Investigating the Effective Indicators on the Sustainable Development of Tourism in Choosing a Health Tourism Destination: A case study of Yazd Province

A B S T R A C T
Health tourism has witnessed substantial growth in recent decades. In this context, selecting the appropriate health tourism destination plays a crucial role in ensuring the success and sustainability of this sector. Yazd province, with its rich array of natural and therapeutic attractions, holds significant potential to emerge as a sustainable health tourism destination. Identifying and analyzing the factors influencing the sustainable development of this industry can make a valuable contribution to the planning and management of health tourism in Yazd. This study aims to investigate these factors and offer strategies for the sustainable development of health tourism in Yazd province. This research follows a descriptive survey design. The sample consisted of 78 health tourists from Yazd province, selected through a purposive, non-random sampling method. Data and scenarios were analyzed using fuzzy cognitive mapping, and the research model was developed using social network analysis. Several factors were identified as significant, with the quality of health services, increasing the destination’s carrying capacity, and policy-making and strategic planning emerging as the most pivotal, respectively, due to their centrality. Senari-Vasazi argued that sustainable development necessitates a simultaneous and balanced focus on all three key factors; neglecting any one, even in the presence of the other two, can result in negative repercussions for other indicators. The findings highlight the importance of continuous monitoring of service quality, investment in infrastructure and capacity-building, and the development of integrated strategic planning for ensuring the long-term sustainability of Yazd's health tourism industry.
Extended Abstract
Introduction
Health tourism, as one of the most value-creating and rapidly growing segments of the global tourism industry, has undergone a remarkable transformation in the last two decades. This exponential growth results from a combination of numerous factors, including increased public knowledge and awareness regarding health, significant achievements in diagnostic and therapeutic technologies, and a substantial cost gap in providing medical services between developed and developing countries. Relying on its rich historical-cultural heritage, unique natural attractions (such as its desert and UNESCO-registered historical texture), and relatively developed medical infrastructure, Yazd Province possesses exceptional potential for positioning itself on the competitive regional map of health tourism. However, transforming this potential into a sustainable competitive advantage necessitates moving beyond short-term approaches and adopting a systematic and program-oriented perspective. The sustainable development of this industry is a multi-dimensional concept achievable only by simultaneously considering economic (e.g., job creation and revenue generation), socio-cultural (e.g., preserving local identity and fostering constructive interaction), and environmental (e.g., resource and waste management) components. Therefore, identifying the key indicators influencing the choice of Yazd Province as a health tourism destination from the tourists' perspective and analyzing the complex relationships between these indicators is the first and essential step in designing any strategic plan. This study was designed and conducted to fill the research gap in this field and to provide a localized model based on the realities of Yazd Province, thereby establishing a solid scientific foundation for policymakers, planners, and investors in this domain.
 
Methodology
In terms of paradigm, this study falls under mixed-methods research, where qualitative and quantitative data collection and analysis were conducted sequentially to complete and deepen the findings. The research design is descriptive-survey. The study population was defined in two distinct layers: 1) The expert community: consisting of 15 university professors with publications in tourism and healthcare service management, managers of private and public medical centers active in attracting health tourists, and experts from the Provincial Cultural Heritage and Tourism Organization, selected through purposive sampling based on the criterion of theoretical saturation. 2) The health tourist community: included 78 non-local visitors to selected medical centers in Yazd Province over a six-month period, chosen via convenience sampling while maximizing demographic diversity (age, gender, education, country of origin).
The research implementation process was designed in four main steps: In the first step (exploratory studies), a preliminary framework consisting of 20 potential indicators was extracted through a systematic review of theoretical literature and domestic and international research background. In the second step (tool design and refinement), this framework was presented to experts in two rounds of a fuzzy Delphi process. In the first round, an open-ended questionnaire was used to evaluate the relevance and clarity of the indicators and to suggest adding or removing factors. In the second round, a closed questionnaire with a fuzzy Likert scale was distributed to reach a final consensus. After analyzing the opinions and removing indicators with low agreement coefficients, 16 final indicators were confirmed. In the third step (quantitative data collection), a matrix questionnaire was designed, asking respondents (experts) to determine the degree of influence of each of the 16 indicators on the others on a numerical scale from -1 (complete negative influence) to +1 (complete positive influence). This questionnaire was completed individually for each expert. In the fourth step (data analysis), two methods—Social Network Analysis (SNA) and Fuzzy Cognitive Mapping (FCM)—were employed using specialized software UCINET6 and FCMapper. First, an aggregated matrix of all experts' opinions was created and defuzzified. Then, key network centrality indicators such as in-degree, out-degree, total degree (centrality), and density were calculated for each factor. Finally, using the simulation capability in FCMapper software, three different scenarios (baseline, single-factor emphasis, and neglect of a key factor) were run, and the dynamic behavior of the system under these scenarios was examined. Content validity of the tools was ensured through expert confirmation, and construct validity was secured using the Quadratic Assignment Procedure (QAP) correlation matrix. Reliability was confirmed by calculating Cohen's Kappa coefficient between coders (0.81) and the Cronbach's alpha of the final questionnaire (0.91).
 
Results and discussion
The findings from the network analysis revealed the complex and intertwined causal relationships between the indicators. Calculating the "centrality" index, which is the sum of a factor's influence and susceptibility, showed that three indicators held a distinctly superior position within the network structure. Quality of medical services, with a centrality of 18.3, ranked first. This overarching indicator is itself influenced by factors such as access to advanced equipment, physician expertise and skill, adherence to health protocols, and professional conduct, and in turn directly impacts tourist satisfaction, revisit intention, and positive word-of-mouth. The indicator increasing the destination's carrying capacity, with a centrality of 15.9, ranked second. This indicator is not limited to merely increasing the quantitative number of hospital beds but encompasses the qualitative and integrated development of supporting infrastructure, including standard accommodation centers (hospital hotels, health-oriented eco-lodges), an efficient transportation network (suitable air access, equipped air and ground ambulance fleets), and ancillary services (specialized translation, visa services, and support for companions). Strategic policymaking and planning, with a centrality of 15.5, ranked third. This indicator plays a facilitative and coordinating role, involving the formulation of transparent regulations, establishing a cross-sectoral coordinating body (such as a High Council for Health Tourism), allocating tax incentives and banking facilities to investors, and defining national standards for licensing centers authorized to serve health tourists.
The scenario analysis yielded a key and cautionary result: the health tourism development system in Yazd is a complex and dynamic system where key indicators have reinforcing and feedback effects on each other. The first scenario (baseline), where all indicators were assumed active, led the system to reach a positive equilibrium and long-term stability. In the second scenario, it was assumed that only the quality of medical services was strengthened, while carrying capacity and strategic planning were neglected. The simulation showed that in this state, despite initial improvement in satisfaction, the system becomes disrupted due to facing increasing demand volume and the lack of a regulatory framework, ultimately causing indicators like satisfaction and revisit intention to follow a declining trend. This situation is precisely an example of overloading the existing limited capacity. In the third scenario, strengthening capacity and policymaking without improving service quality was considered. In this case as well, although infrastructure develops, the destination's attractiveness is lost due to poor service quality, and the created infrastructure faces underutilization, leading to economic loss and stagnant investments. This finding clearly emphasizes the necessity of balanced and simultaneous development of the three main pillars.
 
Conclusion
The results of this study affirm that the model for developing health tourism in Yazd Province must be based on a stable triangle, the sides of which are quality medical services, integrated infrastructural capacity, and intelligent strategic governance. Neglecting any of these sides jeopardizes the stability of the entire structure. To proceed on this path, a set of complementary and sequential operational strategies are proposed. As an initial step, it is essential to establish a single responsible institution with cross-sectoral authority (such as the Yazd Province Health Tourism Development Headquarters) to undertake the responsibility of guiding, supervising, and coordinating all activities. The first action axis of this headquarters should be quality enhancement and standardization, achieved by designing an internal accreditation system for medical centers based on indicators such as the specialist physician-to-patient ratio, possession of the latest diagnostic equipment, and having an international patient services unit. Simultaneously, pursuing valid international certifications such as JCI for leading hospitals must be placed on the agenda. The second axis is the development of smart and sustainable infrastructure. In this regard, instead of building new general hospitals, the focus should be on creating single-advantage specialized treatment centers (e.g., a specialized infertility center, an advanced cosmetic surgery center, or a well-equipped dental clinic) that enable competitiveness at the regional level. Furthermore, establishing an integrated health tourist reservation and support system offering combined packages of accommodation, transfer, translation, and tourism services is essential. The third axis is international marketing and branding. Branding must be based on combining treatment with Yazd's unique cultural experience. Key actions in this section include producing targeted content in various languages, participating in specialized health exhibitions in target countries (such as Iraq, Azerbaijan, Oman), and attracting reputable intermediary companies in the medical field. The fourth axis is engaging and empowering the local community. Implementing educational campaigns about the economic benefits of health tourism for local businesses (hoteliers, restaurateurs, tour guides), as well as training communication and cultural skills for frontline staff in direct contact with tourists (physicians, nurses, ambulance drivers), is crucial for constructive interaction. Finally, establishing a health tourist guarantee and support fund to cover potential treatment risks can significantly increase confidence and attract tourists. In summary, transforming Yazd into a sustainable health tourism destination is not a short-term project but a strategic transformation path requiring firm resolve, targeted investment, and integrated management of all stakeholders. Success on this path, in addition to economic prosperity, will enhance the scientific standing of the province's medical sector and strengthen Iran's international image as a country possessing high medical capabilities and hospitality.
 
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.