True Loyalty or Switching Fear? How Switching Costs Sustain Loyalty in Health Tourism: An Extended TPB Approach

This study investigates whether loyalty intention in health tourism reflects genuine preference or is sustained by switching-related constraints.Building on the Theory of Planned Behavior (TPB), we propose an extended model that integrates switching cost as a context-specific determinant of loyalty intention and examines the mediating roles of attitude and perceived behavioral control (PBC).Data were collected via an online survey administered to Romanian customers of a premium health and spa destination across two operational periods (N = 235).The model was tested using PLS-SEM.Results show strong explanatory power for loyalty intention (R² = 0.657).Attitude is the dominant predictor of loyalty intention (β = 0.585), while subjective norms (β = 0.133) and PBC (β = 0.117) exert smaller but significant effects.Switching cost has significant direct effects on attitude (β = 0.370), PBC (β = 0.292), and loyalty intention (β = 0.149).Mediation analysis indicates a significant indirect effect of switching cost on loyalty intention through attitude (β = 0.217), whereas mediation through PBC is not supported.The findings suggest that loyalty intention is primarily preference-based, yet reinforced by switching costs that shape customers' evaluations of staying.Implications for ethical retention strategies and future research directions are discussed.