International Journal of Pharmaceutical and Healthcare Marketing

Country-of-origin and brand positioning for health care services

Katherine A. Meese, Thomas L. Powers, Andrew N. Garman, Seongwon Choi, S. Robert Hernandez,
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Katherine A. Meese, Thomas L. Powers, Andrew N. Garman, Seongwon Choi, S. Robert Hernandez,
(2019) "Country-of-origin and brand positioning for health care services", International Journal of
Pharmaceutical and Healthcare Marketing, https://doi.org/10.1108/IJPHM-03-2018-0019
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Brand
Country-of-origin and brand positioning for
positioning for health health care

care services
Katherine A. Meese
Health Services Administration, University of Alabama, Birmingham,
Alabama, USA Received 13 March 2018
Revised 8 June 2018
20 February 2019
Thomas L. Powers Accepted 21 February 2019
Collat School of Business, University of Alabama, Birmingham, Alabama, USA
Andrew N. Garman
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National Center for Healthcare Leadership, Rush University, Chicago, Illinois, USA, and
Seongwon Choi and S. Robert Hernandez
Health Services Administration, University of Alabama, Birmingham,
Alabama, USA

Abstract
Purpose – The purpose of this paper is to examine the relationship between country-of-origin (COO) and
brand positioning in the context of the high-involvement service of health care. This paper compares and
analyzes different positioning strategies used in Europe, North America and the Middle East.
Design/methodology/approach – This paper uses content analysis of promotional materials for a
sample of 168 health-care organizations located in 14 countries to identify brand positioning strategies used,
such as foreign, local and global consumer culture positioning. A chi-square analysis and post hoc testing is
used to examine how positioning strategies differ among regions.
Findings – The findings indicate that European and Middle Eastern health-care organizations most frequently
use foreign consumer culture positioning, while North American institutions tend to use global consumer culture
positioning. The findings indicate that health-care organizations in countries with a better reputation for care use
different positioning strategies than in countries with a lesser reputation for quality care.
Practical implications – The findings are of value to international advertising and marketing professionals
and hospitals seeking to attract patients globally in a competitive marketplace. Hospitals must consider their
positioning relative to both domestic and international competitors and the COO of their target audience.
Originality/value – COO is important in high-involvement service industries because consumers lack the
information needed to evaluate service quality. Consumers may rely on COO and brand positioning signals
more heavily relative to goods or low-involvement services. However, little prior research exists examining
COO effects and brand positioning for high involvement services and for health care specifically. This paper
makes a unique contribution by filling this gap.
Keywords Medical tourism, Country-of-origin, Medical travel, Health care, Brand positioning
Paper type Research paper

Introduction International Journal of

The country-of-origin (COO) of a service can have a major influence on a consumer’s Pharmaceutical and Healthcare
Marketing
perception of quality (Roth and Diamantopoulos, 2009). Because of consumer purchase risk © Emerald Publishing Limited
1750-6123
associated with a high-involvement service and the inability to evaluate the quality of the DOI 10.1108/IJPHM-03-2018-0019
 IJPHM service beforehand in an international context, the role of COO and brand positioning has
been suggested to be of increased importance (Zeithaml, 1988; Herbig and Milewicz, 1993;
Berry, 2000). Signaling theory suggests that a variety of external cues can be used as a
proxy for evaluating the quality of a good or service and reducing the risk of purchase
(Wernerfelt, 1988; Erdem and Swait, 1998; Connelly et al., 2011). Consumers rely on these
signals to evaluate quality when a product cannot be readily assessed experientially because
of cost, complexity or logistical challenges (Dawar and Parker, 1994). Although prior
research has investigated relationships between COO and brand positioning, this research
has not focused on high-involvement services, and none to our knowledge has examined
health care services specifically. This creates the need for additional research that examines
and clarifies patterns of positioning for the health care industry. The theoretical
underpinning of this research is based in the COO literature, brand positioning research by
Alden (1999) and signaling theory. Taken together, these studies generally suggest that the
image and reputation of the country in which a company operates will be associated with its
use of foreign, global or local brand positioning tactics.
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This paper adds to the literature by exploring the types of advertising tactics used by
health care organizations globally and examining the association between COO and brand
positioning based on the types of positioning outlined by Alden (1999). As health care
organizations seek to attract travelling patients from around the world, it is important for
international marketers to understand what messages are being presented to the consumer
by competing organizations near and far. Additionally, scholars have suggested that
international advertising plays an important role in understanding a constantly
transitioning global culture, but that more empirical study is needed in this area (Akaka and
Alden, 2010). A literature review of existing research is conducted, and an analysis of brand
positioning of health care institutions using printed promotional materials from a large
international health care conference, ArabHealth, is presented using a sample of 168 health
care organizations located in 14 countries. This paper contributes to the literature by
exploring these relationships in a high-involvement service within the context of health care
and examining these relationships among health care institutions located in a variety of
countries and regions of the world. The literature review that follows examines COO effects,
followed by sections on brand positioning and how high-involvement services such as
health care differ from other goods and services along these dimensions.

Literature review
Country-of-origin research
Prior COO research has examined the effect of a country’s image on perceptions of brands
associated with that country and resulting consumer purchase intentions (Ettenson et al.,
1988; Roth and Romeo, 1992; Papadopoulos and Heslop, 2002; Koschate-Fischer et al., 2012;
Saydan, 2013). COO has been shown to influence perceptions of quality and purchase
intentions through the mechanisms of country image and country brand equity (Javalgi
et al., 2001; Pappu et al., 2006; Pappu et al., 2007; Zeugner-Roth et al., 2008). When less is
known about a product or service, a brand’s COO tends to serve as an external signal for
quality (Schooler, 1965; Verlegh and Steenkamp, 1999; Batra et al., 2000; Pappu et al., 2007;
Roth and Diamantopoulos, 2009; Diamantopoulos et al., 2011). Because the consumer has
limited information to make a purchase decision, the COO serves as a “quality halo” (Han,
1989). A consumer has various impressions about products and services from the
country, which are then used to evaluate the unknown brand, product or service (Schooler,
1965; Al-Sulaiti and Baker, 1998; Hanaysha and Hilman, 2015). These perceptions may
originate from a country’s social, political, technological or economic reputation, from prior
 experience with goods or services from that country or images promoted by media, art, news Brand
or tourist experiences (Wang and Lamb, 1983; Papadopoulos and Heslop, 2002; Fetscherin, positioning for
2010; Godey et al., 2012; Aichner, 2014). The less information available about the product or
service, the greater the effect of COO on the evaluation of the product or purchase intention
health care
(Lim et al., 1994; Pharr, 2005). A brand may signal the COO by using the COO in the
company name, embedding typical COO words in the company name, using COO language,
use of famous or stereotypical people from the country or using symbols such as flags or
iconic buildings (Aichner, 2014).
It has been reported that COO effects have been found to vary by country, with
additional distinctions noted among emerging and developed economies. Developed
countries tend to have a home-country bias when other factors such as price or quality are
held equal because of consumer ethnocentrism or patriotism (Shimp and Sharma, 1987;
Balabanis and Diamantopoulos, 2004; Verlegh, 2007; Michaelis et al., 2008). However,
emerging economies tend to favor foreign products, which may be perceived as higher
quality or more prestigious (Batra et al., 2000; Dakin and Carter, 2010). Additionally, COO
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effects have been found to vary by product or service category (Pappu et al., 2006; Josiassen
et al., 2008) and the individual identity of the consumer (Lin and Wang, 2016).
Types of brand positioning. Companies and consumers are connecting across geographic
borders, giving rise to a new global consumer culture that transcends territorial boundaries
(Hannerz, 1990; Terpstra and David, 1991; Alden et al., 1999; Cayla and Arnould, 2008;
Okazaki et al., 2010; Taylor and Okazaki, 2015). Global consumers attach the same value and
meaning to people, places and things including brands, products and services regardless of
their location (Terpstra and David, 1991; Caudle, 1994). However, local tastes and
preferences are still relevant for many product categories. Therefore, international
marketers must balance the preferences of the global consumer with considerations in local
markets when determining a positioning strategy for a brand (Rigby and Vishwanath, 2006;
Cayla and Eckhardt, 2008; Spielmann and Delvert, 2014).
Alden (1999) defines three possible positioning strategies available to companies: Global
Consumer Culture Positioning (GCCP), Local Consumer Culture Positioning (LCCP) and
Foreign Consumer Culture Positioning (FCCP). Seminal research in this area used five
specific indicators to determine positioning strategy: pronunciation of brand name, symbols
used and spelling of brand name, brand logo, central themes and appearance of
spokespersons. These indicators are considered local if they reflect their own native culture
(written in Arabic for an Arab audience), foreign if they represent another identifiable
culture (German spokespersons for an Arab audience) or global if they are not associated
with a local or specifically identifiable individual culture, but seek to identify with an
international group. A firm may use a combination of these positioning strategies,
contingent upon environmental and cultural factors, consumer attributes or product
categories (Taylor, 2005; Gabrielsson et al., 2008; Vrontis et al., 2009; Jiang and Wei, 2012).
Global consumer culture positioning. GCCP uses commonly accepted symbols that typify
a global consumer (Alden et al., 1999) and involve a brand positioned as a global one without
a national identity. Brands using GCCP appeal to universal themes and may be standardized
across markets with minimal local adaptation (Özsomer, 2012). From a firm perspective,
global positioning can lead to benefits such as reduced costs for R&D, logistics and
marketing and the ability to charge a price premium (Schuiling and Kapferer, 2004; Douglas
and Craig, 2011; Sichtmann and Diamantopoulos, 2013). From a consumer perspective,
globally positioned brands convey a sense of prestige, sophistication, superiority, quality
and widespread availability (Shocker et al., 1994; Steenkamp et al., 2003; Dimofte et al., 2008;
Strizhakova et al., 2011; Warat et al., 2014). These attributes allow the consumer to perceive
 IJPHM themselves as cosmopolitan, modern or elite (Friedman, 1990; Steenkamp et al., 2003; Holt
et al., 2004; Johansson and Ronkainen, 2005).
Global brands, such as those used in GCCP, tend to signal quality to prospective
consumers. Consumers tend to believe that global brands must be higher quality because
they assume quality is a driver for their worldwide acceptance (Steenkamp et al., 2003; Holt
et al., 2004; Özsomer and Altaras, 2008; Özsomer, 2012). Additionally, global brands are
assumed to have more at stake if the product violates quality expectations because they risk
losing a large range of customers across the world (Wernerfelt, 1988). As a result, consumers
assume that global brands have a stronger incentive to produce high-quality products
(Sichtmann and Diamantopoulos, 2013).
Foreign consumer culture positioning. FCCP positions the brand as symbolic of a
foreign consumer culture (Alden et al., 1999). Certain countries or cultures may convey a
positive image for specific goods and services, and thus, companies seek to associate their
product with that culture by using a spokesperson of a specific ethnicity or appearance,
through the pronunciation of the company name or by using foreign language (Alden et al.,
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1999). Researchers have found that the attitudes towards the same brand improved when
the brand name used a French pronunciation versus an English pronunciation for hedonic
goods among US consumers (Leclerc et al., 1994). Additionally, locally owned brands with a
foreign presence may emphasize their foreign popularity to signal quality to a domestic
audience (Verlegh, 2007).
Local consumer culture positioning. LCCP aligns the brand with local culture and norms
and may be portrayed as something that is produced and/or consumed locally (Alden et al.,
1999). Locally positioned goods and services convey benefits to consumers such as cultural
sensitivity, responsiveness, patriotism and the support of the local economy (Schuiling and
Kapferer, 2004; Dimofte et al., 2008; Özsomer, 2012). Prior research has demonstrated a
preference for global brands. However, recent research shows that global brands are not
always evaluated as higher quality or more prestigious and that these effects should be
interpreted as contingent on both corporate and environmental factors in the target market
(Chailan and Ille, 2015). Alden (1999) found that the type of positioning preferred varied
significantly by country. For example, in Latin America, the highest-rated brands often
contain both global and local brands (Farías, 2015), whereas consumers from other
developing economies have demonstrated a preference for Western brands (Friedman,
1990).
Considerations for high-involvement health care services. Research on COO and brand
positioning indicates that effects may vary by product category (Batra et al., 2000; Farías,
2015). The bulk of research in the area has focused on durable goods such as automobiles
and televisions. Less research has been conducted on services, and even fewer studies have
examined high-involvement services such as health care (Warat et al., 2014; Farías, 2015).
Because of the differences noted among specific product categories, it is important to
consider high-involvement services separately. Specifically, health care has unique
attributes as a service that might influence the relationships among COO and brand
positioning. Whereas COO dimensions for goods may include the country or brand
origin and the country of manufacture, these dimensions differ for services. In the service
context, Aichner conceptualized dimensions for COO based on the work of Vianelli and
Marzano, and health-care-specific examples are provided in Table I (Vianelli and Marzano,
2012; Aichner, 2014).
Because services are intangible and difficult to judge without personal experience, the
role of extrinsic cues for developing perceptions of quality may be higher than for goods
(Zeithaml, 1988; Herbig and Milewicz, 1992; Berry, 2000). The lack of readily available
 extrinsic cues makes services more difficult to judge, thus increasing the risk of purchase Brand
(Zeithaml, 1988; Murray and Schlacter, 1990). This may be especially true for high- positioning for
involvement services where the cost of failure is high, such as airlines and health care. To
health care
diminish the uncertainty in utilizing a new service, consumers rely more heavily on
available cues such as advertising, word-of-mouth and corporate image (Gronroos, 1984;
Aydin and Özer, 2005; Chung-Yu and Li-Wei, 2012). As a result, branding and advertising in
the service industry is of critical importance in assuring consumers of quality (Onkvisit and
Shaw, 1989). It follows logically that COO and brand positioning may have a greater role in
signaling quality for intangible and risky services. This may be especially true in marketing
from emerging markets where consumers lack the safeguards of well-established regulatory
systems, forcing firms to provide guarantees to consumers to build trust (Dahlstrom and
Nygaard, 1996; Steenkamp and Geyskens, 2006).
Patients who are willing to mobilize for medical services may travel hundreds or
thousands of miles for health care. Treatments perceived to be high quality and low cost in
countries such as Thailand, India and Brazil are attracting patients from developed
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countries (Goldbach and West, 2010). Similarly, wealthy patients from Asia, Latin America
and the Middle East increasingly travel for treatments that may be unavailable in their
home countries (Goldbach and West, 2010; Johnson and Garman, 2010; Al-Amin et al., 2011;
Cormany, 2013). As a result, hospitals are no longer competing with rivals in neighboring
city blocks but in neighboring countries and continents for international patient volume and
the revenue it brings. In response, hospital systems have used a number of strategies to
attract international patients, such as opening international offices and facilities, affiliations
with international partners, consulting services, education exchanges and direct advertising
(Schroth and Khawaja, 2007; Ruamsak and Beise-Zee, 2010). Because of the highly technical
nature of health care, patients are often unable to appropriately evaluate the actual quality
of the service and must rely heavily on extrinsic cues to assess quality (Babakus et al., 1991;
Babakus and Mangold, 1992; Victoor et al., 2012). This problem is exacerbated when the
facility is located in a foreign country. Coupled with the risks associated with poor care,
these attributes lead patients to rely heavily upon signals of quality when choosing a foreign
facility to receive care. Advertising materials may act as one such signal for patients seeking
to evaluate risk associated with medical travel (Kemp et al., 2015), and prior research has
shown favorable attitudes among patients towards health care advertising (Miller and
Waller, 1979). Given the risks involved with health care and the inability to judge the service
through experience, the external cues of COO and brand positioning may be of increased
importance for perceived quality in health care relative to other services.

COO service dimension Description Health care examples

Country of brand
Country of service delivery
Country-person image
Country training image
Country where the brand
originated
Country in which the service is
delivered
Birthplace of the person
providing the service
Country where the service
provider received training,
education or other credentials
The location of the hospital headquarters
(e.g. Cleveland Clinic in Cleveland, the USA)
The location of the specific hospital facility
where care is delivered (e.g. Hopkins
Aramco and Cleveland Clinic Abu Dhabi)
Table I.
The nationality of the physicians and
nurses Country-of-origin
The country of residency and fellowship dimensions in the
training of the physicians health care service
industry
 IJPHM Research objective
The objective of this research is to better understand which positioning strategies are being
used in different regions, not necessarily which strategies are better or more successful.
Because of the limited positioning research in health care specifically, this paper seeks to
establish a foundation for better understanding what tactics are currently being used
globally. This paper can serve as an initial work to establish a baseline of what trends are
being seen in health care brand positioning globally, which can help orient future qualitative
work, such as patient perceptions and effectiveness. The first issue examined is how brand
positioning may differ by various regions of the world. The effects of global positioning and
brand origin have been shown to differ for developing versus developed countries (Batra
et al., 2000). The literature also suggests that customers from emerging countries are more
likely to have a preference for foreign-owned brands from developed countries relative to
locally owned brands (Warat et al., 2014). It follows that an organization may alter its brand
position based on its COO and the target market it is seeking to attract. Similarly, recent
studies have shown that multinational corporations based in Europe, Asia and North
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America differed regionally in their use of global versus local strategies (Okazaki and
Mueller, 2008; Jiang and Wei, 2012). In the health care context, it is hypothesized that
hospitals seeking to attract patients will attempt to position themselves differently based on
their region. Therefore:

H1. The type of brand positioning used differs significantly by region.

Given the reputation for quality and the availability of innovative treatments in North
America, patients from around the world often seek treatment for acute illnesses in the USA
(Goldbach and West, 2010; Johnson and Garman, 2010; Helble, 2011). The USA is generally
considered the largest global destination for medical travel (Ehrbeck et al., 2008).
Additionally, North American hospitals have a long history of collaboration with
institutions around the world (Schroth and Khawaja, 2007), which may incline them to view
themselves as global organizations. The USA is the largest investor in biomedical science
research in the world, allocating $30bn annually to pursuing discoveries that advance the
field (National Institutes of Health, 2017). Finally, English has become the de facto universal
language of science (Drubin and Kellogg, 2012), including health care and medicine, in many
countries outside of North America. The proliferation of English as the language of health
care may lead American institutions to view themselves as scientific leaders in health care
globally. Therefore, it is hypothesized that North American health care organizations will
predominantly use global positioning to capitalize on their global reputation for scientific
expertise and history of international collaboration to attract international patients.
Therefore:

H2. Health care organizations in the North American region differ significantly in their
use of global consumer culture positioning.
Next, positioning in the European region is examined. European health systems have a
positive reputation for quality care delivery and often rank at the top of the World Health
Organization rankings of health systems (Blendon et al., 2001). Additionally, it is common
for European products to highlight their COO as a symbol of quality, such as German cars,
Italian leather shoes and French cosmetics. Prior research has found that European
institutions commonly highlight their country attributes in other sectors (Alden et al., 1999).
It is expected that European organizations will predominantly position themselves as
foreign to a Middle Eastern patient by highlighting the characteristics and rankings of their
 health system and their country attributes. A hospital emphasizing its European attributes Brand
would be considered foreign to a Middle Eastern patient; therefore: positioning for
H3. Health care organizations in the European region differ significantly in their use of health care
FCCP.
Lastly, the Middle Eastern region is examined. It is hypothesized that health care
organizations in Middle Eastern countries seeking to attract patients use foreign consumer
culture positioning. Given the reputation for quality in the USA, hospitals in developing
countries have begun to pursue US-based accreditations to assuage patient’s fears over
quality (Goldbach and West, 2010). Tactics employed to highlight their “American” qualities
range from JCI accreditation, Magnet hospital recognition, highlighting the presence of
American trained doctors, and affiliations with prestigious US hospital systems (Schroth
and Khawaja, 2007; Goldbach and West, 2010; Johnson and Garman, 2010). It is suggested
that these tactics represent an attempt for hospitals in developing countries with less
established global reputations for care to use FCCP as a quality signal, albeit based on a US
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positioning context. These observations lead us to the following hypothesis:

H4. Health care organizations in the Middle Eastern region differ significantly in their
use of foreign consumer culture positioning.

Methods
While hospitals may seek to attract patients from regions around the world, patients from
the Middle East remain a primary target. These patients are often funded by their
governments to receive health care abroad, thus reducing the administrative burden to
hospitals of dealing with individual payers. Additionally, these governments often
reimburse at rates that compare favorably to other forms of payment available to hospitals.
This government funding also reduces financial barriers to seeking care abroad, making it a
possibility for both wealthy and non-wealthy patients. However, these governments will
often honor a patient’s preference for being treated in a specific country or institution when
possible. Therefore, promotional materials, such as brochures, targeted specifically towards
Middle Eastern patients were the primary focus of this research.
To gather an objective sample of promotional material for analysis, researchers collected
printed brochures from the Arab Health 2016 conference. Arab Health is an annual
conference, hosted in Dubai, which includes a tradeshow with vendors and exhibitors and
continuing medical education (CME) conferences with speakers. The 2016 conference
featured 4,187 exhibitors from 64 countries, ranging from hospitals and universities to
medtech and biotech firms. There were 20 parallel CME conferences with over 500 speakers.
Over 100,000 visitors attended the conference from 160 countries, with roughly 21 per cent
working in the hospital industry, and the remainder divided among governments,
distributors, manufacturers and laboratories (ArabHealth, 2016).
Researchers visited each of the 23 exhibition halls and gathered materials from
exhibitors that were visibly displaying material with at least one of the three common
domains of large academic medical centers: patient care, research and education. It was
assumed that if these elements were not clearly present in any of the promotional materials
or signage offered at the booth, then it was not a major service line or strategic priority for
that organization. This process yielded over 3,300 pages of printed content from 176
organizations for review. This analysis was limited to institutions based in Europe, the
Middle East and North America. Institutions in the Asia Pacific region were excluded
 IJPHM because of their limited number (n = 8), yielding a total of 168 organizations for inclusion in
the final analysis.
Pictures, logos, images and text from the promotional materials were coded for the
presence of various elements of brand positioning, using an approach described by Alden
et al. (1999). These included:
 the country of training for physicians;
 tourist messaging;
 the appearance of providers;
 the appearance of patients;
 images of national icons;
 local, foreign or global awards and certifications;
 mentions of the reputation of the city, country or region;
 the language of the materials (Arabic, English or other); and
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 central themes.

Themes were identified through analysis of any text within the promotional material to
determine if messages positioning the organization as global, local or foreign were used. For
example, if the text highlighted the organization’s reputation worldwide, “world-class”
research facilities or being a “global destination for care”, then this was considered as an
element of global positioning. Alternatively, if the text described the organizations attention
to culturally sensitive care for Arab populations, then this was considered as an element of
local positioning. Highlighting a hospital’s German efficiency was considered foreign
positioning. All of these elements were evaluated to determine if the organization used a
global, local or foreign positioning approach. The totals for each positioning approach were
tallied to determine which positioning strategy was predominantly used. Based on these
factors, the organizations were classified as using FCCP, LCCP or GCCP.
The materials were coded independently by two coders, and any discrepancies were
discussed until 100 per cent agreement was reached. It is important to note, given the
location of the conference in Dubai and a Middle East focus, it is assumed that the primary
target audience for patient care at this conference is for Middle Eastern patients and that
materials would be targeted as such. Materials were coded for LCCP and FCCP relative to
whether the cultural elements would be foreign or local to a Middle Eastern audience. For
example, if an organization in Germany strongly highlighted its German origins and
qualities, training of physicians and location and tourist images, then this would be coded as
FCCP, as the German culture is foreign to the Middle Eastern patient. Conversely, if a US-
based organization highlighted pictures of its Middle Eastern physicians and patients, wrote
its brochures in Arabic and advertised hospital amenities such as Muslim prayer rooms,
then this would be considered LCCP, as they are highlighting elements of culture considered
local to a Middle Eastern patient. If an organization made little mention of its location, had
diversity of physicians and patients represented in images and referenced its global
reputation or standing, then this was considered GCCP. A chi-square analysis was first
conducted to determine whether there was a significant difference in the type of positioning
strategy by the regions examined. A post hoc analysis was then conducted using the
standardized residual method to determine whether each positioning strategy differed
significantly within specific regions (Beasley and Schumacker, 1995; Garcia-perez and
Nunez-anton, 2003). Quantitative results were synthesized with themes and quotes from the
qualitative analysis to highlight regional trends from the promotional materials.
 Results Brand
The 168 organizations included in the analysis were headquartered in 14 countries, as seen positioning for
in Table II. The frequency of positioning strategies and chi-square results by region are
presented in Table III. The results indicate that the type of positioning strategy differed
health care
significantly by region (Pearson chi-square 39.313, p < 0.000), thus supporting H1. This is
consistent with previous literature noting regional difference in brand positioning.
H2, which suggested that GCCP is used significantly more often by hospitals in the
North American region, was also supported. These results indicate that North American
hospitals used GCCP more frequently (72 per cent of organizations) than FCCP (20 per cent
of organizations) or LCCP (8 per cent of organizations). The Chi-square post hoc analysis
showed that GCCP use differed significantly from the other positioning strategies in the
North America region (Chi-square = 19.01, p < 0.000). An examination of the materials from
the North American region highlights these differences. With the exception of two
institutions in Chicago, North American hospitals rarely explicitly mentioned or highlighted
their city or country. Additionally, these hospitals tended to state their position relative to
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the rest of the world, with phrases such as “world’s leading experts” or “world class”. The
US News and World Report rankings were mentioned by roughly 81 per cent of the

Primary location country Count (%)

Europe
Germany 53 32
The UK 47 28
Austria 3 2
Italy 2 1
Switzerland 1 1
Sweden 1 1
France 1 1
Czech Republic 1 1
Middle East
UAE 28 17
Saudi Arabia 3 2
Qatar 1 1
Jordan 1 1 Table II.
North America Primary
The USA 24 14 headquarters of
Canada 2 1 organizations for
Total 168 analysis

North
Europe Middle East America Total
Positioning type Count (%) Count (%) Count (%) Count (%)

Foreign consumer culture positioning (FCCP) 77* 70 19 58 5* 20 101 60

Global consumer culture positioning (GCCP) 32 29 7 21 18* 72 57 34
Local consumer culture positioning (LCCP) 1* 1 7* 21 2 8 10 6
Total 110 100 33 100 25 100 168 100 Table III.
Positioning strategy
Notes: Pearson Chi-square 39.313; p < 0.000; df = 4; *significantly different at p < 0.05 by region
 IJPHM US-based hospitals. Additionally, the text surrounding the US News and World Report
rankings often implied that these rankings also translated to global rankings. The extant
literature on which positioning is most common for North American organizations is mixed,
with some reporting LCCP as the most common and some reporting a global-local
positioning combination strategy as most common. However, positioning has been found to
vary by industry and service category, and there are no direct comparisons for health care in
prior literature.
The results also supported H3, which suggested that European organizations would
predominantly use FCCP. European organizations used FCCP 70 per cent of the time,
followed by GCCP (29 per cent) and LCCP (1 per cent). The Chi-square post hoc analysis
showed that FCCP use differed significantly from other positioning strategies in Europe
(Chi-square = 12.96, p < 0.000). An examination of the materials from the European region
highlights these differences. Foreign positioning included the use of country flags, iconic
European landmarks, pictures of staff with a stereotypical appearance from the home
country and comments and descriptions highlighting the quality of care in the country and
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city. This is consistent with prior research findings that European organizations commonly
highlight their country attributes.
There was limited support for H4, which suggested that Middle Eastern organizations
would use Foreign positioning (highlighting Western attributes) most frequently. In all, 58
per cent of Middle Eastern organizations used foreign positioning, 21 per cent used local
positioning and 21 per cent used global positioning. However, the use of FCCP failed to
reach statistical significance in the Chi-square post hoc analysis. The Middle East
organization’s greater use of LCCP compared to Europe and North America did differ
significantly in the post hoc analysis (Chi-square = 17.06, p < 0.000). An examination of the
materials from the Middle Eastern region highlights these differences. As suspected, Middle
Eastern organizations frequently used Western accreditations, awards or certifications to
represent quality, such as JCI accreditation (43 per cent of hospitals). Other certifications
included membership in the American Hospital Association, Certified Medical Travel
designation and “Guinness World Record for the Most Blood Cholesterol Readings in
8 Hours”. Other foreign positioning tactics included highlighting the Western training of
physicians and highlighting partnerships or affiliations with Western organizations
or doctors. A few hospitals went further in their use of foreign positioning by concealing or
minimizing their ownership and location through the use of Western country names for their
institution. Despite the lack of statistical significance, these findings align with previous
research noting that consumers from emerging economies may prefer foreign brands or
Western brands; thus, it follows that organizations catering to emerging consumers may use
foreign positioning.

Discussion and conclusions

The findings of this research are important to leaders within the high-involvement service
industry and to health care specifically in evaluating their strategy in global markets. First,
it appears that many US hospitals assume that the USA is the best destination for care and
that this reputation is widely accepted. This appears to lead to two tendencies in positioning:
First, the mention of the US News and World Report ranking is assumed to translate to a
global ranking. Second, the reputation or features of health care in the USA are not explicitly
highlighted. Taken together, these practices perhaps discredit the reputation of other health
systems and their component hospitals globally and may overestimate the global
acceptance of the USA as a top destination for care. This assumption is questionable as a
marketing tactic, as it assumes that a given US hospital is only competing with other US
 hospitals in the mind of the patient. While some patients may indeed decide from the outset Brand
that they will only consider American hospitals, patterns of inbound medical travel to other positioning for
countries such as Germany might suggest that patients are weighing multiple options in
other countries, including their own. Additionally, various sources such as the
health care
Commonwealth Fund and WHO commonly rank other health systems far above the USA
(Blendon et al., 2001; Davis et al., 2007). Though these are typically based on broader public
health measures and not the quality of the types of care people travel to the USA to receive,
these rankings are widely publicized and may carry weight with patients evaluating
destinations for care. In combination with highly publicized high costs of health care and
incidence of medical errors in the USA, potential patients may have conflicting views of the
quality of care in the USA. If this is the case, then US-based organizations should give
greater consideration to their global competitors as well as the possible effect of the
reputation of the US health system as a whole compared to their European counterparts.
Another interesting finding is that North American organizations typically avoid
highlighting any touristic elements of their location, whereas European organizations
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displayed tourist information and images prominently. One possible explanation is that
highlighting tourist attractions may seem to somehow diminish the perception of quality
care delivery. The idea is that if the hospital provides excellent quality care, then its
surroundings should be irrelevant. However, given the popularity of medical tourism in
exotic locations, if quality is perceived as similar between organizations, then patients may
prefer to seek care in a more desirable destination. Finally, there is an emerging body of
research suggesting that disparities in health care for minority populations may be reduced
by increasing both cultural sensitivity and provider diversity (Gold, 2014). Therefore,
attracting patients based on cultural attributes may be a step towards providing more
culturally sensitive care and reducing disparities. However, the authors have chosen to
withhold a value judgment on whether there positioning strategies are harmful or beneficial
and instead seek to describe positioning trends in the health care industry to create a
baseline for future research in this area.
The strong use of country identifiers for European institutions may be attributed to
patriotism or strong national identity. Alternatively, because many of the European
countries have highly ranked health care systems with strong reputations and because of
their close proximity to each other, they may face increased competition with resulting
pressure to differentiate themselves from neighboring countries. Highlighting unique
characteristics of one’s country along with tourist attractions may be a tactic for health
care organizations to avoid being lumped into a generic European category in the minds of
the consumer. This approach is highlighted in the following quote from the brochure of one
German hospital, set against the backdrop of historic buildings and cathedrals that are
undoubtedly European:
The German healthcare system has an excellent reputation worldwide. Germans are particularly
known all over the world for being punctual, highly organized, competent and efficient. This
applies especially to German doctors.
This study has several limitations. First, there were a limited number of examples from
many of the countries represented in our sample. Thus, comparison was conducted across
regions rather than among individual countries. There may be nuances in positioning by
country which were not fully captured in our analysis. Second, this research is limited in its
ability to evaluate the effectiveness of these positioning strategies on the target patient
population. Though patients may be influenced in their perceptions by promotional
materials, there are often numerous other factors associated with the eventual selection of a
 IJPHM care provider, including government involvement. The specific advertising domain of this
research is positioning. However, broader implications for advertising beyond positioning
represent an opportunity for future research, specifically regarding issues such as patient
perceptions and advertising effectiveness. Future research is needed to better understand
which brand positioning strategies are more appealing to patients and are more effective in
increasing brand equity and patient volume.
In summary, COO and brand positioning strategy are important factors to consider
for high-involvement services such as health care organizations competing for
international patients. These factors become more important in high-involvement
service industries because consumers lack the information needed to evaluate quality,
and the repercussions of poor quality are potentially severe. Therefore, consumers
may rely on COO and brand positioning signals more heavily relative to goods or
hedonic services. In support of signaling theory and the brand positioning and COO
studies, organizations operating in different regions used different brand positioning
tactics to attract potential customers. The findings indicate that European and Middle
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Eastern health care organizations most frequently use FCCP, while American
institutions tend to use GCCP. However, American hospitals may be missing an
opportunity to capitalize on the appeal of their country and cities and may not be
appropriately considering their global competition in their market positioning.
Hospitals must consider their positioning relative to both domestic and international
competitors and the COO of their target audience. These results further indicate that
health care organizations that choose a positioning strategy that does not consider
both their COO and the preferences of their target audience may be missing an
opportunity to attract potential patients.

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Corresponding author
Katherine A. Meese can be contacted at: kameese@uab.edu

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