A B S T R A C T
Health tourism is increasingly recognized as one of the key drivers of urban development for strengthening city branding at the international level. The main objective of this study is to precisely analyze the destination choice behavior of international health tourists and to identify the set of key factors influencing the selection of the metropolis of Tehran as a competitive medical destination. This research is applied in purpose and analytical–applied in methodology. It is founded upon Random Utility Theory through the use of a Binary Logit model to capture the decision-making process.The data were collected via a structured questionnaire adminstered to 150 health tourists in Tehran during the summer of 2025. A convenience sampling approach, supplemented by purposive screening, was employed to select participants. The results indicate that travel motivation, with a coefficient of 1.135 and an odds ratio of 3.11, is the most influential positive factor in the probability of choosing Tehran. Perceived quality of medical services also exerts a positive and significant effect on destination choice, with a coefficient of 0.92. In contrast, structural and administrative barriers, with a coefficient of −1.07 and an odds ratio of 0.34, have a substantial deterrent impact on the selection of Tehran. Model fit indices (LR=62.4; R2=0.41) confirm the acceptable explanatory power of the model in describing tourists’ choice behavior. Overall, the findings indicate that medical destination choice is a multidimensional process shaped by perceived quality, cost, trust, and ease of access. Based on the quantitative results, enhancing medical service standards and reducing administrative barriers can increase the probability of choosing Tehran by more than 2.5 times. This underscores the central role of quality-oriented policies in strengthening Tehran’s competitive position in the regional health tourism market.
Extended Abstract
Introduction
In the third millennium, the tourism industry has become a substantial, profitable, and fastest-growing global industries, playing a significant role in economic growth, job creation, and the enhancement of social welfare. The development of tourism, especially in less-developed countries, can not only contribute to reducing poverty and inequality, but also, through increasing direct and indirect revenues, provide the groundwork for improving quality of life and achieving sustainable development. Among the various forms of tourism, health tourism—and particularly medical tourism—has gained special importance due to its interdisciplinary nature, substantial economic role, and rapid growth over the past two decades. Medical tourism, as one of the main sub-sectors of health tourism, has quickly consolidated its position in the global market and become a major trend in the healthcare industry. At present, many developing countries, recognizing the great potential and opportunities of this competitive market, have joined it and are seriously pursuing effective policies to increase their attractiveness as destinations for this highly profitable segment of the global tourism industry. Consequently, an intense competitive process has emerged to determine which countries will invest in and benefit from this rapidly growing global industry. Although healthcare-related travel or medical tourism is not a new phenomenon—and people have traveled to foreign lands for the treatment of diseases for thousands of years—its current pattern differs significantly from that of the previous century. Initially, this type of tourism mainly flowed from less-developed countries toward developed ones; however, in recent decades, due to rising healthcare costs in developed countries, advances in medical technologies in developing states, and the substantial reduction in the cost of medical services in these countries, this flow has reversed. Today, many patients from developed countries choose destinations in Asia, Latin America, and the Middle East to receive high-quality and cost-effective medical care. The growing importance of medical tourism has led governments—particularly in the Asia-Pacific region—to initiate widespread competition to attract a larger share of this market.
Iran, benefiting from advanced medical infrastructure, highly specialized physicians, and competitive treatment costs compared to other countries in the region, has emerged as one of the major medical tourism destinations in the Middle East. Scholarly studies indicate that the high quality of specialized and subspecialized medical services, together with the economic advantage arising from the low value of the national currency (the Rial), has placed Iran in a favorable position relative to many of its regional competitors. Nevertheless, the development of health tourism in Iran is still in an embryonic state. Achieving a desirable level of growth requires strengthening integrated management, improving physical and institutional infrastructure, developing national and international regulations and standards, and removing existing barriers such as banking and insurance challenges as well as communication and connectivity restrictions.
In this context, Tehran, as the largest medical hub in Iran and one of the most important healthcare centers in the Middle East, plays a key role in the development of health tourism. Tehran, owing to its specialized and subspecialized hospitals adhering to global standards, internationally recognized physicians, and advanced surgical centers, has a high capacity to attract foreign patients from countries such as Iraq, Afghanistan, Oman, Azerbaijan, and the Central Asian. According to recent studies, Tehran accounts for the largest share of inbound medical tourists to Iran and is considered the most advanced destination in terms of the medical services diversity. At the same time, challenges such as the absence of a comprehensive and integrated health tourism system, weaknesses in international marketing, a shortage of accredited facilitation offices, and logistical and accommodation-related problems have imposed constraints on the development of this sector in Tehran.
Therefore, a scientific examination of international tourists’ perceptions regarding service quality, travel motivations, perceived barriers, and the degree of conformity of Tehran’s medical services with global standards is a necessary step toward designing effective policies for the development of medical tourism in this metropolis. Considering Tehran’s strategic importance within the national healthcare system and its role in attracting health tourists, the study analyzes the perceived quality and standards of Tehran’s medical services from the perspective of international tourists. Furthermore, by employing advanced statistical models, it seeks to propose an analytical framework for the development of health tourism in the city.

Methodology
In terms of purpose, this study is applied, and in terms of nature, it is descriptive–analytical and quantitative. The research adopts a modeling-based approach and employs a binary logit model to analyze health tourism destination choice behavior. This approach enables the modeling of the probability of selecting a specific option (Tehran) from a set of competing alternatives based on observable characteristics.
The statistical population consists of all international health tourists who, during the period of the study, considered Tehran as one of the potential options for receiving medical services—including both those who ultimately selected Tehran and those who preferred alternative competing destinations. The unit of analysis is the individual (health tourist). Sampling was conducted using a convenience and purposive sampling method. This approach was adopted due to the difficulty of obtaining direct access to a comprehensive list of inbound health tourists to the country. The sample size was determined to ensure adequate statistical power for estimating the parameters of the logit model. In accordance with econometric recommendations suggesting a minimum of ten observations per independent variable, the final sample size was determined based on the number and complexity of the variables included in the model.
The data were collected through a structured questionnaire. The designed questionnaire consists of two main sections:
(a) Individual and travel characteristics of tourists:This section includes control variables such as age, gender, level of education, primary purpose of travel (medical tourism), and prior medical travel experience.
(b) Tourists’ perceptions of factors influencing the choice of a health tourism destination: This section comprises the key constructs affecting decision-making, which were measured using a Likert scale. These constructs include:
 Quality of medical services
 Costs and insurance coverage
 Infrastructure and supporting facilities
 Security, safety, and trust in the destination
 Destination image
 Accessibility and ease of entry
A logit model is employed in order to analyze the probability of choosing Tehran as a health tourism destination. Given the focus of the study, the general specification of the logit model is defined as follows:

represents the odds of choosing Tehran relative to other competing destinations;
0β is the intercept;
β 51β- are the model parameters that indicate the effect of each explanatory factor on the logarithm of the odds of choosing Tehran;

Results and discussion
To identify the factors influencing the selection of Tehran as a health tourism destination, the binary logit model was estimated, and the results are presented in Table 3. Before analyzing the coefficients, the model’s goodness-of-fit indices were examined. The LR Statistic of 32.74 with a significance level (p-value) of 0.000 indicates that the model overall possesses high explanatory power, and the independent variables significantly explain the variations in the dependent variable. Furthermore, the Nagelkerke R² value of 0.61 suggests that approximately 61% of the variance in choosing Tehran is explained by the model’s variables, which is considered an acceptable value in discrete choice models. Additionally, the correct prediction percentage of the model was estimated at 73.3%, indicating the model’s considerable accuracy in correctly distinguishing between the choice or non-choice of Tehran by health tourists.
Based on the results, several variables have a significant impact on the probability of choosing Tehran. The Quality of Medical Services, with a significance level of 0.001 and an Odds Ratio (OR) of 2.49, has the strongest positive impact among the variables. This result indicates that improving the quality of services provided in Tehran’s medical centers increases the likelihood of choosing this city as a medical destination by approximately 2.49 times. Medical Knowledge and Awareness also has a significant impact at the 0.014 level, with a positive coefficient of 0.684 and an odds ratio of 1.98. This finding suggests that increasing tourists’ awareness of Tehran’s medical capabilities nearly doubles the probability of selecting this city. Furthermore, Destination Security and Trust, with a positive coefficient of 0.302 and a significance level of 0.041, shows a significant effect; its odds ratio of 1.35 indicates that enhancing the sense of security and trust among tourists increases the probability of choosing Tehran by 1.35 times.
In contrast, the variable of Cost and Insurance Coverage exhibits a negative coefficient of −0.756 with a significance level of 0.010, indicating that rising costs and inadequate insurance coverage reduce the probability of selecting Tehran. The corresponding odds ratio of 0.47 suggests that a one-unit increase in tourists’ perception of costs and insurance-related constraints decreases the likelihood of choosing Tehran to approximately 47% of its previous level. This finding highlights that medical expenses and insurance-related issues are among the most critical deterrent factors in attracting health tourists to Tehran.
On the other hand, the variables of Advertising and Information Dissemination, Infrastructure and Facilities, and Destination Image and Reputation, despite having positive coefficients, are not statistically significant (with significance levels of 0.168, 0.217, and 0.361, respectively). These results indicate that, in the presence of more influential factors such as service quality and costs, these variables do not exert a distinct or substantial effect on the probability of destination choice, and their role remains relatively limited. Finally, the intercept coefficient of the model, with a value of −1.346 and a significance level of 0.021, indicates that when all other variables are held at their baseline levels, the initial propensity to choose Tehran as a health tourism destination is low. This suggests that the selection of Tehran is driven primarily by enhancing factors such as service quality, awareness, and security.
Overall, the results of the logit model indicate that quality of medical services, medical knowledge and awareness, and destination security are the key reinforcing factors in choosing Tehran. In contrast, high costs and weak insurance coverage constitute the most fundamental barriers. These findings can serve as valuable guidance for policymakers in the field of health tourism in Tehran, emphasizing the need to concentrate more on enhancing service quality and reducing financial and insurance-related obstacles.

Conclusion
Based on the logit model analysis, the selection of Tehran as a health tourism destination is the result of a multidimensional interaction among motivational, qualitative, and structural factors. The findings indicate that travel motivation–related factors play a central role in health tourists’ decision-making processes. These motivations include expectations of receiving high-quality medical services, competitive treatment costs, and trust in the scientific and professional capabilities of medical centers, all of which constitute the primary drivers behind the choice of Tehran as a health tourism destination.
The second influential factor is the global standards of medical services. The study demonstrates that compliance with international standards, the availability of advanced medical equipment, hospital credibility, and effective managerial organization play a decisive role in shaping a favorable image of a medical destination. Enhancing these criteria can position Tehran competitively among regional health tourism destinations. In addition, tourists’ medical knowledge and awareness have a positive effect on destination choice. Tourists’ perceptions of physicians’ scientific expertise and their understanding of Iran’s healthcare system increase trust in Tehran and reduce the perceived risk associated with decision-making. This finding underscores the importance of international information dissemination and health diplomacy.
In contrast, the presence of structural barriers and constraints—such as administrative complexities, visa restrictions, weaknesses in international health insurance coverage, and economic volatility—has a substantial negative effect on tourists’ decision-making and may partially neutralize the attractiveness of other positive factors. Therefore, the development of health tourism in Tehran requires a comprehensive and integrated approach that simultaneously focuses on strengthening travel motivations, improving the quality of medical services, and reducing structural barriers. Success in this field is achievable only when the behavior of health tourists is understood in a multidimensional framework that goes beyond purely economic motivations.

Funding
There is no funding support.

Authors’ Contribution
Samira Mottaghi: Conceptualization, methodology, modeling, and software development; Mahnaz Keshavarz: Library data collection, initial writing.

Conflict of Interest
Authors declared no conflict of interest.

Acknowledgments
We are grateful to all the scientific consultants of this paper.