Medical tourism in central Java: Influences of image and promotion

Abstract

Medical tourism has emerged as a globally competitive industry, with regions such as Central Java striving to position themselves as leading destinations. This study examines the roles of destination image, promotion, and product quality in influencing customer satisfaction and revisit intentions among medical tourists in Central Java. A quantitative research approach was employed, utilizing structured questionnaires to collect data from 190 respondents. The relationships among the variables were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM). The analysis revealed that destination image and promotion significantly enhance customer satisfaction, which, in turn, strongly predicts revisit intentions. Notably, product quality exhibited a less direct impact on revisit intentions, suggesting that medical tourists place greater value on holistic experiences that integrate cultural and healthcare attributes. These findings underscore the importance of integrated marketing strategies and service improvements in fostering loyalty within the medical tourism sector. This research contributes to the understanding of medical tourism dynamics by emphasizing the mediating role of customer satisfaction in shaping revisit intentions. It provides practical recommendations for policymakers and practitioners to enhance destination competitiveness through targeted promotional efforts and superior healthcare experiences.

Keywords

Product quality destination image promotion customer satisfaction revisit intention

Introduction

Indonesia, endowed with abundant natural and cultural resources, has identified tourism as a strategic pillar within its economic development framework (Reza, 2019). As the global healthcare landscape continues to evolve, medical tourism has emerged as a unique niche that integrates health services with tourism, offering destinations an opportunity to enhance both economic and social outcomes (Azis and Zulkifli, 2021). Central Java, strategically located in the heart of Java Island and encompassing 25.04% of the island’s area, holds significant potential in this sector. Its rich cultural heritage, natural beauty, and advancing healthcare infrastructure position it as a prime candidate for the development of medical tourism (Ghofur and Ismanto, 2022). The provincial initiative “Visit Central Java” seeks to capitalize on these strengths by attracting both domestic and international medical tourists, offering an integrated experience that combines healthcare excellence with unforgettable travel opportunities.

Globally, medical tourism has experienced exponential growth, driven by three critical factors: rising healthcare costs in developed countries, advancements in medical technology, and the increasing demand for specialized treatments such as dental surgery, regenerative medicine, and cosmetic procedures (Tsekouropoulos et al., 2023). Southeast Asia has emerged as a dominant hub in this market, with Thailand and Malaysia leading the region. For instance, Thailand attracts over 2 million medical tourists annually, while Malaysia offers healthcare cost savings of up to 70% compared to Western countries (Mathijsen, 2019). These countries have successfully leveraged targeted promotional strategies in combination with highly regarded healthcare systems to establish themselves as preferred destinations for medical tourism. In contrast, Central Java struggles to position itself competitively within this market, despite its inherent strengths. Addressing this challenge requires a comprehensive understanding of the factors that drive repeat visits, including product quality, destination image, and effective promotion strategies.

In tourism research, revisit intentions are recognized as a critical indicator of customer loyalty and economic sustainability. They reflect the long-term relationship between tourists and destinations, providing a pathway to consistent revenue streams and positive word-of-mouth. Recent studies have emphasized that revisit intentions are influenced by satisfaction, destination image, and strategic promotion efforts, all of which significantly contribute to destination competitiveness and economic resilience (Gorji et al., 2023; Kutlu and Ayyildiz, 2021; Tsekouropoulos et al., 2023). Repeat visitors not only generate direct revenue but also serve as brand ambassadors through positive word-of-mouth recommendations (Hasan et al., 2019).

Understanding revisit intentions is particularly crucial in medical tourism, where trust, perceived value, and satisfaction play pivotal roles in shaping tourists’ decisions (Kutlu and Ayyildiz, 2021). Among the factors influencing satisfaction, destination image is especially significant, as it shapes perceptions of reliability, safety, and overall quality. Studies have demonstrated that a positive destination image enhances trust and satisfaction by fostering perceptions of security and high-quality experiences, particularly in the context of medical tourism (Gorji et al., 2023; Kutlu and Ayyildiz, 2021; Tsekouropoulos et al., 2023). Similarly, promotion, through strategic campaigns and tailored messaging, enhances destination awareness while building trust and engagement (Ghaderi, 2022). Product quality, characterized by the efficacy, reliability, and consistency of healthcare services, also serves as a foundational element that fosters satisfaction and provides competitive differentiation (Meesala and Paul, 2018).

While these factors are often examined independently, their combined influence provides deeper insights into customer behavior. For instance, research indicates that destination image not only directly affects satisfaction but also moderates the relationship between service quality and revisit intentions (Kutlu and Ayyildiz, 2021). Similarly, promotion enhances the positive effects of customer satisfaction by fostering strong emotional connections with the destination (Ghaderi, 2022). In the context of medical tourism, the reliability and outcomes of healthcare services (i.e., product quality) play a critical role in mitigating perceived risks, thereby further reinforcing the intention to revisit (Mathijsen, 2019). This study aims to investigate these interconnected dynamics through an integrated model, offering a comprehensive framework to understand revisit intentions within the context of Central Java’s medical tourism sector.

From a practical perspective, the findings of this research provide actionable insights for stakeholders. For example, developing targeted promotional campaigns that emphasize Central Java’s unique combination of high-quality healthcare services and cultural attractions can effectively differentiate the region from its competitors. Investments in enhancing healthcare service quality—such as improving patient care protocols, offering specialist training, and strengthening aftercare services—can further elevate customer satisfaction. Additionally, leveraging digital platforms to share success stories, highlight patient testimonials, and present transparent pricing structures can significantly shape tourist perceptions and foster trust. By aligning these efforts, Central Java can enhance its value proposition and position itself as a competitive player in the medical tourism market.

This study contributes to the literature by utilizing Partial Least Squares Structural Equation Modeling (PLS-SEM) to examine the relationships among product quality, destination image, promotion, customer satisfaction, and revisit intentions. The findings address theoretical gaps and offer evidence-based strategies to enhance Central Java’s competitive advantage. Ultimately, this research highlights the significance of an integrated approach in promoting long-term growth and sustainability within the medical tourism sector.

Literature review

Revisit intention

Reevaluating initial intentions in the field of tourism is of paramount importance, as these intentions significantly influence managerial decisions and ensure the sustainability of revenue streams (Shahijan et al., 2018). Revisit intentions are shaped by psychological and experiential factors, including satisfaction, trust, and perceived value. Recent studies emphasize the role of destination image, promotional strategies, and personalized marketing in fostering loyalty and increasing the likelihood of repeat visits (Gorji et al., 2023; Kutlu and Ayyildiz, 2021; Tsekouropoulos et al., 2023). Revisit intention refers to a consumer’s desire to re-engage with a destination, driven by positive experiences and motivations such as leisure pursuits (Virginia, Yusvika Ratri Harmunisa, 2023). It is further described as a manifestation of consumer behavior, encompassing motivations for return visits and positive publicity. These behaviors are often influenced by memorable experiences, strong destination images, and effective communication strategies (Gorji et al., 2023; Kutlu and Ayyildiz, 2021).

In the context of medical tourism, positive word-of-mouth and repeat visits are critical outcomes of consumer satisfaction and trust (Binh Nguyen et al., 2023; Tsekouropoulos et al., 2023). Isa et al. (2020) underscore the influence of interest in shaping consumer attitudes and perceptions, particularly regarding revisiting decisions (Bam and Kunwar, 2020; Nam, 2023). The likelihood of a customer returning is shaped by the perceived benefits of the destination and the quality of the overall customer experience. Understanding these dynamics provides valuable insights for developing strategies that enhance loyalty and long-term engagement.

Customer satisfaction

Customer satisfaction is a complex phenomenon influenced by various factors. Following an acquisition, it is crucial to conduct a comprehensive analysis of customer satisfaction to identify areas requiring improvement. This analysis should encompass a range of emotions, from pleasure to disappointment, stemming from the product’s performance relative to expected outcomes (Ashfaq, 2019). Such an evaluative process is grounded in the discrepancy between anticipated and actual service delivery, a concept rooted in the Latin term for adequacy (Türkay et al., 2018).

Patient satisfaction serves as a critical metric in healthcare, directly influencing repeat engagements and fostering trust between service providers and patients, particularly during health challenges (Tiganis et al., 2023). These metrics also support the implementation of service enhancements and quality improvements. Recent research underscores the importance of leveraging customer satisfaction and service quality metrics to pinpoint areas for improvement and inform strategic enhancements, particularly in service-intensive industries such as healthcare and tourism (Meesala and Paul, 2018; Tiganis et al., 2023). In medical tourism, such metrics are instrumental in ensuring that services meet and exceed patient expectations, thereby fostering loyalty and encouraging repeat visits (Gorji et al., 2023; Tsekouropoulos et al., 2023).

Ultimately, patient satisfaction can be defined as the emotional fulfillment and contentment derived from healthcare services that meet or exceed patient expectations. Satisfaction arises from the alignment between expected and perceived quality, particularly in the context of service-intensive sectors like healthcare and medical tourism (Meesala and Paul, 2018; Tiganis et al., 2023). Emotional fulfillment plays a pivotal role in shaping patient satisfaction, which, in turn, influences loyalty and revisit intentions (Gorji et al., 2023; Tsekouropoulos et al., 2023).

Product quality

Marketing emphasizes the promotion of products and the achievement of measurable outcomes to address consumer needs (Ndukwu et al., 2023). To fulfill consumer expectations and organizational objectives, products must demonstrate superior quality, design, packaging, service, and warranty, thereby securing a competitive advantage (Letunovska et al., 2021). These products comprise both tangible attributes and intangible elements, such as services and ideas, designed to meet market demands (Solimun and Fernandes, 2018).

In the healthcare sector, product quality is of paramount importance, significantly influencing patient satisfaction. It is characterized by both inherent quality and perceived quality, which are often communicated through institutional promotions (Meesala and Paul, 2018). Medical professionals must deliver empathetic and secure services that align with patient expectations and adhere to professional standards to optimize patient recovery. Recent research highlights that empathetic communication and personalized care not only foster trust but also align with professional standards, thereby substantially improving patient outcomes (Meesala and Paul, 2018; Tsekouropoulos et al., 2023).

Providing safe and emotionally supportive healthcare environments is particularly critical in medical tourism, where trust and perceived quality are essential for successful recovery and patient satisfaction (Ghaderi, 2022; Tiganis et al., 2023). These factors collectively underscore the importance of integrating high-quality services with empathetic care to meet the complex demands of medical tourists.

Destination image

In the tourism sector, destination image is a critical determinant of success and attractiveness (Kutlu and Ayyildiz, 2021). It shapes tourists’ decision-making processes and subsequent evaluations of their experiences at the destination (Alamineh et al., 2023). According to Waldo et al. (2023), destination image is a singular perception or understanding of a location that extends beyond direct experiences, significantly influencing travel motivations (Gorji et al., 2023). Gorji et al. (2023) describe destination image as a multidimensional construct, encompassing cognitive dimensions (thoughts and beliefs) and affective dimensions (emotions and perceptions). Together, these dimensions form an overall impression of a destination, which plays a pivotal role in driving satisfaction, trust, and revisit intentions.

Recent research underscores the importance of destination image in creating memorable tourism experiences, particularly in medical tourism, where perceptions of safety and healthcare quality are crucial (Kutlu and Ayyildiz, 2021; Tsekouropoulos et al., 2023). Destination image is understood as a composite product shaped by cultural, socioeconomic, ecological, and political factors, all of which collectively influence tourists’ perceptions (Rittichainuwat et al., 2020). (Ruz-Mendoza and Chabán, 2024) highlight that destination image reflects tourists’ perceptions, which are informed by diverse influences, including media portrayals and societal narratives. Similarly, Nazir et al. (2021) argue that destination image represents evaluative judgments formed through both direct experiences and pre-visit information, further reinforcing its role as a key factor in influencing tourist behavior and fostering loyalty.

Promotion

Promotion is an indispensable component of the marketing mix, playing a critical role in the effective marketing of goods and services (Binh Nguyen et al., 2023). It involves targeted marketing initiatives designed to stimulate demand through strategies that persuade individuals or organizations to engage in market-related actions. The promotional mix optimizes a range of tools, including advertising, personal selling, and public relations, to achieve specific marketing objectives (Martins et al., 2022).

In the healthcare sector, hospitals must conduct thorough assessments of customer needs within their distinct operational environments and implement tailored communication and promotional strategies. Recent research underscores the importance of aligning promotional efforts with patient expectations to enhance satisfaction and foster trust, particularly in medical tourism (Meesala and Paul, 2018; Tsekouropoulos et al., 2023). Effective promotional strategies, such as storytelling and patient testimonials, have been shown to build stronger emotional connections, thereby increasing customer loyalty (Ghaderi, 2022).

Beyond traditional advertising, healthcare promotion also encompasses health promotion initiatives aimed at improving public health awareness and encouraging proactive health management (Devkota et al., 2023). The complexity of promotional activities in hospitals is further heightened by regulatory constraints, necessitating strategic categorization into ‘above the line’ and ‘below the line’ approaches to effectively shape brand image (Chapman and Dilmperi, 2022). Ultimately, promotion functions as a strategic initiative to familiarize consumers with healthcare products and services while stimulating interest and engagement (Petcharat and Leelasantitham, 2021).

Hypotheses

The relationship of product quality to interest in revisits

In their 2022 study, Chatzoglou et al. define product quality as the inherent ability of a product to fulfill both explicit and implicit consumer needs. The relationship between product quality and revisit intentions has been widely investigated, particularly in service-oriented industries such as medical tourism. Recent studies underscore that perceived product and service quality play a pivotal role in enhancing customer satisfaction, which subsequently drives loyalty and revisit intentions (Gorji et al., 2023; Meesala and Paul, 2018; Tsekouropoulos et al., 2023).

Revisit Interest is significantly influenced by product quality

The relationship of the objective’s picture to repurchase interest

It is widely recognized that a traveler’s intention to return is strongly influenced by their perception of the destination’s image (García-Hernández and Garay-Tamajón, 2022). Observational studies consistently demonstrate a significant relationship between an objective destination image and revisit intentions. This perspective is further reinforced by Font Barnet et al. (2021), who emphasize that the perception of a destination plays a crucial role in shaping tourists’ willingness to return. Similarly, research by Liu et al. (2022) highlights the pivotal role of an objective image not only in influencing the decision to return but also in driving subsequent recommendations. These findings align closely with the theoretical and empirical contributions of Pradhan et al. (2023) as well as Lu (2021), underscoring the importance of destination image in shaping travel behaviors.

Nonetheless, contrasting perspectives have emerged. For instance, Nursyamsiah and Setiawan (2023) contend that there is no significant relationship between destination image and repurchase intent, suggesting that other factors may mediate or overshadow the influence of destination image in certain contexts. These divergent findings highlight the need for further research to explore the nuanced interplay between destination image, revisit intentions, and other contributing variables.

Objective picture significantly affects interest in visiting once more

Promotional relationship to repurchase interest

Promotion is a strategic form of communication designed to influence consumers’ purchasing decisions (El Shiffa et al., 2021). As a foundational component of the marketing mix, promotion not only shapes consumer perceptions of a product but also instills confidence in its quality and value (Chen et al., 2023). Furthermore, promotion serves as a dual-purpose tool: it facilitates effective communication while simultaneously fostering mutually beneficial relationships between organizations and their customers (Su et al., 2022). Empirical evidence from Jattamart, Nusawat, and Kwangsawad (2023) underscores the critical role of promotional activities, revealing a strong positive correlation with repurchasing intentions and emphasizing its importance in cultivating consumer loyalty.

Advancement meaningfully affects interest in returning to

The relationship of item quality to consumer loyalty

Product quality is a critical determinant in meeting consumer needs and plays a direct role in influencing customer satisfaction (Asha et al., 2023). Research by Tiganis et al. (2023) indicates that satisfaction levels are positively correlated with product quality, emphasizing the importance of aligning product attributes with consumer expectations. Juárez-Varón et al. (2023) further assert that product quality functions as a key competitive differentiator in the marketplace, allowing businesses to distinguish themselves in highly saturated industries. The pivotal role of product quality in shaping customer desires and fulfilling expectations has been extensively highlighted in the literature (Habib et al., 2023). Empirical studies by Vural et al. (2023) and Misransyah et al. (2023) consistently demonstrate the robust relationship between product quality and consumer satisfaction, findings that are further substantiated by Wei et al. (2023).

Customer satisfaction is significantly influenced by product quality

The relationship of destination image to customer satisfaction

A holistically perceived destination image fosters trust among tourists, reinforcing their confidence in travel decisions (Fernández-Ruano et al., 2022). This image serves as a critical motivator, exerting significant influence on tourists’ choices and behaviors (Siegel et al., 2023). Empirical evidence provided by Can et al. (2023) highlights that the perception of a destination plays a pivotal role in shaping tourist satisfaction. A positive destination image is strongly correlated with higher levels of satisfaction, whereas a negative perception tends to diminish satisfaction (Acharya et al., 2023). Further research by Alipour et al. (2020) substantiates that a destination’s image impacts visitor satisfaction both directly and indirectly, emphasizing its integral role in the overall travel experience.

Objective picture affects consumer loyalty

Limited time relationship to consumer loyalty

Effective promotion of tourism highlights the unique features of a destination, thereby enhancing visitor satisfaction and fostering loyalty. Recent studies emphasize that content-driven promotion strategies and personalized marketing approaches can significantly improve visitor perceptions and strengthen emotional connections with destinations (Binh Nguyen et al., 2023; Tsekouropoulos et al., 2023). By leveraging distinctive attributes such as cultural heritage or advanced healthcare services, destinations can differentiate themselves within competitive markets and create lasting impressions on tourists (Ghaderi, 2022; Gorji et al., 2023).

The effectiveness of promotional outreach depends not only on the clarity of the promotional message but also on the quality and delivery of the content, both of which play a pivotal role in shaping visitor satisfaction (Miah et al., 2022). Research by Bayih and Singh (2020) confirms that well-executed tourism promotion initiatives positively influence tourist satisfaction. This finding is further supported by González-Rodríguez et al. (2023) as well as Rejón-Guardia et al. (2023), who underscore the essential role of strategic promotion in enhancing the overall visitor experience and satisfaction.

Customer satisfaction is significantly improved by promotion

The connection between consumer loyalty and interest in returning to

Customer satisfaction is determined by assessing the ability of a product or service to meet or exceed expectations following its purchase (Flavián et al., 2019). It is characterized as an emotional response to the perceived value of the acquired service, particularly when this perception exceeds initial expectations. Recent studies emphasize that surpassing customer expectations results in heightened emotional satisfaction, which, in turn, fosters loyalty and repeat intentions. This is especially relevant in service-intensive sectors such as tourism and healthcare (Meesala and Paul, 2018; Tiganis et al., 2023). Positive emotional responses derived from perceived value not only enhance satisfaction but also create lasting impressions, reinforcing customer engagement and long-term loyalty (Kutlu and Ayyildiz, 2021).

In the tourism industry, satisfaction is a critical determinant of consumer loyalty, significantly influencing revisit intentions (McLean et al., 2023). Tourists who are pleased with their travel experiences are more likely to plan future visits, whereas dissatisfied tourists are less inclined to return (Li et al., 2023). Empirical research identifies factors such as service quality and emotional engagement as pivotal in shaping revisit intentions. High service quality strengthens satisfaction by meeting practical expectations, while emotional engagement fosters loyalty by creating meaningful connections with customers. Collectively, these factors influence behavioral intentions, including decisions to revisit a destination (Gorji et al., 2023; Tiganis et al., 2023).

The connection between consumer loyalty and revisit intentions has been widely examined, with findings indicating that loyalty is influenced by satisfaction, trust, and emotional bonds to a destination. Recent studies highlight the significance of positive experiences, destination image, and personalized marketing strategies in fostering repeat visits (Binh Nguyen et al., 2023; Gorji et al., 2023; Kutlu and Ayyildiz, 2021). This sentiment is echoed by Lim and Rasul (2022), who affirm that satisfaction serves as a significant driver of revisit intentions, reinforcing its importance in achieving sustainable destination loyalty (Figure 1).

Figure 1.

Conceptual Model.

Interest in returning is significantly influenced by customer satisfaction

Methodology

Sample and data collection

As highlighted by Hair et al. (2019), achieving an adequate level of goodness of fit can be particularly challenging when working with large sample sizes. To address this, it is recommended to have a minimum of five to ten observations per estimated parameter to ensure reliable statistical analysis. This study utilized a sample of 190 respondents, specifically focusing on domestic medical tourists who visited Central Java. Non-probability convenience sampling was employed due to time and budget constraints. Respondents were selected through direct interaction during their visits to medical tourism facilities, ensuring the relevance of their experiences to the study’s objectives.

The survey collected both demographic data and information on visiting patterns and perceptions. The findings revealed that 64.21% of the respondents had visited 1-2 times, 26.32% had visited 3-4 times, and 9.47% had visited more than five times. These results underscore that the majority of respondents were repeat visitors, highlighting the critical roles of satisfaction and loyalty in shaping revisit intentions. While the sample primarily reflects the behaviors and perceptions of domestic tourists, consistent with Central Java’s current strategic focus, the findings also offer insights that may inform future research involving international tourists.

Data collection was conducted through structured questionnaires designed to assess beliefs, perceptions, and satisfaction levels related to the destination. Respondents rated their experiences on a five-point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). The data were subsequently analyzed using Partial Least Squares (PLS) methodology, implemented with SmartPLS 3.0 software (Hult et al., 2021).

Creating the measurement tool

This study aimed to explore the factors influencing repeat visits in medical tourism within Indonesia’s Central Java province. Specifically, the research sought to assess customer satisfaction, identify the challenges faced by the provincial government, and propose a comprehensive marketing management plan. Data collection involved a combination of interviews and structured questionnaires, which were initially developed in English and subsequently simplified to ensure clarity and accessibility for respondents. Following the initial development, adjustments were made to the questionnaire’s layout and sequence to improve usability and coherence.

The survey incorporated a range of question types, including Likert scale items, subjective open-ended questions, and list-based responses. To ensure the consistency and reliability of the questionnaire, a pilot study was conducted to evaluate its accuracy and effectiveness. The primary data collection period took place from October 10, 2023, to December 20, 2023. This period was strategically selected to enable real-time interviews, providing researchers with the opportunity to address any potential misunderstandings or language barriers faced by respondents.

Data analysis

The study utilized questionnaires to collect data on respondents’ beliefs, perceptions, opinions, and characteristics related to specific objects, behaviors, and quality attributes. Data analysis was conducted using Partial Least Squares (PLS) Structural Equation Modeling, with SmartPLS 3.0 software employed for hypothesis testing (Hair et al., 2019). The statistical approach included path analysis to examine both direct and indirect effects of the hypothesized relationships (Table 1).

Table 1.

Attributes of review respondents.

Characteristics	Distribution	Frequency	Percentage
Gender	Man	76	40
Gender	Woman	114	60
Age	18-22	18	9.5
	23-27	24	12.6
	28-32	53	27.9
	>32	95	50
Education	Senior high school	10	5.27
	Diploma	40	21.05
	Bachelor	115	60.53
	Graduate school	25	13.15
Work	State employees	5	2.63
	Private employees	100	52.64
	Student	40	21.05
	Miscellaneous	45	23.68
Visiting intensity	1-2	122	64.21
	3-4	50	26.32
	>5	18	9.47

Validity and reliability were assessed through outer model analysis, which measured the strength of associations between observed indicators and their corresponding latent constructs. Subsequently, inner model analysis was performed to explore causal relationships among latent variables as derived from the theoretical framework. R-square values were used to evaluate the explanatory power of the independent latent variables on dependent constructs, providing insights into the overall model fit and significance (Hult et al., 2021).

Result

External model assessment

As detailed in Table 2, this study surveyed 190 respondents to evaluate revisit intentions within the medical tourism sector of Central Java. The findings revealed that 64.21% of respondents had visited 1-2 times, 26.32% had visited 3-4 times, and 9.47% had visited more than five times. This distribution underscores a significant prevalence of repeat visitors, emphasizing the pivotal role of customer satisfaction and loyalty in fostering repeat visits. These results provide a critical foundation for interpreting the subsequent model evaluation and hypothesis testing.

Table 2.

Distribution of the number of repeat visits.

Visiting frequency	Frequency	Percentage (%)
1-2 Visits	122	64.21
3-4 Visits	50	26.32
More than 5 Visits	18	9.47
Total	190	100.0

To satisfy the criteria for validity and reliability, including convergent validity, Cronbach’s alpha must exceed 0.70, composite reliability must surpass 0.60, and the average variance extracted (AVE) must be greater than 0.50. Meeting these thresholds indicates that the measurement model achieves robust reliability and validity (Hair et al., 2019). Table 3 outlines the results of the external model evaluation, where the values for Cronbach’s alpha, composite reliability, and AVE were all found to exceed the respective thresholds of 0.70, 0.60, and 0.50. These findings confirm the measurement model’s high standard of reliability and validity. Consequently, all constructs demonstrated strong reliability and validity, underscoring the robustness of the measurement framework.

Table 3.

Analyses of the External Model.

Construct / Item	Loadings	Alpha	CR	AVE	R²	Q²
Product quality (X1)		0.841	0.904	0.758
X11	0.851
X12	0.860
X13	0.900
Destination image (X2)		0.782	0.872	0.695
X21	0.878
X22	0.778
X23	0.843
Promotion (X3)		0.834	0.890	0.670
X31	0.707
X32	0.863
X33	0.873
X34	0.820
Customer satisfaction (Z)		0.910	0.937	0.787	0.685	0.517
Z11	0.884
Z12	0.876
Z13	0.906
Z14	0.882
Revisit interest (Y)		0.875	0.910	0.670	0.935	0.614
Y11	0.852
Y12	0.764
Y13	0.871
Y14	0.883
Y15	0.710

Evaluation of the internal model

The data presented in Table 3 indicate that all indicators exhibit outer loadings above 0.7, demonstrating strong convergent validity. As noted by Troiville, Hair, and Cliquet (2019), reliability is established when Cronbach’s alpha exceeds 0.7. This criterion has been met in the present study, with all variables displaying Cronbach’s alpha values above this threshold. Furthermore, the composite reliability values for each variable exceed 0.6, satisfying the standard for internal consistency. The results of the AVE (Average Variance Extracted) test also confirm strong validity, as all variables surpass the AVE threshold of 0.5.

The results of the regression analysis (R²) reveal that 93.5% of the variance in Y is explained by X1, X2, X3, and Z. Additionally, X1, X2, and X3 collectively account for 68.5% of the variance in Z, highlighting their significant influence. Predictive relevance (Q²) further supports the model’s robustness, with a Q² value of 0.614 indicating strong predictive accuracy. Moreover, the reconstructed values for X1, X2, and X3 yielded a Z-score of 0.517, reflecting a high level of satisfaction.

The findings also indicate that a majority of medical tourists were repeat visitors, with over 64% reporting having visited 1-2 times. This underscores the critical role of customer satisfaction in fostering loyalty and encouraging repeat visits. The model evaluation further examines the significance of factors such as destination image and promotion in shaping customer satisfaction and revisit intentions.

Construct testing

The diagrammatic representation that follows is a representation of the structural equation model that is depicted in this study (Figure 2):

Figure 2.

Construct Testing Model.

Discriminant validity

The results of the discriminant validity analysis, as presented in Table 4, summarize the theoretical correlations among the variables under investigation and emphasize the importance of the Average Variance Extracted (AVE). The correlation values range from 0.818 to 0.887, with statistical significance at ρ levels below 0.05. These findings confirm that the acceptable AVE root validity criteria have been met, as recommended by Solimun and Fernandes (2018). Furthermore, the square root of the AVE for all factors exceeds the correlations between each pair of variables, providing strong evidence of discriminant validity.

Table 4.

Discriminant Validity.

Variable	Z	X2	X1	X3	Y
Customer satisfaction (Z)	0.887
Destination image (X2)	0.827	0.834
Product quality (X1)	0.457	0.584	0.871
Promotion (X3)	0.548	0.644	0.454	0.818
Revisit interest (Y)	0.848	0.950	0.552	0.724	0.819

Inner model for full model

The effect size for successive independent variables exceeds 0.00, indicating that the value is more than zero and so meets the criteria for being well-constructed.

Findings from hypothesis testing

The parameter estimation highlights the significance of the relationships between the variables analyzed in this study. Hypothesis testing involves assessing both the p-value and the t-statistic. Statistical significance is established at a p-value of less than 0.05, with the significance level (α) set at 5%. The critical t-value for α = 0.05 is 1.960, indicating that a hypothesis is supported when the variable’s t-statistic exceeds this threshold. Hypothesis testing conducted using the SmartPLS 3.0 software employs bootstrapping to evaluate the relationships between endogenous and exogenous variables, providing robust estimates of the model’s parameters (Tables 5 and 6).

Table 5.

F Square (Effect Size).

Variable	Customer satisfaction (Z)	Revisit interest (Y)
Customer satisfaction (Z)		0.171
Destination image (X2)	1,047	1,692
Product quality (X1)	0.004	0.004
Promotion (X3)	0.002	0.318

Table 6.

The Effects of Bootstrapping (Hypothesis).

Construct	Original sample (O)	T statistics (\|O/STDEV\|)	p values
X1 -> Y	−0.019	0.806	0.420
X1 -> Z	−0.043	0.748	0.455
X2 -> Y	0.684	19,156	0.000*
X2 -> Z	0.831	14,098	0.000*
X3 -> Y	0.189	6,489	0.000*
X3 -> Z	0.032	0.468	0.640
Z -> Y	0.187	6,298	0.000*

This study tested several hypotheses examining the relationships between product quality (X1), destination image (X2), promotion (X3), consumer loyalty (Z), and return on investment (Y) within the medical tourism sector in Central Java, Indonesia. The findings revealed that X1 did not significantly affect either Y or Z, as indicated by t-values of 0.806 and 0.748, respectively, with p-values exceeding 0.05. In contrast, X2 demonstrated a significant positive effect on both Y (t-value = 19.156, p < .05) and Z (t-value = 14.098, p < .05). X3 negatively influenced Z (t-value = 0.468, p > .05) but had a significant positive effect on Y (t-value = 6.489, p < .05). Furthermore, Z significantly contributed to Y, as evidenced by a t-value of 6.298 (p < .05).

These results provide critical insights into the factors influencing the behavior of medical tourists in Central Java. They underscore the importance of promotional strategies and destination image in shaping revisit intentions, consumer satisfaction, and return on investment. The findings highlight the pivotal role of effective marketing initiatives and destination branding in fostering loyalty and achieving sustainable growth within the medical tourism sector.

The findings presented in Table 7 offer valuable insights into the mediation analysis involving product quality (X1), destination image (X2), promotion (X3), and revisit intentions (Y). The analysis indicates that the hypothesis for the mediation effect of Z between X1 and Y was not supported, as evidenced by a t-value of 0.743 and a p-value of 0.458, reflecting no significant impact. Conversely, the mediation effect of Z between X2 and Y was significant and positive, with a t-value of 5.765 and a p-value of 0.000, thereby confirming the hypothesis. In contrast, the hypothesis for the mediation effect of Z between X3 and Y was rejected, with a t-value of 0.471 and a p-value of 0.638, indicating that Z did not exhibit a significant positive effect in this relationship.

Table 7.

Explicit Aberrant Impacts.

Construct	Original sample (O)	T statistics (\|O/STDEV\|)	p values
X1 -> Z -> Y	−0.008	0.743	0.458
X2 -> Z -> Y	0.156	5,765	0.000^*
X3 -> Z -> Y	0.006	0.471	0.638

These results suggest that the mediating role of Z in the relationships between the variables and revisit intentions (Y) is selective and context-specific. In the context of medical tourism in Central Java, Indonesia, Z significantly mediates the relationship between destination image (X2) and revisit intentions (Y), while no mediating effect is observed for product quality (X1) or promotion (X3). These findings underscore the importance of understanding the unique dynamics of each variable in shaping tourist behavior, satisfaction, and loyalty within this specific sector.

Discussion and conclusion

The findings indicate that a significant proportion of respondents were repeat visitors, with 64.21% reporting 1-2 visits and 26.32% reporting 3-4 visits. This highlights the critical importance of retaining customer loyalty in the medical tourism sector. Customer satisfaction serves as a vital link between destination image, promotion, and revisit intentions, as evidenced by earlier studies. For instance, Shahijan et al. (2018) emphasized internal motivations such as interest and trust as key drivers of revisit intentions, while Meesala and Paul (2018) identified trust as a central mediator between satisfaction and loyalty in healthcare settings. Trust, built upon consistent service quality and positive experiences, fosters loyalty and significantly increases the likelihood of repeat visits (Tiganis et al., 2023; Tsekouropoulos et al., 2023).

Moreover, product quality has been strongly associated with patient satisfaction. Researchers such as Gorji et al. (2023) and Ndukwu et al. (2023) have emphasized the necessity of delivering high-quality services to enhance patient experiences. In the context of medical tourism, destination image and promotional strategies play equally pivotal roles. Studies by Kutlu and Ayyildiz (2021) and Waldo et al. (2023) demonstrate that a strong destination image not only attracts tourists but also positively shapes their perceptions. Binh Nguyen et al. (2023) further highlight the effectiveness of tailored promotional strategies in enhancing satisfaction and revisit intentions.

The distribution of visiting frequencies in this study underscores the role of customer satisfaction in fostering loyalty. Previous research, including Ghaderi (2022) and Bayih and Singh (2020), has shown that well-executed promotional strategies directly enhance customer satisfaction while indirectly driving repeat visits. These findings align with the present study, which suggests that repeat visits are shaped by a combination of intrinsic motivations, such as trust and perceived value, and external factors, including promotional strategies (Kutlu and Ayyildiz, 2021; Tsekouropoulos et al., 2023). This study contributes to the existing literature by elucidating the complex interplay between product quality, destination image, promotion, customer satisfaction, and revisit intentions in Central Java’s medical tourism sector. The findings underscore the necessity of integrating these factors into a comprehensive strategy to enhance repeat visits and customer loyalty, ultimately supporting the region’s economic development.

For industry practitioners, improving service quality through targeted staff training, infrastructure enhancements, and personalized care should be prioritized to achieve higher levels of customer satisfaction. Marketing strategies should leverage Central Java’s unique combination of cultural richness and high-quality healthcare services to distinguish it from regional competitors. Engaging promotional campaigns, such as patient success story videos, could further enhance destination visibility and foster positive word-of-mouth recommendations. Despite its contributions, this study has several limitations. First, its focus on domestic medical tourists limits the generalizability of findings to international contexts. Future research should incorporate a more diverse demographic, including international tourists, to provide a comprehensive understanding of medical tourism dynamics. Second, the cross-sectional design of this study restricts its ability to examine temporal changes in tourist behaviors. Conducting longitudinal studies is recommended to capture evolving trends and behaviors among medical tourists over time.

Additionally, the exclusive reliance on quantitative methods may not fully capture the complex and nuanced experiences of medical tourists. Future studies could benefit from integrating qualitative approaches, such as interviews or focus groups, to gain deeper insights into patient motivations and satisfaction drivers. Exploring the role of emerging technologies, including artificial intelligence and telemedicine, in enhancing patient satisfaction and loyalty could also provide valuable insights. Lastly, examining external factors, such as the influence of global health crises or regional competition, would contribute to a more holistic understanding of the medical tourism sector in Central Java.

This study contributes to the growing body of literature on medical tourism by presenting an integrated model that examines the relationships among destination image, promotion, product quality, customer satisfaction, and revisit intentions. The findings underscore the mediating role of customer satisfaction, highlighting its critical function in converting destination attributes into loyalty behaviors. By focusing on Central Java, this research situates these relationships within a distinct geographical and cultural context while demonstrating their broader applicability to other emerging medical tourism markets. The study’s unique contribution lies in its exploration of the interconnected roles of destination image, promotion, and product quality, offering valuable insights for both academic researchers and industry practitioners. For academics, the research expands theoretical frameworks in the field of medical tourism by providing an analytical model that can be adapted and tested in diverse settings. For practitioners, the findings emphasize the importance of adopting comprehensive strategies that integrate targeted promotional efforts, service quality enhancements, and destination branding to cultivate loyalty among medical tourists.

In conclusion, this study highlights the need for coordinated efforts among policymakers, healthcare providers, and tourism operators to bolster Central Java’s competitiveness within the medical tourism sector. Future research should expand on these findings by incorporating additional variables, such as technological advancements and the perspectives of international tourists, to deepen the understanding of medical tourism dynamics. These initiatives will not only enhance Central Java’s positioning in the global medical tourism market but also foster sustainable growth across the broader tourism sector.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Andhi Sukma

Author Biography

Andhi Sukma, with specialisation in marketing management with a particular focus on service marketing in the tourism sector. The author has authored numerous articles and papers in the fields of marketing, tourism marketing, hospitality tourism and digital entrepreneurship.

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