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E. Magier-Łakomy, M. Boguszewicz-Kreft, B. Janiunaite (2016), Dimension of the Country of Origin Effect in the Perception of Medical Services in EU Countries– an International Comparison, Proceedings of the 23rd International Academic Confere

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E. Magier-Łakomy, M. Boguszewicz-Kreft, B. Janiunaite (2016), Dimension of the Country of Origin Effect in the Perception of Medical Services in EU Countries– an International Comparison, Proceedings of the 23rd International Academic Conference,
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  27 April 2016, 23rd International Academic Conference, VeniceISBN 978-80-87927-23-6 , IISES DOI: 10.20472/IAC.2016.023.065 EWA MAGIER-AKOMY  WSB University in Gdask, Poland MONIKA BOGUSZEWICZ-KREFT WSB University in Gdask, Poland BRIGITA JANINAIT Kaunas University of Technology, Lithuania DIMENSION OF THE COUNTRY OF ORIGIN EFFECT IN THEPERCEPTION OF MEDICAL SERVICES IN EU COUNTRIES ANINTERNATIONAL COMPARISON Abstract:  The influence of the countrys images on consumer attitudes has been defined as the country of srcin (COO) effect. So far, the research in that field in services has been relatively scarce, and theanalysis of expert literature indicated that the question of the COO effect in medical services hasbeen discussed only in one article. The aim of the paper is to provide the answers to the following questions: 1) do the COO dimensionsapply to the assessment of medical services?; 2) what is the significance of the particulardimensions in these services?; 3) does the significance of the particular dimensions depend onconsumers srcin?Four dimensions have been introduced: innovativeness, diversity, quality, prestige. Study has beencarried out in three European countries (Germany, Lithuania and Poland) and the survey sampleconsists of 264 respondents. The data have been collected with the use of a questionnaire formdeveloped by the authors. Their statistical processing has been provided with the use of a t test andthe analysis of variance with repeated measurement. The analysis confirms very high significance of the COO dimensions in medical services, and the factthat the significance is of differentiated nature. The research indicates that Quality andInnovativeness are the most important dimensions as regards medical services. Diversity andPrestige are significantly less important. The differentiation pertaining to the significance of dimensions indirectly indicates that medical services are affected by the COO effect. The analysis indicates that the COO dimensions as well as consumers srcin affect the assessmentof the importance pertaining to a particular dimension, however the pattern of dimension preferenceis similar in all three countries. The results of the research may be applied in economic practice: in marketing operations of serviceproviders and in operations of institutions which deal with shaping the image of their country and itspositioning in the international environment. Keywords: country-of-srcin (COO) effect, the dimensions of the COO effect, medical services, servicesmarketing  JEL Classification: M31, L84, L83 304http://www.iises.net/proceedings/23rd-international-academic-conference-venice/front-page    Introduction At the end of the 1990s a fast development of international trade of health services commenced. Media and scientists have often referred to that phenomenon as to medical tourism. Similarly, to other services, the development of medical tourism comes as a result of liberalisation in international trade, based on multilateral agreements among the member countries of the General Agreement on Trade in Services (GATS) under the auspices of the WTO, and on technological advance which makes delocalization and outsourcing possible to the growing number of service providing enterprises. The second reason, which is characteristic for health services, is a change in the structure of international trade (Lautier, 2014). A more significant role is now being played by developing and emerging countries where, in terms of export, competitive prices are provided with attendant improving quality of health care and qualifications of medical staff. In terms of import, it generates growing wealth of citizens in those countries. The increase in international service trade and attendant significant interest of scientific circles have been defined as “a boom in academic analysis”  (Connell, 2013). However, scholars who carry out their research on medical tourism still face a number of challenges resulting from the lack of consensus referring to the very name of the phenomenon, the lack of its explicit definition and the lack of reliable data pertaining to its scale (Lunt, Carrera, 2010; Connell, 2013; Lautier, 2014). A relatively small number of scientific papers refers to medical tourism in Europe. In a literature review provided by Lunt and Carrera (2010), there are 371 articles presented, most of which refer to America and only 23 to Europe. Moreover, world literature on internationalisation of medical services focuses mainly on the description of the market and entities which operate there (Al ‐ Amin, Makarem, Pradhan, 2011). The authors of the presented article have attempted to partially fill in that gap. They focus on consumers and their perception of the discussed services. The aim of the survey is to provide the answers to the following questions: 1) do the COO dimensions apply to the assessment of medical services?; 2) what is the significance of the particular dimensions in these services?; 3) does the significance of the particular dimensions depend on consumers’ src in? The results of the research come as a contribution to the field of knowledge referring to the COO effect in services. So far, the research in that field has been relatively scarce, and the analysis of expert literature indicated that the question of the COO effect in medical services has been discussed only in one article (Mechinda et al., 2010) 1 . Considering the dynamic development of medical tourism, it is advisable to intensify research in that field, including the COO effect as well. In the research presented in the article, the survey sample consists of 264 respondents from Poland, Germany and 1  The literature review is provided with the use of the database of full-text publications accessible in EBSCO, ProQuest, Emerald and ScienceDirect. 27 April 2016, 23rd International Academic Conference, VeniceISBN 978-80-87927-23-6 , IISES305http://www.iises.net/proceedings/23rd-international-academic-conference-venice/front-page    Lithuania. The data have been collected with the use of a questionnaire form developed by the authors. Their statistical processing has been provided with the use of a t test and the analysis of variance with repeated measurement. The article starts with a presentation of medical tourism and its significance. The following part presents the issues referring to the COO effect and its dimensions. Next, the research methodology is presented with the results of the research and ensuing conclusions. The article is ended with recommendations as regards the directions of further research. The results of the research may be applied in economic practice: in marketing operations of service providers and in operations of institutions which deal with shaping the image of their country and its positioning in the international environment. Medical tourism  –  the term and its significance in international trade Expert literature often defines international trade of medical services as „medical tourism” . It is a complex phenomenon, and it is difficult even to provide an appropriate name for that. It contains issues of medical nature as well as those which refer to travelling. Expert literature offers such terms as: medical travel, medical care abroad, treatment abroad, health tourism, overseas medical health services), international trade in health services/health services exports. The authors use these terms interchangeably with medical tourism. For the requirements of the presented research, a definition provided by Cormany and Baloglu (2011) has been assumed: “ the act of travelling abroad to obtain medical care 2 ”, because it is the medical aspect, rather than the one referring to tourism, that the authors have been interested in. It is difficult to precisely define the scale of medical tourism, its market shares and revenue, considering the lack of systematic reports in particular countries and the lack of adequate research on that issue (Connell, 2013; Lautier, 2014). In the years 1997-2010 Lautier (2014) attempted to evaluate trends and the scale of the phenomenon. He based his research on the only available source at an international level: the data collected by the International Monetary Fund. In accordance with the calculations provided by the author, the estimated worth of the global export of medical services in 2010 reached the level of $11.766 million. It means that since 2003 that amount had been doubled. Since 1997 the amount had been growing on average by 8.1% annually. Meanwhile, the structure of supply was changed. At first, the market was dominated by exporters from the North, who had two thirds of the market share. Then, in the subsequent years the South also grew in significance, and its export was growing on average by 12.3% annually (by 5% in the North). In 2010 the market shares of the 2  As cited in: Connell, J. (2013, p.2). Literature offers some complex definitions, the authors of which try to include the variety of aspects referring to the phenomenon, for example: „medical tourism means purposeful travelling to a foreign country to undergo intended medical treatment in order to save good health, to improve quality of life or a patient’s appearance. It is caused by financial or qualitative reasons or because of inaccessibility of particular services in patients’ country (it may result from the lack of medical staff, lack of r  equired knowledge, equipment, procedures or long queues to obtain the required medical treatment, and also from legal restrictions). Medical tourism frequently involves sightseeing of the visited places.” (Białk -Wolf, 2014). 27 April 2016, 23rd International Academic Conference, VeniceISBN 978-80-87927-23-6 , IISES306http://www.iises.net/proceedings/23rd-international-academic-conference-venice/front-page    South reached the level of 54%, whereas the market share of the North was 46%. The author also states that the number of foreign patients was then estimated for 5-6 million annually. In 2010 the average amount spent by a patient was between $1960 and $2360. Expert literature presents some analysis referring to the motivation of medical travellers (Horowitz, Rosenweig, 2007, as cited in: Mechinda et al., 2010; Culley et al., 2011; Connell, 2011a; Laugesen & Vargas-Bustamante, 2010; Menvielle et al.,2014; Inhorn and Shrivastav, 2010, as cited in: Culley et al., 2011; Shenfield et al., 2010; Ehrbeck et al., 2008; Menvielle et al.,2014), postrzeganych zagrożeń (Menvielle et al., 2014)   i wyboru destynacji (Pennings et al., 2009; Culley et al., 2011). The COO effect and its dimensions in marketing Expert literature on international marketing and consumers’ behaviour defines the influence on opinions and purchase behaviour of consumers coming from particular country of srcin as the effect of the country of srcin. It has been profoundly analysed as regards material products (for relevant literature reviews, see eg: Bilkey and Nes, 1982, Al-Sulaiti and Baker, 1998; Peterson and Jolibert 1995; Javalgi, Cutler, and Winans 2001; Pharr 2005; Rezvani   et al., 2012; Saran and Gupta, 2012), whereas the COO effect pertaining services has not undergone thorough research yet. (Ahmed, Johnson, Ling, Fang, & Hui, 2002; Chattalas, Kramer and Takada, 2008; d'Astous et al., 2008; Boguszewicz-Kreft, 2014). So far, the research on the COO effect as regards material goods has referred to its influence on the assessment of quality and value of products, the perception of risk that is connected with their purchase, purchase intentions and decisions, tendencies to pay a particular price for services. The research has been carried out with the consideration of numerous features pertaining to various products, methods and variables (Peterson and Jolibert, 1995). The research has also included factors which affect the COO effect (for relevant literature reviews, see: Pharr, 2005; Ahmed et al., 2002). The research indicates that the image of the srcin country affects the process of evaluation and consumers’  decisions. It comes as a significant factor which affects international marketing (Rezvani et al., 2012). The research also indicates that there are some differences in the perception of the COO by consumers from particular countries (Narayana, 1981; Nagashima, 1970; Sharma, 2011). Considering services, the research has so far confirmed that fact that the COO is an important carrier of information for consumers (Ahmed et al., 2002) which affects their assessment of quality (Wong and Folkes, 2008), purchase risk (Michaelis et al., 2008) and purchase intentions (Harrison-Walker, 1995; Berentzen et al., 2008; Khare and Popovich, 2010; Bose and Ponnam, 2011; Morrish and Lee, 2011;   Boguszewicz-Kreft, Magier- Łakomy, Sokołowska, 2015).  Expert literature on tourism defines an image of the srcin country as a destination image. It is understood as an attitude formed with the sum of beliefs, images and impressions developed by consumers about destination (Crompton, 1997 as cited in: Mossberg, Kleppe, 2005, p. 497). Mossberg and Kleppe (2005, p. 500) state that the 27 April 2016, 23rd International Academic Conference, VeniceISBN 978-80-87927-23-6 , IISES307http://www.iises.net/proceedings/23rd-international-academic-conference-venice/front-page    COO and the destination image „refer to the same object and are based in the same theory (beliefs, attitudes)”.  Referring to the current research which indicates the influence of the image on purchase behaviour of consumers, Mechinda et al. (2010) state that medical tourists who have developed a positive image of a particular destination are more likely to positively process information about medical services. The author and his team have carried out some research on the influence of a destination image pertaining to Pattaya, a city in Thailand on tourists’ attitudinal loyalty towards medical tourism in that city. Other variables which have undergone the research are: satisfaction, perceived value, trust and knowledge of the destination. The research has proved the influence of all the analysed factors. Initially, the COO effect was understood as a unidimensional phenomenon (e.g. Hong & Wyer, 1989), however, it earned the attention of a larger number of scholars who claimed that it had a more complex character. So far, none of those opinions has been explicitly confirmed. In 1992, Roth and Romeo presented a synthesis of the current propositions, and they developed a COO model consisting of four dimensions: 1) innovativeness, defined as the use of technical advance and new technologies; 2) design, understood as appearance, colours, style, variety; 3) prestige, defined as exclusiveness, brand reputation, status, and 4) workmanship, that is namely: durability, reliability, craft and quality of work. 3  After some minor modification, the model was used in later research on entertainment services carried out by Bose and Ponnam (2011). The authors of the presented article provide further adaptation of the abovementioned models to the requirements of the research on the COO in broadly understood services. The authors generally try not to diverge from the srcinal to preserve the possibility of making comparisons to the results of other research and their generalisation. Thus, the following dimensions have been assumed: 1. Innovativeness - the use of the latest knowledge and advanced technology, 2. Diversity- variety, wide range and attractiveness of an offer, 3. Prestige - exclusivity, status, brand name reputation, 4. Quality - reliability, durability, professionalism. Research Methodology Research method. The research has been conducted with the use of a questionnaire form developed by the authors and has been based on the research method provided by M.S. Roth and J.B. Romeo (1992). The following dimensions of the COO effect have been distinguished: Innovativeness, Diversity, Prestige, Quality. The survey participants have been asked to define the importance of the particular dimensions in medical, educational, banking, transport and catering services. The analysis presented below 3  A review of research methods applied in the research on the COE is to be found in : (Bose, S., & Ponnam, A. 2011). 27 April 2016, 23rd International Academic Conference, VeniceISBN 978-80-87927-23-6 , IISES308http://www.iises.net/proceedings/23rd-international-academic-conference-venice/front-page
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