check-up plan based on the length of your vacation in the city. They can also plan a route to the counties and towns near the city. This can meet the needs of itinerary diversification while reducing travel time. Excessive traveling will increase the burden and fatigue of travelers and patients. It is recommended that passengers and patients travel in specific cars to improve transportation convenience and reduce fatigue. In contrast, we can reduce the inconveniences of travelers/patients using public transit by healthcare tourism service providers with more flexible schedules to reduce the fatigue of passengers/patients.

(4) Healthcare tourism provides a significant opportunity to enhance the quality of life for middle-aged and elderly people. Combining professional medical care with meaningful travel experiences offers comprehensive solutions for the health and well-being of people in their later years. This study establishes a healthcare tourism evaluation system to explore the interrelationships between various dimensions and further identifies the most suitable adoption paths. Three suitable adoption paths (TP→MS→MF; TP→HF→MF; TP→HF→MS→MF) have been identified for the evaluation system of healthcare tourism. The TP (tour planning) aspect influences the MS (medical services) aspect, and the MS aspect enhances the MF (medical facilities) aspect in the second suitable adoption path. The TP aspect enhances the HF (hospitality facilities) aspect, and the HF aspect strengthens the MF (medical facilities) aspect in the third suitable adoption path. The TP (tour planning) aspect influences the HF aspect, the HF aspect affects the MS aspect, and the MS aspect affects the MF aspect in the fourth-suitable adoption path. From these three most suitable adoption paths, it is evident that the TP (tour planning) aspect is the primary dominant aspect, while the MF (medical facilities) aspect is the central subordinate aspect. Among the three main travel companion categories (traveling with family/friends, company colleagues, and alone).

(5) For traveling with family/friends groups, this group typically combines family tourism formats, resulting in the most diverse member composition and requiring consideration of various needs. The advantage is that some members serve as primary caregivers and companions, enabling mutual support. The main purpose is family companionship and reunion, allowing for more relaxed and flexible itinerary planning. Some less structured, in-depth travel at specific locations can increase members’ interaction opportunities. For traveling with a company colleagues group, this category includes corporate employee trips and incentive travel, and features a more homogeneous group composed primarily of company colleagues and work partners. While some may participate with spouses or companions, most are company members and their families. Short-term itineraries are suitable, and since the age gap is typically smaller than in family travel, more intensive inter-city travel can be arranged. Health examinations and tests should be completed early in the journey, allowing members to receive their health examination results afterward. Traveling alone, these groups face more flexibility but are more complex and require health status evaluation. For those in good health and physical condition, companion travel similar to the company colleagues group can be arranged, reducing risks through mutual support during the journey. For elderly or less healthy individuals, location-specific travel with care resources is preferred. Institutional fixed-point travel destinations can arrange experiential exchange activities and typically maintain long-term partnerships with nearby medical institutions to provide emergency response capabilities.

(6) The current research found three main categories of travel companions for healthcare tourism based on the composition of travel companions (traveling with family/friends groups, traveling with corporate colleagues groups, and traveling alone groups). The study can understand the main driving factors for healthcare tourism and the relationship between the driving factors. However, the study considered that subsequent researchers should still explore the healthcare tourism evaluation system based on the different groups. In addition, the study also found that, from the sample statistical analysis, the female sample is the leading group of customers, which is higher than that of the male group. In addition to the fact that women generally live longer than men, they are also more enthusiastic about group travel or group activities. Consequently, health tourism service providers should pay more attention to women’s health tourism demand, understand their preferred travel preferences and related medical needs, and provide diversified travel itinerary design and health examination and testing programs. In addition, analysis of sample age composition shows that traditional market segmentation based on legal retirement age cannot fully meet market demands. When we consider healthcare tourism as a progressive development stage, for the middle-aged group (over 40 years), medical tourists have better physical strength and health condition, but relatively less vacation time and funds available; their wellness tourism focuses primarily on stress relief and health status assessment. Launching wellness tourism packages that include mainly health examinations and screening, along with short-term urban tourism, is recommended. On the other hand, people aged 60 and over, who generally enter the retirement phase or transfer family businesses to the next generation, gradually have enough capital to enjoy retirement because of their financial accumulation. However, their physical condition and strength may not be as strong as that of the middle-aged group. They can, therefore, consider long-term fixed-point deep tourism as the primary focus, together with short-distance in-depth visits to nearby cities and villages.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript's authors, “Exploring the service needs and development strategies for the healthcare tourism industry through the APA-NRM technique”, presented a study that considers the possibility of developing health tourism through the provision of personalized medical services. Authors of the study identified four critical driving forces for healthcare tourism services: medical services, medical facilities, tour planning, and hospitality facilities. After that, they used APA (attention and performance analysis) to evaluate aspects/criteria and NRM (network relationship map) to determine network relationships. The research combined the APA and NRM techniques to develop the APA-NRM technique to assess the adoption strategies and suitable paths for health tourism services. This proposal model can help service providers customize health tourism services and improve the current health tourism service experience.

Section 2 explores the driving forces behind the healthcare tourism evaluation system.

Section 3 introduces the APA-NRM technique (attention and performance analysis—network relation map) and proposes suitable adoption paths.

Section 4 describes case-based studies on ealthcare tourism to explain the adoption strategies and suitable paths based on the APA-NRM technique. Finally, section 5 provides future research directions and some valuable recommendations

Though authors follow the Sustainability journal guidelines and form the paper structure properly there are several aspects that should be improved:

Please pay attention to the layout of Tables 3, 4, 5, 6.8, 9.10…. and it is advisable to formative them, as they are shifted to the right
Pay attention to the layout of the figures in the text of the article, where they are placed on the right (for example, Figure 3).
Please pay attention to the list of references, most of the references do not have a DOI indicator, add it if possible.
Please pay attention to the formatting of formulas in the text of the article, make announcements in accordance with the requirements of the journal

Comments for author File: Comments.pdf

Author Response

Comment 1:

The manuscript's authors, “Exploring the service needs and development strategies for the healthcare tourism industry through the APA-NRM technique”, presented a study that considers the possibility of developing health tourism through personalized medical services. Authors of the study identified four critical driving forces for healthcare tourism services: medical services, medical facilities, tour planning, and hospitality facilities. After that, they used APA (attention and performance analysis) to evaluate aspects/criteria and NRM (network relationship map) to determine network relationships. The research combined the APA and NRM techniques to develop the APA-NRM technique to assess the adoption strategies and suitable paths for health tourism services. This proposal model can help service providers customize health tourism services and improve the current health tourism service experience.

Response 1:

Thank you very much for the detailed and profound reading of the manuscript, as well as for your time and willingness to improve the quality and clarity of the paper.

Comment 2:

In the introduction, the authors, based on the literature analysis, consider the main trends in the development of medical health tourism and analyse possible criteria for improving the development of this industry. The authors paid special attention to the analysis of the development of regional medical tourism in most developed countries. In this section, the authors identify the main factors that influence the development of medical tourism. Section 2 explores the driving forces behind the healthcare tourism evaluation system. Section 3 introduces the APA-NRM technique (attention and performance analysis—network relation map) and proposes suitable adoption paths. Section 4 describes case-based studies on healthcare tourism to explain the adoption strategies and suitable paths based on the APA-NRM technique. Finally, section 5 provides future research directions and some valuable recommendations.

Response 2:

Thank you very much for the detailed and profound reading of the manuscript, as well as for your time and willingness to improve the quality and clarity of the paper.

Comment 3:

Though authors follow the Sustainability journal guidelines and structure the paper properly, several aspects should be improved: Please pay attention to the layout of Tables 3, 4, 5, 6.8, and 9.10… It is advisable to format them, as they are shifted to the right.

Response 3:

Comment 4:

Please pay attention to the layout of the figures in the text of the article, where they are placed on the right (for example, Figure 3).

Response 4:

Comment 5:

Please pay attention to the list of references. Most references do not have a DOI indicator; add one if possible.

Response 5:

Comment 6:

Please pay attention to the formatting of formulas in the article's text and make announcements according to the journal's requirements.

Response 6:

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

I found your article very interesting and well written, and I am grateful for the opportunity to read it. I found the subject of the research interesting, and the results provide a wealth of new information and possibilities for further analysis.

The article addresses an important issue at the intersection of healthcare and tourism by analysing user needs and service development strategies in the health tourism sector, with a particular focus on the growing group of older people. The authors have adopted an innovative methodological approach, combining attention and performance analysis (APA) with network relationship analysis (NRM). This has enabled them to identify the key factors influencing the development of this sector.

I would like to emphasise that the study was conducted thoroughly and with great analytical depth. Despite limitations in the description of the sample and tools, the analysis process, data structure and interpretation of the results in relation to the APA-NRM framework are highly praiseworthy. The results are consistent and well-reasoned, with application potential, particularly in the design of services for older people. This strong empirical section makes the article a valuable and original contribution to literature on medical services and health tourism.

Unfortunately, against the backdrop of this high level of empirical research, the other elements of the article are weaker.

The literature review, although present, is superficial and lacks analysis. While the authors do refer to a number of publications on health tourism, they do so in a very general way without taking a critical approach or contrasting different perspectives.

The APA-NRM methodological approach used is bold and creative, and definitely stands out in the literature on the subject. The analytical process was carried out with great attention to internal consistency, as confirmed by the high reliability coefficients (Cronbach's α > 0.97). However, the methodology is not fully described, which reduces its transparency. The sample size is not clearly presented, the selection criteria are not explained, and it would be useful to describe the research questionnaire. There is also no broader theoretical justification for choosing this particular research method, which would be advisable for publication in a scientific journal.

Even though it is formally separated as 'Section 4.2 Discussion', the discussion section remains the paper's biggest shortcoming. Its content is limited almost exclusively to the practical implications of the results, offering little in the way of theoretical reflection. There are no references to literature, comparisons with previous studies or theoretical reflections. It does not indicate whether or to what extent the results confirm the findings of other authors, nor does it discuss the limitations or significance for future research. As it stands, the discussion section does not fulfil the role of critical analysis; it is more of a summary of the results than an actual scientific study.

The recommendations formulated in the article are logical and follow directly from the analysis. They have clear practical potential and are well suited to the needs of the health tourism sector. However, to have real implementation value, they should be clarified and supplemented with specific action proposals, assigned to responsible entities, and referred to examples from other countries or systems where possible.

The article is based on solid and valuable empirical research that has been conducted in an innovative and in-depth manner. The authors present interesting results that could be important for developing health tourism services. In order for the text to be published in a highly ranked journal, however, the theoretical basis must be strengthened, the literature review deepened, the methodology refined in terms of transparency, and the discussion section thoroughly expanded.

I think your article is very good. I really enjoyed reading it and I appreciate your work. The topic is interesting and the conclusions could pave the way for further research. You could make some changes, but my overall impression of your research and the article as a whole is positive.

I wish you good luck!

Author Response

Comment 1:

I found your article very interesting and well written, and I am grateful for the opportunity to read it. I found the research subject fascinating, and the results provide a wealth of new information and possibilities for further analysis. The article addresses an important issue at the intersection of healthcare and tourism by analysing user needs and service development strategies in the health tourism sector, focusing on the growing group of older people. The authors have adopted an innovative methodological approach, combining attention and performance analysis (APA) with network relationship analysis (NRM). This has enabled them to identify the key factors influencing the development of this sector. I want to emphasise that the study was conducted thoroughly and with great analytical depth. Despite limitations in the description of the sample and tools, the analysis process, data structure, and interpretation of the results about the APA-NRM framework are highly praiseworthy.

Response 1:

Thank you very much for the detailed and profound reading of the manuscript, as well as for your time and willingness to improve the quality and clarity of the paper.

Comment 2:

The results are consistent and well-reasoned, with application potential, particularly in the design of services for older people. This strong empirical section makes the article a valuable and original contribution to medical services and health tourism literature. Unfortunately, against this high level of empirical research, the other elements of the article are weaker. The literature review, although present, is superficial and lacks analysis. While the authors refer to several publications on health tourism, they do so in a general way without taking a critical approach or contrasting different perspectives.

Response 2:

2. Literature review

2.1. The critical driving factors for the evaluation system of healthcare tourism

Geriatric tourism is a new style involving medical, health, and wellness tourism. The study examined the innovative approach of senior tourism packages and the service needs of geriatric tourism hospitality and tourism in a holistic approach. The geriatric tourism consumers are people who are, but not necessarily, long-term care recipients for frailty, multiple diseases, and possibly a slight cognitive impairment. Geriatric tourism can be adopted for entertainment, not treatment and care. Researchers believe travelers over 50 cannot represent the segment of the market for senior tourism because these tourism products can attract clients of different ages. A study found that senior tourism differed from medical or health tourism. During travel, geriatric tourism can provide long-term treatment and care services for elderly travelers and meet the leisure needs of elderly travelers[7]. With the increase in medical service globalization, Asia has become the preferred destination for high-quality medical services at affordable prices. Monitoring the quality of the international medical industry is critical to maintaining service demand. The experience of health professionals (HCPs) in providing IMS (international medical services) services to international cancer patients has not yet been discussed. A study investigated the experiences of Taiwanese cancer doctors with the quality of IMS, which is essential for hospitals to develop high-quality IMS. The study collected data from 19 respondents through in-depth semi-structured interviews and identified four main themes: patient selection, psychological treatment, conditions, and promotion recommendations. Since IMS is a global trend, it is recommended that health professionals, administrators, and policymakers improve the quality of IMS in lower cancer research[8]. In addition, wellness activities include traditional healing practices, thermal treatments, gentle exercise programs, and nutrition consultations. These comprehensive services enable people to regain the joy of traveling while maintaining their health. Medical care is integrated into tourism to ensure safety and comfort and provide a meaningful and enriching travel experience. The global trend toward aging the world’s population, particularly in developed countries, has created significant opportunities for medical and health tourism markets targeting the silver-haired generation. This demographic change has enabled the health and tourism sectors to cooperate and develop specialized services to meet the specific needs of elderly travelers. The industry provides personalized professional services for a wide range of elderly care and travel. These include personalized medical programs with regular health monitoring, specialized consultations, preventive health care, and rehabilitation services. Improved travel experiences can be provided by accessible transportation, age-friendly accommodations, adapted tour routes, and emergency medical support, as shown in Table 1.

2.1.1 Medical services (MS)

Furthermore, the model’s key factor is satisfaction with the country’s medical services. In Jordan, Poland, and Turkey, a comprehensive, structured questionnaire was conducted for young consumers, and several regression models were used to verify the hypothesis[11]. Medical tourism is a growing industry of billions of dollars. Low costs, all-inclusive vacation surgery packages, globalization, and affordable flights encourage patients to seek cosmetic surgery abroad. In a 12-year medical record survey, 56 patients were admitted to plastic surgery on average at age 37.46, of whom 91.07 percent were women. The most common procedures are liposuction (40 cases) and abdominoplasty (38 cases). Most patients are on multiple operations per trip (average of 2,34 procedures). The most common complication was surgical site dehiscence, with 11 patients requiring re-operation. Although medical tourism benefits both patients and health providers, short-term multiple procedures, short follow-ups, and different microbial environments have caused serious complications and have seriously affected many patients[12].

The patient care process is divided into several key stages. In the reservation service stage, doctors and nurses assist patients in confirming surgical procedures, scheduling appointments, handling personal payments, processing insurance applications, and managing other related scheduling needs. During treatment assessment, a team of doctors, nurses, and medical technicians helps patients arrange physical examinations and diagnostic tests, provides medical advice, and ensures informed consent. Before surgery, doctors and nurses evaluate the patient's condition and coordinate all aspects of the procedure, including cross-disciplinary surgeries, anesthesia, specialized operations, and necessary support services. After surgery, nurses support patients throughout their recovery by arranging further specialized or cross-disciplinary treatments, managing postoperative outpatient visits, and facilitating home medical services to ensure comprehensive ongoing care. Therefore, how to enhance medical and care services in health tourism has become a central focus for researchers in this field. Medical and care services are a key factor in the attractiveness of health tourism destinations and an essential element in maintaining customer satisfaction, as shown in Table 1.

Comment 3:

Furthermore, the study lacks a theoretical framework in terms of both service quality management and the systemic concepts of healthcare integration. There is no reference model to justify using the APANRM method, and the results are not linked to existing needs theories or customer relationship management. The APA-NRM methodological approach used is bold and creative, and stands out in the literature on the subject. The analytical process was carried out with great attention to internal consistency, as confirmed by the high reliability coefficients (Cronbach's α > 0.97). However, the methodology is not fully described, which reduces its transparency. The sample size is not presented, the selection criteria are not explained, and it would be helpful to describe the research questionnaire. There is also no broader theoretical justification for choosing this particular research method, which would be advisable for publication in a scientific journal.

Response 3:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper. The study has already increased the sample information explanations in section 3.1 on pages 11- 12.

3.1 The population sample information explanation, and reliability analysis

The researcher surveyed participants of healthcare tourism. The study defined four evaluation aspects (medical services, medical facilities, tour planning, and hospitality facilities) and 16 evaluation criteria through the expert interviews and literature review. The study analyzed attention and performance levels by the different tourist styles of healthcare tourism (traveling alone, traveling with family/friends, traveling with company colleagues) using an online and paper questionnaire survey. The survey was open between March 2024 and October 2024, and 160 complete and 124 valid samples were collected, as shown in Table 2. The study surveyed the participants’ profile information in five parts: gender, age, average annual income (New Taiwan dollars, NTD), healthcare tourism budget (NTD), and leading travel companions. The sample information included 45 men and 79 women, 32 people under 39, 47 people between 40 and 49, 32 between 50 and 59, and 13 people over 60. Regarding the main travel companions, 17 are alone traveling, 94 are family/friends traveling, and 13 are corporate colleagues traveling, as shown in Table 2.

Cronbach’s Alpha (Cronbach ) can be adopted to analyze the degree of reliability of attention and performance for each aspect/criterion. The attention indicator’s Cronbach’s Alpha was 0.982, and the performance indicator’s Alpha was 0.986, which was also higher than the proposed 0.7 (Cronbach > 0.7). Thus, the reliability indicators of attention and performance were highly consistent. Further, Cronbach’s Alpha of the evaluation aspect was 0.977, higher than the suggested 0.7 (Cronbach > 0.7). So, the aspect’s reliability of the service system was highly consistent. The MS (medical services) aspect Cronbach’s Alpha was 0.974, and the Cronbach’s Alpha of the MF (medical facilities) aspect was 0.984. The TP (tour planning) aspect’s Cronbach’s Alpha was 0.967, and the Alpha of the HF (hospitality facilities) aspect was 0.972. Hence, the reliability of the four aspects (MS, MF, TP, and HF) was highly consistent, as presented in Table 3.

Table 2. The population information profile of valid samples.

		Frequency	Percentage (%)
Gender	Male	45	36.29%
Gender	Female	79	63.71%
Age	Less than 39 years	32	25.81%
	40 to 49 years	47	37.90%
	50 to 59 years	32	25.81%
	Over 60 years	13	10.48%
Main travel companions	Traveling alone	17	13.71%
	Traveling with family/friends	94	75.81%
	Traveling with company colleagues	13	10.48%
	Total	124	100%

Table 3. The reliability analysis (Cronbach ).

Items	Aspects/Criteria	Alpha	Result
Attention indicator		0.982	High
Performance indicator		0.986	High
Aspects of the evaluation system		0.977	High
Criteria of aspects	Medical services (MS)	0.974	High
	Medical facilities (MF)	0.984	High
	Tour planning (TP)	0.967	High
	Hospitality facilities (HF)	0.972	High

Note: Cronbach suggests Alpha α-value: is low reliability, Middle reliability, is high reliability.

Comment 4:

Even though it is formally separated as 'Section 4.2 Discussion', the discussion section remains the paper's most significant shortcoming. Its content is limited almost exclusively to the practical implications of the results, offering little theoretical reflection. There are no references to literature, comparisons with previous studies, or theoretical reflections. It does not indicate whether or to what extent the results confirm the findings of other authors, nor does it discuss the limitations or significance for future research. The discussion section does not fulfil the role of critical analysis; it is more of a summary of the results than an actual scientific study.

Response 4:

4.2 Discussion

Based on the research results, the MS3 (medical surgery) criterion is in the first quadrant for the MS (medical services) aspect. In contrast, the MS1 (reservation service), MS2 (treatment assessment), and MS4 (postoperative recovery) criteria are located in the third quadrant. Adoption strategy A (continuous strengthening) can be applied to the MS3 (medical surgery) criterion, and adoption strategy C (progressive development) can be adapted to the MS1, MS2, and MS4 criteria. Therefore, no suitable adoption path exists for the MS (medical services) aspect, as shown in Table 26. Authorities and service providers should continue to enhance the quality of medical services, as outstanding medical surgery and comprehensive care remain the key factors in attracting health and medical tourism visitors or patients. At the same time, it is essential to gradually improve appointment systems, treatment evaluation, and post-operative recovery services in medical institutions. A well-designed appointment process makes arranging their trips more convenient for travelers or patients. At the same time, practical treatment evaluation and post-operative care can reduce uncertainties during the journey and enhance the overall safety and quality of the travel experience.

Comment 5:

The recommendations formulated in the article are logical and follow directly from the analysis. They have clear practical potential and are well-suited to the needs of the health tourism sector. However, to have real implementation value, they should be clarified and supplemented with specific action proposals, assigned to responsible entities, and referred to examples from other countries or systems where possible.

Response 5:

Comment 6:

The article is based on solid and valuable empirical research conducted in an innovative and in-depth manner. The authors present interesting results that could be important for developing health tourism services. For the text to be published in a highly ranked journal, the theoretical basis must be strengthened, the literature review deepened, the methodology refined in transparency, and the discussion section thoroughly expanded.

Your article is excellent. I enjoyed reading it, and I appreciate your work. The topic is interesting, and the conclusions could pave the way for further research. You could make some changes, but my overall impression of your research and the article is positive.

I wish you good luck!

Response 6:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper.

Reviewer 4 Report

Comments and Suggestions for Authors

First of all, I would like to congratulate the authors on their work. It is an excellent study. It brings a lot of contributions to the literature.

The size of the letters differs throughout the article.

In abstract the aim of the study should be clearly identified.

This article should be summarised. It's too long.

Introduction: In the introduction, you should emphasise the originality of this work.

Since this article doesn't have a literature review chapter, in my opinion the introduction should be more complete. The authors should review more articles including spas and thermal treatments.

There are also some subjects that are covered in the methodology, which in my opinion should be a literature review. The methodology should describe the methodology to be followed and explain how the methodologies were applied.

The studies described by other authors should be summarised, indicating the important points for this study.

Materials and methods. The methodology should be more complete. For example, are you presenting a quantitative or qualitative methodology? What is the reason for the choice made?

Table 1 was drawn up. But then it isn't mentioned throughout the text. What is its purpose?

For me, in point 3 is where the methodology begins.

With regard to the questionnaire, was a pilot test carried out? If so, how many people responded and what conclusions were drawn. How was the number of people who responded to the pilot test defined?

Part of the results should be summarised, indicating the most important parts.

The conclusions drawn should be supported by the listed citations, and the theoretical and practical implications should be indicated.

Author Response

Comment 1:

First, I would like to congratulate the authors on their work. It is an excellent study that makes many contributions to the literature.

Response 1:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper.

Comment 2:

The size of the letters differs throughout the article.

Response 2:

Comment 3:

The aim of the study should be identified in the abstract. This article should be summarized. It's too long.

Response 3:

Comment 4:

Introduction: In the introduction, you should emphasise the originality of this work.

Response 4:

The study identified four aspects (medical services, medical facilities, tour planning, and hospitality facilities) to assess travelers’/patients’ preferences. The researchers used the APA technique (attention and performance analysis) to evaluate attention and performance status, service preference, and service gap. The NRM (network relation map) technique is a network structure technique used to assess medical tourism evaluation systems. Besides, the study also combines APA and NRM techniques and proposes the APA-NRM technique. This proposed method can help medical tourism providers evaluate suitable adoption strategies and paths to improve service quality and attractiveness for the medical tourism industry.

Comment 5:

Since this article doesn't have a literature review chapter, the introduction should be more complete. The authors should also review more articles, including spas and thermal treatments.

Response 5:

Hospital websites can promote staff expertise, medical facilities, medical treatments and services, and medical equipment for foreign and domestic patients. A study explored the websites of these private hospitals in three competitive Asian countries (India, Thailand, and Malaysia). The authors analyzed how these hospitals present themselves and understand the needs of future medical tourists. The researchers examined the form and content of 51 hospitals’ websites using five aspects (technology, interactive online services, hospital facilities and information, medical services and admissions, and external activities). The findings noted that the websites of Thai, Indian, and Malaysian hospitals have differences, and hospital managers need to strengthen the interaction between hospital websites and the online presence of hospitals [13]. Medical tourism research focuses on the driving factors of destination images based on data from private hospitals in Malaysia. The research results indicated that the doctors’ expertise, hospitals’ facilities, perceived warmth, and perceived competence can influence the image of a medical tourism destination, and interaction with other patients plays a moderating role in certain relationships. This study offers valuable suggestions for destination images and may give practical ideas for medical tourism[14]. Mineral Spa treatments and thermal are critical therapeutic tools through numerous scientific studies and experience. The study adopts content analysis to determine the five essential factors of influence (location, room, thermal/Spa, pool, and staff) through the 1,254 online reviews from 2015 to 2019. Researchers explore satisfaction and dissatisfaction with tourism attributes through sentiment analysis for thermal and mineral spa centers. Besides, the study also provides valuable suggestions for tourism satisfaction and dissatisfaction with mineral spa centers [15].

Comment 6:

The methodology also covers some subjects, which, in my opinion, should be a literature review. The methodology should describe the methodology to be followed and explain how the methods were applied. The studies described by other authors should be summarised, indicating the crucial points for this study.

Response 6:

3.3 The NRM analysis based on the DEMATEL technique

The DEMATEL (decision-making trial and evaluation laboratory) technique is a valuable tool for decision-makers in analyzing complex problems through the network relation map (NRM) method. This approach has been successfully applied across various research fields. Recent applications include user interface analysis [30], failure sorting system evaluation [31], strategies development of science and technology park evaluation systems [32], optimization of threshold values [33], and strategy development for vehicle telematics services [34], strategic supply chain management for recycled materials vendor selection [35], methodological improvements through modified DEMATEL [36], vehicle navigation systems product positioning [37], pharmaceutical company performance evaluation using fuzzy MCDM [38], digital music service assessment [39], and analysis of critical factors in EMI (English-medium instruction) for MICE industry training [40], corporate sustainability in electronics [41], package tour service positioning [42], industrial heritage tourism enhancement[43], sustainable tourism strategies for urban and rural areas [44], talent development strategies in the service industry[45], regional development assessment in Colombia using SDG criteria [46], biomass energy challenges in Tehran [47], professional development in the coffee service industry[48], and green supplier selection using an integrated DEMATEL-ISM approach[49].

This study divides the DEMATEL technique into five stages: (1) analyze the original average matrix, (2) evaluate the direct influence matrix, (3) evaluate the indirect influence matrix, (4) determine the full influence matrix, and (5) determine the NRM (network relation map).

Comment 7:

Materials and methods. The methodology should be more complete. For example, are you presenting quantitative or qualitative methods? What is the reason for the choice made?

Response 7:

The study adopted the APA-NRM (attention and performance analysis-network relation map) technique to analyze healthcare tourism assessment systems. The APA-NRM technique consists of six analysis processes: (1) definition of critical decision problems, (2) determination of aspects/criteria for assessment, (3) measurement of aspects/criteria for evaluation (APA technique), (4) determination of NRM (network relationship map), (5) determination of service adoption strategies (APA-NRM technique), and (6) determination of appropriate adoption paths as presented in Figure 1.

Comment 8:

Table 1 was drawn up, but isn't mentioned throughout the text. What is its purpose?

Response 8:

2. Literature review

2.1. The critical driving factors for the evaluation system of healthcare tourism

2.1.1 Medical services (MS)

Medical tourism has become more convenient globally, and patients can easily travel abroad to obtain medical treatment. The excellent medical service and facilities can attract more medical tourists, but unfairly distributed medical services and patient complaint behaviors still exist. The study adopts the fairness theory to evaluate consumer complaint behaviors and analyze online feedback and surveys from 354 medical tourists who have received cosmetic treatments in Korea. Researchers find that outcome fairness was the critical factor affecting dissatisfaction, followed by interpersonal, procedural, and informational fairness. Besides, dissatisfaction will cause specific behaviors (complaining, negative word of mouth, and switching), and the participation level also influences particular behaviors. So, the study considers that the medical hosting country and its hospitals should provide a fair medical service to reduce medical tourism patients' dissatisfaction and propose complaint improvement measures and service recovery strategies [9]. Medical tourism combines health and wellness tourism and is becoming increasingly popular worldwide. Researchers examined the key factors influencing Malaysia’s medical tourism development. The researchers established a framework for evaluating through literature reviews. They adopted DEMATEL (decision-comparative evaluation laboratory) and Fuzzy TOPSIS (the fuzzy preference order by similarity to ideal solution) to assess the structure of Malaysia’s medical tourism relationship and the performance of the evaluation service. The research indicated that technological and human factors are the most critical factors for adopting medical tourism in Malaysia. The study proposed valuable suggestions for medical tourism service providers in developing countries[10]. Another study examined the role and significance of perceived risks in medical tourism (MT). Researchers showed that the origin country and self-assessment of the health status of respondents significantly reduced their attitude to behavioral intentions. The perception of the risk of MT services is strongly related to their attitudes, and the awareness, sensitivity, and gender of the risk significantly moderated this relationship. Furthermore, the model’s key factor is satisfaction with the country’s medical services. In Jordan, Poland, and Turkey, a comprehensive, structured questionnaire was conducted for young consumers, and several regression models were used to verify the hypothesis[11]. Medical tourism is a growing industry of billions of dollars. Low costs, all-inclusive vacation surgery packages, globalization, and affordable flights encourage patients to seek cosmetic surgery abroad. In a 12-year medical record survey, 56 patients were admitted to plastic surgery on average at age 37.46, of whom 91.07 percent were women. The most common procedures are liposuction (40 cases) and abdominoplasty (38 cases). Most patients are on multiple operations per trip (average of 2,34 procedures). The most common complication was surgical site dehiscence, with 11 patients requiring re-operation. Although medical tourism benefits both patients and health providers, short-term multiple procedures, short follow-ups, and different microbial environments have caused serious complications and have seriously affected many patients[12].

Comment 9:

For me, point 3 is where the methodology begins. Concerning the questionnaire, was a pilot test carried out? If so, how many people responded, and what conclusions were drawn? How was the number of people who responded to the pilot test defined?

Response 9:

3.1 The population sample information explanation, and reliability analysis

Cronbach’s Alpha (Cronbach ) can be adopted to analyze the degree of reliability of attention and performance for each aspect/criterion. The attention indicator’s Cronbach’s Alpha was 0.982, and the performance indicator’s Alpha was 0.986, which was also higher than the proposed 0.7 (Cronbach> 0.7). Thus, the reliability indicators of attention and performance were highly consistent. Further, Cronbach’s Alpha of the evaluation aspect was 0.977, which was higher than the suggested 0.7 (Cronbach> 0.7). So, the aspect’s reliability of the service system was highly consistent. The MS (medical services) aspect Cronbach’s Alpha was 0.974, and the Cronbach’s Alpha of the MF (medical facilities) aspect was 0.984. The TP (tour planning) aspect’s Cronbach’s Alpha was 0.967, and the Alpha of the HF (hospitality facilities) aspect was 0.972. Hence, the reliability of the four aspects (MS, MF, TP, and HF) was highly consistent, as presented in Table 3.

Table 2. The population information profile of valid samples.

		Frequency	Percentage (%)
Gender	Male	45	36.29%
Gender	Female	79	63.71%
Age	Less than 39 years	32	25.81%
	40 to 49 years	47	37.90%
	50 to 59 years	32	25.81%
	Over 60 years	13	10.48%
Main travel companions	Traveling alone	17	13.71%
	Traveling with family/friends	94	75.81%
	Traveling with company colleagues	13	10.48%
	Total	124	100%

Table 3. The reliability analysis (Cronbach).

Items	Aspects/Criteria	Alpha	Result
Attention indicator		0.982	High
Performance indicator		0.986	High
Aspects of the evaluation system		0.977	High
Criteria of aspects	Medical services (MS)	0.974	High
	Medical facilities (MF)	0.984	High
	Tour planning (TP)	0.967	High
	Hospitality facilities (HF)	0.972	High

Note: Cronbach suggests Alpha α-value: is low reliability, Middle reliability, is high reliability.

Comment 10:

Part of the results should be summarised, indicating the most important parts. The listed citations should support the conclusions drawn, and the theoretical and practical implications should be shown.

Response 10:

4.2 Discussion

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Author/s

Your paper analyses a very interesting subject giving the major importance on quantitative analysis and something that is not totally wrong! But you have to consider the following comments in your revision

Your Introduction section is too long
There is NO Literature review section and you have to create one
On Matearials and Methods, you present the 'Previous studies analysis' which is wrong. After the Literature Review, you have to present in a new section 'Previous studies analysis' and then the section with 'Methods and Materials'
I would also to see what exactly are your research questions, RQ1, RO2 ....
I would suggest you to include a table with each variable that you used with reference to previous studies presenting, the aim and the methods that these studies used. You can put at the end of the section 'previous studies analysis'
Finally, I would like to discuss some policy implications of your results for stakeholders and policy makers

Author Response

Comment 1:

Your paper analyses a fascinating subject, giving paramount importance to quantitative analysis, and that is not wrong! But you have to consider the following comments in your revision:

Response 1:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper.

Comment 2:

Your Introduction section is too long.

Response 2:

Comment 3:

There is NO Literature review section, and you have to create one.

Response 3:

2. Literature review

2.1. The critical driving factors for the evaluation system of healthcare tourism

2.1.1 Medical services (MS)

Medical tourism has become more convenient globally, and patients can easily travel abroad for medical treatment. The excellent medical service and facilities can attract more medical tourists, but unfairly distributed medical services and patient complaint behaviors still exist. The study adopts the fairness theory to evaluate consumer complaint behaviors and analyze online feedback and surveys from 354 medical tourists who have received cosmetic treatments in Korea. Researchers find that outcome fairness was the critical factor affecting dissatisfaction, followed by interpersonal, procedural, and informational fairness. Besides, dissatisfaction will cause specific behaviors (complaining, negative word of mouth, and switching), and the participation level also influences particular behaviors. So, the study considers that the medical hosting country and its hospitals should provide a fair medical service to reduce medical tourism patients' dissatisfaction and propose complaint improvement measures and service recovery strategies [9]. Medical tourism combines health and wellness tourism and is becoming increasingly popular worldwide. Researchers examined the key factors influencing Malaysia’s medical tourism development. The researchers established a framework for evaluating through literature reviews. They adopted DEMATEL (decision-comparative evaluation laboratory) and Fuzzy TOPSIS (the fuzzy preference order by similarity to ideal solution) to assess the structure of Malaysia’s medical tourism relationship and the performance of the evaluation service. The research indicated that technological and human factors are the most critical factors for adopting medical tourism in Malaysia. The study proposed valuable suggestions for medical tourism service providers in developing countries[10]. Another study examined the role and significance of perceived risks in medical tourism (MT). Researchers showed that the origin country and self-assessment of the health status of respondents significantly reduced their attitude toward behavioral intentions. The perception of the risk of MT services is strongly related to their attitudes, and the awareness, sensitivity, and gender of the risk significantly moderated this relationship.

Comment 4:

You present the 'Previous studies analysis' in the Materials and Methods section, which is wrong. After the Literature Review, you have to show in a new section 'Previous studies analysis', and then the section with 'Methods and Materials'

Response 4:

3. The service system for healthcare tourism based on the APA-NRM technique.

Figure 1. The APA-NRM technique for healthcare tourism.

3.1 The population sample information, explanation, and reliability analysis

Cronbach’s Alpha (Cronbach ) can be adopted to analyze the degree of reliability of attention and performance for each aspect/criterion. The attention indicator’s Cronbach’s Alpha was 0.982, and the performance indicator’s Alpha was 0.986, which was also higher than the proposed 0.7 (Cronbach> 0.7). Thus, the reliability indicators of attention and performance were highly consistent. Further, Cronbach’s Alpha of the evaluation aspect was 0.977, higher than the suggested 0.7 (Cronbach> 0.7). So, the aspect’s reliability of the service system was highly consistent. The MS (medical services) aspect Cronbach’s Alpha was 0.974, and the Cronbach’s Alpha of the MF (medical facilities) aspect was 0.984. The TP (tour planning) aspect’s Cronbach’s Alpha was 0.967, and the Alpha of the HF (hospitality facilities) aspect was 0.972. Hence, the reliability of the four aspects (MS, MF, TP, and HF) was highly consistent, as presented in Table 3.

Comment 5:

I would also like to see your research questions, RQ1, RQ2....

I suggest you include a table with each variable you used, concerning previous studies presenting the aim and methods used. You can put it at the end of the section 'previous studies analysis'

Response 5:

Table 1. The descriptions of aspects/criteria for healthcare tourism evaluation systems.

Aspects/criteria	Descriptions
Medical services (MS)
Reservation service (MS1)	The doctor and nurse will assist patients with confirming surgical procedures, appointments, personal payment, and insurance applications, and other appointment scheduling services.
Treatment assessment (MS2)	Doctors, nurses, and medical technicians will assist patients in arranging physical examinations and diagnostic tests, provide medical advice, and obtain informed consent at the end of the process.
Medical surgery (MS3)	Doctors and nurses will confirm the patient’s condition and assist in arranging cross-disciplinary surgery, anesthesia processes, specialized surgeries, and coordinating support services.
Postoperative recovery (MS4)	After the patient has completed the surgery, the nurse will assist the patient in arranging cross-disciplinary medical treatment, specialized medical treatment, postoperative outpatient, and home medical services.
Medical facilities (MF)
Surgical equipment (MF1)	The facility will provide a safe and comfortable sterile surgical environment for patients, thereby avoiding improper infections during surgery and increasing the chances of patient recovery.
Diagnosis facility (MF2)	The facility will provide customized medical and nursing services that respect patient privacy, allowing postoperative patients to recover and return home under adequate medical care.
Medical equipment (MF3)	The facility will provide emergency medical rescue facilities and related advanced medical and surgical equipment to reduce the burden on the patient’s body and improve the recovery rate.
Medical examination facilities (MF4)	The facility will provide travelers/patients with a complete full-body health check-up and arrange for relevant blood tests and organ function examinations before the patient’s surgery.
Tour planning (TP)
Intercity sightseeing (TP1)	Tour guides and leaders will assist clients, their friends, and their families in arranging long-distance travel that spans more than a day, crosses two countries, and includes accommodation and tours.
City tour (TP2)	Tour guides and leaders will help clients and their friends and family arrange city sightseeing, attraction visits, and short-term travel services that do not require accommodation.
Reception service (TP3)	Tour guides and leaders will assist clients and their friends and family in arranging airport pick-up services, accommodation arrangements, and guidance on subsequent itinerary arrangements and introductions.
Traffic connection (TP4)	Travel agency bus drivers and outsourced shuttle service personnel assist clients, friends, and family with shuttle services between accommodation and tour attractions.
Hospitality facilities (HF)
Accommodation facilities (HF1)	Patients/travelers are provided with a home-like environment to relieve fatigue and get sufficient rest during the journey.
Restaurant facilities (HF2)	During the journey, patients/travelers can taste local cuisine, replenishing their energy and allowing them to enjoy regional delicacies.
Emergency treatment (HF3)	During the journey, adequate medical emergency measures are provided for patients/travelers, therefore reducing their worries.
Medical connection (HF4)	During the journey, the local medical system establishes an emergency medical network to provide emergency medical shuttle services when necessary.

Comment 6:

Finally, I would like to discuss some of the policy implications of your results for stakeholders and policymakers.

Response 6:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper. The study has already modified the sections of the Conclusions and recommendations on pages 32~35.

Conclusions and recommendations

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

The article is substantially better, however there are some points that the authors have not yet answered:

In abstract the aim of the study should be clearly identified.
This article should be summarised. It's too long.
Materials and methods. This subtitle disappeared.
With regard to the questionnaire, was a pilot test carried out? If so, how many people responded and what conclusions were drawn. How was the number of people who responded to the pilot test defined?
Part of the results should be summarised, indicating the most important parts.

Author Response

Comment 1:

The article is substantially better; however, there are some points that the authors have not yet answered: In the abstract, the aim of the study should be identified.

Response 1:

Abstract: With the arrival of an aging society and the continuous extension of human lifespan, the quality of life has not improved in a corresponding manner. People's demand for happiness and health is increasing. As a result, a model emerged that integrates tourism and medical services, which is health tourism. This growing demand has prompted many service providers to see it as a business opportunity and enter the market. Tourism can help travelers release work stress and restore physical and mental balance; meanwhile, health check-ups and disease treatment can help them regain health. Consumers have long favored health and medical tourism because it helps relieve stress and promotes overall well-being. As people age, some consumers experience a gradual decline in physical functions, making it difficult for them to participate in regular travel services provided by traditional travel agencies. Therefore, this study aims to explore the service needs of health and medical tourism customers (tourists/patients) and the interrelationships among these service needs so that health and medical tourism service providers can develop more customized and diversified services. This study identifies four key drivers of medical tourism services: medical services, medical facilities, tour planning, and hospitality facilities. The study uses the APA (Attention and performance analysis) method to assess each dimension and criterion and utilizes the DEMATEL method with NRM (Network relationship map) to identify network relationships. By combining APA and NRM techniques, the study develops the APA-NRM technique to evaluate adoption strategies and identify suitable paths for health tourism services, providing tailored development strategies and recommendations for service providers to enhance the service experience.

Comment 2:

This article should be summarised. It's too long.

Response 2:

This study determined nine suitable adoption paths across four evaluation systems of healthcare and medical tourism. Among them, the MS (medical services) aspect lacked suitable adoption paths. The MF (medical facilities) aspect had two suitable adoption paths (MF4→MF3→MF2; MF4→MF3→MF1→MF2). By partnering with health screening and early treatment centers, service providers can offer travelers and patients timely alerts and interventions using medical testing and diagnostic equipment. Therefore, service providers should consider the needs of both travelers and patients, and strengthen partnerships with medical hospitals equipped with comprehensive examination facilities. Through collaboration with health screening and early treatment centers, they can deliver early detection and timely intervention for travelers and patients using medical testing and diagnostic equipment. The TP (tour planning) aspect had three suitable adoption paths (TP1→TP4→TP3; TP1→TP2→TP3; TP1→TP2→TP4→TP3). In other words, for most customers, the primary motivation for choosing healthcare tourism is travel itself. After unwinding and reducing stress, they have the opportunity better to understand their health status through comprehensive medical checkups, enabling early disease prevention and treatment. As a result, engaging travelers and patients with well-designed itineraries can increase their interest and is a key reason why they opt for healthcare tourism services. Lastly, the HF (hospitality facilities) aspect had four suitable adoption paths (HF2→HF3; HF2→HF4→HF3; HF2→HF1→HF3; HF2→HF1→HF4→HF3), as shown in Table 26. Additionally, healthcare tourism providers should address the varied accommodation and dining needs of their clients, offering tailored arrangements such as specific lodging policies or facilities designed for elderly guests. Some providers also offer special meal plans for travelers or patients before medical examinations, helping to minimize inconvenience and enhance the overall travel experience.

Comment 3:

Materials and methods. This subtitle disappeared.

Response 3:

Thank you very much for the detailed and profound reading of the manuscript and for your time and willingness to improve the quality and clarity of the paper. Because some reviewers suggested that the literature review should be an independent section, the materials and methods section was divided into Section 2 (Literature Review) and Section 3 (The Service System for Healthcare Tourism Based on the APA-NRM Technique).

Comment 4:

Was a pilot test carried out regarding the questionnaire? If so, how many people responded, and what conclusions were drawn? How was the number of people who responded to the pilot test defined?

Response 4:

3.1 The population sample information explanation and reliability analysis

The study targeted medical tourism participants and conducted a questionnaire survey. Four evaluation categories (medical services, medical facilities, tour planning, and hospitality facilities) and sixteen evaluation criteria were defined based on expert interviews and a literature review. The study employed both online and paper questionnaires to analyze the concerns and performance levels of different types of travelers (those traveling alone, with family or friends, or with company colleagues) regarding medical tourism. The survey was open from March 2024 to October 2024. A pilot test with 40 small sample questionnaires was conducted in advance to confirm that the reliability and validity met the expected requirements (Cronbach’s Alpha > 0.7) before proceeding to the formal research testing. A total of 160 completed questionnaires were collected, with 124 valid responses, as shown in Table 2. The survey collected participants’ personal information, including gender, age, average annual income (NTD), medical tourism budget (NTD), and primary travel companion. The sample comprised 45 males and 79 females. Among them, 32 were under the age of 39, 47 were aged 40 to 49, 32 were aged 50 to 59, and 13 were aged 60 or above. Regarding primary travel companions 17 traveling alone, 94 traveling with family or friends, and 13 traveling with corporate colleagues, as shown in Table 2.

Cronbach’s Alpha (Cronbach ) can adopted to analyze the degree of reliability of attention and performance for each aspect/criterion. The attention indicator’s Cronbach’s Alpha was 0.982, and the performance indicator’s Alpha was 0.986, which was also higher than the proposed 0.7 (Cronbach> 0.7). Thus, the reliability indicators of attention and performance were highly consistent. Further, Cronbach’s Alpha of the evaluation aspect was 0.977, which was higher than the suggested 0.7 (Cronbach> 0.7). So, the aspect’s reliability of the service system was highly consistent. The MS (medical services) aspect Cronbach’s Alpha was 0.974, and the Cronbach’s Alpha of the MF (medical facilities) aspect was 0.984. The TP (tour planning) aspect’s Cronbach’s Alpha was 0.967, and the Alpha of the HF (hospitality facilities) aspect was 0.972. Hence, the reliability of the four aspects (MS, MF, TP, and HF) was highly consistent, as presented in Table 3.

Table 2. The population information profile of valid samples.

		Frequency	Percentage (%)
Gender	Male	45	36.29%
Gender	Female	79	63.71%
Age	Less than 39 years	32	25.81%
	40 to 49 years	47	37.90%
	50 to 59 years	32	25.81%
	Over 60 years	13	10.48%
Main travel companions	Traveling alone	17	13.71%
	Traveling with family/friends	94	75.81%
	Traveling with company colleagues	13	10.48%
	Total	124	100%

Table 3. The reliability analysis (Cronbach).

Items	Aspects/Criteria	Alpha	Result
Attention indicator		0.982	High
Performance indicator		0.986	High
Aspects of evaluation system		0.977	High
Criteria of aspects	Medical services (MS)	0.974	High
	Medical facilities (MF)	0.984	High
	Tour planning (TP)	0.967	High
	Hospitality facilities (HF)	0.972	High

Note: Cronbach suggests Alpha α-value: is low reliability, Middle reliability, is high reliability.

Comment 5:

Part of the results should be summarized, highlighting the most important aspects.

Response 5:

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Exploring Service Needs and Development Strategies for the Healthcare Tourism Industry Through the APA-NRM Technique

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