Medical Tourism Research Articles

Antibiotic profile classification of Proteus mirabilis using machine learning: An investigation into multidimensional radiomics features

Antimicrobial resistance (AMR) presents a significant threat to global healthcare. Proteus mirabilis causes catheter-associated urinary tract infections (CAUTIs) and exhibits increased antibiotic resistance. Traditional diagnostics still rely on culture-based approaches, which remain time-consuming. Here, we study the use of machine learning (ML) to classify bacterial resistance profiles using straightforward microscopic imaging of P. mirabilis for resistance classification integrated with radiomics feature analysis and ML models.From 150 P. mirabilis strains isolated from catheters of patients diagnosed with a CAUTI, 30 % displayed multidrug resistance using the standardized disk diffusion method, and 60 % showed strong biofilm activity in microtiter plate assays. As a more rapid alternative, we introduce wavelet-based and regular microscopy imaging with feature extraction/selection, following image preprocessing steps (image denoising, normalization, and mask creation). These features enable training and testing different ML models with 5-fold cross-validation for P. mirabilis resistance classification. From these models, the Random Forest (RF) algorithm exhibited the highest performance with ACC = 0.95, specificity = 0.97, sensitivity = 0.88, and AUC = 0.98 among the other ML algorithms considered in this study for P. mirabilis resistance classification.This successful application of wavelet-based feature Radiomics analysis with RF model represents a crucial step towards a precise, rapid, and cost-effective method to distinguish antibiotic resistant P. mirabilis strains.

EP51 - Uses of pharmaceutical and mechanical VTE prophylaxis - A clinical audit

Abstract Aim Venous thromboembolism (VTE) is a serious global health care safety concern for both patients and staff. Although it has been amply demonstrated that pharmaceutical and mechanical methods of prophylaxis against VTE are effective, their application has been uneven and insufficient. The purpose of this audit was to assess junior physicians working in general surgery, regarding their adherence to local and NICE guidelines regarding the pharmacological VTE prophylaxis practice as well as the mechanical prophylaxis Methodology Pre-intervention audit took place for two weeks. Throughout the course, it covered every adult general surgical emergency inpatient admission at conquest hospital who were deemed indicated for VTE prophylaxis. Each evening while the patients were still in the hospital, data was collected using the prescription charts, nursing and medical notes. The proforma used for data collection detailed the characteristics of VTE risk, the prophylactic medication prescribed for each patient, TED stockings and whether or not this aligned with the NICE clinical guideline (CG) 46,6.8. Post intervention took place for two weeks after teaching of junior doctors and the same as above was carried out, using the new proforma Results Pre-intervention showed that 87% of patients had the proforma filled in and 100% of patients received the appropriate dose of pharmaceutical prophylaxis. However, less than 40% of patients received the appropriate mechanical prophylaxis. Therefore, intervention was made in the form of a new proforma and teaching to junior. Post intervention data is currently being carried out Conclusion Implementation was necessary to ensure that at-risk patients receive appropriate prophylaxis.

EP431 - It's all in the NEWS: Can Early Warning Scores help identify severe post-operative complications in Medical Tourism patients?

Abstract Introduction Complications following surgical procedures abroad are regularly reported in news media. Often stories indicate delayed presentation to local medical services, possibly due to lack of good safety netting advice. Within the NHS, National Early Warning Score (NEWS) is used to identify those at risk of deterioration. This study aimed to determine if NEWS were associated with severity of post-operative complications. Methods A retrospective study was performed between January 2022-December 2023 at a DGH close to Gatwick Airport. The study included all emergency patients with complications following operations performed outside of UK. Data collected via electronic patient records included demographics, treatment and length of stay (LOS). Outcomes were analysed in two subgroups: NEWS 0 & NEWS ≥1. Results A total of 36 patients (mean age 40 years) were included in the study. NEWS at presentation ranged from 0-10. 25 (70%) patients had NEWS ≥1. In 100%, tachycardia (HR >90) was the abnormal parameter. NEWS ≥1 group demonstrated greater severity of complications (32% Clavien-Dindo Classification >3a vs 9%), increased rate of surgical intervention (36% vs 9%) and increased mean LOS (5.73 days vs 2.36 days). Relative Risk for severe complication was 3.96 in the NEWS ≥1 group. Conclusion Post-operative complications after surgery abroad are a significant risk to patients and a burden for local NHS services. Early presentation may lead to reduction in complex intervention and LOS. Promoting NEWS to patients going abroad for surgery may lead to improved outcomes. Advising patients to monitor their pulse after surgery is a simple message for health promotion.

“I Felt Like There Was Something Wrong in My Brain”: Growing Up with Trauma – How Young People Conceptualise, Self-Manage and Seek Help for Mental Health Problems

Abstract Background Youth mental health is an important global healthcare topic and early interventions that are timely and evidence-based to support young people can increase quality of life and lower deaths by suicide. Research exploring young people’s mental health experiences and how they manage can further understanding into help-seeking processes. Objective This study aimed to explore young people’s experiences of living with and managing mental health problems and how this impacts professional help-seeking. Methods Eighteen young people were recruited, aged 16–25 years, with experiences of help-seeking to services for mental health problems (N = 18). Data were analysed using Constructivist Grounded Theory methods (Charmaz, Constructing grounded theory, 2014). Findings The findings were presented across three sub-categories: (1) “Early experiences”; (2) “Conceptualising mental health” and (3) “Managing mental health”. Findings expand understanding on the resource pressures that young people experience whilst managing persistent mental distress emanating from early experiences of trauma, life stressors, and developmental tasks. Findings also report lived experiences of pain, loneliness and stigma, and how individual conceptualisations of mental health are informed. The preference for self-reliance can be rooted in developmental needs or learned behaviours and how this impacts self-management and help seeking is discussed. Conclusion Through an enhanced understanding about how young people experience mental distress, developmental pressure points, marginalisation and stigma, mental health providers can prioritise individualised approaches to healthcare that can both respect a young person’s individual conceptualizations and positively leverage self-management strategies, which can contribute positively to young people’s development, quality of life, and healthcare outcomes.

Impact of Corticosteroid on Covid-19 Pneumonia Patients

Background: Globally over 704,753890 had COVID -19 Out of which 7,010,681 died compared to 12031 death in Nepal out of1003450 cases Nationwide. Corticosteroids because of their anti- inflammatory effect may have beneficial effect/s on COVID-19 patients. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. Corticosteroids are a potential therapeutic agent for patients with COVID-19 pneumonia. The RECOVERY (Randomised Trials in COVID-19 Therapy) trial provided data on the mortality benefits of corticosteroids. Aim: The study aims to see the effect of Corticosteroids on COVID-19 patient outcomes concerning disease progression, length of hospital stay, 28-day mortality, and use of resources like Ventilator. Method: Single Hospital-based Prospective observational study among RT-PCR positive for COVID-19 patients admitted at Kathmandu Medical College Teaching Hospital from June 01, 2021 –July 31st, 2021 requiring oxygen therapy. Patients were grouped into either usual care, including symptomatic treatment only, or a group receiving both usual care and Corticosteroid. Results: This study included 160 RT-PCR-positive cases. There were 53 patients with mild symptoms and 107 with moderate symptoms. Patients with mild symptoms who received standard care had an odds ratio of 1.875 for progression to moderate and severe COVID-19 Compared to those who received both standard care and corticosteroid. Similarly, Patients with moderate symptoms who received standard care had an odds ratio of 1.8 for progression to severe and critical COVID-19 Compared to those who received both standard care as well as corticosteroids. Among patients with mild symptoms, the overall use of a ventilator was 35.85 % and mortality was 13.21 %. Similarly, in patients with moderate symptoms at presentation, a ventilator was needed in 33.64 % and mortality was 24.30 %. Conclusion: Though Corticosteroids seem to have a beneficial role in preventing disease progression, they failed to show a statistically significant reduction of ventilator use and mortality benefit amongst groups.

Computational identification of promising therapeutics via BACE1 Targeting: Implications for Alzheimer's disease.

Alzheimer's disease (AD) is a significant global healthcare challenge, particularly in the elderly population. This neurodegenerative disorder is characterized by impaired memory and progressive decline in cognitive function. BACE1, a transmembrane protein found in neurons, oligodendrocytes, and astrocytes, exhibits varying levels across different neural subtypes. Abnormal BACE1 activity in the brains of individuals with AD leads to the formation of beta-amyloid proteins. The complex interplay between myelin sheath formation, BACE1 activity, and beta-amyloid accumulation suggests a critical role in understanding the pathological mechanisms of AD. The primary objective of this study was to identify molecular inhibitors that target Aβ. Structure-based virtual screening (SBVS) was employed using the MCULE database, which houses over 2 million chemical compounds. A total of 59 molecules were selected after the toxicity profiling. Subsequently, five compounds conforming to the Egan-Egg permeation predictive model of the ADME rules were selected and subjected to molecular docking using AutoDock Vina on the Mcule drug discovery platform. The top two ligands and the positive control, 5HA, were subjected to molecular dynamics simulation for five nanoseconds. Toxicity profiling, physiochemical properties, lipophilicity, solubility, pharmacokinetics, druglikeness, medicinal chemistry attributes, average potential energy, RMSD, RMSF, and Rg analyses were conducted to identify the ligand MCULE-9199128437-0-2 as a promising inhibitor of BACE1.

Monkeypox: A Growing Global Health Challenge and the Need for Vigilant Preparedness

The Ongoing Public Health Challenge of Monkeypox Monkeypox is relatively a new threat to the global community as it has brought into focus the issue of improved surveillance and response to infectious diseases[1]. Initially, a rather exotic zoonotic pathogen limited to certain regions of Central and West Africa, monkeypox is being detected in the countries that previously did not report its occurrence, which creates new challenges for the health care systems of the world[2]. Understanding the Disease Monkeypox is an infectious disease that results from the attack of monkeypox virus which is in the Ortho poxvirus group of the virus family Poxviridae though the smallpox virus has been eradicated. The disease has some symptoms are similar to smallpox and includes fever, body aches, and rash that goes through different stages. Despite the fact that monkeypox is less severe when compared with smallpox, significant morbidity and potentially mortality cannot be ruled out[3]. Direct human-to-human transmission is by contact with infected body fluids, aerosols, or fomites such as used clothing, beddings among others. Recent epidemics have been experienced in the urban areas as this makes it easier for the virus to spread due to high population densities. This has transformed the disease from one which affected isolated African communities to a problem in developed, globally connected cities[4]. Why Should We Be Concerned? The stoppage of smallpox vaccination has exposed the people to Ortho poxviruses such as monkeypox. The constant risk of getting zoonotic diseases due to factors such as deforestation, urbanization and close interaction with animals means that diseases, which are mainly associated with animals, can easily infect human beings. Furthermore, the flexibility in the global interconnectivity of today’s world through travel and business has facilitated the spread of the virus across the borders. In 2022, 34 monkeypox cases were reported in European countries, the Americas, and other areas of the world, where the disease had not been identified[5, 6]. The Public Health Response To this recent outbreak of the disease, the WHO and the CDC have scaled up awareness campaigns and encouraged surveillance as well as put in place measures to contain the spread of the disease. Mass vaccination campaigns using smallpox vaccines that work against monkeypox have been intensified in the affected countries, however, there are several problems with implementing this approach: the difficulties of delivering vaccines in time and the scarcity of the vaccines themselves[7]. These are important in educating communities on how to avoid the disease and this include avoiding contact with sick persons, washing hands regularly and consulting a doctor when experiencing early symptoms of the disease. It also means that health systems need to be ready and able to identify such patients and isolate them to avoid spreading of the virus[8, 9]. Looking Forward The spread of monkeypox in the non-endemic countries is a cause of concern and questions the efficiency of our societies’ prevention, detection, and controlling of infectious diseases. Even as the current outbreaks have informed the world of the virus, it is important to note that this is not a one-off case[10]. Zoonotic diseases, which can be transmitted from animals to people, will remain a threat into the future as people increase in numbers and expand their living space into the domain of wildlife. The fight against monkeypox is the fight against all other infectious diseases that can be most effectively fought for with a proper approach and mutual cooperation of all countries[11]. Monkeypox is not as dangerous as some other infectious diseases but looking at the example of how this disease affected people one can conclude that public health cannot be unguarded. Prevention of such diseases in the future would require increased investment in the global health care system, outcome of research on new diseases and vaccination exercises. We cannot afford to wait for another pandemic to happen in order to start acting[12, 13].

The transformation of Jordan’s healthcare system in an area of conflict

BackgroundThe Jordanian healthcare system has evolved over the past decades expanding its services, technological, and educational resources. A comprehensive view of this system is lacking. The objective of this report is to describe the structure of the Jordanian healthcare system, the challenges facing it, and the current and recommended health policies.Materials and methodsThis study reviewed the current status of the Jordanian healthcare system. The following parameters were analyzed: health indicators, infrastructure, human resources, insurance system, pharmaceutical expense, health education system, and medical tourism. Data were collected from various relevant official institutions and related published literature.ResultsJordan has a young population with a median age of 23.8 years. Life expectancy is 78.8 years for females and 77.0 years for males. The Jordanian healthcare system is divided into three major categories: (1) Governmental Insurance (i.e., the Ministry of Health (MOH), the Royal Medical Services (RMS) and semi-governmental insurance); (2) Private Insurance; and (3) Refugee Insurance, including the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the United Nations High Commissioner for Refugees (NHUR). The Governmental Insurance covers 64.30% of the total population. Health expenditure is 6.37% of the gross domestic product (GDP). Pharmaceutical expenses make up 26.6% of the total national healthcare budget. Human resource assessment shows a high ratio of medical staff per 10.000 inhabitants, especially concerning physicians (31.7), dentists (7.9), and pharmacists (15.1). However, the ratio of nursing staff per 10.000 inhabitants is considered low (37.5). The Hospital bed/1000 population ratio is also relatively low (1.4). Healthcare accreditation is implemented through the Joint Commission International (JCI) accreditation which was achieved by 7 hospitals and by the National Health Care Accreditation Certificate (HCAC) achieved by 17 hospitals and 42 primary healthcare centers. Postgraduate medical education covers almost all medical and surgical fields. Medical tourism is currently well-established.ConclusionsAssessment of the Jordanian healthcare system shows high ratios of physicians, dentists, and pharmacists but a low ratio of nursing staff per 10.000 inhabitants. The hospital bed/1000 population ratio is also relatively low. Pharmaceutical expenses are significantly high and medical tourism is well-developed.

T lymphocyte‑related immune response and immunotherapy in gastric cancer (Review).

Gastric cancer (GC) remains a global healthcare challenge because of its high incidence and poor prognosis. The efficacy of current chemotherapy regimens for advanced GC is limited. T cells, which have been implicated in the progression of GC, have a significant impact in the tumor microenvironment. With a more detailed understanding of the mechanisms underlying the cancer immunoediting process, immunotherapy may become a promising treatment option for patients with GC. Several clinical trials are currently investigating different mechanisms targeting the tumor immune response. The present review summarized T cell-involved immune responses and various immunotherapy strategies for GC.

Carbon footprint of non-melanoma skin cancer surgery.

Climate change poses a significant global health threat and healthcare, including surgery, contributes to greenhouse gas emissions. Efforts have been made to promote sustainability in surgery, but the literature on sustainability in plastic surgery remains limited. A life-cycle analysis was used to assess and quantify the environmental emissions associated with three distinct reconstructive methods utilized in non-melanoma skin cancer surgery: direct closure, split-thickness skin graft, and full-thickness skin graft. Analyses were conducted in March 2023 in Morriston Hospital, Swansea, UK. The carbon footprints for non-melanoma skin cancer surgery in England and Wales were then estimated. The mean carbon emissions for non-melanoma skin cancer surgery ranged from 29.82 to 34.31 kgCO₂eq. Theatre energy consumption (4.29-8.76 kgCO₂eq) and consumables (16.87 kgCO₂eq) were significant contributors. Waste produced during non-melanoma skin cancer surgery accounted for 1.31 kgCO₂eq and sterilization of reusable surgical instruments resulted in 1.92 kgCO₂eq of carbon emissions. Meanwhile, transportation, dressings, pharmaceuticals, and laundry accounted for 0.57, 2.65, 1.85, and 0.38 kgCO₂eq respectively. The excision of non-melanoma skin cancer with direct closure (19.29-22.41 kgCO₂eq) resulted in the lowest carbon emissions compared with excision with split-thickness skin graft (43.80-49.06 kgCO₂eq) and full-thickness skin graft (31.58-37.02 kgCO₂eq). In 2021, it was estimated that non-melanoma skin cancer surgery had an annual carbon footprint of 306 775 kgCO₂eq in Wales and 4 402 650 kgCO₂eq in England. It was possible to predict that, by 2035, carbon emissions from non-melanoma skin cancer surgery will account for 388 927 kgCO₂eq in Wales and 5 419 770 kgCO₂eq in England. This study highlights the environmental impact of non-melanoma skin cancer in plastic surgery departments and emphasizes the need for sustainable practices. Collaboration between surgeons and policymakers is essential and further data collection is recommended for better analysis.

Exploring the Hospital Performance during the COVID-19 Pandemic from the Perspective of Intellectual Capital: An Empirical Study of Taipei Hospital in Taiwan

The COVID-19 pandemic, starting in 2019, posed unprecedented challenges to global healthcare systems, with Taiwan's rapid response gaining notable attention (Cheng, Li, & Yang, 2020). This paper examines how non-profit hospitals can improve crisis management capabilities, using Taipei Hospital as an empirical study. It proposes a framework for constructing an intellectual capital report based on the ARC model, enhancing traditional financial statements with a comprehensive view of the hospital's intangible assets. Employing Data Envelopment Analysis (DEA) to evaluate Taipei Hospital's operational performance from 2013 to 2023, the study finds that the hospital's operational efficiency during the pandemic exceeded pre-pandemic levels, demonstrating its ability to leverage the crisis for improvement. This supports the assertion that intellectual capital is crucial for research and development organizations, validating the proposed reporting framework.

Prime Components Influencing the Foreigners Towards the Medical Tourism in India –A Factorial Approach

The prevalent of universal corporate sectors and government initiatives in India have enhanced the service sector venture in recent years. To draw more medical tourists, the Indian government and the medical sector have substantially spent in enhancing the Indian healthcare abroad. However, it's also crucial to consider the traits of the patients who select India for their medical care. Medical Tourism in India has peculiar traits and special abilities, specialized services and platforms, expertise and well-equipped hospitals and medical staff, a culturally rich region, cutting-edge facilities, supportive individuals, and overall warmth and hospitality. Previous studies focus on the problems faced by the tourists, study in other nations and how people choose their destinations for treatments especially Americans’. With a sample of 600 respondents, the data is directly observed at the hospitals from the international patients in the six states of Kerala, Tamil Nadu, Andhra Pradesh, Telangana, Karnataka and Pondicherry. In order to produce a unique dataset that may be utilized to address more inquiries about India's tourism in general, the study compiles data from also the other secondary sources. To study and predict patients' intentions to return to India and their loyalty, it is and to frame the hypothesis assess their opinions of the various facilities and services provided during medical tourism. Factorial analysis, a multivariate statistical technique, has been used to analyze the data and identify the top ten factors motivating the tourists to India. The current study throws light to identify the key areas on which hospitals should concentrate in order to promote medical tourism in the current, cut throat climate.

Satisfaction Level of Medical Tourism Services Based on Classified Factors - A Discriminatory Approach

Medical tourism has the potential to promote high-class learning, well equipped human resources, flattering visa policies, nations’ charisma, and sound flourished infrastructure facilities available in the nation. Countries have recognized this opportunity as a means in support of overall communal and economic upliftment. More governments are valuing these advantages and developing plans and policies for the sector as a result, WTTC states that by means of the appropriate policies, guidance and regulation mechanisms, medical tourism can achieve sustainable growth among the developed and developing nations. With a sample of 600 respondents, the data related to satisfaction in the medical tourism services is directly observed at the hospitals from the International Patients in the six states of Tamil Nadu, Kerala, Karnataka, Telungana, Andhrapradesh, and Pondicherry. Data collected are compiled for the analytical purpose and the hypothesis is framed with regard to the opinion of the patients regarding various facilities and services offered and their satisfaction level towards the medical tourism services. In this present study, the Canonical Discriminate statistics was successfully employed for identifying the satisfaction over various reasons for preferring the medical tourism services in India. The outcome of the study is the classification of different groups under the satisfaction derived from the medical tourism services of four continuous variables are assigned and they are general reasons, treatment reason, cost reason, and sources reason with all 600 respondents. Findings reveal that Treatment Factor is the strong reason contributing towards the construction of low satisfaction group, followed by general reasons. The study highlights that cost is the least reason for low level satisfaction and reveals that cost of medical tourism services are nominal in India.

Co-creating a Shared Vision Post-Covid in a Health and Human Services Organisation

The global healthcare sector, deeply impacted by covid 19, faced unprecedented challenges in resilience and organisational complexity. Resilience in organisations where health and human services combined are served, especially in the disability sector, has often been less visible than that of healthcare professionals. This article explores the post-covid reconstruction of one such organisation, aiming to co-create an inspiring shared vision for a post-pandemic future.

Horizontal Inequality in Healthcare Utilisation in Rural Sabah, Malaysia

Ensuring universal access to healthcare is essential for societal equity. However, significant inequalities exist within global healthcare systems, resulting in unequal access to services and divergent health outcomes. Socioeconomic inequity, poor living conditions, and inadequate healthcare infrastructure perpetuate poor health among poor communities. Despite greater healthcare needs, economically disadvantaged populations face substantial barriers to obtaining necessary services. This research evaluates the equitable aspect of healthcare utilisation in Sabah’s rural areas to guide policy formulation. Nabawan, a rural area in Sabah with high poverty rates, was selected to assess income-related inequality and inequity in healthcare utilisation. Using the horizontal equity index and decomposition analysis, it was found that economic status significantly influences healthcare distribution, typically favouring the affluent. Central to this analysis is the concept of “equal treatment for equal need,” ensuring individuals with similar healthcare needs receive similar care regardless of economic status. Results indicate that wealthier individuals are slightly more likely to utilise healthcare services, although the difference is minimal. To address disparities, enhancing targeted financial assistance programs like PeKa B40 could reduce out-of-pocket expenses for low-income households. Additionally, increasing healthcare funding for rural infrastructure and training local healthcare workers can ensure equitable access for all households.

When western concept meets eastern culture: Exploring the impact of Confucianism on shared decision-making in China

This commentary explores how Confucian values influence shared decision-making (SDM) in Chinese healthcare, particularly in oncology. It highlights two key cultural foundations: Family Harmony and Filial Piety, which underscore the deep-rooted involvement of families in medical decision-making, often prioritizing collective decisions over individual autonomy; and Ritual Governance, which explains the cultural roots of power imbalances in healthcare relationships, where patients typically defer to the authority of doctors, and the role of nurses in SDM is limited. The paper argues that for SDM to be effectively integrated into Chinese healthcare, strategies must be adapted to align with cultural norms while encouraging patient empowerment. It also calls for a nuanced understanding of the evolving Chinese culture and emphasizes the need for global healthcare providers to develop cultural competence to better support Chinese patients, especially in the context of oncology, both domestically and internationally.

Intimal Macrovascular Pericytes: Their Role in Vascular Biology and Atherogenesis.

Atherosclerosis remains a major challenge to global healthcare despite decades of research and constant trials of novel therapeutic approaches. One feature that makes atherosclerosis treatment so elusive is an insufficient understanding of its origins and the early stages of the pathological process, which limits our means of effective prevention of the disease. Macrovascular pericytes are cells with distinct shapes that are located in the arterial wall of larger vessels and are in many aspects similar to microvascular pericytes that maintain the functionality of small vessels and capillaries. This cell type combines the residual contractile function of smooth muscle cells with a distinct stellar shape that allows these cells to make numerous contacts between themselves and the adjacent endothelial layer. Moreover, pericytes can take part in the immune defense and are able to take up lipids in the course of atherosclerotic lesion development. In growing atherosclerotic plaques, the morphology and function of pericytes change dramatically due to phagocytic and synthetic phenotypes that are actively involved in lipid accumulation and extracellular matrix synthesis. In this review, we summarize our knowledge of this less-studied cell type and its role in atherosclerosis.

Optimizing safe and sustainable public transit for wellness tourism: Southeast Asian case studies

This study presents the development of the Reinforcement-Learning Multi-Objective Artificial Multiple Intelligence System (RL-MOAMIS) framework, aimed at optimizing public transport systems specifically designed for wellness tourism in Southeast Asia. The framework is tailored to enhance the safety, sustainability, and economic viability of bus routes that connect key wellness destinations across Thailand, Laos, and Vietnam. By integrating safety and environmental sustainability principles through a mixed-integer programming model, the RL-MOAMIS framework introduces two innovative improvement methods inspired by metaheuristic operators and employs a reinforcement-learning-based approach to dynamically select enhancement strategies. The empirical results demonstrate that the RL-MOAMIS framework significantly outperforms conventional methods, such as the Genetic Algorithm and Whale Optimization Algorithm, achieving a 27.45% increase in optimization efficiency, a 15% improvement in safety metrics, and a sustainability index enhancement ranging from 7.35% to 13.48% across all routes. The findings underscore the potential of RL-MOAMIS as a comprehensive and adaptable solution for optimizing public transport in wellness tourism. These improvements not only provide safer and more sustainable transportation options but also support economic development in rapidly urbanizing regions. The implications of this study are significant for policymakers, urban planners, and tourism developers, offering critical insights for the design and implementation of public transport systems that cater to the unique demands of wellness tourism.

Relationship Between Tourists' Perceived Restorative Environment and Wellness Tourism Destinations

ABSTRACTThis study aims to determine the importance of tourists' perceptions of wellness tourism destinations and their performance based on tourists' perceived restorative environments. An empirical analysis was conducted using sample data collected through a survey with 428 tourists who have experienced wellness tourism. According to the analysis results, there were differences in the level of tourists' perception of the restorative environment. Based on these differences, tourists were subdivided into “the high‐perception group,” “the medium‐perception group,” and “the low‐perception group.” A clear difference in the importance and performance of wellness destinations considered by tourists based on clusters was also found. This segmentation based on the restorative environment can be applied to the development of tourism resource tailored to tourist characteristics.

Medical Tourism Attribute Competitiveness: An Importance–Performance Analysis

ABSTRACTThis study aimed to analyze the performance of medical tourism in Iran using importance–performance analysis (IPA). In this cross‐sectional study, five hundred ninety‐six medical tourists from West Asian countries (Iraq, Azerbaijan, Kuwait, Qatar, Bahrain, Oman, Syria, Lebanon, Oman, Saudi Arabia, and Yemen) referring to health centers to receive medical services in Iran in 2020 were recruited. A standard IPA questionnaire was used for data collection. IP gaps were negative in all three attributes (medical treatments and service attributes, destination attributes, and tourism‐specific attributes). Respondents attached the highest importance to medical treatments and service attributes. The highest IP gap was related to medical treatments and service attributes. The results highlighted that the Iranian tourism industry is not performing well in many areas. Tourism managers and stakeholders should adopt useful strategies for improving those areas with high importance and low performance.