2.1 Health tourism
Although China's health and wellness culture has a deep history, the development of health tourism started late and lagged relatively behind[33, 34]. Currently, the concept of health tourism is not uniform in academic fields. Health tourism usually refers to activities where consumers travel to destinations to access a variety of health services and medical care [35]. The purposes are improving health, disease diagnosis and treatment, and prevention[36]. Among them "Restoring, maintaining, and enhancing health" is the core content of health tourism[33]. It is worth noting that medical rehabilitation services provided by medical institutions, rehabilitation care facilities and nursing homes in China are not included in the scope of health tourism[33].
With the COVID-19 epidemic sweeping the world in 2020, public health awareness has greatly increased amidst the threat to the health of the entire society[37]. The market demand for health tourism products is getting increasingly strong. Even many countries have used health tourism as a tool to revitalize their tourism industry and economy[38, 39]. Health tourism, as a new economic growth driver, not only meets the dual needs of residents' health and tourism but also provides a feasible path to promote the transformation and upgrading of China's tourism industry. Existing research on health tourism has focused on its product development, marketing, and development strategies[40–42]. There is still relatively scant research on consumer health tourism decisions. However, health tourism in China depends to a large extent on the spending intentions of domestic health consumers[33]. Therefore, exploring the factors that influence consumers' health tourism intention has an important role to play in driving consumer health tourism decisions.
2.2 Future Time perspective
Time perspective is considered to be a mental construct representing an individual's relationship to time, which arises from the cognitive process of dividing one's experience into past, present, and future time frames[27]. Time perspective theory divides time perspective into five independent dimensions based on the individual's attitude toward each time frame: past-positive, past-negative, present-hedonic, present-fatalistic, and FTP[27]. FTP refers to an individual's perception of future possibilities or time left in life[26] and plays an important role in consumers' travel decisions and goal choices[17, 43].
According to SST theory, age-related changes in 'time perception' lead to changes in social goals. While Carstensen and Lang [44]viewed FTP as a one-dimensional and bipolar variable ranging from limited to vast futures, Cate and John [45]demonstrated that FTP consists of two dimensions, open-end FTP and limited FTP, that vary with age. Since then, Cozzolino et al[46] and Kooij et al [21] have also distinguished between the dimensions of FTP using limited time and open-end time. Individuals prioritize social goals in an instrumental sense when they see their future as open-ended, and in an emotional sense when they see their future as limited[21, 26]. In line with these studies, we divided FTP into limited FTP and open-end FTP to explore the impact of different dimensions of FTP on health tourism intention.
2.3 Future Time perspective and Health tourism intention
Numerous psychologists studies have shown that when a person focuses on the future, it inevitably has a serious impact on his or her present cognition and behavior[25, 47]. Based on Socioemotional Selectivity Theory, FTP can predict individuals' choice of social goals [48]. It reflects an integral future orientation, the tendency to resist temptation and to focus more on future goals and rewards. It can be expressed as open-ended future time perspective (OFTP), where there is plenty of time left in the future and the focus is more on opportunities, or limited future time perspective (LFTP), where there is limited time left in the future and the future will not change much [49, 50].
Individuals with different FTPs will differ in their choice of social goals[49, 51]. For example, people with OFTP, who are more focused on acquiring resources and knowledge, will prioritize optimizing their future goals.; when future time is perceived to be limited, there is more focus on the "present moment" and LFTP is more focused on emotion regulation goals [23, 52]. However, these two target choices are not mutually exclusive and can be used as two side-by-side startup paths. That is, when individuals have different time perspectives, it will influence their intention to travel based on different purposes.
In the health tourism context, consumer health tourism intentions are defined as the level of effort consumers are willing to put in to participate in health tourism activities or to purchase health tourism products[53]. A broader future perspective on time may be an important factor for people to choose health tourism. When time is considered open-end, optimizing future goals will be prioritized[51]. These goals often relate to acquiring knowledge, experience novelty or seeking connections that may be useful in the future [54]. Choosing health tourism satisfies the consumer's need to acquire instrumental social goals, such as gaining knowledge about wellness and expanding their social circle. Therefore, based on these motivations, it is possible to promote consumers' health tourism intention.
When people are aware that they have a limited amount of time to live in the future, they prioritize meeting their emotion regulation goals and they are less likely to postpone rewards [55]. Self-regulation strategies have been identified as an effective tool for translating intentions into behaviors [56]. At this time, they may pay more attention to the well-being and improvement of life quality brought by health tourism[23, 57]. Thus, when individuals with high LFTP, they will focus more on the goal of emotion regulation. The acquisition of positive emotions becomes a motivation for health tourism, which in turn promotes the individual's intention to travel. Therefore, the following hypotheses are formed regarding the impact of FTP on health tourism intention:
H1a
OFTP has a direct positive impact on health tourism intention
H1b
LFTP has a direct positive impact on health tourism intention
2.4 Health awareness as a mediator
Health awareness is a mental structure, a state of mind in which an individual perceives his or her health [58, 59]. It is often expressed as the extent to which people are concerned about their health[60], including alertness to health, participation in health behaviors, and self-monitoring of health. Health awareness is an integral part of building health-promoting behaviors and plays an even greater role than sociodemographic characteristics[61]. Health-conscious consumers are more concerned about their state of well-being. Therefore, they are more likely to be motivated to engage in activities that improve their health[62]. In studies on medical tourism, health awareness has indeed influenced the consumer's decision-making process[63]. Health tourism has the effect of enhancing or restoring an individual's physical and mental health [64]. This provides an incentive for health-conscious consumers to participate in health tourism activities. Thus, we hypothesize:
H2a
Health awareness positively affects health tourism intention
FTP reflects the individual's general future orientation as well as the perception of plans [27]. Time frames have an inevitable influence on motivation and behavioral self-regulation and are implicit in many healthy psychological constructs[52]. The consciousness of an individual is also influenced by the FTP.In studies on ecotourism, individuals with high FTP will have higher awareness of environmental protection[65]. Thus, the influence between time perspective and health awareness relationship is established.
SST suggested that when time is perceived as open-end, knowledge-related goals are given priority[23]. When individuals believe that the future is infinite, the preference for knowledge goals will lead them to focus more on information and knowledge for health care. We, therefore, hypothesized that when individuals perceive the future to be infinite, the prioritization of knowledge goals would lead them to pay more attention to information and knowledge about health care, resulting in greater health awareness.
In contrast, when time is perceived as finite, emotional goals are given primacy [23]. Goal limitations increase the desire for emotional comfort. The experience of positive emotions can broaden a person's consciousness[66]. Those with a more limited view of future time will maximize the achievement of emotionally meaningful goals. The most prominent goals will be those that can be achieved in the short term. They are more likely to combine new information with previous experiences[67]. Because of its bias toward the positive processing of information and the pursuit of positive emotions and beneficial experiences that health brings, it may enhance its awareness of health. Thus, the following hypotheses are developed:
H2b
OFTP positively affects Health awareness
H2c
LFTP positively affects Health awareness
It has been suggested that health awareness mediates the role of time-related personality and health-promoting behaviors [31]. Based on H2a, H2b, and H2c, this study concluded that people with FTP are more health conscious and more likely to participate in wellness tourism activities. Hence, the following hypotheses are developed:
H2d
Health awareness mediates between OFTP and health tourism intention
H2e
Health awareness mediates between LFTP and health tourism intention
2.5 Involvement as a mediator
Involvement is an individual's perceived relevance to something and its importance to him or her based on intrinsic needs, interests, values, etc[68]. The higher the degree of involvement, the greater the relevance of the thing to oneself, and thus the stronger the individual's involvement and attention perception [69]. Involvement can be either situational or persistent. Contextual involvement is a temporary elevation of interest that usually fluctuates within the time frame of the purchase decision, while persistent product involvement is a stable phenomenon that represents the consumer's interest in the product over a long period[70].
The level of involvement can affect the behavioral decision-making of consumers [71]. In particular, the antecedents of involvement (timing of purchase, personal needs, and perceived decision risk) influence the direction of consumer involvement or object selection[72]. Consumers in the high product involvement scenario have already spent a lot of time choosing and comparing products before making a purchase decision, and customers will have more comprehensive information about the products, which will be more conducive to their decision. The research on the effect of travel motivation on the willingness to revisit shows that an increase in involvement is associated with a corresponding increase in the willingness to revisit[73]. In addition, the degree of involvement in the product also affects consumers' intention to purchase[74]. Thus, we hypothesize:
H3a
Involvement positively affects health tourism intention
People who are "future-oriented" are often better able to articulate future goals. Their decisions are based on a cost-benefit analysis of the expected consequences of events[17]. Individuals perceive that the future time is open-end and the preference for knowledge goals will lead them to pay more attention to the assessment of the value of health tourism, which in turn will enhance their involvement in health tourism. According to Socioemotional Selectivity Theory, individuals with LFTP are more "Present-oriented". They show a strong interest in hedonic pursuits and pay more attention to the enjoyment attributes of the product [75]. People's motivation for participating in health tourism has multidimensional attributes, including relaxation, the pursuit of diverse activities, recreation, and enjoyment[76]. Individuals with high LFTP may be more likely to be involved in health tourism products for hedonic-needs. Thus, the following hypotheses are developed:
H3b
OFTP positively affects Involvement
H3c
LFTP positively affects Involvement
Based on H3a, H3b, and H3c, it can be hypothesized that individuals with FTP will be more involved in health tourism products and more likely to participate in health tourism activities. Hence, the following hypotheses are developed:
H3d
Involvement mediates the effect of OFTP and health tourism intention
H3e
Involvement mediates the effect of LFTP and health tourism intention