A Systematic Review of the Factors Affecting the Growth of Medical Tourism in Iran

s of articles assessed


Introduction
According to the definition of the United Nations World Tourism Organization (UNWTO), a tourist refers to a person who travels and stays away from his or her usual environment for more than 24 hours and less than one year for various purposes, including recreation, rest, or business. 1 Another reason for tourists is the search for healthcare that is known as a branch of tourism and has a long history. 2 In its broadest conceptualization, medical tourism refers to "travel with the explicit purpose of obtaining health services abroad". 3 Medical tourism today is one of the most important indicators of the tourism industry and has many socio-economic benefits. The integration of medical tourism with consumer health guidance programs is potentially a pivot for accelerating the development of medical tourism and economic development. 4,5 Medical tourism has experienced remarkable growth in the last two decades. 6,7 Various studies have suggested that the main reasons for this development are as follows: increasing waiting lists in advanced countries, [8][9][10][11] increasing international exchange rates, the Internet (With the development of the communications network, new companies have been formed as the interface between international patients and the hospital network, which provides basic information to the patients.), the low cost of services in developing countries, [11][12][13][14] and modern technologies and equipment that fit into new health services. 15 In Iran's fourth development plan of Article 87, the ground for effective participation in world markets and the transformation of the Islamic Republic of Iran into a center for addressing the health and medical needs of the region has been emphasized. Considering the fact that Iran has neighboring countries that have lower therapeutic and medical standards, with the help of experienced medical staff and competent therapeutic centers, Iran can be one of the best destinations for medical tourists.
It is estimated that the income of every case of medical tourism is three times that of a typical tourist. 16 In 2012, 3.3 million tourists entered the country, and 687 500 people were employed in the industry. 17 Therefore, planning based on the priorities specified in the field of medical tourism are very important. The main objective of this research was to identify and analyze the factors affecting the growth of medical tourism in Iran.

Search Strategy
In this systematic review study, studies published in the Persian and English languages during the years 2006-2019 in the databases of Science Direct, ProQuest, Springer, Medline, Scopus, Ovid, and SID were reviewed, and the findings were then compared. Keywords for the search included tourism, medical tourism, and health tourism, specifically in Iran. The text of the reviewed articles and their results were extracted by the researchers. Finally, the results of the studies were summarized and reported.

Article Selection
The inclusion criteria for the present study were: 1. use of the keywords designated for the title and abstracts of articles, 2. completed research, 3. research conducted on the subject of Iran, 4. English or Persian language articles, 5. use of quantitative and qualitative research methods, and 6. Including factors or programs on the topic of tourism in the field of health. The exclusion criteria included: 1. abstracts only, 2. studies published in other countries despite having an Iranian author, and 3. studies published in other languages that were unfamiliar to the researchers. Duplicate studies were also excluded. Studies that met the inclusion criteria were coded and compared. Figure 1 displays the process of the study selection. Overall, the literature search identified 2191 records of databases. After excluding duplicate articles and articles with unrelated topics, 470 records remained. Based on a review of the abstracts, 182 articles remained. A total of 107 articles were excluded due to the lack of stating the factor and development plan. Ultimately, 75 articles were entered into the current study.
Seven papers written between 2008 and 2011, 26 papers written between 2012 and 2014, and 41 articles written between 2015 to 2018 indicated that more attention has been paid to medical tourism in Iran in recent years. Eighteen articles cited cost factor and 11 articles cited medical equipment  It is suggested that advertising practices be revised and novel methods adopted to appeal to a greater range of potential tourists.
Senior executives of hospitals are recommended to account for the safety, comfort, and well-being of patients as basic requirements of marketing. The authorities in the field of health and tourism help more in the development of this industry by providing the necessary substructures of this sector and execution of macro politics.
as influencing factors in attracting medical tourism. Most articles cite advertising, marketing, and updated medical procedures as planning for these factors.

Discussion
The present study attempted to find a set of strategies and programs for the development of medical tourism in hospitals affiliated with the Shiraz University of Medical Sciences. Based on the present findings, important factors such as policymaking, coherent planning, and informing about capabilities and capacities through appropriate information channels will play an important role in the development of medical tourism. In general, information plays an important role in attracting medical tourists. Hospitals and medical centers, insurance companies, tours, intermediaries, and settlement centers play important roles in providing information. In other words, there should be a network of communication between various institutions in medical tourism, and the information and marketing method should be coordinated based on the cooperation of these institutions. The proper information process attracts tourists. Azimi et al 81 and Alizadehsani 92 pointed to the role of advertising and information on the development of medical tourism in their research and suggested that countries must develop a regular system of marketing and information activities to be successful in tourism. In studies conducted by Rokni et al, 41 Jabbari et al, 43 Goodarzi et al, 46 Ayoubian et al, 51 and Taghi Zadeh Namen et al, 52 effective advertising was reported as one of the important factors in attracting medical tourists. Viladrich and Baron-Faust's 93 research in Argentina showed that internet marketing has made the country a hub of cosmetic surgeries. In studies conducted by Momeni et al. 87 Najafi Nasab et al 86 and Haji Ahmadi et al 80 marketing was mentioned as one of the effective factors in attracting medical tourists. Yang 94 also conducted a study on the factors influencing medical tourism marketing from the perspective of practitioners in this field, including tourism agencies and medical institutions in Taiwan, which showed that among the 15 factors studied, branding was the first priority; factors regarding medical facilities and the quality of medical services were also top priorities.
Zuhri et al 95 concluded that the perceived quality of medical services and their perceptual value, trust, mental image, and competitiveness can directly influence the choice of destination and tourists' loyalty.
In addition to these factors, there are the physical and infrastructural factors in research that are undeniable necessities for medical tourism. The quality of a country's infrastructure is one of the most important factors contributing to the development of medical tourism. In studies conducted by Sadr Momtaz et al, 25 Mahmoudifar et al, 74 Naami et al, 83 Najafi et al, 84 and Asgarnezhad Nouri et al, 89 infrastructure is mentioned as one of the factors effective in attracting medical tourists.
In studies conducted by Sadeh et al, 88 Najafi Nasab et al, 86 and Bishami et al, 58 cost is one of the effective factors in attracting medical tourists.

What Is Already Known?
In Iran, little attention is paid to medical tourism. Identification and planning factors based on the priorities specified in the field of medical tourism are very important.

What This Study Adds?
Strategies offered by various managers and authorities in tourism can lead to the increased attraction of medical tourists to public and private hospitals in Shiraz, relying on the capabilities and potential of Shiraz, and thereby generating more foreign exchange earnings and employment.

Conclusion
Today, medical tourism in the world is a developing industry with a significant turnover. Iran has the potential to make the most of this opportunity. Strategies offered by various managers and authorities in tourism can lead to increased attraction of medical tourists to public and private hospitals in Shiraz, relying on capabilities and potential of Shiraz and its health sectors, including climate and nature, cultural and historical attractions, renowned practitioners, advanced equipment, facilities, and methods. Thereby, more foreign exchange earnings and employment will be generated.