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Hope across the seas: the role ofemotions and risk propensity inmedical tourism advertisingElyria Kempa, Kim H. Williamsb & McDowell Porter IIIca College of Business Administration, Department of Management& Marketing, University of New Orleans, New Orleans, LA, USAb The Lester E. Kabacoff School of Hotel, Restaurant and TourismAdministration, University of New Orleans, New Orleans, LA, USAc E. J. Ourso College of Business, Department of Marketing,Louisiana State University, Baton Rouge, LA, USAPublished online: 26 Mar 2015.

To cite this article: Elyria Kemp, Kim H. Williams & McDowell Porter III (2015): Hope across theseas: the role of emotions and risk propensity in medical tourism advertising, International Journalof Advertising: The Review of Marketing Communications

To link to this article: http://dx.doi.org/10.1080/02650487.2015.1024385

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Hope across the seas: the role of emotions and risk propensity in

medical tourism advertising

Elyria Kempa*, Kim H. Williamsb and McDowell Porter IIIc

aCollege of Business Administration, Department of Management & Marketing, University of NewOrleans, New Orleans, LA, USA; bThe Lester E. Kabacoff School of Hotel, Restaurant and Tourism

Administration, University of New Orleans, New Orleans, LA, USA; cE. J. Ourso College ofBusiness, Department of Marketing, Louisiana State University, Baton Rouge, LA, USA

(Received 9 November 2013; accepted 24 February 2015)

Rising US medical costs as well as more competition in the health care industry have ledmany Americans to pursue health care in foreign destinations. As a result, leadingcountries in medical tourism have begun launching international advertising campaigns.A growing trend in much of this advertising is the use of emotional appeals. Thepurpose of this research is to examine whether the use of emotional appeals by non-domestic health care providers contributes to more favourable evaluations of the targethealth care provider than rational appeals. Specifically, two experimental studiesinvestigate the efficacy of advertisements that induce the emotion of hope to determinewhether these advertisements increase trust perceptions and reduce perceived risk, givenan individual’s level of risk propensity. Implications for public policy makers andmarketing managers who work in health care are discussed.

Keywords: medical tourism advertising; emotions; hope; trust; risk

Introduction

Rising US medical costs and more competition in the health care industry have led Amer-

icans to pursue health care in foreign destinations (Doheny 2007). This phenomenon,

known as international medical tourism, is when individuals travel to destinations outside

their home countries to receive medical care. Often, consumers can save as much as 20 to

80% of the cost of a medical procedure by receiving treatment abroad (Chandrasekaran

2012). Experts predict that medical tourism will become a US $100 billion international

industry in the coming years, with more than 780 million consumers seeking non-domes-

tic health care (Chandrasekaran 2012).

Reasons for the rapid growth in medical tourism can be attributed to increasing health

care costs in wealthy countries, consumers’ preferences for privatization of health care,

quality enhancement of medical care systems, communication technologies, and exotic

cultural attractions (Lee, Groves, and Lengfelder 2010). Among the top medical tourism

destinations are Mexico, Costa Rica, Thailand, India, Turkey, Ireland, South Korea,

Singapore, Taiwan, and Germany (Jacobs 2013). Not only are private individuals taking

advantage of health care abroad, but employers and government-run health care agencies

have also taken an iterative approach by including international medical travel options as

‘value-added’ services for non-covered services or for pre-existing conditions (Boucher

2010). As competition in the US health care industry has intensified, health care providers

*Corresponding author. Email: ekemp@uno.edu

� 2015 Taylor & Francis

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have made aggressive efforts to reinforce their brands through advertising (Larson et al.

2005; Ugar and Riecken 2001). At the same time, leading countries in medical tourism

are competing for some of the same business and have begun launching international

advertising campaigns.

Advertising to consumer markets in health care has existed in the United States since

the early 1980s, with the pharmaceutical industry being one of the early purveyors of

direct-to-consumer advertising (DTCA; Frosch et al. 2010; Myers, Royne, and Deitz

2011; Rod and Saunders 2009). As prescription drug brands have proliferated throughout

American culture, supporters of DTCA have argued that it increases consumer awareness

of treatable medical conditions and improves health care decision making (Calfee 2002;

Capella et al. 2009). However, critics have argued that DTCA increases primary demand,

medicalizes normal human experiences, and promotes the use of new drugs that offer

minimal advantages over existing drugs (Lexchin and Mintzes 2002; Myers, Royne, and

Deitz 2011; Strange 2007). The policy implications of DTCA are still up for debate. How-

ever, a growing trend in pharmaceutical and health care advertising is the use of emo-

tional appeals (Larson et al. 2005).

Often, these advertisements highlight the benefits of a service or product offering but

do not quantify positive claims. Advertisements from health care providers (i.e., special

treatment centers) in particular may provide limited information on potential harms

(Larson et al. 2005; Singer 2009). In addition, many of these ads tend to promote newer,

more advanced procedures. Similarly, advertisements for medical tourism also enlist

emotional overtones, with many emphasizing affordability, opportunities for travel and

leisure, and treatment for rare, chronic and terminal illnesses.

Experts caution that medical tourism may involve some risks. Consumers considering

travelling abroad for health care services are advised to carefully review the accreditation

of the hospital and take into account the nature of the procedure they are interested in hav-

ing performed (Doheny 2007). For example, consumers may need to refrain from typical

vacation activities, which are sometimes promoted as part of a surgery trip, to allow for

proper healing and reduce the risk of complications, such as pathogen spread. In addition,

consumers should investigate the credentials of physicians and the health care organiza-

tion where their procedure will be performed.

Fundamentally, health care is a personalized, high-involvement service offering with

associated risks. Furthermore, the health care consumer may be considered a ‘vulnerable

consumer’. Many consumers have limited knowledge of health care services, and often

the efficacy of such services is difficult for them to evaluate, even after the service has

been rendered. As these consumers confront high levels of uncertainty and limited infor-

mation, rational decision making may be constrained. Subsequently, health care advertis-

ing messages, which evoke positive emotions (e.g., hope), may especially be effective in

cultivating favourable evaluations from consumers of health-related product or service

offerings � with some consumers failing to seek objective information about the offering.

Thus, the purpose of this research is to examine whether emotional appeals by non-

domestic health care providers contribute to favourable evaluations of the target health

care provider. Specifically, this research investigates whether advertisements that foster

hope engender more trust and aid in reducing perceived risk for consumers, given their

level of risk propensity. Implications for public policy makers and marketing managers

who work in health care are discussed, as marketing health care services to consumers

will require a balanced and nuanced approach in the coming years.

The section that follows addresses the role of emotions in health care advertising.

Emotional advertising in health care may be especially instrumental in instilling trust and

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reducing perceived risk in individuals. The conceptual underpinnings of emotions in per-

suasive appeals are explicated next.

Conceptual background

Emotions play an important role in the formation of attitudes towards and judgements

about advertisements (Cornelis, Adams, and Cauberghe 2012; Edell and Burke 1987;

Faseur and Geuens 2012), and can be an important component in explaining the relation-

ship between cognitive and behavioural reactions to advertising (Dens and De Pelsmacker

2008; Kemp, Bui, and Chapa 2012). Advertisers have long believed that advertising must

arouse some emotion to be effective (Bagozzi and Moore 1994; Holbrook and Batra

1987; Mehta and Purvis 2006; Potter et al. 2006), and researchers have purported that

effective advertisements make promises to consumers by inducing ‘hope’ (Poels and

Dewitte 2008; Rossiter and Percy 1991).

Hope

Hope is a positive emotion evoked in response to an uncertain but possible goal-congru-

ent outcome (MacInnis and De Mello 2005; Shaver et al. 1987). Hope consists of reality-

based appraisals of the ‘will’ and the ‘ways’ of achieving goals (Snyder 1989). The more

important the person perceives a goal-congruent outcome, the greater the value he or she

attaches to it (MacInnis and De Mello 2005); therefore, hope is an emotion experienced

when individuals place great significance on the outcome.

One way that hope can be induced is by improving an individual’s perceived possibil-

ity of achieving a goal (MacInnis and De Mello 2005). This can be done by highlighting

the benefits of a customized product offering. Many advertisements in health care try to

induce hope by highlighting the beneficial outcomes of a product/service offering (Larson

et al. 2005; MacInnis and De Mello 2005). In these cases, innovations imply possibilities

for achieving goal-congruent outcomes that were previously viewed as difficult to

achieve.

As previously discussed, hope consists of reality-based assessments of uncertain

goal-congruent outcomes (MacInnis and De Mello 2005; Snyder 1989). However,

over-confidence in achieving goals can breed false hope. False hope is grounded in

unrealistic positive outcome expectancies and is characterized as an increased per-

ception of control, which engenders distorted beliefs about the effects of success

(Polivy and Herman 2000). Agreement exists in the clinical literature that genuine

hope and false hope can be differentiated by examining whether the expectations are

grounded in reality (Beavers and Kaslow 1981). Another factor that differentiates

genuine hope from false hope is whether the hope generates a constructive response

(Beavers and Kaslow 1981).

Moreover, individuals who entertain false hope may possess positive illusions of real-

ity (Baumeister 1989). An illusion represents a false mental image or conception that

may be a misinterpretation of a real appearance or may be something imagined. Illusions

that blatantly distort reality can be maladaptive and possess inherent risks to the individ-

ual (Baumeister 1989; Snyder 1989). These illusions may lead people to ignore legitimate

risks and fail to take measures to mitigate risks (Weinstein and Klein 1996).

Medical tourism advertising messages may evoke hope by emphasizing the afford-

ability and efficacy of services as well as the ability to vacation shortly after treatment.

Importantly, advertisements that elicit hope may be especially effective because they

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engender trust. Similarly, these advertisements may also help reduce risk perceptions.

Thus, cultivating an emotion such as hope can have persuasive power; however, temper-

ance should be exercised because claims in such health care advertising may overstate

the ease of the medical process (Larson et al. 2005; Sfikas 1989; Singer 2009).

Trust and perceived risk

Trust is essential in health care (Berry 2000). The buyer surrenders completely to the

seller and, in many cases, even temporarily lives in the health care facility (Berry and

Bendapudi 2007). Moorman, Deshpande, and Zaltman (1993, 82) define trust as ‘a will-

ingness to rely on an exchange partner in whom one has confidence’. Morgan and Hunt

(1994, 23) conceptualize trust as the perception of ‘confidence in the exchange partner’s

reliability and integrity’. According to Morgan and Hunt (1994), the presence of trust in a

relationship encourages marketers to cooperate with exchange partners, maintain a long-

term orientation with them, and consider high-risk actions that positively affect the rela-

tionship. Advertisements in health care that induce hope might be effective in creating

trust. Hope helps instill confidence and assurance in an exchange relationship (Morrison

and Firmstone 2000). Thus, the presence of hope is a key element in creating trusting

relationships.

Additionally, emotional advertisements that foster hope might be effective at mitigat-

ing risk perceptions. Humans generally have difficulty coping with uncertainty and

perceived risk (Bauer 1960; Bettman 1973; Chaudhuri 1997; Choi et al. 2013; Mitchell

and Greatorex 1990). Perceived risk refers to the concerns or anxieties an individual

anticipates in carrying out a specific activity (Taylor 1974). Such risk can be functional

or performance related, physical, psychological, social, financial, and time related

(Jacoby and Kaplan 1972; Sarin, Challagalla, and Kohli 2012).

Perceived risk in health care can affect whether a patient will follow through with a

treatment regimen prescribed by his or her health care provider or clinician. Furthermore,

risks associated with performance, or performance risks, may be of primary concern in

health care and medical tourism. Performance risks are related to potential loss due to a

product/service failure (Laroche et al. 2005). Such risks play an important role in whether

individuals will enlist health care services in foreign destinations.

Advertisements that induce hope may be successful in reducing anxieties related to

performance risk because hope is an emotion that elevates confidence. It activates percep-

tions that goals can be met (Snyder et al. 1991). Hope is dependent on the condition that a

positive outcome is probable (Snyder 1989); thus, uncertainties and anxieties about taking

a course of action may be reduced when hope is present. However, individuals may vary

with respect to how they evaluate risks.

Risk propensity

Research has found that while the degree of risk perceived in a situation can vary accord-

ing to the situation, attitudes towards perceived risk, or the degree to which people find

perceived risk attractive, may remain stable across situations (Nicholson et al. 2005).

Thus, factors that influence risk behaviour may include individual difference factors.

Specifically, research findings confirm that risk propensity, or the tendency of an individ-

ual to either take or avoid risks (Sitkin and Weingart 1995), is a highly consistent predic-

tor of various types of risk taking, including compulsive gambling and participation in

high-risk activities (Zuckerman and Kuhlman 2000).

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An individual’s degree of risk propensity may influence his or her willingness to seek

medical care abroad. Individuals who are less risk averse (high risk) may be more amena-

ble to enlisting such health care services, while individuals who are risk averse (low risk)

may be less likely to use such services. However, emotional advertisements that induce

hope may appeal more to individuals who are risk averse (low risk) than advertisements

that contain limited emotional innuendo. As mentioned previously, hope promotes goal

activation and confidence in achieving a desired outcome. Furthermore, advertisements

that elicit hope may foster trust and reduce perceived risk, which may help mitigate the

inherent risk propensities of risk-averse individuals.

As a result, it is predicted that emotional advertisements that induce hope will have an

advantage over non-emotional or rational advertisements for individuals who are charac-

teristically low-risk individuals. Specifically, it is proposed that hope-inducing advertise-

ments will be especially effective at engendering trust. Because of hope’s ability to foster

trust, low-risk individuals will express perceptions of trust that differ little from those of

high-risk individuals. However, for a non-emotional or rational advertisement, the differ-

ences between low- and high-risk individuals will be more pronounced, with low-risk

individuals expressing less trust when exposed to the advertisement. Thus, the following

is predicted:

H1: Low-risk individuals will express lower perceptions of trust when exposed to a ratio-

nal advertisement than high-risk individuals. However, no significant differences in per-

ceptions of trust will exist between low- and high-risk individuals when exposed to an

emotional advertisement that induces hope.

Similarly, it is proposed that an emotional advertisement that evokes hope will influ-

ence perceptions of performance risk for low-risk individuals. Again, the differences

between low- and high-risk individuals should be minimized when an emotional adver-

tisement is presented, but the differences between low- and high-risk individuals will be

significant when exposure to a rational advertisement occurs. Consequently, the following

is hypothesized:

H2: Low-risk individuals will express greater perceptions of risk when exposed to a

rational advertisement than high-risk individuals. However, no significant differences in

perceptions of risk will exist between low- and high-risk individuals when exposed to an

emotional advertisement that induces hope.

Testimonials

In addition to emotional appeals that induce hope, marketers may enlist other persuasive

features. Testimonials, or endorsements of a product/service, are often at the heart of many

advertising efforts (Martin, Wentzel, and Tomczak 2008; Shimp, Wood, and Smarandescu

2005). Such source effects have become prevalent in health care marketing. In particular,

patient testimonials are now common in advertising for allergists, cardiology, oncology,

dermatology, weight loss, and dentists (Gaughran 2010). Testimonials are effective at gain-

ing product trial because consumers learn experiential information quickly (Wright and

Lynch 1995) and consider it in choice decisions (Shapiro and Spence 2002).

Research suggests that testimonials are used as a peripheral cue (Petty, Cacioppo, and

Schumann 1983; Singh, Cuttler, and Silver 2004), in which endorser source credibility

influences message persuasion. As a result, inclusion of endorsers in advertisements often

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leads to more favourable attitudes towards products (Raju, Rajagopal, and Unnava 2002)

and increased credibility perceptions of advertisements (Feick and Higie 1992).

Furthermore, first-hand experiences influence consumers, especially when personal

outcomes are high (Adams, Tineke, and Geuens 2011; Sivacek and Crano 1982). From

this perspective, a testimonial from an ordinary or typical consumer with product experi-

ence can be quite persuasive (Wu and Shaffer 1987). Research suggests that consumers

are more influenced by a testimonial from an endorser whom they view as similar to

themselves (Feick and Higie 1992). These ‘typical person’ testimonials offer informa-

tional influence (Martin, Wentzel, and Tomczak 2008), such that a person accepts infor-

mation from another person as a form of evidence because the endorser is another

consumer with relevant product experience (Burnkrant and Cousineau 1975; Martin,

Wentzel, and Tomczak 2008).

Accordingly, because of the ability of testimonials to increase perceptions of credibil-

ity and encourage product trial, it is proposed that the use of a testimonial will be as per-

suasive as an emotional appeal that induces hope for low-risk individuals. Specifically,

when a testimonial from a typical consumer is paired with a rational message, it will be

just as effective in fostering trust and reducing perceived risk in low-risking-taking indi-

viduals. This is predicted to occur for the rational advertisement but not the emotional

advertisement that induces hope, because hope is an emotion grounded in optimism about

an uncertain outcome. Hopeful individuals create positive imagery and expectations

about an indeterminate event. Because such positive expectations are already present,

additional anecdotal evidence in the form of a testimonial will have limited effect. As a

result, the following hypotheses are put forth:

H3: Low-risk individuals will exhibit more trust for a rational advertisement with a testi-

monial than high-risk individuals. However, no significant differences in trust will exist

between low- and high-risk individuals for an emotional advertisement that induces hope

with a testimonial.

H4: Low-risk individuals will exhibit lower levels of performance risk for a rational

advertisement with a testimonial than high-risk individuals. However, no significant dif-

ferences in performance risk perceptions will exist between low- and high-risk individu-

als when exposed to an emotional advertisement that induces hope with a testimonial.

Study 1

Procedure and design

Study 1 tested H1 and H2 using a 2 (message: emotional [hope] vs. rational) £ 2 (risk

propensity: low vs. high) between-subjects experiment. The participants were 82 non-stu-

dent adults who were recruited using a snowball sampling methodology (see He and Li

2011; Maher and Mady 2010; Winkler and Buckner 2006). Undergraduate college stu-

dents enlisted non-student adults to participate in the study and received extra credit in

exchange for the participants they recruited. The mean age for participants was 34 years

(standard deviation [SD] D 11.89; range D 22 to 75). The mean income of participants

was US $49,999. Forty-four percent of the sample was male, and 56% was female.

Participants were presented with a fictitious advertisement (designed for this study)

that was either emotional or rational in nature, about dental care in Puerto Vallarta,

Mexico. The emotional advertisement included language to elicit hope:

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New Smile Dental CarePuerto Vallarta, Mexico

For years, Cara refused to smile because she was ashamed of her teeth. Her employer did notprovide dental insurance and having the work she needed performed proved to be too expen-sive in the United States. Cara’s life was changed by New Smile Dental Care in Puerto Val-larta, Mexico. She now has healthy teeth and a beautiful smile that she cannot stop sharingwith family and friends.

New Smile Dental Care provides the same quality of care as in the United States � often upto 70% cheaper. Our clean facility and friendly English-speaking staff are present to assistyou with your specific dental needs. All doctors at New Smile Dental Care are members ofthe American Dental Association and the quality of all dental work performed is guaranteed.

Book your appointment at New Smile Dental Care today!

Mexico has become a leading destination for dental care services. Enjoy the beaches,wonderful scenery and facilities!

The rational condition did not explicitly enlist emotional overtones but provided

objective information about the dental services provided:

New Smile Dental CarePuerto Vallarta, Mexico

At New Smile Dental Care in Puerto Vallarta, Mexico, all our dentists are licensed and certi-fied to practice dentistry. We perform white composite fillings, all types of extractions,crowns, dentures, surgical implants, preventive care and use board certified endodontists todo root canals. New Smile Dental Care is also located near fine hotels in the area to makeyour trip as convenient and comfortable as possible.

New Smile Dental Care provides the same quality of care as in the United States � often upto 70% cheaper. Our clean facility and friendly English-speaking staff are present to assistyou with your specific dental needs. All doctors at New Smile Dental Care are members ofthe American Dental Association and the quality of all dental work performed is guaranteed.

Book your appointment at New Smile Dental Care today!

Mexico has become a leading destination for dental care services. Enjoy the beaches, won-derful scenery and facilities!

After exposure to the appeal, participants were asked to indicate their level of trust in

the service provider using two items adapted from Chaudhuri and Holbrook (2001): ‘I

believe that New Smile Dental Care’s claims are believable’ and ‘I believe that New

Smile Dental Care is a dental provider I can trust’ (r D 0.76). Both items were measured

on a 7-point Likert scale, summed and then averaged. Participants were also asked to

assess the degree of performance risk associated with receiving dental care at the service

provider. Three items, adapted from Stone and Grønhaug (1993), were used: ‘I worry

about whether the dentists at New Smile Dental will really perform as expected’, ‘I am

concerned about how reliable New Smile Dental will really be’, and ‘I worry about

whether the dentists at New Smile Dental will really perform as expected’. Again, these

items were measured using a 7-point Likert scale, summed and then averaged (a D 0.89).

After completing the dependent measures, participants filled out the Risk Taking

Index, also known as the Risk Propensity Scale, developed by Nicholson et al. (2005).

The inventory consists of six different areas (i.e., recreational, health, career, financial,

safety, and social) in which participants are asked to assess their everyday degree of risk

taking. All six items were measured with a 5-point Likert scale, summed and then

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averaged (a D 0.79). Participants also responded to manipulation check measures. Specif-

ically, manipulation checks asked participants on a 7-point Likert scale whether the

advertisement gave them ‘hope’ or if the advertisement provided ‘useful’ information.1

Results

An analysis of variance (ANOVA) was performed on the manipulation check measures.

Results indicated that there was a main effect for the emotion condition (F(1, 78) D 3.0,

p < 0.05), with participants expressing that they felt more ‘hope’ (M D 4.27) than those

in the rational condition (M D 3.8). Similarly, there was a main effect for the rational con-

dition (F(1, 78) D 4.33, p < 0.05), with participants indicating that they believed that the

information presented was more ‘useful’ (M D 4.81) than did those in the emotion condi-

tion (M D 4.27).2

To assess the interaction predictions of H1 and H2, separate regressions were per-

formed on trust perceptions and risk performance. Dummy variables were assigned to

indicate the message type (i.e., emotional vs. rational), the risk propensity, and the inter-

action between message type and risk propensity (Fitzsimons 2008). Variables were also

centered before creation of the interaction term (Hayes 2008). An analysis of the data

indicated that a message £ risk propensity cross-over interaction manifested (b D 0.80;

t D 2.37, p < 0.05). In the emotion condition, low-risk individuals exhibited more trust

than high-risk individuals (M D 4.53, M D 3.74; p < 0.05). In addition, in the rational

condition � and as predicted in H1 � low-risk individuals displayed less trust than high-

risk individuals did (M D 3.5,M D 4.59; p < 0.05; see Figure 1).3

Figure 1. Trust perceptions (Study 1).Note: The numbers represent the average group mean assessment of trust perceptions (e.g., thegroup mean of trust perceptions for the participants in the high risk, emotional condition is 3.74).Higher numbers indicate greater trust perceptions.

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Regression analysis also revealed that there was a message £ risk propensity interac-

tion for performance risk perceptions (b D �0.78; t D �2.48, p < 0.05). In the emotion

condition, as predicted, there were no significant differences between low- and high-risk

individuals (M D 4.8, M D 5.11; p > 0.05) � higher numbers indicate higher degrees of

risk assessment. However, in the rational condition, there were significant differences, with

low-risk individuals exhibiting higher degrees of performance risk perceptions than high-

risk individuals (M D 5.7, M D 4.4, p < 0.05; see Figure 2). Thus, H2 was supported.

Discussion

Study 1 demonstrates that emotional advertisements that induce hope help to foster trust

in low-risk-taking individuals. A cross-over interaction revealed that low-risk-taking individ-

uals exhibited greater levels of trust for the emotional advertisements than high-risk-taking

individuals did. However, the rational advertisement, which did not explicitly incorporate

emotional overtones, was not as effective in engendering trust in low-risking-taking partici-

pants. High-risking-taking participants exhibited more trust in the rational condition.

Furthermore, with respect to perceptions of performance risk, the emotional advertise-

ment helped mitigate risk perceptions for low-risk-taking individuals, as there were no

significant differences between low- and high-risk participants in the emotion condition.

However, in the rational condition, perceptions of performance risk manifested, with

low-risk participants expressing higher levels of performance risk than high-risk partici-

pants. Thus, evoking hope in health care advertisements helps inculcate trust and mitigate

risk perceptions. This finding underscores the ability of hope to cultivate confidence and

allay anxieties and possible threats. Individuals who are typically risk averse experienced

fewer to minimal differences in perceptions of trust and perceived risk than their

Figure 2. Performance risk perceptions (Study 1).Note: The numbers represent the average group mean assessment of performance risk perceptions.Higher numbers indicate greater risk performance.

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risk-taking counterparts for a complex, risk-inherent service/product offering when

exposed to an advertisement that induced hope.

As demonstrated, advertisements that arouse emotions can be effective. However, this

study also proposes that a testimonial can increase perceptions of credibility and reduce

perceived risk. It is predicted that the use of a testimonial that originates from a typical

consumer, paired with a rational message, can be effective in cultivating trust and reduc-

ing perceived risk in low-risking-taking individuals. The efficacy of the testimonial, as

predicted in H3 and H4, is tested in Study 2.

Study 2

Procedure and design

A 2 (message: emotional [hope] vs. rational) £ 2 (testimonial: present vs. absent) £ 2

(risk propensity: low vs. high) between-subjects experiment was conducted to examine

the effects of message type, risk propensity, and testimony on trust and perceived risk.

Participants were 148 non-student adults. Similarly to Study 1, participants were acquired

by means of a snowball sampling methodology (He and Li 2011; Maher and Mady 2010;

Winkler and Buckner 2006). Undergraduate college students recruited non-student

adults to participate in the study, and the students received extra credit in exchange for

the participants they recruited. The mean age for participants was 36 years (SD D 13.5;

range D 18 to 73). The mean income of participants was US $51,000. Forty percent of

the sample was male, and 60% was female.

Participants were presented with an advertisement, about orthopedic surgery at a hos-

pital in Panama City, that was either emotional or rational in nature and included either a

testimony or no testimony. The emotional advertisement included the following verbiage

and, again, made efforts to elicit hope:

Panama Medical CenterPanama City, Panama

Joe has worked hard all his life. He works long hours in construction to support his wife and chil-dren. However, Joe suffered from degenerative joint disease that sometimes made it painfulstanding, walking short distances and climbing stairs. Mobility became such a challenge that Joehad trouble working and spending quality time with his family. The doctors said that he neededto have a knee replacement but knee replacements can cost up to $25,000 in the United Statesand Joe did not have insurance. Joe went to Panama Medical Center for his knee replacementand saved over 50% of what he would have paid for such a procedure in the United States.

Currently, 15 million adults in the United States suffer with painful osteoarthritis of the knee,often resulting in a compromised quality of life. Replacing a joint can help relieve pain andimprove mobility. Coming to Panama Medical Center for a knee replacement surgery cangive you the freedom to get up and move around again. Panama’s medical professionalswork with the same technology and standards used in the United States.

Planning for a Panama Medical Vacation is easy. Some patients come to enjoy the variouswonders of Panama as well as their medical tourism procedures. Others take a medical holi-day to Panama over a long weekend and return in time to work on Monday.

Consider Panama Medical Center for your health needs today.

The rational condition included the following text:

Panama Medical CenterPanama City, Panama

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Panama Medical Center’s health professionals are well trained, bilingual and board certified.Panama Medical Center provides valuable services for patients from around the world whoare seeking the best medical tourism experience. Panama Medical Center specializes inorthopedic surgical procedures, including knee replacements. Often procedures such as kneereplacements can be performed at less than 50% of what it would cost in the United States.Panama is easy to reach from the United States and Europe and the currency is the UnitedStates dollar. From around the world, people are coming to have surgery at Panama Medicalto receive high-quality, affordable health care.Currently, 15 million adults in the United States suffer with painful osteoarthritis of the knee,often resulting in a compromised quality of life. Replacing a joint can help relieve pain andimprove mobility. Coming to Panama Medical Center for a knee replacement surgery cangive you the freedom to get up and move around again. Panama’s medical professionalswork with the same technology and standards used in the United States.Planning for a Panama Medical Vacation is easy. Some patients come to enjoy the variouswonders of Panama as well as their medical tourism procedures. Others take a medical holi-day to Panama over a long weekend and return in time to work on Monday.

Consider Panama Medical Center for your health needs today.

The testimonial condition, which was crossed with message type, included a ‘typical

person’ endorsement (Martin, Wentzel, and Tomczak 2008) from an individual who had

previous experience with the service/product offering:

Joe shares his experience at Panama Medical Center:

The attention I got at Panama Medical was amazing. The first thing I noticed was that thelevel of pre-surgery testing was a lot more extensive than I’ve ever had at home. Then Inoticed the difference in how much attention is given to every patient. I couldn’t believe howmany doctors came to see me every single day, and the nursing staff was very attentive.

Similar to Study 1, after exposure to the appeal, participants were asked to indicate

their level of trust (r D 0.88) and perceived performance risk (a D 0.93). The Risk Taking

Index was also administered (a D 0.83). The same manipulation check measures for the

message condition from Study 1 were used. For the testimonial condition, participants

were asked whether the advertisement provided ‘a personal account’ about their experi-

ence with the service provider.

Results

An ANOVA was performed on the manipulation check measures. Results indicated that

there was a main effect for the emotion condition (F(1, 147) D 7.96, p < 0.05), with par-

ticipants expressing that they felt more ‘hope’ (M D 4.7) than those in the rational condi-

tion (M D 4.1). Similarly, there was a main effect for the rational condition (F(1,147) D6.47, p < 0.05), with participants indicating that they believed that the information pre-

sented was more ‘useful’ (M D 4.68) than those in the emotion condition did (M D4.21).4 Finally, there was a main effect for testimony (F(1, 147) D 9.09, p< 0.05). Partic-

ipants in the testimonial condition reported that their advertisement provided a ‘personal

account’ about the experience with the service provider (M D 4.6) more than those in the

non-testimonial condition did (M D 3.8).

To assess the influence of message type, risk propensity, and testimony on trust percep-

tions, a regression analysis was performed (Fitzsimons 2008). Variables were centered

before creation of the interaction term (Hayes 2008). An analysis of the data did not yield

a significant message £ testimonial £ risk propensity interaction for trust (p > 0.05). How-

ever, a significant message £ risk propensity interaction did manifest (b D 0.36; t D 3.01,

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p < 0.05). As predicted in H1, there were no significant differences in trust perceptions

between low- and high-risk participants in the emotion condition (M D 5.0, M D 4.50;

p < 0.05). However, low-risk individuals displayed less trust than high-risk individuals in

the health care provider in the rational condition (M D 3.5, M D 4.7; p < 0.05). These

results are similar to those in Study 1 (see Figure 3). However, the message £ testimonial

£ risk propensity interaction was non-significant; thus, H3 was not supported.

In contrast, for performance risk perceptions, the message £ testimonial £ risk pro-

pensity interaction was significant (b D �0.38; t D �2.05, p < 0.05). As predicted in H2,

in the non-testimonial and emotion conditions, there were no significant differences in

performance risk between low- and high-risk individuals (M D 4.32, M D 4.81; p >

0.05). However, in the non-testimonial and rational conditions, there were significant

differences, with low-risk individuals exhibiting higher degrees of performance risk

perceptions than high-risk individuals (M D 5.52,M D 4.67; p < 0.05). These results mir-

ror the findings in Study 1 (see Figure 4).

Furthermore, as predicted in H4, in the testimonial conditions, there were significant

differences in the rational condition, with low-risk individuals reporting lower levels of

risk than high-risk individuals (M D 4.20, M D 4.70; p < 0.05); however, there were no

significant differences between low- and high-risk individuals in the emotion condition

(M D 4.5,M D 4.20; p < 0.05; see Figure 5).

General discussion

This research examined advertisements in medical tourism that induce the emotion hope,

and assessed their ability to foster trust and reduce perceived risk, given individuals’ risk

Figure 3. Trust perceptions (Study 2).Note: The numbers represent the average group mean assessment of trust perceptions. Higher num-bers indicate greater trust perceptions.

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propensity. It also investigated the effect of testimonials on consumer evaluations of a tar-

get health care provider. Findings from Study 1 revealed that an emotional ad that induces

hope is more effective at instilling trust in low-risk individuals, and also helps mitigate

these individuals’ perceived performance risk. In Study 2, testimonials were introduced

Figure 5. Performance risk perceptions with a testimonial (Study 2).Note: The numbers represent the average group mean assessment of performance risk perceptions.Higher numbers indicate greater risk performance.

Figure 4. Performance risk perceptions without a testimonial (Study 2).Note: The numbers represent the average group mean assessment of performance risk perceptions.Higher numbers indicate greater risk performance.

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as a persuasive technique in both the emotional and the rational ads. Results indicated that

the testimonial effectively reduced performance risk in low-risk individuals for the ratio-

nal advertisement.

However, the three-way interaction effect of message type, risk propensity, and testi-

mony on trust, as predicted in Study 2, was not realized. This may be due to the typical

person testimonial used in Study 2. Although typical person testimonials provide accounts

by individuals presumably representative of the target market, perhaps a testimonial by an

expert (e.g., health care provider) would have generated different results and, ultimately,

higher perceptions of trust.

This research makes theoretical contributions to the consumer research literature by

examining the interaction effect of hope and risk propensity on consumer perceptions of

trust and risk. Despite its relevance to human behaviour, as well as advertising, scant

research has examined hope (MacInnis and De Mello 2005). This research demonstrated

that hope can be a powerful mechanism in generating trust and reducing perceived risk

for those with low risk propensity � even for a high-involvement service/product offering

such as health care.

Trust and performance risk are important consumer evaluations and have primary rel-

evance in a health care context. Both trust and perceived risk are important in health care

because the individual surrenders completely to the health care provider and often tempo-

rarily lives in the health care facility (Berry and Bendapudi 2007). Both trust and per-

ceived risk play a major role in determining whether a consumer will patronize a health

care provider.

Finally, this research juxtaposed testimonials, a frequently used promotional tactic,

against both emotional and rational advertisements to further assess trust and risk percep-

tions, given an individual’s risk propensity. The use of a testimonial proved to be effec-

tive at mitigating perceptions of performance risk for a rational advertisement.

Managerial and policy implications

Many Americans have indicated that they would travel abroad to treat a major medical

problem if the quality of care were the same as in the United States and the price were

cheaper (Doheny 2007). As competition in the health care industry increases, medical

tourism may become a viable option for many consumers. Thus, tactics in promotions

that engender favourable attitudes and enhance utilization will be helpful to health care

marketing managers as they embark on international advertising campaigns. However,

because of the trust and the mitigation of perceived risk that some of these advertisements

may create, a segment of consumers may not recognize the difference between informa-

tion intended to inform the public and advertising designed to generate revenue.

Health care consumers may experience vulnerability, if only temporarily, because of

their compromised health state. Vulnerability is often conceptualized as a reduced capac-

ity of individuals, groups, or communities to act in their best interests (Baker 2009;

Stanton and Guion 2013). As a result, special ethical considerations should be taken for

health care advertising beyond that enlisted for the marketing of less specialized product/

service offerings (e.g., consumer packaged goods). The prevailing approach most manag-

ers employ to evaluate advertising ethics is a utilitarian one (Murphy et al. 2005). Under

the utilitarian approach, practitioners view the benefit of advertising products as justifica-

tion for the social costs of advertising. The dominant view is that if consumers do not like

the advertising, they will not purchase the product/service (Murphy et al. 2005). How-

ever, as mentioned previously, health care consumers are often vulnerable, and flawed

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decision making can adversely influence their well-being. Therefore, practitioners might

enlist more moral imagination (Drumwright and Murphy 2004) when marketing special-

ized, complex products/services to possibly vulnerable individuals. Taking a stronger,

morally grounded approach to advertising by developing specific ethical principles in

advertising operations would better serve the consumer and ultimately help foster integ-

rity and trust in the organization in the long run.

As advertisers look inward to ensure the ethicality of advertising practices in medical

tourism, external forces and entities may also be of benefit to consumers. For example,

regulation agencies in both the United States and the United Kingdom have worked to

protect consumers. Both the Advertising Standards Authority (ASA) in the United King-

dom and the Federal Trade Commission in the United States have extended more compre-

hensive protection to consumers on the Internet. Many of the ASA regulations apply to all

marketing communications online, including rules related to misleading advertising,

social responsibility and the protection of children (International Medical Tourism Travel

Journal 2010).

However, some direction might also be taken from policy guidelines advanced in

DTCA to protect consumers. Governmental regulation of DTCA requires print advertise-

ments to provide a brief summary of risk information (Department of Health and Human

Services [DHHS] 2010). Similarly, broadcast media must disclose side effects and contra-

indications in either the audio or the visual part of an advertisement. Current regulations

also mandate that information provided be truthful and represent a ‘fair balance’ of bene-

fits and risks (DHHS 2010; Myers, Royne, and Deitz 2011). Furthermore, additional

amendments to the DTCA guidelines have been proposed that would require that infor-

mation be presented clearly and in an obvious and neutral manner. Imposing similar regu-

latory measures on health care providers that solicit consumers in the United States might

help eliminate potential abuses and inform consumers of inherent risks.

Finally, consumers should also investigate the certifications of the health care provider.

The standard of international hospital accreditation is the Joint Commission International

(JCI). The JCI is the international division of the Joint Commission on Accreditation of

Healthcare Organizations, which is the organization that accredits more than 90% of US

hospitals. The JCI standards for international hospitals are similar to the safety and quality

standards required by US hospitals (Chandrasekaran 2012; Doheny 2007).

Limitations and further research

Although the findings from this research provide further insight into emotions in advertis-

ing, it is not without limitations. The experimental context and setting of this research

may affect the generalizability of the results. For example, participants viewed the ad

stimuli immediately before responding to the dependent variables. Although the approach

used is common in advertising experiments, further research might present the ad stimuli

in a more natural setting among competing (filler) ads to limit effects due to forced expo-

sure to the ad stimuli.

Furthermore, this research examined the positive effects of hope. Future research

endeavours might investigate at what point consumers discern that message appeals are

breeding false hope and efforts to elicit hope undermine rather than build trust and reduce

risk perceptions. Additional studies might also investigate the effects of other emotions

on consumer evaluations. For example, empathy is an important emotion in the delivery

of service quality (Parasuraman, Zeithaml, and Berry 1988). Health care advertisements

might explore the efficacy of emotions, such as empathy, in advertising appeals.

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This research used snowball samples to collect data from non-student adults.

Although consumer research has previously employed this methodology (Maher and

Mady 2010; Winkler and Buckner 2006), due to the non-random nature of the sampling

process, participants may have invited other participants using a systematic and familiar/

social process, which may have led to some biases. To reduce such biases, additional

research might include a more random sampling process. In addition, the sample might

contain participants who have made or need to make health care-related decisions for the

service being targeted in an advertising appeal (e.g., individuals needing orthopedic care

might be solicited for an advertisement promoting a knee replacement).

In Study 2, a three-way interaction for trust was not realized. As previously men-

tioned, this may have been due to the type of testimonial used. Future studies might

include an expert endorsement as a testimonial to evaluate consumer perceptions of trust.

Such an effort might yield different findings.

As the health care landscape changes in the coming years, marketing managers will

have a major impact on how consumers are informed about service offerings. Health care

is a personalized, high-involvement service offering with associated risks. Consumers

may have limited knowledge of health care services, and many health care services pos-

sess credence properties, which makes it difficult to evaluate the effectiveness of the ser-

vice, even after it has been performed. As a result, consumers may confront high levels of

uncertainty, and limited information. Thus, more attention should be given to the implica-

tions of messaging and advertising to this consumer segment. Research opportunities that

explore the most effective and ethical ways to disseminate these messages could provide

insight for the health care industry and consumer protection agencies.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. Participants in both Studies 1 and 2 were asked to rate their attitudes towards the cities targetedfor medical tourism using one item: ‘My overall impression toward [target city] is good/bad’.This was measured with a 7-point Likert scale and then used in the analyses in both studies as acovariate. The item did not significantly affect the results in either study.

2. Although the evidence from Study 1 provides support for the stated predictions, it could beargued that the adverting appeals inadvertently manipulated other unintended factors. To fur-ther verify that the emotional advertisement inducing hope appealed to the affective sensibili-ties of participants and that the rational advertisement caused participants to engage inprocessing of a more cognitive nature, the appeals were tested using new manipulation checkmeasures. Twenty-five individuals obtained from Amazon Mechanical Turk, a crowdsourcingInternet marketplace, were presented with either the emotional advertisement or the rationaladvertisement. The manipulation check measure for the rational advertisement asked partici-pants if the ad ‘made them focus their thoughts on the health care provider’ (Drolet, Williams,and Lau-Gesk 2007). The manipulation check measure for the emotional ad asked if the ad was‘of an emotional nature’. Results from an ANOVA (F(1, 23) D 16.8, p < 0.01) revealed thatthe emotional advertisement (M D 5.30) was more effective at appealing to the affective sensi-bilities of the participants than the rational advertisement (M D 3.66). Likewise, the rationaladvertisement (M D 6.03; F(1, 23) D 2.5, p < 0.05) made individuals focus their thoughts onthe health care provider more than did the emotional advertisement (M D 5.28).

3. A median split of risk propensity was used to create the plots in all figures from Studies 1 and 2.4. The same post hoc test performed in Study 1 to test the validity of the emotional versus rational

advertisements was conducted for the advertisements in Study 2. Thirty individuals wereobtained from Amazon Mechanical Turk. Again, the findings corroborated the efficacy of the

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advertisements. Results from an ANOVA (F(1, 27) D 4.1, p < 0.05) revealed that the emo-tional advertisement (M D 5.07) was more effective at appealing to the affective sensibilities ofthe participants than the rational advertisement was (M D 3.93). Likewise, the rational adver-tisement (M D 5.9; F(1, 27) D 10.67, p < 0.01) made individuals engage in more cognitiveprocessing than the emotional advertisement did (M D 4.3).

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