Exploring Marketing Insights for Healthcare: Trends and Perspectives Based on Literature Investigation

Abstract

The study aims to provide a series of information that will contribute to the understanding of the concept of healthcare marketing and other associated concepts from the perspective of how research in the field has evolved. We aim to quantify the scientific interest in the field of healthcare marketing and to extract aspects that will contribute to a better understanding of the trends that characterize the specific vision of this topic. The research involves a bibliometric analysis, and the conduct of the study is based on the investigation of the academic literature from the Scopus and PubMed databases based on the PRISMA methodology. The study investigates 1077 papers published between 2000 and 2022. According to our study, the most productive countries in the field of healthcare marketing academic publications are the United States, the United Kingdom, and India. As research themes, the study revealed that customer/patient satisfaction, medical tourism, social marketing, and hospital-related marketing topics are highlighted based on cluster analysis of authors keywords. We also discuss the significant lack of research to clarify the use of the concepts such as patient/client/customer in healthcare marketing and to understand the role of prevention services as essential in sustainable healthcare.

1. Introduction

Healthcare is a major concern both on individual and community level, which makes the proper functioning of the system of providing healthcare services to be an essential pillar for the proper functioning of society itself. This fact gives the healthcare system crucial importance in the context of the sustainable development of society, becoming a priority for all constituents who are part of the system’s infrastructure, at the both national and international levels [1], as a healthy population is considered an essential contributor for the sustainable development of a country [2]. The importance of developing a sustainable healthcare system is increasingly emphasized by recent academic literature [1,3,4,5,6,7]. Understanding healthcare systems through a sustainable development approach can open up consistent directions on how marketing can contribute to achieving the goals of a sustainable healthcare system in general and of sustainable healthcare organizations in particular. The role of marketing in developing sustainable healthcare is emphasized in current research [8,9,10], but a more consistent understanding of healthcare marketing and the benefits marketing principles and values can bring to a modern health ecosystem is needed.

The market on which the organizations in the field of healthcare services operate has multiple and specific particularities, outlined by the specificity and particularities of the provider-client relations, whose content differs essentially in relation to any other service [11]. This is due partly to the difficulty of accurately establishing the demand, to the differentiated access to information for participants, to the mechanism governing the pricing rule and tariffs and the intervention of the third-party payer, the major role of the bylaw in ensuring equitable access to basic services for the population and last but not least, the ethical and moral aspects involved in the provision of healthcare services [12].

The global healthcare services industry of year 2022, dramatically influenced by the COVID-19 pandemic period, has outlined a series of trends aimed at essential changes in consumer preferences and behavior, an integrative approach of life sciences and health care, increasing evolution of digital technology in healthcare, new models of healthcare delivery, and clinical innovation [13]. Moreover, Deloitte’s vision for the future of health is defined by changes that include a shift from “health care” to “health”, where the focus will be on wellness, greater data connectivity, new secure and interconnected platforms and a higher level of customer engagement—which will redefine the health ecosystem [14]. The dynamics and development of the global healthcare services market has implicitly developed their marketing [15], and the change in society can lead to new and more inclusive healthcare markets [16], much more oriented towards the sustainable development of society. Sustainable healthcare implicates a complex approach involving economic, social, environmental components and a long-term perspective [1]. From the perspective of sustainable development, a healthcare system mainly focuses on developing the kind of framework and infrastructure that facilitates the maintaining of people’s health by empowering them to develop healthier habits and to manage their health [4], and this offers a new standpoint on the importance of prevention as part of healthcare.

Before approaching the specificity of marketing in the field of healthcare services, it is necessary to highlight that the marketing of services, as a field of study, has its own characteristics that differentiate it from the marketing specific to material goods. First of all, this fact comes from the specific characteristics of the services. From the etymological point of view, the term “service” has its origin in Latin, “servitium” designating the situation of a person in the service of another [17]. Although there is no unanimously accepted definition of services, most experts agree that there are four key characteristics that define them: intangibility, variability or heterogeneity, the inseparability of production from consumption, and perishability [18].

The field of healthcare services is characterized by a high degree of complexity, interdisciplinarity in many respects, thus becoming a separate field with specific characteristics, a sensitive area where several categories of interests intersect, both economic and social [19,20]. A special feature of the humanitarian nature of healthcare services is that patient satisfaction is important not only to support the profitability or survival of the hospital, but also to increase the efficiency, effectiveness and benefits of treatment [21]. Aspects such as well-being, happiness or quality of life are directly related to health status [22] and this fact gives additional significance to research in the field, including through the lens of the interdisciplinary and sustainable approach. The increase in the importance of healthcare marketing is directly proportional to the increase in the importance of this sector of activity for the economy and society in general, and this is also in line with the increase in healthcare marketing research [23]. Referring to the field of healthcare services, the American Marketing Association (AMA) [24] states on the association’s website (www.ama.org, accessed on 14 May 2022) that the marketing of healthcare services is designed to influence the behavior of the targeted audience in order to obtain benefits that will be reflected in their physical and/or mental health.

Although marketing has not easily found its place and role in the healthcare industry [19,25,26], recent specialty literature seems to indicate unanimity on the growing importance and benefits that marketing can bring to the field of healthcare services [22,27,28,29]. If the concept of value in marketing is generally quite difficult to define, it is much more difficult to define the concept of value when we refer to the field of healthcare services. The delicate and difficult task of defining value in the marketing of healthcare services derives from the multitude of elements that outline the needs of consumers of healthcare services and the categories of objectives of those involved in providing these services. From this perspective, value creation involves issues starting from the ethical dilemmas and emotional involvement of the patients and the healthcare providers, the requirement for existence and access to complete and timely personal and medical data, the need for the best possible syncronization between the actors involved in value creation, both organizations, medical professionals and patients [30]. A specific aspect of marketing that reflects a current trend for healthcare services refers to patient empowerment, a concept that guarantees effective self-management with effects in improving the healthcare and well-being of the target audience, respectively in the voluntary behavioral change of health [31]. Recent research highlights the role and active involvement of clients/patients in the process of value co-creation next to the healthcare providers as a premise for ensuring a sustainable healthcare system [32]. This starting point in the approach of marketing in the healthcare industry indicates from the beginning the sensitive aspects that outline this field of research. However, there is a growing interest in research on issues related to understanding and defining the concept of value in the field of marketing of health services. Value-centered marketing opens up new dimensions of approaching from the perspective of emerging technologies and analytics by proposing three key dimensions of defining value: consumer preferences based on what they consider to be important to them, precision in addressing consumer healthcare, and a consumer-oriented process [33]. Essential influences for the process of creating and co-creating value in healthcare services come from the area of digital technologies [33,34,35,36], data analysis, and big data [37,38], and blockchain, respectively [30,39].

Although more reluctantly accepted than in other industries, marketing has also made its presence needed in the field of health services in recent years, so that today it plays an important and universal role in organizations operating in this field [28,40]. Moreover, Kotler, Shalowitz, and Stevens [40] argue that marketers can play an important role in creating a better healthcare system. However, a number of characteristics, including the ethical aspects involved in the provision of health services, the specific features of the market, the particular profile of the consumer of health services, the specific behavior of buying and consuming, the perception of healthcare providers regarding who their potential customer is, the misunderstanding of the role of marketing in the life of organizations in this field [19,20], have made the use of marketing in the field of health services to have just a history of only a few decades.

A sensitive aspect is given by the differences in perception regarding what the client of the health services means and to what extent it identifies/overlaps with the concept of patient. An interesting observation, revolutionary from our point of view for the way marketing is approached in the field of health services, refers to the fact that, at the current stage, the trend in the field is to overlap, as meaning, the concepts of patient and client [40,41]. Rada [42] investigated the transition from the concept of “patient” to “client” and “customer” in the context of health services in a 1986 paper. This change in perspective is also supported by Thomas [43], in whose opinion, the reconsideration of the concept of the patient is probably the change of optics with the greatest impact produced in the field of health services in the period 1980–1990. In fact, this idea is consistent with the way the World Health Organization defines a health system that, according to this organization, includes “… all the activities whose primary purpose is to promote, restore or maintain health” (World Health Report, 2000) [44]. According to Thomas [43], not long ago, in the field of health services, it was started from the premise that a person is not a potential client of these services until the moment when they become ill and, consequently, non-patients were ignored by the providers of these services, who made no effort to develop relationships with them. However, realizing the potential of a new approach, in which any individual is a potential client through their desire to maintain their health, the organizations in the field tend to develop their services to prevention, sports or lifestyle management activities. We find this idea in line with the trend manifested since the early 90’s in the developed countries of the world, a trend that involves reorganizing the lifestyle, valuing more aspects such as family time, health, spiritual life [45]. Customer-centricity will be an essential dimension of the future health ecosystem in terms of “delivery of products, care, wellness and well-being” [14]. This paradigm shift, based on the differentiation between needs and desires in terms of health services (where the need for medical service is based on the need for treatment to recover/improve health, and the desire on the ability of the individual to choose to seek medical services without being determined by the perceived lack of health), creates the context in which marketing can fully manifest itself in this area as well. The reconsideration of the concepts of patient and/or client of health services still leaves room for analysis and research as a sensitive but important topic for the implementation of a specific marketing vision for the organizations that operate on the health services market. New approaches to marketing also target healthcare providers who have the opportunity to discover new and different marketing approaches for use in their own organizations, offering mutual benefits, including extremely important competitive advantages [28]. The number of hospitals with marketing departments has increased by 75% in recent years (2017–2020), which is partly due to the increased competitive pressure [29]. This has occurred both as a natural consequence of the fact that marketing is centered, as the main purpose and concern on the customer, the consumer, but also due to the fact that healthcare organizations are forced to operate at an optimal level due to the extreme intensity of competition and the growing needs of patients [28]. Social responsibility, together with the market orientation and the performance of the hospital, are fundamental elements on which the management of health organizations [46] creates its approach as a sustainable provider in the context of the competitive market in which it operates. Medical marketing increased substantially between 1997 and 2016, especially direct-to-consumer (DTC) advertising for prescription drugs and health services, and pharmaceutical marketing for healthcare professionals [47].

The investigation of the academic literature highlights more and more the growing interest of researchers in the analysis of the role and place of marketing in the field of healthcare services [48]. The importance of research in the field of healthcare services highlights the essential contribution of stakeholders, providers, and consumers, both to the individual and societal well-being [49]. Research on the role of marketing in improving the performance of an organization that provides healthcare services, whether in the public or private sector, highlights the importance of aspects such as: the need for customer orientation and learning-oriented cultures [50], the role of marketing technology, digital platforms and mobile apps [51,52,53], customer/patient behaviour in health services [53], the process of continuous innovation [54], customer/patients satisfaction [55,56,57], trends regarding the medical tourism [58,59]. Special attention is paid to consumer behavior in co-creating value in healthcare services [49,60,61]. In changing the behavior of the target audience in the field of healthcare services, an important place takes the aspects related to the principles and actions specific to social marketing which aims to adapt the generic framework of traditional marketing to achieve the objectives of organizations operating in the healthcare industry [1,62,63] based on a consumer-centered orientation and a voluntary attitude to change behavior [64]. Moreover, Crié and Chebat [23] consider that ”health marketing is essentially a marketing of services whose client is always a co-creator of value”.

A number of trends are highlighted in terms of field research, further classified from general trends to specific trends:

• The trend of transition from transactional marketing to relational marketing due to the possibilities offered by new technologies, but also by the need to focus on prevention and maintaining health. In this context, the patient must exist for the healthcare service provider even when they do not have a health problem that will bring them to the hospital unit. As a result, the healthcare system must constantly communicate with a consumer in order to provide them with the tools they need to self-assess their own health and to provide them with the support they need to restore the balance when necessary. An important challenge for healthcare marketing remains the specific activity of customer relationship management [22].
• The trend of transition from segment marketing to personalized marketing in the healthcare sector: This means increasing the availability of service providers to start from the premise that each patient is unique and therefore must be treated in a unique, personalized way. The providers‘ ability to do so will significantly increase the patients’ satisfaction and thus their competitive ability.
• The trend from product to experience: Given that the patient is an ecosystem whose parts interact by determining their health as well the major impact of the quality of healthcare services on meeting the needs of the Maslow pyramid, it is recommended that organizations that work in the field of healthcare services think in terms of consumer experience.
• The trend of transition from the passive patient approach to the active patient approach in the process specific to the medical act [61,65] as a result of the awareness of the benefits of patient empowerment with the healthcare provider in the process of co-creating value [32].
• The trend of increasing the availability of consumers in the use of digital tools and applications in connection with their condition and health problems and the development of the concepts of e-health and e-patient [66,67,68].
• Trends in the development of the field of “medical tourism” as a result of the internationalization and globalization of the healthcare industry [25,69].
• The trend toward a more sustainable healthcare system from an ecological, economic and social point of view [7], supported by the transition from the concept of “patient” to that of “client” of healthcare services which implies the transition from the approach based on treating health problems to prevention and maintaining health [1,4], with substantial implications in the development of a sustainable healthcare system.

All these dynamics in shaping the trends of redefining healthcare and restructuring the future health ecosystem according to the demands and needs of a new modern society must be reviewed and deeply researched. From the perspective of sustainable development, an adequate and deep understanding of marketing as an ingredient of a modern healthcare system can generate essential contributions at both theoretical and managerial levels. A thorough look at what marketing in healthcare has meant and the current trends in light of the literature can open new perspectives for specific research in the field and a new vision regarding the applicative values of marketing in healthcare. We find that the use of bibliometric analysis is very fashionable in the exploration of academic literature. However, the number of studies presenting bibliometric analyses in the sphere of health services has not yet reached the desired clarification of relevant concepts and trends. Through the present study, we aim to increase the level of knowledge of the general field of healthcare marketing, both by outlining trends and by generating more specific research directions.

2. Research Methodology

The present research is mainly descriptive in nature, as we intend to set some coordinates meant to define the general context regarding the literature review on the topic of healthcare marketing. A large volume of data is considered, and many variables are analysed to establish the pillars of the scientific literature we will investigate. Highly considered nowadays by academics, bibliometry and scientometry gained a lot of interest when it comes to investigate the scientific output included in the scientific databases. In their comprehensive article, Donthu et al. [70] discussed bibliometric analysis alongside other methods aiming at the same goal, such as meta-analysis and systematic literature reviews, emphasizing as important advantages of bibliometric analysis the possibility to handle large volumes of scientific data and the ability to generate a high-impact in research. As a consequence, bibliometric analysis can be an important form of knowledge of a field even if it is restricted to providing the most quantitative details on the production of scientific literature in that field. Considering the two main objectives, namely to evaluate the publishing activity of various scientific actors, such as researchers or academic institutions, based on productions and citations data, respectively, to evaluate the scientific approach of a specific research topic, two dimensions are indicated in the context of the bibliometric analysis: performance analysis and science mapping analysis (SMA) [71,72]. The performance bibliometric analysis aims to highlight the production and impact within a scientific area based on indicators like number of publications, number of citations, the most cited publications, number of non-cited publications, the most cited authors, research field classification, etc. [70,71,73], while science mapping bibliometric analysis highlights the relationships between the fundamental entities considered as relevant in bibliometry.

In our study we aim to investigate the interest of specialists in the way in which marketing is approached in the field of healthcare services in the light of quantitative analysis of scientific production in the field. The research aims at the two important objectives of bibliometric analysis: productivity (reflected in the number of published papers) and impact/influence (reflected in the number of citations) [74]. The research is based on a bibliometric analysis of healthcare marketing studies. Systematic reviews and statistical methods have an increasingly important role to play in the field of healthcare. Their value depends on what was done, what was found, and the clarity of reporting [75].

The research questions considered as relevant for the current study are:

Q1. How has the research in the field of healthcare marketing evolved during the last two decades?

Q2. Which are the countries with the highest scientific output in the field of healthcare marketing?

Q3. Which are the leading journals in healthcare marketing literature based on scientific productivity and impact?

Q4. Which are the most relevant topics approached in the healthcare marketing literature?

To ensure the credibility of the results generated by such research, the first step is to choose the most suitable data sources for the research area [71]. A consistent bibliometric analysis involves choosing the most appropriate database combination that should be considered to provide conclusive results. The opinions of the specialists vary when it comes to choosing the most appropriate databases for bibliometric analyzes specific to various fields. For the field of marketing, among the existing databases are considered especially the Web of Science (WoS) [76,77,78] and Scopus [79,80,81]. Based on previous research in the field of healthcare in general and healthcare marketing in particular, we considered SCOPUS and MEDLINE/PubMed databases [48,82,83,84] as representative for the study.

2.1. The Paper Selection Process

The process of data selection to be included in our study was based on the PRISMA methodology. The PRISMA methodology offers the benefits of increased transparency and minimization of bad reporting in the way the review is managed [48]. The PRISMA methodology helps researchers to improve the reporting of systematic reviews and analyzes based on statistical methods. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) methodology, designed for reporting the systematic reviews [75], is frequently used in papers on literature review analysis (e.g., [48,77,85,86,87]). Based on these considerations, in our research we used the PRISMA methodology. Inclusion and exclusion criteria are presented in

Table 1. Inclusion and exclusion criteria.

Inclusion Criteria	Exclusion Criteria
It must explore at least one topic related to healthcare marketing reflected by the title or the abstract of the paper;	Papers containing the terms “marketing” and “healthcare” in authors’ keywords section but in reality the papers main topic was about something else;
Papers released between 2000 and 2022;	Book, book chapter, letter, conference review, editorial, note, short survey;
Jurnal and Conference Proceedings;	Papers that focused mainly on health topics, but also mentioned the word marketing.
The papers are written in English

and the Flow Diagram in Figure 1. The PRISMA framework has been designed to reflect the data selection on which the study was performed, the number of included and excluded papers can be found for every step.

2.2. The Searching Algorithm

An essential step in ensuring the veracity of a bibliometric analysis is the selection of papers of interest to the subject. After investigating a number of papers related to similar topics (e.g., [48,88]) we initially considered the following terms as significant for the search and have developed the following searching algorithm: “healthcare marketing” OR “medical marketing” OR “health-care marketing” OR “marketing of health services” OR “marketing of medical services”. Thus, from the Scopus database, a number of 14,180 results were obtained. Through a refinement of the terms searched, we chose (healthcare AND marketing) OR (marketing AND “medical services”) and we got 4983 results. To filter the results, we used Year: 2000–2022; Document type: Paper, Review and Conference Paper; Source Type: Jurnal and Conference Proceeding; Subject Area: Medicine, Business, Management and Accounting, Social Sciences, Health Professions, Economics, Econometrics and Finance, Computer Science; Language: English, thus obtaining a number of 1819 results. Moreover, after excluding the inconclusive journals for the healthcare marketing field, we obtained 1713 results. The next stage was to download the bibliographic records from SCOPUS based on the previously described searching algorithm. The application of the search algorithm generated a substantial number of papers that had as predominant subject components related to the medical field. Therefore, the papers were analyzed based on keywords and abstract information, eliminating the results that were not of interest for the present study. After an analysis of the title, keywords, and abstract, 645 papers were excluded for reasons, such as lack of information on healthcare marketing.

Due to the fact that our research covers the field of healthcare services, we considered it relevant to collect data from the PubMed database as well, data that we later added to the previously obtained database. For the initial query we used the words (“healthcare marketing” OR “medical marketing” OR “health-care marketing” OR “marketing of health services” OR “marketing of medical services”) and we got 13,226 results. By refining the search and filtering the results we obtained 534 results for the period 2000–2022. In this case, too, we conducted an analysis of the title, abstract, and keywords, and 448 papers were excluded for reasons such as lack of information on healthcare marketing. By adding the 86 selected papers from the PubMed database to the papers obtained by querying the Scopus database (1068), 1154 papers were obtained. Finally, after removing the duplicates, a total of 1077 papers were considered for our research, in the Scopus and PubMed databases. The SCOPUS and PubMed databases were queried in March 2022. The literature indicates a number of software applications recommended for bibliometric analysis [71,89,90]. In order to achieve the objectives of the study, VOSviewer software was used for data processing and ensuring the aspects related to the presentation of data were arranged in an intuitive graphical manner, completed by the EXCEL and WordStat software applications.

3. Results

3.1. Annual Productivity: Number of Publications by Year (2000–2022)

A first starting point for assessing the academic world’s interest in healthcare marketing is to analyze the trend in the number of papers published over time. The evolution of the number of publications is a relevant indicator for understanding the trends of the scientific research area [88]. Figure 2 shows the annual trends in publications on healthcare marketing topics from 2000 to 2022, generated from the selected papers for research.

Between 2000 and 2017, there is a slightly increasing trend in the number of published papers that contain references to topics in the “healthcare marketing” category, but starting with 2018, the trend of increasing the number of papers in this category is more pronounced. In particular, 345 (32.03%) of papers were published between 2018 and March 2022. This study has been conducted in 2022, the papers indicated for 2022 are those published in only the first part of the year. The largest number of published papers was in 2020, accounting for 9.37% of all considered scholarly papers.

The 5-year analysis also indicates a growing interest in healthcare marketing in the academic literature (

Table 2. Number of papers published in 5-year intervals.

5 Years Range	Number of Papers Published	Increase Compared to the Previous Period (%)
2000–2004	142	-
2005–2009	202	+42.25
2010–2014	235	+16.33
2015–2019	304	+29.36
2020—March 2022	194	Not Available
Total	1077	-

). It can be noted that there is a 42% increase in the number of works from 2005–2009 compared to the previous interval. The growth trend continues even if the growth rate is not as high.

3.2. Country Productivity: Number of Publications by Country

Table 3. Number of publications in coauthorship by country (2000–2022).

Country	Number of Papers	% of Total (1077)
United States of America	410	38.07%
United Kingdom	89	8.26%
India	64	5.94%
Australia	53	4.92%
Romania	30	2.79%
Canada	28	2.60%
Malaysia	28	2.60%
Taiwan	27	2.51%
Italy	26	2.41%
China	19	1.76%
Germany	18	1.67%
Sweden	17	1.58%
Netherlands	16	1.49%
Iran	15	1.39%
Total	840	77.99%

shows the countries that produced the most papers in the field of our research, according to the database generated by the search algorithm in the SCOPUS and PubMed databases. Together, they represent 77.99% of the total number of papers published. The United States is the country with the highest number of published papers (410 papers, 38.07% of the total number of papers in our dataset), followed by the United Kingdom (89 papers) and then India (64 papers), Australia ranked 4th (53 of papers), and Romania in 5th place (30 papers). The top three countries represent more than half (52.27%) of the total number of papers included in our dataset.

A visual representation of the situation that reflects the countries from which the authors of the selected papers come is presented in Figure 3.

The cluster of countries United States of America, United Kingdom, and India are in evidence. This is because these countries have the most published papers (563 papers), representing 52.27% of the total papers selected for research. In Figure 3, the lines indicate coauthorship between countries, and the distance between clusters indicates how much these countries publish in co-authorship.

3.3. Journal Productivity: Number of Publications by Journal (2000–2022)

The papers selected for the research were published in 501 journals. Depending on the number of papers published in a journal, we grouped the journals into six categories (

Table 4. Number of papers published by journal category.

Journal Category	Number of Journals	%
1 published paper	339	67.67%
2 published papers	88	17.56%
3 published papers	27	5.39%
4 published papers	15	2.99%
5 published papers	6	1.20%
more than 5 published papers	26	5.19%
Total	501	100%

).

Most of the journals (67.67%) contain only one paper related to the researched topic. This indicates that these journals are not from the healthcare marketing area but, in the context of the main topic of the journal, they also included papers that addressed topics in the healthcare marketing category. In Figure 4 we presented the journals that published more than 5 papers (5.19%) related to the researched topic. According to the selection made in our study, the journal with the most papers published in the healthcare marketing area is Health Marketing Quarterly (59 papers), followed closely by the journal International Journal of Pharmaceutical and Healthcare Marketing (54 papers).

In

Table 5. Top 10 journals in terms of the number of papers published.

Journal	Number of Papers Published	% of 1077
Health Marketing Quarterly	59	5.48
International Journal of Pharmaceutical and Healthcare Marketing	54	5.01
International Journal of Healthcare Management	26	2.41
Journal of Medical Marketing	25	2.32
BMC Health Services Research	23	2.14
Journal of Medical Marketing: Device, Diagnostic and Pharmaceutical Marketing	23	2.14
International Journal of Health Care Quality Assurance	21	1.95
Journal of medicine and life	16	1.49
Journal of Services Marketing	14	1.30
Journal of Hospital Marketing and Public Relations	12	1.11
Total	273	25.35%

, we present the first 10 journals, in terms of the number of papers published in the field of interest of our research.

As it can be seen in Table 5, the top 10 journals published 273 papers together, representing 25.35% of the total papers taken into account in the research conducted. Even if the research context is different (significant differences concern the search algorithm, the scientific databases and journals considered etc.), the results reflected by the fact that Health Marketing Quarterly is the most productive journal in the field of healthcare marketing are in line with the results from Butt, Iqbal, and Zohaib study [91] on a similar topic. The International Journal of Pharmaceutical and Healthcare Marketing and International Journal of Healthcare Management complete the top three most productive journals according to our research.

3.4. Journal Impact: Top Journals That Have Published the Most Cited Papers (Including Journal Characteristics)

Of the 501 journals identified, 98 journals contain publications that have no citation to date.

Table 6. Top journals that have published the most cited papers, including the journal’s characteristics.

Rank by Total No of Citation	Journal Name	Scopus Coverage Years	Total No. of Citations	Average No. of Citations/Year	Rank by No. of Citation/Year	2020 CiteScore according to SCOPUS	2020 SNIP according to SCOPUS	2020 Scimago Journal Ranking
1	International Journal of Health Care Quality Assurance	from 1988 to Present	1135	101.3	(1)	2.1	0.716	Q2 (Business, Management and Accounting: Business, Management and Accounting (miscellaneous))
2	Journal of Services Marketing	from 1987 to Present	813	66.65	(4)	5.9	1.530	Q1 (Business, Management and Accounting: Marketing)
3	Journal of Service Research	from 1998 to Present	805	89.80	(2)	14.01	3.968	Q1 (Business, Management and Accounting)
4	Annual Review of Public Health	from 1980 to 2020	700	44.52		23.5	8.467	Q1 (Public Health, Environmental and Occupational Health)
5	International Journal of Pharmaceutical and Healthcare Marketing	from 2007 to Present	691	87.16	(3)	1.3	0.634	Q3 (Business, Management and Accounting: Marketing)
6.	Health Marketing Quarterly	from 1983 to Present	682	54.96		0.9	0.455	Q3 (Business, Management and Accounting: Marketing)
7	BMC Health Services Research	from 2001 to Present	522	59.92	(5)	3.5	1.445	Q1 (Medicine: Health Policy)
8	Journal of Business Research	from 1973 to Present	504	67.63		9.2	2.852	Q1 (Business, Management and Accounting: Marketing)
9	Journal of the Academy of Marketing Science	from 1973 to Present	314	48.11		17	4.963	Q1 (Business, Management and Accounting: Marketing)
10	Journal of Health Communication	from 1996 to Present	260	24.89		3.5	1.348	Q1 (Social Sciences: Communication)

shows the top 10 journals with the highest impact, evaluated based on the analysis of citations for published articles. For each journal 3 quality indicators of the journal are mentioned in the table: CiteScore, SNIP (Source Normalized Impact per Paper) and SJR (SCImago Journal Rank) [92]. These citation indicators are benchmarks used to assess the quality of journals indexed in Scopus [93,94]. SCImago Journal Rank (SJR) is defined as a prestige metric “that weights the value of a citation based on the subject field, quality and reputation of the source” (Elsevier, n.d. [95]). The value of SJR indicates how prestigious an academic journal is by classifying it in one of the four categories: Q1, Q2, Q3, and Q4, where Q1 is the most prestigious category, Q2 follows it in terms of prestige, and so on [93]. According to the bibliometric indicators presented in the table, it is obvious that all the academic journals in the top 10 are leading journals of the investigated research field. 7 of the first 10 journals ranked according to the total number of citations are included in the first category of journals, identified as being in the Q1 category. In terms of the total number of citations collected, the top five impact journals evaluated in terms of citations are: International Journal of Health Care Quality Assurance, Journal of Services Marketing, Journal of Service Research, Annual Review of Public Health, International Journal of Pharmaceutical and Healthcare Marketing. Another impact assessment of the journals took into account the fact that the journals were launched at different times and, implicitly, those with a longer existence accumulated a higher number of citations for the published papers over time. Consequently, we considered it appropriate to calculate the indicator Average no. of citations/year. This indicator reports the number of citations of a publication to the number of years since the paper was published. Based on this indicator, the top three impact journals for the healthcare marketing field are: International Journal of Health Care Quality Assurance, Journal of Service Research and International Journal of Pharmaceutical and Healthcare Marketing.

3.5. Most Significant Papers Based on the Number of Citations

The algorithm used to identify the papers that address the topic of marketing in the field of healthcare services has led to the selection of over 1000 papers. Overall, the papers can be grouped into two major categories, one category of papers that mainly addresses the topic of marketing with application to the field of healthcare services, and another category that mainly addresses the healthcare services but also refers to marketing-related topics. The top 10 papers, ranked according to the number of citations, which address specific topics in the marketing of healthcare services are presented in

Table 7. Top 10 most cited papers centered on healthcare marketing topics.

	Title	Authors	Year of Publication	Journal	Total Citation	Average Citation/Year	Authors Keywords/Index Keywords
1	Health Care Customer Value Cocreation Practice Styles	McColl-Kennedy J.R., Vargo S.L., Dagger T.S., Sweeney J.C., van Kasteren Y.	2012	Journal of Service Research	588	58.80	coproduction; health care; practice styles; value; value cocreation
2	Social marketing in public health	Grier S, Bryant CA.	2005	Annual Review of Public Health	563	33.12	Audience segmentation; Consumer orientation; Consumer research; Evaluation; Theory
3	Customer loyalty to content-based Web sites: The case of an online health-care service	Gummerus J., Liljander V., Pura M., Van Riel A.	2004	Journal of Services Marketing	250	13.89	Customer loyalty; Customer services quality; Health services; Internet; Trust
4	Factors affecting patient satisfaction and healthcare quality	Naidu A.	2009	International Journal of Health Care Quality Assurance	231	17.77	Customer satisfaction; Health services; Performance monitoring; Quality management
5	Customer Effort in Value Cocreation Activities: Improving Quality of Life and Behavioral Intentions of Health Care Customers	Sweeney J.C., Danaher T.S., McColl-Kennedy J.R.	2015	Journal of Service Research	217	31.00	activities; customer effort; customer effort in value cocreation activities; health care; hierarchy; participation; quality of life; resource integration; satisfaction; value cocreation
6	What is known about the patient’s experience of medical tourism? A scoping review	Crooks V.A., Kingsbury P., Snyder J., Johnston R.	2010	BMC Health Services Research	216	18.00	attitude to health; …; Marketing of Health Services; Medical Tourism; Patient Preference; Patient Satisfaction
7	Modeling the impact of internet atmospherics on surfer behavior	Richard M.-O.	2005	Journal of Business Research	183	10,76	Atmospherics; Healthcare marketing; Internet; Model; Structural equations
8	A critical review of patient satisfaction	Gill L., White L.	2009	Leadership in Health Services	174	13.38	Australia; Customer satisfaction; Health services; Patients; Quality management
9	Integration of standardization and customization: Impact on service quality, customer satisfaction, and loyalty	Kasiri L.A., Guan Cheng K.T., Sambasivan M., Sidin S.M.	2017	Journal of Retailing and Consumer Services	170	34.00	Customer loyalty; Customer satisfaction; Customization; Malaysia; Service quality; Standardization
10	Customer positivity and participation in services: An empirical test in a health care context	Gallan A.S., Jarvis C.B., Brown S.W., Bitner M.J.	2013	Journal of the Academy of Marketing Science	170	18.89	Broaden-and-build theory of positive emotions; Customer participation; Customer satisfaction; Professional services; Service quality; Value co-creation

.

3.6. Keyword Co-Occurrence Analysis

An important objective of the study is the analysis of the most frequently used keywords that appear in the papers that are part of the sample. A first keyword analysis led to the identification of 2660 keywords in 1077 papers analyzed. Of these, 2213 keywords appear only once and represent 83.19% of all keywords. A total of 32 keywords have at least 10 occurrences (1.2%). The top 10 keywords identified in the list of keywords indicated by the authors are shown in

Table 8. Top 10 keywords.

	Main Keywords *	Occurrences	Percent of Total Keywords
1	healthcare marketing	65	2.44%
2	patient/customer satisfaction	48	1.80%
3	hospitals	43	1.62%
4	medical tourism	39	1.47%
5	social marketing	35	1.32%
6	health services	27	1.02%
7	social media	26	0.98%
8	marketing strategy	26	0.98%
9	internet	25	0.94%
10	pharmaceutical industry	24	0.90%

* words with similar meanings have been grouped.

. We did not take into account the terms “healthcare” and “marketing”, considering them to be general terms, used in the search algorithm and which, implicitly, were the terms with the most occurrences (“healthcare” and “health care”—142 occurrences, “marketing”—92 occurrences”).

As the study also aimed at identifying general topics addressed in the articles, we used a thesaurus file for merging keywords with similar meanings. Subsequently, the grouping of the keywords by cluster analysis generated the map shown in Figure 5. As a result, a total of four clusters was generated, centered around the following keywords: cluster one with the main keyword “patient/customer satisfaction”, cluster two main keywords “healthcare marketing”, “medical tourism” and “social marketing”, cluster three main keywords “hospitals” and “health services”, and cluster four main keyword “marketing strategy”.

Another useful analysis for the objectives of the study in terms of keywords is the one that shows the evolution over time of the appearance of the keywords in the papers included in the sample. Figure 6 indicates that the papers in recent years have addressed topics that have referred to the terms “COVID-19”, “value co-creation”, “social media” or “big data”. Papers on medical tourism are also relatively recent papers. The term “medical tourism” appears in a significant number of papers included in the sample. This is a topic of interest to authors who focus on healthcare marketing in their papers.

The analysis of the keywords indicated by the authors was completed with the analysis of the titles of the selected papers in the database (Figure 7). The WordStat (Provalis Research) [96] application was used for this analysis. The analysis of the titles of the papers in the database shows that the most common phrases in the titles are “social marketing” (41 appearances) and “medical tourism” (40 appearances), followed by “healthcare services” and “healthcare marketing” with 38 and 37 appearances, respectively. “Patient satisfaction” appears in the title of 30 of the analyzed papers, and “customer satisfaction” in 10.

4. Discussion

An important goal we pursue in our study is to gain an improved perspective on how marketing is perceived in healthcare services. Starting from the premise that an exhaustive and in-depth analysis of the researched subject implies an approach in which the results of the quantitative research are corroborated with the results of a qualitative research, we still consider that the quantitative results generated based on the bibliometric analysis can establish benchmarks for shaping the framework for new qualitative research with perspectives to bring even more relevance to the investigated field, especially from the perspective of sustainable development. Analyzing the literature publications on the research topic, we can conclude that the number of articles on the bibliometric analysis of the scientific literature in healthcare marketing is reduced. This situation is partially explained by the fact that the approach of marketing in the field of healthcare services has a relatively recent history. We believe that such research can contribute to a better understanding of how marketing activity has been perceived in the context of healthcare services and can contribute to the opening of new perspectives for the analysis of topics specific to marketing in healthcare services, focused on sustainable healthcare approach. In this study we are trying to extract essential ideas regarding the evolution of research and academic approaches in the field of healthcare marketing. Following the main directions of analysis specific to bibliometric analyses, the study aims at analyzing the scientific productivity and the impact of the specialized literature related to the subject approached. Thus, 1077 papers published between 2000 and 2022 in the PubMed and SCOPUS databases were selected for our research.

The results of the study show that scientific productivity on topics related to healthcare marketing places the United States of America in the first place (over 30% of authors come from the USA), followed by the United Kingdom and India. Regarding the evolution over time of the number of papers published in the field of healthcare marketing related topics, the year 2018 indicates a time when the number of papers began to increase, the trend continuing until now. Based on the study, the results indicate that the top 3 most productive journals with papers on healthcare marketing are Health Marketing Quarterly, International Journal of Pharmaceutical and Healthcare Marketing and International Journal of Healthcare Management. From the point of view of the total number of citations collected, the top five impact journals evaluated in terms of citations are: International Journal of Health Care Quality Assurance, Journal of Services Marketing, Journal of Service Research, Annual Review of Public Health, International Journal of Pharmaceutical and Healthcare Marketing. Moreover, the study indicates that most journals (67.67%) contain only one paper related to the researched topic. We take this as an indicator that these journals are not from the healthcare marketing area but, in the context of the main topic of the journal, also included papers that addressed subjects in the healthcare marketing category. In the context of the analysis of keywords indicated by the authors, based on cluster analysis and the clusters generated using VOSviewer, we identified that research topics centered on customer/patient satisfaction, medical tourism, social marketing and hospitals stand out as important research topics for the papers analyzed. Most of the top 10 most cited articles on healthcare marketing topics—according to our study, frequently include the concept of “customer” (not patient) in the Author Keywords/Indexed Keywords or Title sections. The study also indicates that the papers in recent years have addressed topics that have referred to the terms “COVID-19”, “value co-creation”, “social media” or “big data”. Papers on medical tourism are also relatively recent papers. On the other hand, from the perspective of sustainable development, no clear research themes were identified in this activity sector, which shows us that this field is waiting to be explored more and more.

The lack of research on prevention as a core topic in healthcare marketing is an indicator of the idea that, to date, little research has discussed healthcare marketing from a sustainable development point of view.

The role of prevention in healthcare services gains increased importance in the context of sustainable healthcare and sustainable development of society. However, according to our results, the research on this topic is not yet at its level of importance. More than that, there is a lack of research on the role of marketing in developing sustainable healthcare strategies.

Health is a major concern for individuals, organizations and society as a whole. However, the field of healthcare services is understudied in many countries. Our study, based on the quantitative analysis of scientific production, reveals an increase in the interest of specialists in the field in a few countries. Even so, the role of marketing in healthcare remains undervalued and insufficiently understood by healthcare professionals/practitioners. The study aims to complete the knowledge in the field through the lens of the marketing vision. However, in the future, the specialists will need to expand research in healthcare marketing to bring more clarity to the understanding of the role of marketing for both healthcare professionals/practitioners and organizations involved in this process. On the other hand, we emphasize that the new perspective offered by sustainability-focused thinking opens both new research directions and managerial implications for organizations operating in the healthcare field. Sustainable healthcare is a practical aspiration, not just a theoretical vision. Even if there is still a long way to go, we believe that marketing can have an important say in achieving the goals of a sustainable healthcare system, both through the lens of macromarketing thinking, which aims at the well-being of society as a whole, as well as at the level of marketing strategies of healthcare organizations. Both for the organizations that develop health policies and for the management of healthcare organizations, the development of viable marketing strategies for sustainable healthcare is based on understanding the trends in the field and the generation of suitable research topics for the current period.

5. Conclusions

In the context of the dynamics of the healthcare services industry, of the market orientation tendency of the organizations active in this field, marketing defines an increasingly clear place. Research in the field highlights the role of marketing in increasing the performance of healthcare organizations. The trends manifested in the marketing of health services are determined both by the general marketing trends and by the specific evolutions of this sector of activity, by the technological, economic, social, and environmental challenges, but also by the sustainable development trends shown at the level of healthcare services management.

The research perspectives in the field of healthcare marketing are numerous and necessary to eliminate the possible ambiguities that could call into question the benefits that marketing concepts and theories can bring to organizations that provide healthcare services. In order to establish the current situation and the interests of the academic environment for the field of healthcare marketing, bibliometric analysis is a research method that can bring greater clarity and understanding of the trends in the approach of the investigated field.

The re-evaluation and rethinking of the use of marketing tools in the activity of organizations operating in the health services market is still an important research topic, which has not reached the stage where all dilemmas and ambiguities are solved. Research in the field is still needed to make conceptual clarifications. However, the approach and use of marketing theories, concepts, and tools must take into account the specificity and the sensitive aspects of this field so as to avoid situations in which an inappropriate use of marketing tools negatively affects the confidence of consumers (or patients) in the organizations providing healthcare services, respectively of the healthcare system as a whole. A major research topic remains the clarification of the use of patient/client/consumer concepts so that a new possible approach to terms can bring benefits to the understanding of the role of marketing for healthcare providers. Surprisingly, according to our research, the topic of prevention and the sustainable development does not stand out as a central research topic in the field of healthcare marketing. However, we consider that it remains a topic of interest that could open perspectives for defining segmentation criteria for the healthcare services market. Therefore, we consider that there is a significant lack of research to clarify the use of the concepts such as patient, client, and customer in healthcare marketing and to understand the role of prevention services and sustainable development as an essential part of healthcare services provided by organizations in the field. At the same time, the present study highlights considerable research interests related to customer/patient satisfaction, medical tourism, and technology and digital applications in assessing health status.

Although the results of the research present a number of benchmarks that can contribute to a better understanding of research productivity and impact in the context of healthcare marketing and open perspectives for future studies, it should be noted that this study should be evaluated in the context of its limitations. One of the important limitations is that the sample of papers considered was selected only from the SCOPUS and PubMed databases. This led to the disregard of some relevant papers in the field but which are found only in other important databases.

We consider that similar research carried out by selecting papers from other leading databases, such as Web of Science, Google Scholar, etc., could generate different results from certain points of view. However, the comparison of such results could contribute to a better understanding of the field under investigation. Second, removing papers from the results originally generated, based only on titles, keywords, and in some cases the abstract text, could lead to the retention of papers in the database that are not significantly relevant to understanding the field.