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Johnston et al. Globalization and Health 2012, 8:23http://www.globalizationandhealth.com/content/8/1/23

RESEARCH Open Access

“I didn’t even know what I was looking for”: Aqualitative study of the decision-making processesof Canadian medical touristsRory Johnston1*, Valorie A Crooks1 and Jeremy Snyder2

Abstract

Background: Medical tourism describes the private purchase and arrangement of medical care by patients acrossinternational borders. Increasing numbers of medical facilities in countries around the world are marketing their servicesto a receptive audience of international patients, a phenomenon that has largely been made possible by the growth ofthe Internet. The growth of the medical tourism industry has raised numerous concerns around patient safety and globalhealth equity. In spite of these concerns, there is a lack of empirical research amongst medical tourism stakeholders. Onesuch gap is a lack of engagement with medical tourists themselves, where there is currently little known about howmedical tourists decide to access care abroad. We address this gap through examining aspects of Canadian medicaltourists’ decision-making processes.

Methods: Semi-structured phone interviews were administered to 32 Canadians who had gone abroad as medicaltourists. Interviews touched on motivations, assessment of risks, information seeking processes, and experiences at homeand abroad. A thematic analysis of the interview transcripts followed.

Results: Three overarching themes emerged from the interviews: (1) information sources consulted; (2) motivations,considerations, and timing; and (3) personal and professional supports drawn upon. Patient testimonials and word ofmouth connections amongst former medical tourists were accessed and relied upon more readily than the advice offamily physicians. Neutral, third-party information sources were limited, which resulted in participants also relying onmedical tourism facilitators and industry websites.

Conclusions: While Canadian medical tourists are often thought to be motivated by wait times for surgery, cost andavailability of procedures were common primary and secondary motivations for participants, demonstrating thatmotivations are layered and dynamic. The findings of this analysis offer a number of important factors that should beconsidered in the development of informational interventions targeting medical tourists. It is likely that trends observedamongst Canadian medical tourists apply to those from other nations due to the key role the transnational medium ofthe Internet plays in facilitating patients’ private international medical travel.

Keywords: Medical tourism, Decision-making, Qualitative, Surgery, Canada

* Correspondence: [email protected] of Geography, Simon Fraser University, 8888 University Drive,Burnaby, BC, CanadaFull list of author information is available at the end of the article

© 2012 Johnston et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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Johnston et al. Globalization and Health 2012, 8:23 of 12http://www.globalizationandhealth.com/content/8/1/23

BackgroundThe term ‘medical tourism’ describes the intentionalmovement of patients across international borders toseek medical care that has been privately purchased andarranged for [1,2]. The elements of intentionality andprivate arrangement are key to defining which care-seeking behaviours constitute medical tourism asopposed to other forms of international medical travelsuch as formal cross-border care arrangements andemergency care for vacationing tourists, although theterm has been used at times to describe all of theseforms of care. The global medical tourism industry issteadily growing, although accurate estimates of itscurrent size or scale are not available given the presenceof exaggerated figures and inconsistencies in trackingflow numbers, in part due to a poor universal definitionof what constitutes medical tourism [3,4]. Despite this, itis known that steady flows of patients traveling from theGlobal North (e.g., Canada, the United States [US],Western Europe, Australia) to clinics in the GlobalSouth (e.g., India, Thailand, Costa Rica) have emergedover the past decade [5,6]. These new patterns of tradehave joined the long-established South–north andNorth-North flows of international patients to inter-nationally reputed medical centres, such as the MayoClinic in the US, as well as existing flows of patients be-tween Southern nations [7,8]. The growth of the medicaltourism industry has been made possible by increasinglyglobalized flows of trade, transportation, and informa-tion [5,9]. In turn, medical tourism ties the interests ofdisparate populations together, for example by introdu-cing novel global pathways for the spread of infectiousdisease and through the sharing of scarce healthresources amongst citizens of different nations [10,11].A series of recent scholarly reviews about medical

tourism have consistently revealed that there are signifi-cant gaps in our understanding of this phenomenon[2,12–14]. In addition, these reviews have indicated thatmuch of the existing knowledge base is derived fromspeculative claims [3]. These knowledge gaps persist des-pite an increasing desire amongst global health research-ers to better understand medical tourism because of theimplications this practice is thought to hold for theequitable delivery of health services, the involvement ofnew actors (e.g. medical tourism facilitators) in the deliv-ery of health care, and the novel responsibilities ofpatients seeking and physicians providing health careacross international borders, among other concerns[2,15,16]. For example, a scoping review completed byCrooks et al. [12] concluded that we have much to learnabout patients’ experiences of medical tourism, includinghow medical tourists access and evaluate informationsources prior to departure. Lunt et al.’s [17] more recentarticle echoes this conclusion, and identifies patient

decision-making as one of the priority areas for medicaltourism research given its relevance to continuity ofcare, patient health and safety, and the commodificationof care. While media accounts provide some valuableinsights into the experiential dimensions of medicaltourism [e.g. 18–20], deep inquiry into the process ofpatients’ medical travel, from conception to return,remains lacking. This absence of knowledge leaves majorquestions about which factors and actors inform thedecision-making of medical tourists, especially in regardto their reliability and modes of dissemination. In thisarticle we address this knowledge gap through examin-ing Canadian medical tourists’ decision-making pro-cesses regarding seeking surgery abroad.Canadians are amongst those participating in the med-

ical tourism industry, not only as patients, but also asinvestors and facilitators (i.e., agents specialized in co-ordinating international medical care, including arran-ging for visas and accommodation and dealing withdestination hospitals) [2]. The only quantitative reporton medical tourism in Canada produced to-date indi-cates that 2% of 2,304 Canadian survey respondents havetraveled outside the country to “consult with a doctor,undergo a medical test or procedure, or receive treat-ment” [21]. As a description of how this care has beenpaid for or arranged is not indicated, other forms ofinternational medical travel (e.g., cross border carearranged through the public system) may be in the esti-mate. Further, 20% of those surveyed indicated theywould travel abroad for private-pay health services [21].Certainly, this is no reliable indication of how manypatients are indeed traveling abroad for private medicalcare. Numbers aside, it is indeed the case that Canadianpatients are choosing to take part in medical tourism, aphenomenon that is receiving increasing media attentionin the country [2].The phenomenon of Canadian patients privately

choosing to travel outside of their home health systemto access medical care abroad is intriguing, as medicallynecessary health care in Canada is publicly funded anduniversal. Federal legislation limits the availability of do-mestic private health care, making privately purchased,on-demand access for many treatments largely inaccess-ible to most Canadians [22]. There is no single Canadianhealth care system, as the management and delivery ofhealth care is the separate responsibility of each of the13 provinces and territories [23]. Canada’s federal gov-ernment contributes to the financing of each provincialhealth system through equalization payments that workto minimize inequities in essential services, with theamount paid to each province differing on the basis ofneed [22]. The balkanization of the management and fi-nancing of the national health system contributes tosubstantial differences in temporal and spatial access to


care across the country for the same procedures or treat-ments due to differences in the priorities and resourcesof the health administrations in each province or terri-tory [23]. For example, in 2010 42% of patients in theprovince of Nova Scotia had timely access to knee re-placement surgery (i.e. within the national benchmarkperiod of six months between referral to specialist tosurgery), compared with 89% of patients in Ontario [24].These wait times are likely to serve as a prompt to con-sider care elsewhere for some Canadian patients [2].Canadians also travel abroad for non-medically-necessary procedures such as dental care and cosmeticsurgeries that are not covered by the public health caresystem. It has been speculated that procedure costs arelikely to serve as motivators for seeking such care abroadfor Canadian patients [2].Much research exists about patients’ decision-making as

it pertains to surgical care sought domestically. It has beenreported that patients are often hesitant to change sur-geons, even if it means an earlier surgical date, suggestingthat trust and familiarity with care providers and venuescan outweigh other decision-making concerns such aswait times [25,26]. Striking a balance between appropriatepreparation times and meeting personal expectations ofprompt care is also a factor in patients’ decisions about ifand when to receive care. For example, it has been foundthat Canadian patients appreciate having time to preparefor elective surgery and will seek to organize about twomonths between the booking date and surgical date intotheir trajectory of care [27]. However, if this two monththreshold is crossed, resentment builds as the wait time isgenerally perceived to be excessive [28]. Another elementof surgical decision-making that has been explored is thesharing of information between physicians and patients.While providing informed consent is a keystone principleof Western clinical practice, it has been reported that thecomprehensiveness of information shared between sur-geons and patients about the risks and benefits of surgeryvaries widely [29,30]. The outcomes of this informationsharing are thought to influence the willingness of patientsto ultimately seek treatment [29]. More generally, it hasbeen shown that the ability of individuals to discern statis-tical representations of the risks of surgical treatments aregreatly influenced by anecdotal accounts of proceduresuccess or failure, suggesting that personal narratives oftreatment can be potent influences on patient decision-making [31]. In the current analysis we extend this exist-ing body of knowledge by investigating how the unique lo-gistical and informational challenges posed by privatelyaccessing care internationally as a medical tourist coincidewith or depart from receiving surgical care domestically.Existing understandings of patients’ decision-making

for surgical care have yet to consider the unique dimen-sions of medical tourism, such as concurrently seeking

and synthesizing information about surgical treatment,travel, foreign destinations, and how the risks of eachmay interact to heighten the potential for negative healthoutcomes [14,32]. While it is often speculated that med-ical tourists rely primarily on the Internet to informthemselves about destination facilities, the frequency ofaccess to information found online and its actual influ-ence on decision-making requires dedicated attention[33,34]. Furthermore, it is widely reported that medicaltourists from particular source countries seek careabroad based on singular motivations found in theirhome context, such as the high cost of medical care inthe US, limited availability of medical care in the GlobalSouth, or long wait times for medical care in countrieswith public health care systems such as Canada [35,36];yet, this tendency toward simplistic accounts potentiallybelies complex interaction among the factors that com-pel individuals to investigate seeking care abroad. Weseek to unpack some of these assumptions in the currentanalysis through examining the experiential accounts of32 Canadians who sought private surgical care abroad.The purpose of this article is to shed light onto how

Canadian medical tourists go about deciding to accesssurgery abroad and what kinds of information sourcesinform their decisions. Our goal is to contribute todeveloping an empirically-informed knowledge baseabout the global health services practice of medical tour-ism through addressing the knowledge gaps identifiedabove. Because of their exposure to a public and univer-sal health care system for medically necessary care athome, Canadian medical tourists encounter an entirelydifferent mode of access to care when privately seekingsurgery abroad, foregoing public payment for the abilityto determine what kind of care they wish to access, andwhen [12,37]. Even when seeking surgical care that isnot offered through the public system, such as experi-mental surgeries only available in other countries or cos-metic procedures, Canadian medical tourists are likely toencounter significant differences in facilitating access tomedical care abroad than they would domestically.These differences are likely to include protocols aroundprocedure booking and patient record transfer, amongother factors [12]. As such, Canadian medical touristsmay need to adopt more extensive roles as informationassessors and decision-makers than they are used to,shifting them from the more passive role of the trad-itional patient to the more active, neo-liberalized pos-ition of the ‘patient-consumer’ [38].

MethodsThis analysis forms part of a larger exploratory study ofthe decision-making processes and experiences of Canad-ian medical tourists. The study involved interviewing Can-adian medical tourists and medical tourism facilitators.


This analysis exclusively considers the former participantgroup.

RecruitmentWe sought to recruit Canadians who had previouslyundergone surgical treatment abroad for semi-structured phone interviews. As there is no organizedtracking or surveillance of this patient group, potentialparticipants were identified through numerous decentra-lized avenues. These included: (1) collecting names ofmedical tourists from Canadian news reports and con-tacting them via phone or email; (2) advertising in Can-adian print news outlets; (3) posting invitations toparticipate on online medical tourism forums; (4) snow-ball sampling through participants’ networks; and (5)providing study details to facilitators to disseminate. Noapparent differences emerged between participantsbased on how they were recruited, such as in their moti-vations for travel abroad or experiences of medical tour-ism. People interested in participating in an interviewwere asked to contact a toll-free phone number or an e-mail address. Detailed study information was providedupon contact and eligibility assessed. Upon establishinga participant’s eligibility, an interview time was thenscheduled.Participation was limited to those who met the eligibil-

ity criteria of: (1) having successfully pursued privately-arranged surgery outside of Canada paid for out-of-pocket; (2) being enrolled in a Canadian public healthcare plan at the time of surgery; and (3) being over theage of 18 at the time of the interview. To maintain focus,participants who went abroad for care other than sur-gery (e.g., diagnostic testing, tooth cleanings or fillings)were excluded. Those who had procedures that involvedthird parties (e.g., transplants, some reproductive surger-ies) were also excluded. This is because confidentialitycannot be guaranteed to participants who report illegalactivities, as per Canadian research ethics policies, and itwas thought that there is a risk among this populationthat such activities would be discussed. Because wewanted to extend confidentiality to participants, we didnot include people who had had these surgeries in thestudy. All those who scheduled an interview followedthrough with participating and no participants elected towithdraw from the study after being interviewed. Priorto participant recruitment, ethics approval was soughtfrom and granted by the Office of Research Ethics atSimon Fraser University.

Data collectionSemi-structured interviews were conducted by phonebetween July and November, 2010. A semi-structuredapproach was employed to allow common issues to beexplored, while giving participants the freedom to

introduce unanticipated topics of relevance to their ex-perience. Table 1 includes selected questions from theinterview guide. All interviews were conducted by thesame investigator (the lead author) in order to enhanceconsistency. Interviews typically ran for 1–1.5 hours andwere digitally recorded. The interviews covered a widerange of topics, including participants’ motivations, as-sessment of risks, information seeking process, experi-ences in both the domestic and international healthsystems, and pursuit of post-operative care. Data collec-tion ceased upon the exhaustion of all of our recruit-ment methods. This was determined after no newparticipants were identified through public sources orcontacted us after a month-long period.

AnalysisAll interviews were transcribed verbatim. A review ofthe transcripts was conducted by all authors. Followinginitial review, a meeting was held to share impressionsof common issues emerging from the interviews. A pre-liminary coding scheme was constructed, which wasstructured around the agreed upon issues. Generallyspeaking, scheme creation involved identifying umbrellaterms or concepts to which data segments were assignedthat could be drawn together in different combinationsand permutations in order to inform a thematic analysis.Coding of the transcripts followed, which was doneusing NVivo qualitative data management software. Toensure the utility of the codes, one investigator under-took the coding while another reviewed the first codedtranscript to confirm the functionality and interpretationof the scheme. Through an iterative process of codingand team discussion, superfluous codes were eliminatedand overpopulated single themes were disaggregated aspart of a second stage of coding. Upon completion ofthe coding process, thematic analysis was undertaken.Thematic analysis involves reviewing coded data to find-ing patterns or trends within the dataset that are com-pared to study objectives and existing knowledge inorder to refine the interpretation of their meaning [39].By examining full narrative accounts by theme, com-monalities in particular domains emerged despite theunderlying structural differences (e.g., destination loca-tion, procedure type) in the medical tourists’ rawaccounts.

ResultsIn total, 32 medical tourists from eight of Canada’s 13provinces and territories were interviewed. On average,two years had elapsed from the time of the surgeryabroad to the time of the interview, with the longestbeing six years. Figure 1 and Table 2 provide an over-view of some of the participants’ key characteristics. Intotal, 21 participants sought surgeries that were not

Table 1 Selected Interview Questions

Selected Questions Sub-Probes

Tell me about when you traveled to___________ for surgery.

○ What was it like?○ What procedure did you get?○ How long did you go for?○ Did anyoneaccompany you?○ Had you been to__________ before?

When was it that you traveled to__________________ for the procedure?

○ For how long before then had you been planning the trip?○ For how long before then didyou know or decide that you were going to get that surgery done?

Why did you decide to go to ______________? ○ Did anyone tell you about it?○ What kinds of information did you look at?○ Where did you getthis information from?○ Were personal finances an important deciding factor in choosing to go to_________?○ Did you consult with your family doctor about your plan to go abroad for surgery?


available to them in Canada. Of these, six sought proce-dures not approved in Canada, four were unable to re-ceive referrals for desired surgical care domestically, and11 sought procedures where expertise was lackingdomestically.The processes by which participants discovered,

researched, and ultimately decided on pursuing medicalcare outside of Canada was extensively probed over thecourse of the interviews. Three distinct themes emergedfrom the accounts of the decision-making process: (1)information sources consulted during the decision-making process, (2) motivations, considerations, andtiming regarding accessing medical care abroad, and (3)personal and professional supports drawn upon duringthe decision-making process. These themes areexpanded on in the remainder of this section. As muchas possible we have included verbatim quotations fromthe interviews in order to enable the participants them-selves to ‘speak’ to these issues. Quotations were selectedby the lead author as being a cogent representation ofan issue assigned to a particular theme, and independ-ently confirmed as such by the other authors.

Information sources consultedParticipants identified four means of initially learning ofmedical tourism, namely: word-of-mouth (n = 13), non-targeted Internet searches (n = 10), print and televisedmedia stories and advertising (n = 6), and familiarity withother countries’ health systems due to their having emi-grated from them (n = 2). One person could not remem-ber how they originally learned of medical tourism. Forthose who first learned of medical tourism online, thepossibility of accessing care abroad usually emerged asan extension of researching treatments or trying to findan alternative means of accessing a surgery for whichthey were wait-listed domestically. “I was looking for amagic bullet on the Internet. . .to address the. . .wait listissue that I was facing and so I had no idea what wasout there. . .so I wasn’t actively seeking. . .I didn’t evenknow what I was looking for. . .I just thought there had tobe something else. . .” For those who learned about med-ical tourism from other people, former medical tourists(ranging in intimacy from close friends to one-off

informal encounters), and friends and family with a pas-sing knowledge of medical tourism served as importantprompters. One exceptional case emerged where a Can-adian family physician raised orthopedic care abroadwith multiple participants amongst our dataset. Whileadvertisements by medical tourism facilitators initiatedsome participants’ decision-making processes, news stor-ies were more influential in raising participants’ aware-ness. Finally, for the two participants who weremotivated by existing familiarity with non-domestichealth systems, medical care outside of Canada was al-ways seen as a possibility and there was no process of‘discovering’ the option of care abroad.Upon first learning of medical tourism, the vast major-

ity of participants relied upon the Internet for detailedinformation. For these participants, it was used as a re-search tool to access the websites of facilitators, destin-ation hospitals, joint replacement manufacturers, andempirical research. The Internet was also a powerful so-cial tool, facilitating contact between participants andformer medical tourists who provided personal anec-dotes and advice. This communication sometimes tookplace in the context of online forums, though it was alsocommon for participants to contact former medicaltourists directly by e-mail. This sometimes resulted inhaving extended telephone conversations about theirexperiences. Participants also used the Internet to con-tact surgeons abroad directly for phone or e-mail con-sultations. These consultations were often informed bythe sharing of diagnostic scans or reports between theprospective medical tourist and surgeon, the transmis-sion of which was also facilitated by the Internet. Themost common fact-finding approach amongst the med-ical tourists interviewed is characterized by this partici-pant’s comments: “I had had so little care here [inCanada] I figured it couldn’t be any worse over there.Maybe it could, I knew it was a third world country, butafter I researched the hospital on the Internet and Italked to the four or five different people who went overthere I had no concerns whatsoever.” Six participants didnot use the Internet at all in informing their decisions togo abroad, relying instead on family members in the des-tination country to obtain and relay information directly

Figure 1 Destination countries visited by participants. This figure outlines where participants travelled for their procedures and how manywent to each country. Note that one participant travelled to two countries for treatment addressing the same health problem, resulting in a totalof 33 unique trips.


from and to the facility, the advice of former medicaltourists, and/or the information provided by facilitationcompanies.Although it was not directly probed, few participants

discussed how they assessed the reliability of the infor-mation sources they consulted in the process of learningabout medical tourism. Some outlined basic quality and

Table 2 Participant Overview

Characteristic Count

Recruitment Method forStudy Participation

Word of mouth (n = 9); Facilitator referral(n = 8); Study advertising (n = 7); Mediareports (n = 5); Online testimonials (n = 3)

Province or Territory ofResidence

British Columbia (n = 18); Newfoundland &Labrador (n = 3); Ontario (n = 3); Quebec(n = 2); Alberta (n = 2); Nova Scotia (n = 2);Manitoba (n = 1); Northwest Territories(n = 1)

Procedure Sought Abroad Orthopaedic surgery (n = 15); CCSVI therapy(n = 4); Eye surgery (n = 4); Bariatric surgery(n = 3); Cosmetic surgery (n = 3);Gastrointestinal surgery (n = 2); Dentalsurgery (n = 1)

Participant Ages Average of 53 years; Median of 50 years;Range from 22 to 80

Sex 19 females; 13 males

reliability assessment practices. For example, one partici-pant relied heavily on online physician rating sites, say-ing “he [the surgeon] didn't have like any. . .bad write-ups online or anything. . . and when I didn’t see anythingbad I figured well it must be okay, because I’ve looked upsome doctors here for other things and I have seen badcomments.” Another participant primarily relied upon atrusted hospital brand, saying “But there’s no real deepresearch, it’s just uh a matter. . . [of] calling up yourMayo Clinic. . .on the computer screen, reading a bit andmaking a few calls and going from there.” Other partici-pants characterized themselves as savvy researchers, sug-gesting their skills extend to assessing the reliability ofinformation, saying “. . .now when some people. . .say ohthey do online research. . .well sometimes they just meanthat they’ve looked at a lot of ads, at advertisements forthis kind of thing [procedure]. . .I didn’t do that, I lookedfor statistical surveys about the pros and cons of whichprocedure.” While the majority of participants looked tothe Internet as their primary information source, theycommonly neglected to clearly delineate or discern whatkind of information was ultimately accessed or whohosted it until they were prompted, while a minoritymade concerted attempts to convey the effort investedin seeking out what they thought was accurate and


neutral information provided by third parties withoutcommercial interests.

Motivations, considerations, and timingParticipants identified many different motivations thatspurred their initial consideration of medical tourism,which are summarized in Table 3. Despite this variety,all of the motivations discussed fall into the three broadcategories of seeking procedures that are unavailable,wait-listed, or more costly in Canada. Cost was the pri-mary motivation to pursue care abroad for four partici-pants, all of whom sought cosmetic or dental surgeriesthat were available domestically for private purchase butnot covered under public Medicare. Of the 14 partici-pants that identified wait-listing as a key element motiv-ating their trip, only seven ultimately pursued surgeriesabroad that were available (and for which they could beput on a wait-list) domestically. The other seven con-cerned with wait-listing sought surgeries unavailable intheir home provinces or territories. These alternate pro-cedures were often described as more technically sophis-ticated and desirable than the domestic equivalent.These considerations became a keystone in their deci-sion to travel for care that combined with, and some-times eclipsed, the initial issue of wait-listing. Fourteenparticipants were solely motivated by procedure avail-ability, seeking procedures that were not available tothem in their provincial health or territorial system atthe time of their medical travel. Reasons for this unavail-ability included the procedure not being approved bysafety regulators, the patient being ineligible for surgerydue to age or the absence of a diagnosis, or the lack ofdomestic surgical expertise to perform the surgeryParticipants were faced with choosing which destin-

ation facility to visit. For many, the key deciding factorwas the reputation of a surgeon they had found onlineand/or through social networks. The quality of the sur-geon was assessed by looking at where s/he had trained,experience with the surgery, and/or testimonials fromformer patients. The perceived skill of the surgeon regu-larly outweighed more practical concerns, such as the

Table 3 Primary motivations to pursue surgery abroadreported by participants

Primary motivation(s) # ofparticipants

Availability (where the procedure is not availabledomestically)

14

Wait-listing (where the procedure is availabledomestically)

7

Combined wait-listing & availability (where being wait-listed prompted a search for alternative surgeries notavailable domestically)

7

Cost (where the procedure is not covered by publicMedicare)

4

possibility of encountering language barriers: “I went forthe surgeon. That was. . .the fundamental reason forgoing there. It was, not in terms of you know, where itwas, no. I went for the surgeon.” A group who deviatedfrom this tendency to prioritize a particular surgeon overother variables were those who went abroad for CCSVItherapy. The majority who sought this procedure wentto whichever clinic could treat them the soonest, regard-less of its location. Another group of participants whodid not choose their destination based on the surgeonwere those returning to their countries of origin for sur-gery. Related to this, some made decisions based on pre-vious international travel or living experience. Theamount of in-hospital recuperation time offered alsoinfluenced destination choice. Those who stressed theimportance of this put a high premium on the attentionthey would receive post-operatively, choosing the facilitythat would offer the most lengthy and attentive recuper-ation period. Proximity of the destination to Canada wasrelevant for some, but was never an overriding concern.Finally, cost was influential to a varying degree. Forsome, the affordability of care in the Global Southgreatly influenced their decision-making, as they wouldhave accessed the surgery in a more developed nation ifthey had the money. For example, “India was the cheap-est of all of the ones that I researched or the least expen-sive rather than cheapest. I didn’t mean to cheapen it.The least expensive option was Chennai and that was abig factor. . .if I’d been a millionaire. . .I would have goneto Britain.” Other participants reported finances as beinglow on the decision-making hierarchy, characterizing itas unimportant when compared with the other factorsmentioned here.There was great variety in the length of time it took

participants to come to the ultimate decision to travelabroad for medical care, ranging from ten years to oneweek. Excluding the outlier of ten years, the averagetime from the discovery of the possibility of goingabroad for surgery to contacting a facilitator or destin-ation hospital with the intent to book a trip was sixmonths (median = 3 months). This six month period wascommonly spent researching potential destinations,assessing risks, speaking with other medical tourists,undertaking multiple calls or e-mails to facilitators and/or destination clinics, and in some cases attending localinformation seminars arranged by facilities seeking inter-national patients. The time between booking and surgerywas much more compressed, ranging from under oneweek to six months, with the average being two months(median = 2 months). For those who were assigned thistwo month period, it was seen as a reasonable and desir-able amount of time to get things in order prior to traveland surgery while also giving time to arrange travelvisas, where necessary.


Decision-making supportsTwo groups of people were commonly reported to haveplayed supportive roles during participants’ decision-making processes. First, participants greatly appreciatedand heavily considered anecdotal accounts from formermedical tourists. These accounts were overwhelminglypositive endorsements of particular surgeons, destinationhospitals, and/or the practice of medical tourism itself.In fact, the majority of participants sought advice fromother medical tourists, ranging from reading online testi-monials to speaking directly with such individuals. Thefollowing account is characteristic of the potency ofthese supportive encounters: “I talked to some [formermedical tourists], one guy especially who has been therea year before me. . .and his experience actually made mereally go for it and have no, no more doubts. . .[because]he said ‘it’s totally up to standard, to Western standards,and a lot of people are trained in the West,’ and he saidthe service was so good he would send his daughter thereon her own.” Several participants also reported beingcontacted ‘out of the blue’ by former medical touristswho had heard about their upcoming trip throughacquaintances or the local news media and offeredstrong support and additional advice, further validatingtheir decision to go abroad for care. Second, familymembers played key supporting roles in helping to re-search and interpret information. For at least four parti-cipants this support extended to assistance withfinancing their medical care abroad. Although an im-portant source of support, the opinions of friends andfamily had little impact on the outcomes of the decision-making process, with many participants adamant thatthey would have pursued their medical tour with orwithout the approval of their family or friends. This con-viction was largely hypothetical, though, as nonereported being seriously challenged by anyone duringtheir decision-making.Although most participants reported visiting with ei-

ther their family physician or treating specialist duringthe time in which they were considering booking surgeryabroad, they rarely sought physicians’ advice during thedecision-making process. Instead, they more commonlywaited to hear their regular physicians’ opinions on theirdecisions after having made a booking. Interestingly, theperception that one’s family physician or treating special-ist would be unsupportive was cited as justification fornot informing them of the plan to go abroad for surgeryprior to booking. For example, one participant who didnot speak with their family doctor explained that hersurgery was “None of his business. . . and he would havebeen prejudiced and he was prejudiced in any case.” Oneof the most common reasons participants consulted withtheir regular physicians prior to going abroad was to ac-quire medical records or diagnostic tests in order to

relay this information to destination physicians. Whilethese physicians commonly complied with participants’requests for records and/or tests, their reaction to thedecision to go abroad for surgery ranged from support-ive and caring to dismissive and dissuading. Remainingneutral and offering neither support nor discouragementwas most common. Two examples of demonstrating un-commonly supportive family physicians include one whobrought up the possibility of pursuing surgery abroad topatients before they had considered it and another whoprovided their personal cell phone number for the pa-tient to provide their overseas surgeon in the case of anemergency to try and ensure a high degree of informa-tional continuity. In both examples these physiciansserved as a significant source of support and guidanceduring decision-making.Participants reported drawing on two industry-based

sources of support in the course of their decision-making, those of medical tourism facilitators and clinicsabroad. Ten participants reported using a medical tour-ism facilitator to arrange for care abroad. Many of themsolely relied upon the facilitator for information abouttheir procedure, the facility, and the surgeon abroad. Forexample, when asked “Did you hear about the hospitalthat you went to in Bangalore from anyone else or was itjust solely through the recommendation of the facilitationcompany?” a participant replied “Yeah. That was throughthe company that sent us; we had no idea where we weregoing.” In the course of their decision-making, partici-pants regularly reported having direct contact with theirsurgeon abroad via e-mail, phone, or less commonly, atin-person information seminars. Participants took theopportunity to ask questions regarding the potentialrisks of surgery, probable outcomes, and their suitabilityfor the procedure. These interactions were greatlyvalued, and strengthened the resolve of many to accesscare abroad. When asked what the main deciding factorwas in seeking surgery abroad, one participant appealedto these interactions with the surgeon, saying: “You knowit probably was the doctor, I can’t think of anythingelse. . .I was in touch with him two or three times, hecalled me by telephone and spoke to him about a lot ofthe concerns and things and. . .I think. . .he was the mainfactor."

DiscussionThe opportunity to seek care abroad through the med-ical tourism industry creates new means of acting onmotivations and needs that have likely always under-pinned surgical decision-making in domestic contextsbut may have been constrained by structural arrange-ments. The current Canadian model of accessing surgi-cal care privileges the position of the expert over thenon-expert by requiring patients to seek referrals to


tertiary care providers from their primary care physi-cians [40], with the exception of surgical care not pro-vided through the public health care system. Themedical tourists we spoke with, however, tended to seekadvice and information from many sources other thantheir regular physicians or other members of the medicalcommunity and were ultimately responsible for decidingwhen and where care was to be delivered as long as theycould find a willing surgeon abroad. As such, involve-ment in medical tourism changed participants’ typicalenactment of the ‘patient role’ and the means by whichthey decided on medical treatment. The significance ofthese changes is discussed below in regard to partici-pants’ layered motivations, the timelines of care com-monly seen, and the sources of information accessedand relied upon in their decision-making processes.The current literature on medical tourism broadly

categorizes patient motivations, typically attributing asingle motivator to medical tourists from any givenhealth system [e.g., 36,41]. In these accounts, Canadianmedical tourists have generally been afforded only onemotivation for accessing medical care abroad, that ofwait-lists [e.g., 42]. While wait-lists and wait-listingplayed a role in motivating many of the participants tolook for care outside of Canada, it is important to notethat participants provided examples of all three of theregularly cited motivations for medical tourism, those ofprocedure cost, availability, and wait-listing [12]. Giventhe lack of universal coverage by public insurance plansfor dental and cosmetic surgeries in Canada, it was notsurprising to have heard accounts of Canadians choosingto access these treatments at more affordable ratesabroad. Cost also served as a secondary motivator formany, serving to promote more affordable destinationsonce participants were seriously researching theiroptions for a specific procedure abroad. The role of pro-cedure availability played a far more nebulous role as amotivator when compared with cost. It played a primarymotivating role for those seeking experimental surgeries(e.g., CCSVI, eye surgery for retinosis pigmentoria), asthere are no similar treatments available in Canada. Italso served as a primary motivator for those who wereunable to get specialist referrals domestically, or whoseconditions were deemed inoperable by their domesticphysician. Similarly, previous discussions of medicaltourists have rarely accounted for individual back-grounds that might influence the countries they visit formedical care. Meanwhile, our analysis suggests that pre-vious exposure to foreign countries, either through travelor emigration, might bear influence on the destinationsthey ultimately select.For many participants who were initially motivated to

explore the option of care abroad as a result of havingbeen wait-listed or being worried about the prospect of

one, the availability of procedures performed abroadwhich were perceived to be technically superior sup-planted this initial motivation. This supplantation ofavailability with wait-listing was seen repeatedly forthose who sought hip resurfacing, an alternative to atotal hip replacement, and vertical sleeve gastrectomies,a form of gastric bypass surgery. Meanwhile, the desireto avoid a wait list for the same surgery available domes-tically played a role in only six participants’ accounts.These layered motivations suggest that the decision toaccess surgery abroad cannot be crudely reduced to asingle motivator, and that contextual elements and sec-ondary motivators should be considered alongside themost powerful motivator in any given account. Perhapsunsurprisingly, a common element to all of the accountswas a strong hope that the surgery sought abroad wouldimprove the participants’ quality of life, as a sentimentof the importance of achieving good health at any costemerged in many of the interviews. If the barrier to agood quality of life through surgery was perceived to beavailability, cost, or a lengthy domestic wait list, partici-pants were compelled to find the means abroad to over-come them, regardless of the procedure’s objectivelyscored urgency and/or necessity.Notably, the particular contexts of individual destin-

ation countries were relatively unimportant in most ofparticipants’ decision-making processes. More specific-ally, the particular details of a destination country’swealth, politics, history, language, and other characteris-tics were of minor importance when compared to thereputation of the surgeon and the facility. In this way,the ‘global’ aspect of medical tourism is both effaced andaffirmed as the differences between potential destinationnations disappear and are replaced by placeless imagesof homogenous clinical spaces in the imaginations ofmedical tourists. This finding departs from some of theconceptual decision-making models that have been pub-lished in the tourism studies literature that have empha-sized the importance of destination nationcharacteristics to potential medical tourists’ decision-making processes [e.g. 43,44].While word-of-mouth information sharing has been

noted as an important factor in other studies of surgicalpatient decision-making [e.g., [45], the degree to whichword-of-mouth recommendations and endorsementsserve as a primary consideration for medical tourists wasfound to be remarkably consistent. This factor wasfound to be equally important in a recent study ofOmani medical tourists [46]. Another consistencyamong our participants was a general lack of consult-ation with their regular physicians during the decision-making process. Within the Canadian system, familydoctors and other primary care physicians serve as akeystone in patients’ pursuit of the majority of elective


surgical care by assessing need, providing counseling,and arranging for appointments with specialists whorelay detailed information about the risks and benefits ofsurgery [47]. Despite these established roles in support-ing patients’ medical decision-making, far more valuedwas the advice and support provided by other medicaltourists. This mirrors Kangas’ [48] findings amongstYemeni medical tourists, whose considerations of andwhere to go abroad for medical care were deeplyinformed by word-of-mouth networks recommendingparticular destination clinics and physicians.While the value placed on the expertise from former

medical tourists by those engaging in decision-makingaround pursuing care abroad should not be discountedgiven their first-hand knowledge of what to expect fromparticular hospitals or surgeons, the conspicuous ab-sence of a neutral, yet informed, third party informingthe decision-making process must be noted. Positive tes-timonials have been found to skew the interpretation ofsurgical risk, resulting in a disproportionate weighting ofthe potential positive outcomes even when presentedwith the statistical likelihood of the potential negativeoutcomes [31]. This raises concern about whether or notmedical tourist are always in a position to give informedconsent to care abroad based on the information theyhave considered, given that such consent requires asound understanding prior to surgery of their condition,success rates, treatment options, and risk of complica-tion [30,48]. Given the current lack of comprehensiveand neutral guidance available to medical tourists, therehave been a number of calls for stronger informationalsupport by third-parties that do not have a vested finan-cial interest in medical tourism [33,49,50]. Knowing thatformer medical tourists play such an influential role ininforming prospective medical tourists could be usefulto those designing such interventions, wherein formermedical tourists could be targeted in informational cam-paigns with the intent of having them pass such infor-mation along to those contacting them for advice.Furthermore, awareness of our finding of the wide vari-ance in the timing of the pre-booking research period bymedical tourists and the relative two month consistencyof the post-booking period could aid in developing strat-egies to disseminate informational interventions that aresensitive to the timeline of prospective medical tourists’informational needs.

Wider relevanceThe growth of the medical tourism industry has clearimplications for global health equity [3,51]. By extension,the decision-making considerations of individual medicaltourists and the information they access is tied to thedevelopment of this industry and its potential to operateequitably and ethically. One commonly cited health

equity concern pertains to the use of public resources bythe private medical tourism industry [3]. Although muchconsideration has been given in the medical tourism lit-erature to the potential for patients to require expensivefollow-up care in their home countries [12,52,53], ourfindings show that most of the medical tourists we spokewith sought out some degree of advice or logistical sup-port from their family physicians and treating specialistsprior to going abroad (but not necessarily before book-ing the procedure). As primary care consults and manylab costs in Canada are covered by public funding, thisis another potential pathway through which public fundssupport the operation of this private, for-profit industry.More research attention needs to be given to uncoveringthe ways in which patients’ home health care systems in-directly support the medical tourism industry in order toinform health equity debates surrounding this globalhealth services practice.In terms of health equity in medical tourism destin-

ation countries, it is thought that medical tourists travel-ing to economically developing nations may exacerbateexisting health inequities by raising the cost of care and/or lessening the availability of specialists to local citizensthrough increasing demand for their services [54].Meanwhile, it has also been suggested that the revenuesfrom medical tourists could be used to cross-subsidizethe care local patients in order to mitigate potentialnegative health equity impacts [11]. Should the appropri-ate redistributive financing mechanisms and regulationsbe developed in destination countries or at individual fa-cilities, medical tourists’ willingness to incur added feesto access more equitable care is likely contingent ontheir understanding of the health challenges faced byeconomically developing destination nations. Our find-ings suggest a general lack of awareness amongst themedical tourists we spoke with in terms of their know-ledge of contextual details of the particular destinationsthey chose to travel to during decision-making aboutseeking care abroad. In fact, consideration of the destin-ation country in any way held little weight in thedecision-making process. Medical tourists may morecarefully consider health equity in the destination andthe impacts of their decisions if prompted to do so in in-formational interventions or through other means andmediums.While this analysis has focused specifically on Canad-

ian medical tourists, our findings have relevance formedical tourists from other nations. Here we highlightthree such issues. First, while the contextual details ofmedical tourists’ home health systems may differ, theyseek care in a common global marketplace. Our findingshave confirmed that this marketplace is largely mediatedthrough the Internet, where much of the informationthat prospective medical tourists consider is accessed


online. Second, amongst our participants, context-specific domestic health system considerations informedtheir decision making processes. For example, particularstrengths (e.g., universal access) and weaknesses (e.g.,care rationing) of the Canadian public health care sys-tem underlay the kinds of surgeries that were soughtout-of-country and the motivations to go abroad.Patients exiting other countries with universal publichealthcare coverage, such as the United Kingdom andNorway, may too be motivated to go abroad for thesame reasons at the Canadian medical tourists we spokewith. Third, upon entering the same global marketplace,potential medical tourists are exposed to many of thesame web pages and advertisements regardless of theregulatory, legal, and political environments from whichthey will depart. This reality underscores the importanceof thinking of this patient group as influenced, but notstrictly defined by, their home health system contexts.

LimitationsAs recruitment was limited to English, we have excludedFrench-language participants as well as other linguisticminorities who do not have spoken English fluency.Additionally, given the difficulty of recruiting the studypopulation and our subsequent reliance on snowballsampling, there is likely a disproportionate focus on par-ticular surgeries sought in specific destinations and med-ical tourists from certain regions of Canada. Finally, ourreliance on the retrospective recollections may haveresulted in the omission of key details and/or heightenedthe bias of their recall of events when compared with aprospective approach to data collection.

ConclusionsIn this article we have presented the findings of inter-views with 32 Canadian medical tourists, with a specificfocus on their decision-making processes regarding seek-ing surgery abroad. Our analysis confirms accounts ofmedical tourism that attribute its growth to the ability ofthe Internet to connect distant parties with mutual inter-ests to one another [55,56]. That prospective Canadianmedical tourists relied upon the Internet to put them intouch with information about clinics, surgeons, andother medical tourists is therefore not surprising. Whatis noteworthy, however, is the degree to which the opi-nions and advice of other medical tourists informed par-ticipants’ awareness of medical tourism and theirultimate decision to travel abroad for care. This addsevidence to existing concerns that prospective medicaltourists may have limited access to accurate and un-biased sources of information about their treatments, es-pecially online [16,33]. The creation of such sourcescould greatly benefit all medical tourists considering

surgery abroad by providing a more complete picture toinform their decision-making.The accounts provided by Canadian medical tourists

complicate existing broad characterizations in the med-ical tourism literature that attribute the motivations ofmedical tourists leaving any given country to a singlemotivating force, such as cost of care, wait-listing, or theavailability of procedures. The medical tourists we inter-viewed made it clear that all three of these motivatorswere at play in their decision to seek care abroad, oftenin combination with one another. Future accounts orinvestigations of medical tourism would benefit from amore nuanced consideration of the layered motivationsthat are driving patients to seek medical care abroad, ra-ther than accepting the current broad-stroke accountsthat attribute a single motivator to the medical touristsof any one locale. It is also important that future re-search addresses the quantitative knowledge gaps rife inmedical tourism research to provide broader contextand grounding for the trends described in this analysisand other qualitative studies.

AbbreviationsCCSVI: Cerebro-Spinal Venous Insufficiency; US: United States.

Competing interestsThe authors declare they have no competing interests.

Authors' contributionsRJ undertook data collection, coding, wrote the first draft, and undertook thebulk of subsequent edits. VAC developed the study protocol, contributed tocoding scheme development, was involved in interpreting the findings, andclosely edited multiple drafts. JS contributed to the data collectioninstrument and coding scheme, confirmed the RJ’s interpretation of thefindings, and provided feedback on drafts. All authors reviewed andapproved of the submitted manuscript.

AcknowledgementsWe would like to thank those who participated in this study for sharing theirexperiences and views with us. This study was funded by a Catalyst Grantfrom the Canadian Institutes of Health Research.

Author details1Department of Geography, Simon Fraser University, 8888 University Drive,Burnaby, BC, Canada. 2Faculty of Health Sciences, Simon Fraser University,8888 University Drive, Burnaby, BC, Canada.

Received: 16 February 2012 Accepted: 17 June 2012Published: 7 July 2012

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doi:10.1186/1744-8603-8-23Cite this article as: Johnston et al.: “I didn’t even know what I was lookingfor”: A qualitative study of the decision-making processes of Canadianmedical tourists. Globalization and Health 2012 8:23.

http://www.cbc.ca/news/background/healthcare/medicaltourism.html

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http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php

http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf

http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf