Acknowledgements
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ACKNOWLEDGEMENTS My greatest debt is owed to my Director of Studies, Mrs. Aileen French, my supervisor, Dr. Jan Harwell and the Head of Doctoral Programme, Dr. David Bowen for their continuous guidance, constructive suggestions, encouragement and patience throughout the duration of this dissertation. Without their guidance and support, it would have been very difficult to journey through the voluminous subject in question. Their comments inspired me to explore various avenues and initiated a stronger consistency in the performance of my work. I very much appreciate all their time, effort and kind support. I will also send my regard and appreciation to all the staffs and members of the business school for all their support. My special thanks to all respondents of my primary research for taking time out for their busy schedules to allow me to carry out the interview, the co- operation and willingness of Thai people made the research process very effective and stress free. Finally, I would like to express my appreciation to my family and close friends for their moral support and encouragement during those times when the task of completing this dissertation seemed uncertain and overwhelming. Without their love, support and patience I would not have been able to complete it. Dararat Simpattanawong 28 January 2016 iii ABSTRACT Medical tourism is a niche market. Non-invasive aesthetic medical tourism is a type of cosmetic medical tourism with no surgery involved. This type of global interconnection is a relatively new phenomenon within the context of the current sphere of internationalism, thus explaining why few have explored the economic and health factors in a deeper context than simply a cost/ benefit analysis. Therefore, the purpose of this research is to investigate how risk of stakeholders may act as a barrier to the development of aesthetic medical tourism, and to establish how competitive advantage may be sustained in Bangkok. Semi-structured interviews with 15 non-invasive aesthetic clinic owners, 25 English-speaking international tourist-patients, and five government representatives have been conducted in Bangkok. The findings from fieldwork were coded and analysed thematically using a framework derived from the literature review. This research identified six factors related to Thailand's competitiveness and six barriers to the development of this industry. The research made a significant original contribution to academic and practitioner knowledge in that it examined and evaluated risk perception in a new tourism context and with a new group of tourists. This research has established a classification of six types of risk in relation to non-invasive aesthetic medical tourism: functional, physical, financial, time, psychological and social risk. It also demonstrated how interpretivist qualitative approach can make a contribution to aesthetic medical tourism research practice. A framework of risks in relation to the development and management of aesthetic medical tourism in Bangkok was also established for both consumers and service providers in order to realise related risks and develop risk reduction strategies appropriately. iv CONTENTS TITLE PAGE i DECLARATION ii ACKNOWLEDGEMENTS iii ABSTRACT iv CONTENTS v LIST OF FIGURES xii LIST OF TABLES xiii Chapter Page 1 INTRODUCTION 1 1.1 Introduction 1 1.2 Background of tourism 1 1.3 Health and medical tourism 2 1.4 Tourism and medical tourism in Thailand 5 1.5 Research aim and objectives 12 1.6 Research methodology 12 1.7 Structure of the dissertation 13 2 MEDICAL TOURISM AND NON-INVASIVE AESTHETIC 15 MEDICAL TREATMENT 2.1 Introduction 15 2.2 Tourism 15 2.3 What is medical tourism? 16 2.4 Background of medical tourism 20 2.5 Reasons to consider using medical tourism 21 2.5.1 Lower cost 22 2.5.2 No waiting lists 23 2.5.3 The absence of medical treatments at home 24 v 2.6 The negative impacts of medical tourism 26 2.6.1 Negative impact of medical tourism on medical tourism 26 destination country 2.6.2 Negative impact of medical tourism on patient’s home 28 country 2.7 The rise of global medical tourism 32 2.8 Medical tourism in Asian destination countries 33 2.9 Medical tourism in Thailand 35 2.9.1 Why Thailand? 38 2.9.2 Standards and accreditations 40 2.10 Other perspectives of medical tourism in Thailand 42 2.10.1 Health tourism and Wellness tourism 42 2.10.2 Aesthetic medical tourism 44 2.10.2.1 Non-invasive aesthetic clinics 46 2.11 Non-invasive aesthetic medical treatments: What are they? 48 2.11.1 Types of non-invasive aesthetic medical treatments 52 2.11.2 Non-invasive aesthetic medical tourist 57 2.12 Conclusion 57 3 PRECEIVED RISKS AND RISK REDUCTION STRATEGIES 59 3.1 Introduction 59 3.2 Motivation and decision-making 59 3.3 Risk and uncertainty 61 3.4 Definitions of risk 63 3.5 Objective and subjective risks 64 3.6 The concept of perceived risk 65 3.7 The element of risk 67 3.8 Perceived risk as a travel determinant 68 3.8.1 A behavioural approach 71 3.8.2 A supply approach 72 vi 3.9 Six categories of risks related to non-invasive aesthetic medical 75 tourism and treatments 3.9.1 Functional risks 77 3.9.1.1 Botulinum toxin injections 79 3.9.1.2 Mesotherapy injections 79 3.9.1.3 Dermal filler treatments 80 3.9.1.4 Chemical peels 81 3.9.1.5 Laser treatments 81 3.9.2 Physical risks 84 3.9.2.1 Political and security issues 85 3.9.2.2 Epidemic crises 86 3.9.2.3 Health risks 87 3.9.3 Financial risks 90 3.9.4 Time risks 91 3.9.5 Psychological risks 92 3.9.6 Social risks 93 3.10 Strategies of risk reduction 99 3.10.1 Risk and service guarantees 101 3.10.2 Risk and general information 102 3.10.3 Risk and price information 103 3.11 Conclusion 104 4 RESEARCH METHODOLOGY 105 4.1 Introduction 105 4.2 Research aim and objectives 105 4.3 Research philosophy 106 4.3.1 Positivism 107 4.3.2 Interpretivism 108 4.4 Research design 109 4.4.1 Exploratory research 110 vii 4.4.2 Research strategy 111 4.4.3 Research approach 112 4.4.3.1 Deductive and inductive approach 112 4.4.3.2 Quantitative approach 113 4.4.3.3 Qualitative approach 115 4.5 Medical tourism research: Qualitative and quantitative studies 117 4.5.1 What method is missing from non-invasive aesthetic 124 medical tourism research? 4.6 Data collection 125 4.6.1 Secondary data collection 125 4.6.2 Collection primary data using semi-structured interviews 128 4.7 Interview questions development 135 4.8 Sampling techniques 136 4.8.1 Non-probability sampling technique 137 4.8.2 Determining sample size 141 4.8.3 Recruiting participants 143 4.8.3.1 Stage one: Pilot study 144 4.8.3.2 Stage two: Main stage of fieldwork 145 4.9 Seeking access 147 4.9.1 Gatekeepers 149 4.10 Interview duration and recording data 150 4.11 Interview settings and process 152 4.12 Ethical issues 155 4.13 Potential risks to participants and risk management procedures 157 4.14 Interpretation and data analysis 158 4.14.1 Interpretations 158 4.14.2 Data analysis 159 4.14.2.1 Analysis of individual interview and transcripts 163 4.15 Validity and reliability of the research 165 4.16 Reflection on research method 166 viii 4.17 Summary 168 5 FINDINGS ANALYSIS AND INTERPRETATION: COMPETITIVE 169 ADVANTAGES AND BARRIERS TO THE DEVELOPMENT 5.1 Introduction 169 5.2 The benefits of Thailand’s location 169 5.2.1 Unique tourist features 169 5.2.2 A strong history of medical tourism 170 5.2.3 Facilitative infrastructure 171 5.2.4 Cost 172 5.2.5 Ease of access 172 5.2.6 Privacy 173 5.3 Non-invasive aesthetic medical tourism: Thailand as leader 176 5.3.1 Internationally accredited medical facilities 174 5.3.2 Highly qualified medical professionals 181 5.3.3 Cost saving 184 5.3.4 State-of-the-art technology 189 5.3.5 Excellent service providers 191 5.4 Barriers and obstacles to the development and management of 193 non-invasive aesthetic medical tourism in Bangkok 5.4.1 Communication skills 194 5.4.2 Law and regulations 197 5.4.3 Performing medical treatments in non-clinical locations 202 5.4.4 Shortage of staff in public hospitals 203 5.4.5 Common selling points and over supply 207 5.4.6 Missing follow up appointments 207 5.5 Future market trends 208 5.6 Conclusion 210 6 FINDINGS ANALYSIS AND INTERPRETATION: 212 RISKS AND RISK REDUCTION STRATEGIES ix 6.1 Introduction 212 6.2 Risks from travelling abroad for medical care 212 6.3 Risks related to non-invasive aesthetic medical treatments 214 6.3.1 Functional risks 215 6.3.1.1 The quality of aesthetic medical equipment 216 6.3.1.2 Renaming non-invasive aesthetic medical 221 treatment 6.3.1.3 The quality of aesthetic medicines and 225 injected medicines 6.3.1.4 The quantity of injected drugs 229 6.3.1.5 The skill and experience provided by 230 the service provider 6.3.1.6 Post treatment care and instruction problems 233 6.3.1.6.1 Laser treatment 233 6.3.1.6.2 Chemical peels 235 6.3.1.6.3 Drug injection 236 6.3.1.6.4 Fat and cellulite reduction treatment 237 6.3.1.6.5 Weight loss programme 238 6.3.2 Physical risks 240 6.3.2.1 Laser treatment 242 6.3.2.2 Carboxy therapy 244 6.3.2.3 Mesotherapy 245 6.3.2.4 Law and legislation on food and health safety 246 6.3.3 Financial risks 250 6.3.3.1 Hidden costs 254 6.3.4 Time risks 255 6.3.5 Psychological risks 257 6.3.5.1 Addiction to maintaining a youthful look 258 6.3.5.2 Refusal to accept the effectiveness of results 262 6.3.5.3 Hiding the fact of having had cosmetic treatment 265 x 6.3.5.4 How bargain prices create over-consumption 266 6.3.6 Social risks 271 6.3.6.1 Embarrassment of having too obvious a result 271 6.3.6.2 Embarrassment from telling other people about 272 non-invasive aesthetic