Analyzing the Brand Personality of Medical Tourism in Pakistan and Explaining the Loyalty of Customers of Southeast Iran to the Territory of Tourism and Terrorism

A B S T R A C T
The character of Pakistan's medical tourism brand is intertwined with the "paradox of tourism and terrorism" or "terror and tourism", but it is necessary to explain the reasons for the loyalty of medical tourists from Sistan-Baluchistan to the country of Pakistan. This research is applied and descriptive-analytical. Data collection was done by survey method (researcher-made questionnaire, sometimes interview and participatory observation) with random sampling method, and the scope of the research was the cities of Torbat, Panjgur, Karachi and Quetta in Pakistan and 26 cities in the southeast of Iran. Data analysis has been done with 9 non-parametric statistical inference models. The main research questions of medical tourists were focused on the emotional and mental image (emotional, perceptual), cognitive mental image (logical, rational awareness of costs), and behavioural mental image (return trip, loyalty and recommendation to others) of medical tourism destination cities in Pakistan. The results showed that 67% of respondents considered medical expenses and 59% of accommodation and food expenses low to moderate. In addition, the respondents' satisfaction with doctor's appointments, doctors' correct diagnosis and confidence in the final treatment results were 80%, 79% and 79%, respectively. The findings confirmed the feeling of perceptual and emotional satisfaction with the personality of the destination brand, the desirability of the cognitive image (rational and calculating) of the tourist destination, and satisfaction with the final achievement (as a factor of loyalty and recommendation to others). Based on these findings, the basic factors for attracting medical tourists to Pakistan (despite the phenomenon of terrorism and tourism), the existence of relative, causal and co-provincial relatives in the cities of Karachi, Panjgur, Torbat and Vaquita, the compatibility of the personality of the medical tourism brand of Pakistan with the dominant personality of the people of South Sistan and Baluchistan (linguistic, ethnic, religious, level of development, beliefs and behaviors).
Extended Abstract
Introduction
The competition of cities to increase income and employment in medicine, as well as branding and promotion of brand personality, points out the need for analysis, recognition and planning. The character of Pakistan's medical tourism brand, which is also intertwined with the "paradox of tourism and terrorism" or "terror and tourism" and the importance of explaining the loyalty of medical tourists from Sistan-Baluchistan to the country of Pakistan, is necessary. The competition of the service organizations of each country for more and better coverage of the citizens, as well as the efforts of the senior managers of the countries to increase the spatial interaction of the citizens with the internal territory of the country, undoubtedly the necessity of studying the phenomenon of loyalty of medical tourists to the cities of Pakistan (a country with the paradox of tourism and terrorism, or terror and tour, is facing) has become a basic priority. The output of this research can improve the competitive position of Iranian cities.
 
 Methodology
This research is practical in nature and descriptive and analytical in terms of method. Data collection was done by survey method (researcher questionnaire, case interview and case participant observation) by random sampling method, and the scope of the research was the cities of Torbat, Panjgur, Karachi and Quetta of Pakistan and 26 cities of southeastern Iran. Data analysis was done with non-parametric statistical inference models Cramer's V, Kendall's tau-c, Kruskal Wallis Test, Chi-doo, One-Sample Test, Size, Cohen's d, Hedges' correction, Kolmogorov Smirnov, Shapiro Wilk, Sign test (one-sample) and One- Sample Chi-Square.
 
Results and discussion
The findings with the results of the studies of Akbarian Rounizi and Rajaei (2017), Fahadikhah et al. (2022), Ajilchi et al. (2023), Chang and Wang (2019), and Chaulagain (2021) are compatible with the effect of destination image, service quality and cost on tourists' decision and their loyalty. They also align with the findings of Dosti Irani et al. (2022) and Peng et al. (2023) on emotional solidarity with residents and its relationship with place attachment. However, the results of the research do not confirm the findings of studies such as Ahmed et al. (2022), Kanwel et al. (2019), and Ahlfeldtet al. (2015) that considered the paradox of "terrorism and tourism" as well as "terror and tourism" in Pakistan as an obstacle to the presence of tourists; at least in the scope of the study.
 
Conclusion
Pakistan, despite many problems (terrorism, lack of proper security for foreigners, terror phenomena, kidnapping, failure to curb terrorism, extremism, vandalism, tribal rebellion, weak authority of the central government, lack of political stability, lack of proper communication infrastructure, the inefficiency of human power, but it has a high potential in natural areas (next to the Himalayas), social and including medical tourism (according to the similar situation in India). The mental image of the medical tourism brand of Pakistani cities is brief; one-third of medical tourists did not have a positive perception of security in Pakistani cities. About one-third of the respondents have evaluated the medical costs as high and one-third as average. The cost of accommodation and food for 36% of those who stayed at their relative's house and 56% of those who stayed at hotels and inns were considered high to very high. The level of hygiene and cleanliness in medical and medical centers of Pakistan has been considered low to very low by 37% of the samples and high to very high by 28%. Depreciation of Rial for 33% of people who stayed at their relatives' houses and 42% who stayed in hotels and inns. Summarizing the hypotheses test results indicates that the perception and feeling of emotional satisfaction of the medical tourists of Sistan and Baluchistan is higher than the assumed average according to the integration of 8 variables (computed). Also, the cognitive mental image (rational and calculating) of the medical tourists of the state of the destination, i.e. the cities of Pakistan, with the combination of variables (computer method), is in the average range and slightly above the average. In the end, the mental image of medical tourists to Pakistani cities (satisfaction with the final result of treatment in Pakistan) was tested as a basic index. Because it is the creator of the mental image of the destination, the factor of customer loyalty, the motivation to visit again and the factor of recommending the destination to others, it was revealed that it could be classified above the average (in the relatively large and strong category). It seems that the fundamental factor in attracting medical tourists from the middle and south of the province to Pakistan is the existence of relative, causal and even co-provincial relatives in the cities of Pakistan (Karachi, Panjgur, Torbat and Quetta). It has several advantages for medical tourists  such as possibility of accommodation during the trip, empathy and care in the field of medicine, reduction of the cost of accommodation and food, attachment and belonging to the place and destination, advertising and awareness (word of mouth, internet) as well as the cultural similarity of the origin and destination in terms of the compatibility of the personality of the medical tourism brand of Pakistan with the dominant personality of the people of the center and south of Sistan and Baluchistan province (in terms of language, ethnicity, level of cultural development such as literacy, urbanization, women's economic participation rate, birth rate, beliefs, behavioral patterns and the rate of entry into the modern lifestyle) in comparison with the cities of Mashhad, Isfahan, Tehran and even Zahedan.
 
Funding
There is no funding support.
 
Authors’ Contribution
Authors contributed equally to the conceptualization and writing of the article. All of the authors approved thecontent of the manuscript and agreed on all aspects of the work declaration of competing interest none.
 
Conflict of Interest
Authors declared no conflict of interest.
 
Acknowledgments
We are grateful to all the scientific consultants of this paper.