Antecedents and outcomes of health risk perceptions in tourism, following the COVID-19 pandemic

Abstract

The purpose of this paper is to clarify the concept of perceived risks, identify the main antecedents and outcomes of health risk perceptions and propose a conceptual model of health risk perceptions in tourism.

Design/methodology/approach
This paper provides a review of the literature on customer risk perceptions, along with their antecedents and outcomes, and proposes a conceptual model of health risk perceptions in tourism.

Findings
Key findings reveal that the main factors of health risk perceptions can be broadly classified into cognitive, affective, individual and contextual components. The proposed conceptual model of health risk perceptions provides a theoretically integrated overview of relationships between all groups of factors, tourists’ risk perceptions and travel intentions.

Originality/value
The paper contributes to theory by offering a new approach to health risk perceptions in tourism, which remain underexplored in previous studies. The literature review adds to the body of knowledge by introducing four main groups of factors affecting tourists’ health risk perceptions, while the conceptual model proposes relationships between these factors, tourists’ risk perceptions and travel intentions.

Full text

Antecedents and outcomes of health risk perceptions in tourism,
following the COVID-19 pandemic
Maksim Godovykh, Abraham Pizam, and Frida Bahja
University of Central Florida
Abstract
Purpose
The purpose of this paper is to clarify the concept of perceived risks, identify the main antecedents and
outcomes of health risk perceptions, and propose a conceptual model of health risk perceptions in
tourism.
Design/methodology/approach
This paper provides a review of the literature on customer risk perceptions, along with their antecedents
and outcomes, and proposes a conceptual model of health risk perceptions in tourism.
Findings
Key findings reveal that the main factors of health risk perceptions can be broadly classified into
cognitive, affective, individual, and contextual components. The proposed conceptual model of health risk
perceptions provides a theoretically integrated overview of relationships between all groups of factors,
tourists’ risk perceptions, and travel intentions.
Originality/value
The paper contributes to theory by offering a new approach to health risk perceptions in tourism, which
remain underexplored in previous studies. The literature review adds to the body of knowledge by
introducing four main groups of factors affecting tourists’ health risk perceptions, while the conceptual
model proposes relationships between these factors, tourists’ risk perceptions, and travel intentions.
Keywords: risks; risk perceptions; tourism; health; COVID-19; travel intentions.
To cite this article:
 Godovykh, M., Pizam, A., & Bahja, F. (2021). Antecedents and outcomes of health risk
perceptions in tourism, following the COVID-19 pandemic. Tourism Review.
https://doi.org/10.1108/TR-06-2020-0257

Introduction
Tourists’ risk perceptions have been described as one of the major factors of decision making
and behavioral intentions (Artuger, 2015; Hasan et al., 2017; Wolff et al., 2019). Although the
COVID-19 pandemic significantly changed the tourism and hospitality industry through travel
restrictions in different countries and regions worldwide, tourists’ behavior after reopening
depends on their perceptions of safety and risks associated with various travel activities
(Dryhurst et al., 2020; Wen et al., 2020). Risk perceptions, however, are different from real
risks. Whereas real risks are traditionally characterized by uncertainty about the effects of the
activity and probability of outcomes in question (Kahneman and Tversky, 2013; Schmidli,
2017), perceived risks are related to an individual’s subjective perceptions, which are influenced
by multiple social, cultural, and contextual factors based on personal judgments, attitudes,
experiences, and feelings (Brown et al., 2018; Pidgeon, 1998; Ropeik, 2011). As a result,
perceived risks might influence people’s attitudes, decisions, and behavior even if the real risks
are minimal (Cakar, 2020; Quintal et al., 2010; Reichel et al., 2007). Conversely, unperceived
risks will not have any effect on people’s behavior even if the risks are real, significant, and
tangible.
People’s perceptions about risks also depend on their individual differences, including
personality traits, gender, culture, and prior experience (Dryhurst et al., 2020; Menon et al.,
2006). While some people strictly follow government guidelines and generally accept rules of
isolation, social distancing, and sanitation, others ignore these norms due to differences in
perception of health-related risks, which vary by groups and individuals (Cori et al., 2020).
Furthermore, various cognitive, affective, individual, and contextual risk factors might interact
with each other and exert different effects on tourists’ behavioral intentions. The purpose of this
paper is to discuss the concepts of health risk perceptions in tourism, identify the main
antecedents and outcomes of health risk perceptions, propose a conceptual model of health risk
perceptions in tourism, and call for a further investigation of the impacts of different factors of
health risk perceptions on tourists’ behavior during the COVID-19 pandemic and other disease
outbreaks.

The concept of risk perceptions
The majority of risk perceptions studies originated from the fields of risk management and
behavioral finance (e.g., Hoffmann et al., 2013; Hopkin, 2018; Kahneman and Tversky, 2013),
which describe risks in terms of uncertainty, severity, and the probability of negative outcomes
(Loewenstein et al., 2001; Slovic, 2016). Risk perceptions were also presented as important
determinants of customer attitudes and behavior in consumer behavior studies (Hasan et al.,
2017). In a broader context, risk perceptions can be defined as people’s subjective judgments
about risk characteristics and severity (Cui et al., 2016).
Categories of risk perceptions traditionally included financial, political, social, psychological,
and physical (Hasan et al., 2017), while several studies further introduced property risks, health
risks, security risks, facilities risks, value risks, moral hazards, weather risks, and other types of
risks (Cui et al., 2016; Li, 2010; Liu and Gao, 2008). It is often difficult to clearly differentiate
between such categories, as physical risks might influence psychological and social risk
perceptions. For this reason, measuring risk perceptions as a multi-dimensional construct became
popular in marketing, consumer behavior, and tourism literature (Hasan et al., 2017).
Risk perceptions in tourism
In contrast with economic and psychological research, tourism studies apply distinct
explanations of risk perceptions, mostly associated with tourists’ fear, anxiety, worry, and
nervousness (Fuchs et al., 2013; Reichel et al., 2007; Wolff et al., 2019). Tourists’ concerns
about financial and security risks are abundant in the tourism and hospitality literature (Fuchs
and Pizam, 2011; Pizam et al., 1997; Quintal et al., 2010), while a minority of studies described
other categories of tourists’ risk perceptions such as security (Liu and Gao, 2008), property loss
(Dolnicar, 2005), crime (Maser and Weiermair, 1998), terrorist attacks (Law, 2006), and natural
disasters (Fuchs and Reichel, 2011). Among the other previously discussed factors influencing
tourists’ risk perceptions and travel avoidance were negative media coverage (Brown, 2015),
susceptibility (Cahyanto et al., 2016), destination image (Carter, 1998), novelty preference (Lepp
and Gibson, 2003), and cultural characteristics (Kozak et al., 2007).
A number of studies explored tourists’ risk perceptions as an important determinant of travel
intentions and avoidance of potentially dangerous destinations (e.g., Casidy and Wymer, 2016;
Cooper, 2006; Khan et al., 2019). Common findings from the previous research yielded a

negative correlation between risk perceptions and tourists’ behavioral intentions. It was reported
that higher levels of perceived risk evaluations led to lower levels of satisfaction, loyalty, attitude
toward a destination, and visit intentions (e.g., Casidy and Wymer, 2016; Hasan et al., 2017;
Roehl and Fesenmaier, 1992). Health risk perceptions, however, have not received much
attention in previous tourism research.
Health-related risk perceptions
Tourism has been previously described as one of the major factors in contagious disease
transmission (Hall, 2006). The mobility of international tourism can introduce new infectious
diseases to world populations, and tourists might bring unfamiliar pathogens from remote areas
to their home countries (Richter, 2003). Among the previously described health-related risks in
tourism are HIV, schistosomiasis, Legionnaires’ disease, sexually transmitted infections, SARS,
and COVID-19 (e.g., Bauer, 2007; Jonas et al., 2011; Joseph et al., 1996; McKercher and Chon
2004; Schwartz et al., 2005). While several empirical papers examined the effects of global
health issues on travel intentions (e.g., Nazneen et al., 2020; Wen et al., 2020), their results
describe the impact of the pandemic on attitudes toward different types of travel without
specifying the nature and relative importance of various factors affecting tourists’ perceptions.
Most health studies in tourism describe tourists’ visit intentions in medical tourism settings (e.g.,
Collins et al., 2019; Dryglas and Lubowiecki-Vikuk, 2019; Medhekar et al., 2020; Rahman,
2019).
Notwithstanding, several previous studies reported the influence of tourists’ health-related risk
perceptions on travel behavior during the previous SARS outbreak, as well as the significant
effects of cultural dimensions, previous experience, and perceived control (e.g., Jonas et al.,
2011; Kozak et al., 2007; Rittichainuwat and Chakraborty, 2009). These findings, together with
theoretical insights from psychology, medicine, and risk research, can be used as a benchmark
for developing a conceptual model of health risk perceptions in tourism. Previous explanations of
health risk perceptions include factors such as people’s knowledge and understanding of the
disease, personal experience, trust, and cultural values, as well as demographic, cultural, and
personality characteristics (Prati and Pietrantoni, 2016; van der Linden, 2015; Zambrano-Cruz et
al., 2018). These factors can exert a great influence on tourists’ behavior than the disease itself

(Cooper, 2006; McKercher and Chon, 2004). Therefore, it is important to identify the
antecedents of health risk perceptions in tourism and ascertain their effects on tourists’ behavior.
Antecedents of risk perceptions
Numerous factors of risk perceptions were identified and described in previous studies (Table 1).
The first group of factors is related to tourists’ trust in tourism providers, governmental officials,
healthcare institutions, and knowledge about the risk. For instance, trust significantly affected
tourist behavior during the COVID-19 pandemic period, and it is anticipated that regaining trust
in these institutions will be a long time in coming after the COVID-19 pandemic (Cori et al.,
2020; Slovic, 2000). Tourists’ knowledge about risks also affects risk perceptions (Ropeik,
2011). Unknown risks are usually perceived as more frightening than known ones. In the case of
SARS and the COVID-19 pandemic, the fear of new and unknown viruses, coupled with
contradictory information about origin and outcomes, had significant negative effects on tourists’
perceptions, attitudes, and behavioral intentions. Knowledge about risks is mostly formed
indirectly via the media or word of mouth. In turn, media affects risk perceptions through the
valence, amount, and tone of the coverage, the trustworthiness of the information sources, and
the applied frames for presenting risks (McCarthy et al., 2008). As an illustration, Oh et al.,
(2015) explored perceptions of H1N1 influenza risks in South Korea and found that news
coverage and entertainment media had significant effects on various dimensions of risk
perceptions.
Table 1
Antecedents of risk perceptions.
Authors
Factors
Block and Keller (1995)
Positive and negative affect.
Carter (1998)
Destination image.
Slovic (2000)
Perceived lack of control, dread, catastrophic potential, fatal
consequences, unknown hazards.
Lepp and Gibson (2003)
Health, political instability, strange food, novelty preference.
Kozak et al. (2007)
Power distance, individualism, uncertainty avoidance.
McCarthy et al. (2008)
Amount of media coverage, frames used for presenting
risks, valence and tone of media coverage, trustworthiness
of risk information sources.

Ropeik (2011)
Trust, origin, control, nature, scope, awareness, imagination,
dread, uncertainty, familiarity, specificity, personal impact,
fun factor.
Sharot (2011)
Optimism bias.
Zhang et al. (2013)
Age, education, profession, risk experiences, knowledge.
Brown (2015)
Negative media coverage.
van der Linden (2015)
Cognitive, experiential, socio-cultural, demographic.
Henrich et al. (2015)
Framing of risks.
Cahyanto et al. (2016)
Perceived susceptibility, severity, self-efficacy, subjective
knowledge, socio-demographics.
van Hoorn et al. (2016)
Social desirability.
Becken et al. (2017)
Destination image.
Paek and Hove (2017)
Voluntariness, controllability, familiarity, equity, benefits,
understanding, uncertainty, dread, trust in institutions,
reversibility.
Murdock and Rajagopal
(2017)
Framing of risks.
Xie et al. (2019)
Affect, descriptive norms, mitigation response inefficacy.
Dryhurst et al. (2020)
Knowledge, experience, prosociality, trust, efficacy.
Bogacheva et al. (2020)
Travel experience.
Cori et al. (2020)
Voluntariness, knowledge, visibility, trust.
Source: Authors.
The next group of factors affecting risk perceptions is related to personality traits, including risk
aversion, adventurousness, neuroticism, conscientiousness, agreeableness, and emotional
stability (Chauvin et al., 2007; Hampson, 2012; Zambrano-Cruz et al., 2018), as well as peoples’
cognitive biases such as optimism bias, anchoring, adjustment, social influence, status quo bias,
and perceived control (Cui et al., 2016). According to previous research, people with optimism
bias believe that they are less likely to contract a disease than others (Sharot, 2011; Brewer et al.,
2007). Several studies demonstrate that risk is perceived as low if it is taken voluntarily (Cori et
al., 2020) and that people are ready to follow the majority (van Hoorn et al., 2016). Previous
studies also identified that risk perceptions are influenced by travel characteristics (Adam, 2015),
destination image (Becken et al., 2017), previous travel experience (Bogacheva et al., 2020;
Sternberg et al., 2000), and other factors.

All factors affecting tourists’ health risk perceptions can be broadly classified into cognitive,
affective, individual, and contextual types. The first group of cognitive factors is related to
destination characteristics, gravity of the health risk event, media coverage, information
accessibility, and risk-mitigating measures (Brown, 2015; Paek and Hove, 2017). Among the
current measures undertaken by tourism practitioners to mitigate the risks of COVID-19 are
social distancing, sanitizing, temperature checks, and contactless services. The second group of
affective factors plays an important role in people’s ability to deal with negative information
(Block and Keller, 1995). Previous studies show that, just as customers in positive emotional
states are readier to deal with negative information and outcomes, negative affective states
prevent the processing of negative information about possible risks while enhancing self-
positivity biases.
Among the previously described contextual factors of risk perceptions are the framing of risk
information and the availability of alternative information sources. People tend to take
preventive actions when the outcomes are framed in negative terms (Robberson and Rogers,
1988; Murdock and Rajagopal, 2017). For instance, a study by Henrich et al. (2015) reported
significant effects of the framing of earthquake risk scenarios on participants’ risk perception.
The final group of individual differences includes gender, age, cultural characteristics, prior
travel experience, and personality traits, all of which significantly influence risk perceptions.
While tourism providers, destination marketing and management organizations, and
governmental authorities can affect some cognitive and contextual factors of risk perceptions,
they have no real influence on individual characteristics that determine tourists’ subjective
evaluations of risk. The effects of the previously described factors of risk perceptions were not
explored in the context of global life-threatening health risks and, therefore, a series of studies
should be conducted to investigate the influence of each factor on tourists’ health risk
perceptions to determine their effects on behavioral intentions.
Outcomes of risk perceptions
Previous studies described the effects of risk perceptions on tourist attitudes and behavioral
intentions (Table 2). Baker (2014) pointed out that tourist risk perceptions have strong negative
effects on attitude toward a destination. In a similar vein, Sohn et al. (2016) found that perceived
risk led to negative perceptions of a local festival. Jin et al. (2016) described the negative effects

of risk perceptions on trust, customer satisfaction, and loyalty. Another group of risk perceptions
outcomes is related to tourists’ behavioral intentions. Le and Arcodia (2018) described purchase
intentions as the main outcomes of customer risk perceptions in different settings. Chew and
Jahari (2014) found that the relationship between different components of tourists’ risk
perceptions and revisit intentions were mediated by affective and cognitive destination image.
Among the other described consequences of perceived risks are destination image (Lepp and
Gibson, 2003), avoidance behavior (Nomura et al., 2004), loyalty (Hossain et al., 2015),
willingness to pay more (Casidy and Wymer, 2016), need for variety (Sohn et al., 2016), and
self-protected behavior (Wang et al., 2019).
Table 2
Outcomes of risk perceptions.
Authors
Outcomes
Weber et al. (2002)
Risk-taking behavior.
Nomura et al. (2004)
Risk-taking attitude, avoidance behavior.
Floyd et al. (2004)
Travel intentions.
Reisinger and Mavondo (2006)
Behavioral intentions.
Yuksel and Yuksel (2007)
Emotions, satisfaction, behavioral
intentions.
Fuchs and Reichel (2011)
Visit motivation.
Lepp and Gibson (2003)
Destination image.
Chew and Jahari (2014)
Revisit intentions, destination image.
Baker (2014)
Attitude toward a destination.
Hossain et al. (2015)
Destination loyalty.
Sohn et al. (2016)
Negative perceptions, need for variety.
Jin et al. (2016)
Trust, customer satisfaction, loyalty.
Casidy and Wymer (2016)
Willingness to pay more.
Hasan et al. (2017)
Revisit intentions.
Le and Arcodia (2018)
Purchase intentions.
Wang et al. (2019)
Self-protective behavior.
Source: Authors.

The relationships between risk perceptions and tourist outcomes, however, are not always
straightforward and might be mediated and moderated by other constructs, such as tourists’
individual characteristics, attitudes, and previous experience. For instance, the study by
Reisinger and Mavondo (2006) reported the effects of risk perceptions on international travel
intentions as moderated by tourists’ cultural differences. Yuksel and Yuksel (2007) found that
the relationship between tourists’ risk perceptions, satisfaction, and behavioral intentions is
mediated by tourists’ emotions. A study by Liu et al. (2013), however, did not reveal significant
effects of risk perceptions on customer purchase intentions in an online context. Moreover, risk
perceptions can even stimulate risk-taking behavior among certain groups of customers (Weber
et al., 2002). Therefore, it is important to develop a conceptual model of health risk perceptions
in tourism and empirically test it among different groups of tourists and destinations.
Conceptual model and future research directions
The main predictors of tourists’ risk perceptions include cognitive, affective, contextual, and
individual factors (Figure 1). The cognitive factors are associated with the perceived gravity of
health-related risks, media coverage, availability of information about risks, and mitigating
measures including social distancing, sanitizing, required wearing of masks, temperature checks,
and contactless services. The affective factors include tourists’ positive and negative affective
states that can influence people’s ability to deal with negative information and self-positivity
biases. The effects of the above factors are moderated or complemented by a group of contextual
factors related to the framing of risk information and availability of alternative information
sources and individual factors, such as cultural characteristics, gender, age, personality traits, and
previous experience.

Figure 1. Conceptual model of health risk perceptions in tourism.
Travel intentions are introduced as the main outcome in the proposed model. On the one hand,
most research demonstrates that low levels of risk perceptions predict greater behavioral
intentions (e.g., Cahyanto et al., 2016; Kozak et al., 2007; Law, 2006; Reisinger and Mavondo,
2005). At the same time, a few studies suggest that perceived barriers to action related to costs
and competing activities might disrupt the link between risk perceptions and behavioral
intentions (e.g., Akompab et al., 2013; Bubeck et al., 2012). Therefore, the pathway between
tourists’ health-related risk perceptions and their travel intentions demands additional
investigation in relation to the current COVID-19 situation.
The main components of risk perceptions include cognitive and affective dimensions (Dryhurst
et al., 2020; Xie et al., 2019). The previously applied measurement scales of risk perceptions in
tourism, however, mostly measured the cognitive components and were validated in contexts that
are completely different from global health-related risks such as the COVID-19 pandemic. For
instance, Fuchs and Reichel (2006) explored risk perceptions of a tourist destination by asking
respondents to evaluate their judgments regarding terrorism, crowds, and other dimensions of
risk. Chew and Jahari (2014) evaluated financial risk, physical risk, and socio-psychological risk
to investigate the effects of perceived risks on revisit intentions in post-disaster Japan. None of
the previously applied scales focuses on health issues and fully satisfies the need to measure

physical health-related risk perceptions. Therefore, new scales should be developed and
validated specifically to assess tourists’ health-related risk perceptions by using a mixed-methods
approach (Churchill, 1979, Creswell and Clark, 2019; DeVellis, 2016).
Conclusion
This paper intends to clarify the concept of health risk perceptions in tourism, identify the main
factors of health risk perceptions, and propose a conceptual framework of health risk perceptions
in tourism. The conceptual model advances a systematic and theoretically integrated overview of
the main factors affecting tourists’ risk perceptions and behavioral intentions and suggests that
future research ought to understand these factors and their effects on travel behavior. New
measurement scales of health-related risk perceptions should be developed and validated in
tourism settings by using a mixed-methods approach. The relative importance of each of the
cognitive, affective, contextual, and individual factors that affect health risk perceptions for
different groups of tourists, as well as their relationship with tourists’ behavioral intentions,
should be empirically explored in future studies by conducting surveys, interviews, online
content analysis, experiments, and longitudinal studies.
This paper contributes to theory by offering a new approach to health risk perceptions in tourism,
which remain underexplored in extant studies. The literature review adds to the body of
knowledge by introducing four main groups of factors affecting tourists’ health risk perceptions,
while the conceptual model advances relationships between these factors, tourists’ risk
perceptions, and travel intentions. The paper provides important practical implications as well.
While tourism providers, destination marketing and management organizations, and
governmental authorities currently make every effort to eliminate the negative consequences of
COVID-19, they cannot influence tourists’ individual characteristics such as personality traits,
socio-demographic characteristics, and prior experience. Therefore, it is necessary for tourism
practitioners to be aware of individual factors of perceived risks, constantly measure the factors
and outcomes of tourists’ risk perceptions, and segment proposals to potential customers based
on their sociodemographic, experiential, and personality characteristics. The proposed
conceptual model can be used as a framework for exploring the effects of different factors of risk
perceptions on tourists’ behavioral intentions in the context of the COVID-19 pandemic and
other disease outbreaks.

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