The rise of digital beauty trends and social media has resulted in an unprecedented increase in the number of individuals seeking out plastic surgery procedures to enhance their appearance. This trend is especially noticeable among individuals who are 50 years old and above. For instance, the number of over 65 individuals is expected to double within the US by 2060. This shift in the demographic group has a significant societal effect, impacting fields like marketing and healthcare. The rise of the aging population has had a significant impact on the marketing industry.

As people get older, they are turning to plastic surgery and procedures to maintain their youthful appearance (Cashin, 2024). In 2018, Americans reportedly received over seven million injections of Botox and more than two-and-a-half million filler injections. Around 92% of the procedures that year were carried out on women. This indicates that the trend toward cosmetic procedures has shifted toward older individuals who desire to enhance their appearance rather than fight the signs of aging. The ideals of beauty have changed due to technological, social, and cultural factors (Balouchi et al., 2024). As society continues to develop, it's possible that we will see more changes in how we view beauty.

In this vein, cosmetic tourism has been on the rise due to various factors. Some of these include the lower cost of operations in other countries, the lure of vacationing with the procedure, and the availability of information about cosmetic procedures online (Au, 2023). A study, which analyzed the search trends related to cosmetic tourism using Google Trends data, showed that the terms such as "Lithuania" and "Turkey" had more than 5000% increases in popularity. Along the same lines, the rise of Instagram, which was founded in 2010, has revolutionized the way people view beauty. Its aesthetic language encourages users to embrace a generic, cyborgian face that features a low-key skin tone, long lashes, and a small nose. Due to the increasing popularity of this face, many individuals have started to undergo various procedures related to cosmetic surgery, they can also use photo-editing tools such as FaceTune to achieve their desired look (Szczepaniak, 2021).

Nevertheless, women are often put under pressure to conform to the ideals of digital beauty, as being seen as unattractive can negatively affect one's romantic relationships and failure (Cashin, 2024). This has led to a rise in women seeking out procedures related to genital surgery, which are commonly used by pornographers. In Western nations, cultural diversity has led to various changes in beauty norms (Mady et al., 2023). Nowadays, women are more likely to seek out procedures such as lip augmentation and buttock implants in order to copy celebrities such as Kim Kardashian.

Likewise, it is important to note that the rise of digital beauty trends has led to an increase in the number of individuals who seek out procedures related to cosmetic surgery (Balouchi et al., 2024). These procedures are commonly used by individuals who want to enhance their appearance due to the ideals of Instagram and other social media platforms. However, before going under the knife, it's important to consider the risks and ethical concerns associated with the procedure. As technology and society continue to evolve, our perceptions of beauty will also change. It's not yet clear how this will affect the future of cosmetic surgery or our self-image.

In fact, the rising number of seniors looking into getting plastic surgery has major implications for both the healthcare and marketing sectors (Ng & Indran, 2024). Both parties need to be cognizant of this demographic's distinct needs and motives. Providers must also take into account the various challenges they may encounter when working with such people, such as health issues. Also, the ethical and legal implications of cosmetic surgery should be addressed by practitioners. This can be done by relatives or friends who pressure people into getting the procedure. Also, seniors might not be fully aware of its disadvantages and benefits. Additionally, marketing professionals should be aware of the distinct needs and desires of seniors, as well as the ethical and legal implications of doing business with them.

Medical tourism is becoming a well-established entrepreneurial and innovational industry, as healthcare providers serve as business strategists who create differentiated service packages, take advantage of online branding, and establish international partnerships. Research in Asia and the Middle East demonstrates that the clinics have established themselves as competitive by using niche business strategies including cosmetic tourism, wellness packages, and technology-based care delivery (Horowitz et al., 2007; Ormond and Sulianti, 2017). Affordability, professionalism, and increasing digital interaction drive entrepreneurship in medical tourism in Tunisia to help providers acquire an increasing number of foreign patients (Lautier, 2014).

Tunisia is placing itself more and more as a viable healthcare destination not only based on the competitive prices, specialized skills, but also based on cultural tourism experiences. With an annual export of over 1 billion Tunisian dinars, it is estimated that the medical tourism business contributes 9 percent of the GDP, and is facilitated by policies that combine both healthcare export and tourism policies (Al Arabiya, 2024; Medical Tourism Business, 2024). The endeavors by the government to align the ministries and enhance the digital infrastructure underscore the intent by the government of Tunisia to nationalize achievements in health services. This follows the trend being witnessed across the world because health tourism has been linked to both economic growth and destination branding (Gan & Frederick, 2013).

Sustainability, inclusive growth and corporate social responsibility (CSR) are also intersecting with medical tourism. Providers not only earn foreign exchange and create jobs but also contribute to the local development via inclusive service ecosystems (Sousa and Alves, 2019; Zsarnoczky, 2016). In this case, CSR is especially applicable to older patients, who can be vulnerable. Responsible marketing and open communication should be complemented by truly caring practices that will, in turn, facilitate the development of trust and reputation (Au, 2023; Honigman and Castle, 2006). Tunisian providers could increase their competitiveness, at the same time making a contribution to socially responsible healthcare tourism by incorporating CSR and sustainability in their business models.

This paper will address the gap in the literature by examining the motivations of seniors who seek out cosmetic surgery. We will also discuss the role of social media in influencing the decision-making process of seniors who are considering cosmetic surgery. Finally, we will discuss the implications of the growing trend of cosmetic surgery among seniors for the healthcare industry and the field of marketing.

We believe that our findings will also add to the expanding body of literature on marketing to seniors, as well as the body of literature on sustainable entrepreneurship, inclusive growth, and CSR in the context of healthcare tourism.

1.1.    Senior’s motivations for social networking and social connectedness 

A sense of belonging and social connection are important features of people’s quality of life with each other (Putnam 2000). This is because communities and social networks are necessary for people to meet their various needs (Huysman and Wulf 2004; Balouchi et al., 2024). A social network is a web of social ties that an individual has with other people. It can be characterized by its various structural properties such as its size, density, and strength (Berkman and Glass 2000). The characteristics of a social network can also influence the well-being of its members (Goswami, Suparna, et al, 2010; Berselli et al., 2024).

For instance, they can help individuals overcome isolation and enhance social integration. Previous studies have shown that social support and social connectedness can help improve the quality of life for the elderly (Cornwell et al. 2008, Mathe et al., 2012). In business, the core idea of using social media is to stimulate possible customers via visual messages (Kaplan & Haenlein, 2010).

In this vein, seniors are increasingly using the internet, especially to communicate with their friends and family, and they are increasingly present on social networks. Indeed, according to the latest figures provided by the CREDOC (2015), 26% of seniors between 60 and 69 years are on social networks (2015). The social network provides individuals with the opportunity to interact with each other, which leads to the perception of being socially connected (Ashida and Heaney 2008).

However, this concept is not always objectively measured. Instead, it is subjective and can be assessed by how people feel about their social relationships. The concept of social connectedness is used to describe the number of people in a person's social circle who share similar interests and experiences. Indeed, the lack of social connections can be considered a symptom of loneliness (Rook 1990).  Although social connectedness is a concept that applies to all segments of the population, it is especially relevant to seniors due to the negative effects of isolation. For instance, being isolated can have detrimental effects on one's mental and physical health (Cohen 1988).

Being isolated from social interactions due to various factors such as health issues and retirement can lead to a decline in social interactions. Being able to maintain an active social network is one of the most important factors that can help older adults live a long and healthy life (Cornwell et al. 2008). Recent studies conducted on the effects of information and communication technology (ICTs) on the well-being of older adults have shown that they can improve a person's psychological and social well-being. Some of the factors that have been studied include the use of e-services, such as banking and travel, and the interaction with friends and relatives (Szabo et al., 2019).

The studies revealed that older adults who use the Internet for various purposes are more likely to engage in social activities and lower levels of loneliness. They were also more likely to access health-related information. They have also shown that they can prevent cognitive decline and depression (Hunsaker and Hargittai, 2018; Xavier et al., 2014; Fang, Chau et al., 2018). Based on the concept of social support, a person or group of people is being supported and valued by a network of mutual obligations (Cobb 1976). This belief can be expressed in terms of a person's perceived sense of belonging and security. The positive effect of social support can be attributed to various factors such as increased self-esteem and feelings of belonging (Goswami, Suparna, et al, 2010).

2.2. Silver tourism and cosmetic surgeries  

The term silver tourism refers to an integrated approach to senior leisure activities that can be performed in a variety of settings (Zsarnoczky, 2016). The older generation or the 'silent generation' is more likely to participate in tourism (kotler et al, 2012). This group is typically composed of Baby-boomers who were born during the 1940s and 1960s. They usually buy travel packages and are interested in the length of their stay. Due to the increasing popularity of medical tourism, it has become a constantly developing product. The main attractions of this type of tourism are its various health benefits and general well-being (Michalkó et al., 2012; Berselli et al., 2024).

In this veil, the desire to stop aging has revealed the market for "anti-aging" which includes food supplements, cosmetic surgery, or "anti-aging" treatments. Other factors that can influence an individual’s desire for cosmetic surgery include body dissatisfaction and psychological factors (Sharp, 2018). Body dissatisfaction is a negative thought that relates to the perception of one's body (Grogan, 2008). It can feel like one's body is not ideal. In a study conducted by Markey and Markey in 2009, body dissatisfaction was linked to higher levels of interest in cosmetic surgery among young women. It has been hypothesized that body dissatisfaction is a contributing factor to the lack of desire for bodily change in young women. This behavior change occurs when women who negatively perceive their appearance become dissatisfied with their current state.

This could motivate them to seek cosmetic surgery (Walker et al., 2021). Self-esteem is also linked to the likelihood of having cosmetic surgery. In addition, people with low self-esteem are more likely to have cosmetic procedures than those with high confidence (Walker et al., 2021). Diet and weight are also linked to the desire to have cosmetic surgery. For women, heavier weight has been linked to the desire to have more cosmetic procedures (Henderson-King and Brooks 2009). Studies have shown that social media use can affect a person's desire for cosmetic surgery (Holland and Tiggemann 2016). We assume that those who use it more will have a higher desire for cosmetic surgery. The United States is largely ahead in this field, partly because of the flexible regulations (Serrière, 2016).

Likewise, Tunisia hosts more than 500,000 foreign patients every year as part of medical tourism. According to the American Society for Plastic Surgeons, in 2014, people aged 55 or older accounted for 24% of cosmetic surgery procedures, while those aged between 40 to 54 accounted for 34%, which is the highest percentage of all age groups. Over the past five years, non-surgical cosmetic procedures (such as injections like Botox and Juvederm Ultra) have increased by 93% for people aged 65 and over. According to the American Society of Aesthetic Plastic Surgery, the number of cosmetic surgeries for seniors has almost doubled in the last two decades. Seniors make a calculated decision by trying to escape the stigma of aging and gain some time, stay in the world, and not be marginalized because of their appearance.

According to Tresidder (2011), it is important to distinguish between medical tourism and health tourism, as the two are very different products and have varying ethical and social issues. There are also a variety of factors that go into deciding on health tourism. It is widely acknowledged that due to the increasing number of people seeking medical services and treatment overseas, the demand for healthcare services has also increased (Henderson, 2004; Tresidder, 2011). Medical tourism refers to the practice of individuals traveling to other countries for medical treatment (Ormond and Sulianti, 2017). Unlike traditional international medical travel, which involves patients traveling to major medical centers in developed nations for treatment, medical tourism involves individuals traveling to less developed regions for treatment (Horowitz et al., 2007). The various segments of the health tourism industry are shown in Figure 1.

Figure 1. The shape of health and medical tourism

Source: Sousa & Alves, (2019)

Health tourism is a more traditional type of tourism experience that focuses on the enhancement of one's health and well-being. On the other hand, cosmetic surgery is a more modern form of tourism that involves an operation and usually involves a combination of procedures with usual tourist behavior (Tresidder, 2011). According to Hudson and Li (2012), the literature on medical tourism has been fairly descriptive. However, various factors have led to the growth of this field. Some of these include the concept of medical tourism, the quality of services offered, and consumer attitudes toward this type of tourism.

2.3. Entrepreneurship in Healthcare Tourism

Medical tourism operates more and more on a border between health care and entrepreneurship where the providers operate as strategic innovators in service delivery, marketing, and communication with international patients. The medical services and the tourism experience and cultural immersion programs which have been introduced in Asian clinics and wellness centers have helped Thailand, Malaysia, and South Korea to develop entrepreneurial ecosystems (Horowitz, Rosensweig, and Jones, 2007; Ormond and Sulianti, 2017). New investigations additionally say that health tourism entrepreneurship was also developed under the circumstances of the coronavirus crisis, and the image of the business opportunity and the market strategic orientation took up the leading positions in the development under the conditions of resiliency and adaptation (Dehghan et al., 2022). Additional medical services are not the only entrepreneurial opportunities that are noted as significant value-adding elements of medical tourism systems, with concierge services, recover vacation packages, and well-being tours being regarded as such by narrative reviews (Badulescu & Badulescu, 2014).

The vibrancy of the individual clinics and digitally-oriented providers can be seen as the energy of entrepreneurship in Tunisia. The actors use the price differentiation, the multilingual service provision and the internet marketing differentiation to reach the patients within Europe and North Africa (Lautier, 2014). Tunisian government has coordinated between ministers through inter-ministerial task force that was inaugurated in August 2025, to streamline patient receiving process and enhance Tunisia image as a medical tourist destination in the region and globally.

2.4. CSR and Ethical Medical Tourism

Rapid development of cosmetic and health tourism raises fundamental issues of corporate social responsibility (CSR) and ethical care. Marketing providers should also address susceptible populations, especially the elderly-informed consent, no exploitation and support after surgery (Au, 2023; Honigman and Castle, 2006). It has been established that these components of ethical branding open dialogue, post-discharge care, and respect to patient dignity are crucial to trust and reputation maintenance, particularly among older adult populations (Sousa and Alves, 2019; Zsarnoczky, 2016). Not only do these CSR practices boost patient satisfaction, but they also make the sector sustainable in the long run. Meanwhile, more general issues of ethics arise in the commodification of medical services. Researchers state that the potential to transform healthcare into some sort of a marketplace as a result of uncontrolled entrepreneurial growth, the lack of any regulation and ethical standards can impact negatively the very fundamentals of bioethics (Nayak, 2015).

2.5. Policy and Institutional factors

Healthcare tourism competitiveness and sustainability rely not just on the efforts of providers but also, to a considerable degree, on institutional structures and government subsidies. In Singapore and Malaysia, the governments have formalized medical tourism by accreditation, continuous medical visa programmes and national branding campaigns that feature quality healthcare with tourism experiences (Henderson, 2004; Gan and Frederick, 2013). Medical tourism is already a sound economy in Tunisia.

According to recent statistics, the number of foreign patients each year has reached more than two million, and the sector has reached about 3.5 billion Tunisian dinars in revenue generated by the combination of tourism and health services, which is approximately 9 percent of GDP. Health services export revenue has increased to 2.22 billion dinars in the first half of 2023 alone; this represents an increase in demand in sub Saharan Africa and neighboring. It was in light of this growth potential that Tunisian authorities in August 2025 introduced a high-level inter-ministerial task force. The initiative is a joint venture of Health, Tourism, and Family ministries to harmonize foreign patient processes, simplify policies on elderly matters, and improve the overall service delivery-highlighting the fact that Tunisia aspires to become a leading regional and international medical tourism destination.

These structural developments demonstrate the significance of the policy environments to support and expand healthcare tourism. Active institutional intervention can promote infrastructure, digital platforms, regulatory transparency--in other words, empower provider entrepreneurship and deliver quality, ethical standards, and economic impact in the long term.

2.   Research methodology

The study is founded on a qualitative design but seeks to address not only medical but entrepreneurial and managerial approaches of healthcare professionals in the cosmetic tourism industry of Tunisia. The most effective technique in research of perceptions, strategic decisions, and lived experiences is the qualitative approach (Macdonald et al., 2008). We used semi-structured interviews (Dicicco-Bloom and Crabtree, 2006), a method that enables the interviewee to discuss the clinical and business facets of their practice and provides the researcher with the freedom to investigate the emergent themes.

Eleven interviews were carried out with medical providers, who comprised of surgeons, clinic directors, and healthcare managers. The average years of professional experience was 10 that made all the respondents highly experienced in healthcare tourism and medical practice. The interviews were 30 to 60 minutes using a pre-designed guide which included a set of open-ended questions on motivations of silver tourists, marketing, ethical practices and challenges managers encounter. Additional open-ended questions facilitated the discussion of how providers understand their business models, utilize e-platforms and competitive positioning strategies.

The interviews were taped, transcribed and analyzed in NVivo software. To achieve consistency in the coding a codebook was jointly created. Intercoder agreement was reviewed then revised after coding the initial five transcripts and then continuing with the rest. Thematic saturation appeared when 11 interviews had been conducted as no new codes appeared. The coding was focused on consumer-level (senior motivations, expectations) and provider-level (innovation, CSR, digital branding, cross-border partnerships) strategies.

Notably, this research does not deal with providers as mere medical professionals, but as enterprisers as well. Medical tourism is being acknowledged as an element of the global service economy, requiring its providers to operate in terms of branding, patient acquisition, and quality assurance in the manner of classic entrepreneurs (Dehghan et al., 2022; Ormond and Sulianti, 2017).

The analysis of strategies used by providers hence provides knowledge on the role of entrepreneurship in healthcare tourism to economic development, destinations competitiveness, and sustainability. Tunisia was selected as the study site since it is highly rated as a medical tourism destination in Africa and MENA region. It is reported that Tunisia accepts more than two million international patients annually and is considered to be one of the most popular countries in the world as a destination for cosmetic surgery (Medical Tourism Report, 2023; Lautier, 2014). Its mix of competitive pricing, cultural accessibility, and government support make it a topical case to investigate how healthcare providers perform the roles of clinicians and entrepreneurs.

RESULTS

• Sample profile

Sample Profile Table

The age range of the participants in the study spans from 40 to 55 years, with an average age of approximately 48.5 years. This demographic composition indicates that the respondents are seasoned professionals who likely possess substantial industry knowledge and experience. Also, the participants have accumulated between 9 and 20 years of professional experience, averaging around 13.6 years. This considerable amount of experience signifies that the participants are well-experienced professionals, capable of offering in-depth and comprehensive perspectives on the medical tourism industry and plastic surgery in Tunisia.

In fact, the sample consists of a variety of professions: 6 doctors, 3 directors, and 2 individuals in managerial roles. This diverse representation ensures a holistic comprehension of the sector from multiple viewpoints, encompassing clinical practice, administrative oversight, and operational management. Consequently, the maturity and expertise of the participants bolster the reliability and validity of the research outcomes. Their seasoned viewpoints are expected to be well-grounded, diminishing the risk of bias or incomplete data.

• Data analysis

In order to conduct a thorough examination of the qualitative information obtained from the 11 interviews conducted with healthcare professionals within the medical tourism industry in Tunisia, content analysis through NVivo was conducted. Through NVivo, the management and coding of the extensive discussions were made more efficient, allowing for the identification and classification of recurring themes and sub-themes. From the word cloud (Annexe 1) generated in NVivo, we extracted the key themes such as self-direction, cost-saving, security of destination, and the influence of digital media. The tabulated presentation of these themes and sub-themes produced by NVivo delivers a methodical summary of these findings, guaranteeing a thorough comprehension of the viewpoints expressed by the participants.

Table of Themes and Sub-Themes with Frequencies

Source: NVIVO

The coding structure and coverage percentages provided in the NVivo output (Annexe 2) demonstrate the degree to which the entire content of the interview is associated with each theme, as well as its importance in the study compared to the others. Entrepreneurial Use of Digital Platforms (23.09%), being the highest cover, highlights the key position of online branding and social media in the development of the Tunisian medical tourism industry. Next came Innovation in Service Delivery (12.59%), an aspect where a provider attempts to adjust and create new services to suit silver tourists. Another pointer that providers are not just clinicians but also entrepreneurial players is that Strategic Management Factor (cost-saving and destination security) and CSR and Ethical Expectations are high-ranking factor.

Theme 1. Innovation in Service Delivery

Self-direction

The providers repeatedly stressed the importance of breaking new ground in the quality of service provision to older tourists. According to the interviewees, aging patients look for the treatment that suits their own perception of youth and vitality:

‘’ some people are living longer and feel even healthier than before, but their looks don’t reflect this image, some of our patients told us that the only time they visited a doctor is for plastic surgery’’.  Others said: ‘’ we see an increase in numbers of seniors’ patients over 60 who said that 60, 70or even 75 are just numbers they feel much younger, and they want to see that in the mirror, for them it is not about the chronologic age but how they feel they should look like’’.

The innovation is manifested in the way of adjusting the process to elderly citizens (minimal invasiveness, shorter recovery time, less risk), in the packaged services merging medical intervention with leisure and well-being activities. This reflects the entrepreneurial capabilities of service providers to adapt services to new consumer demographics.

Stimulation

With the new trend to look younger, people over 75 could have health complications, so we asked if there is a theoretical age that prevents older patients to have such surgeries. We didn’t have enough respondent answers this question. In this vein, the increasing longevity, and the challenge of becoming older have given rise to the concept of successful aging. This concept has been the subject of numerous studies over the years. Despite this, the concept is still not widely explored in consumer research (Sengès et al., 2019). Due to the critical importance of the senior’s target, it is necessary to understand their perception of successful aging and its influence on their decision. According to our interviewees: ‘the more people resort to cosmetic surgery the more they feel that they need it’. The increasing use of cosmetic surgery among senior men and women is linked to their subjective age. This effect is evidenced by the number of cosmetic procedures among male consumers.

‘Since people tend to identify themselves as younger as a way of adapting to changes in their lives, it is not surprising that they have expectations for longer life. Our senior patients stated that they enjoyed their mental health and life satisfaction. They also liked the quality of their lives and the aging process.’

‘Patients who are older than their chronological age feel that they are not living up to their ideal selves… The new beauty trends make it hard for patients to accept their image. Instead, they look for a new look that reflects their inner beauty.’

Through plastic surgeries, seniors can easily and effectively manage the effects of aging. It can help them maintain a positive and healthy lifestyle by preventing or improving the negative effects of old age. The pictures shared on social media that accompany these values can also serve as a reminder of the importance of maintaining a healthy lifestyle for older people.

Theme 2.  Strategic Management Factors

Security of destination

With a unique perspective, plastic surgeons have the privilege of working with a wide range of patients and care teams. However, after the outbreak period, it was important to establish a set of priorities to ensure that their services were being provided safely. ‘Due to the limitations of COVID19, patients may be reluctant to undergo surgery and may prefer other treatment plans.’ According to our interviewees, due to the varying volume of patients and the complexity of the practices, new coverage plans were developed because of COVID19.

‘it’s not surprising that during the work stoppage, we extended our efforts to other means of communication so that we can maintain our services for our patients.’

Cost-savings

Security and cost-efficiency appeared to become the key factors behind the attractiveness of Tunisia. Providers noted that Tunisia has huge savings relative to the European markets but remains at international standards. Strategically in management terms, providers have focused on pricing competitiveness, tourism packages and safety guarantees as conscious initiatives to brand Tunisia as a trusted medical tourism destination.

As a result of our investigation, the experts see that cosmetic procedures have become more accessible to the general public. Indeed, the cost of care proposed by the facilities abroad is lower than that of the same care in the country of origin. This benefit is considered when calculating the health insurance refund.

‘With the increasing number of people wanting to save money, many patients are now turning to medical tourism. This is a process where they book flights accommodations, hotels, and medical services in developing countries.’

Enjoyment

With the help of foreign exoticism, it is possible to associate "body care" and "tourism" with unpleasant memories, letting the patient especially seniors swallow the pill more easily. A change of scenery, or even a change in culture and the leisure activities that accompany the treatment would allow senior patients to overcome their sufferings more easily.

‘, for most senior patients, plastic surgery can be masked under a tourist journey. This procedure allows keeping their secret of the treatment.’

Theme 3.  Entrepreneurial Use of Digital Platforms

Digital platforms were named as radical equipment of entrepreneurial branding and acquiring of patients. Every provider stated that they had an online presence, and most of them used websites and social media (Facebook, Instagram, LinkedIn).

Digital branding allows providers to compete on a global scale through the focus on quality, testimonials and cost. Another area that social media was utilized to manage reputation was on, but interviewees admitted that negative feedback can be difficult to manage in real time. This is a strategic change in healthcare provider marketing that manifests as an entrepreneurial use of platforms.

Universalism through digital media

Plastic surgeons have numerous ways of communicating with their patients. This is very helpful for them as they can respond efficiently to the needs of their patients. Our results revealed that our respondents don't need to be in a physical location to access vital information. This ensures that patients' records are kept up-to-date and without the need for an individual recall. The new communication channels help improve communication between the surgeons and the patients. ‘Through social media, I was able to reach out to my patient in a more efficient manner. Another advantage of using it is that it allowed me to communicate with my older patients without complicating the message they receive.’

According to our interviewees, the digital platforms have created a revolutionary image that promotes health, beauty, and fitness which is in favor of cosmetic surgery. ‘In today's world, women are more concerned with having a more attractive figure and a clear and glowing eye line than ever before. This is why many of them seek for procedures that can improve their appearance.’

Most of our medical providers (plastic surgeons) have a website and they are also increasingly using social media to promote themselves and expand their practice. According to the interviewees: ‘Most of the time, our patients searched for information on the Internet before their first appointment.’

Respondents were asked about the communication tools that might have encouraged senior targets to come to their facilities:

 ‘’ the use of social media is essential for the attraction of customers, but our website remains our first digital identity, yet we are present in all digital accounts for any information’’.

Before starting our interviews, we made use of an exploration of the digital presence of each firm on the internet (account on social media, linked-in, website ...). All these firms have developed websites (of course there are websites better than the others) and they are present on social media platforms. We observed a low average response to negative comments, yet the assimilation of digital business positively existed.

To answer our question about the digital platforms used in each case, our interviewees claimed:

• ‘’our patients share their stories on our Facebook page, and we are blessed for the good reputation that we have’’.
• ‘’ the amount of information diffused on the Internet has created a certain curiosity. Also, because of the shared selfies on social media such as Instagram or Facebook, seniors have developed a virtual and psychological identity that they want to see it in reality. Social media has created a revolutionary image that promotes beauty and fitness’’.
• ‘’ We are following the new trends that society made by itself, the obsession of keep looking younger made our service indispensable’’.

For modern society, the desire for plastic surgery stems from a personal factor that was influenced by an external factor. This external factor could be dissatisfaction with one's body or the desire to improve one's appearance that is highly influenced by social media.  Most of the interviewees, report using social media platforms such as Facebook and Instagram in their professional practice. Half of the respondents stated that they lately started to use Instagram to promote their activities through a staff member to manage their social media activities.

‘In fact, due to COVID19, we face a pressure to post messages to various social media platforms almost daily.’

Theme 4.  CSR and Ethical Expectations

Lastly, the providers became aware of the ethical issues related to service provision to elderly patients. The concept of CSR was also a common topic, particularly in regards to transparency, dignity, and the lack of exploitative marketing.

“We must ensure that older patients understand the risks, not only the benefits.”

“Ethical communication is part of building long-term trust with international patients.”

Procedural problem-solving explanations, realistic communication of the findings, and follow-up care were clear descriptions of CSR practices. This theme assists in highlighting the reality that, not only are providers businesspeople, they are responsible custodians of patient health, making their businesses exemplars of responsible and sustainable business practices.

In today's information age, informed consent is no longer a requirement before meeting with a surgeon. Instead, patients are more likely to initiate the process through websites and social media (Balouchi et al., 2024; Vardanian et al., 2013). Understanding the reasons why patients seek outside information can help surgeons prepare for their new target and improve their satisfaction. Recent studies debate the position of the senior segment that will soon become one of the main potential segments in the hospitality and travel industry (Balderas & al., 2019). We first investigated the medical providers’ perception of seniors who had undergone cosmetic surgery and the reason behind their increased desire for cosmetic surgery. Conforming to the results of Vardanian et al. (2013), most senior patients seek information about a plastic surgeon before their first appointment or asking advice about their sources.

On the entrepreneurial side, this move implies that the providers will have to adjust their business models to include the introduction of digital presence as one of the strategic instruments. Interestingly, the interviews identified a majority of clinics as investing in websites and social media branding, not only to get patients, but to stand out among international competitors. This shows that medical providers are entrepreneurial actors, who control not only the process of healthcare provision but also the space within a globalized service economy.

They do so due to the variety of sources available to them, ranging from social media to websites. Aside from wanting to save money, many people also need to pay for their medical expenses. Therefore, many of them visit developing nations for their health care (Bakhiet et al., 2024; Karla & Milica, 2007). According to Anvekar (2012), the cost of treatment is the main reason people go to other countries for medical procedures. Medical facilities play a vital role in the prestige of a hospital. Numerous studies have shown that these facilities contribute to the medical providers’ success (Nikbin et al,2019). According to Kumar, S. (2009), there has been a rise in the number of people seeking medical treatment abroad. Many of them are looking for procedures that are considered complicated. Many foreigners who seek medical procedures like plastic surgery, knee replacement, and cosmetic surgery, are satisfied with their treatments.

In the case of Tunisia, the cost advantage is integrated with the geographical proximity to Europe and North Africa, the presence of multilingual providers, and cultural familiarity, forming a good value offering. These benefits are the ones that providers actively seek to highlight during their marketing, demonstrating the alignment of strategic management drivers such as pricing, destination branding and safety with the entrepreneurial business models.

Medical tourism refers to the people who attend to the patients during their medical emergencies. The providers themselves play an important role in making sure that the patients' expectations are met (Guiry et al., 2013). To sustain the competitiveness of medical tourism in the country, the facilities must have the right number of skilled professionals. This can be done by recruiting and retaining the right individuals (Manaf et al, 2015).

Simultaneously, the respondents have further stressed the role of ethical marketing and CSR in addressing the elderly population. Unrealistic expectations may be more likely in older patients, and, therefore, clear communication, informed consent, and realistic presentation of results will be required. With older patients, as one surgeon put it: “We must ensure that older patients understand the risks, not only the benefits”. The result is part of wider evidence that responsible marketing and CSR activities, including post-surgery follow-up and patient dignity, are essential to long-term sustainability (Au, 2023; Sousa and Alves, 2019). The task of the providers at that point is to incorporate the elements of entrepreneurship and ethical responsibility to balance the interests of the patients with the revenues.

Following the results of Ladeiras et al., (2010), getting to experience new cultures can be a great source of destination loyalty for seniors. It can help them connect with new people and make new friends. In terms of procedures, each country has its specialties and varying standards of care. This allows patients to choose the best fit for their needs. Other factors that attract or repel medical tourists include the availability of qualified medical personnel, a favorable political environment, and adequate infrastructure (Gan L. et al., 2013). However. certain demographic differences can affect the way patients perceive information sources (Walker et al., 2021).

Within this study, we tried to evaluate the role of the new beauty trends diffused by digital platforms in older adults’ motivations. The research demonstrates that seniors present an important segment of the medical sector. From respondents’ perception, the self-perception of seniors of how they look after their sixties may be connected to different motivations. This is in line with Damodaran et al., (2015). The physical appearance, lower costs, new norms of society, confidence, and psychological effect of aging are the findings of our study. For some seniors, looking younger becomes an obsession and a way of self-improvement (Honigman & Castle, 2006). People of all ages are exposed to programs and advertisements that promote the use of money and time to improve their bodies.

However, these programs and advertisements make people look unrealistic (Farid, 2019). Society values beauty as the standard for judging others and this leads to an obsession with achieving the ideal image that society has assigned to women but also men. This study revealed that digital media can help in forming judgments about body image and self-esteem. Digital media can also influence people's self-esteem and body image perception. We noticed that social media has transformed society norms and seniors’ expectations of older adults represent an increasing group of technology users (Çarçani & Mörtberg, 2018).

This brought about feelings of perceived pressure to stay young. Our respondents expressed that failing to be part of society would put older adults at risk of being incapable of engaging with modern society. Our findings suggest that engaging with technology is increasingly important for seniors, which is in line with the study of Helsper & Reisdorf (2017). Also, the fear of not fitting in may lead to reduced psychological well-being in their life. In other words, adopting the new beauty trends is something that was forced upon older adults to pursue their life.  On the other hand, our respondents claimed that their older adults’ patients have positively experienced a life change because of social media.

They realize that they have the power to act even advanced age. They felt that their world expanded, and new opportunities had opened to them because of their look transformation. On the other hand, regarding the marketing communication of the medical providers, the respondents find digital presence very important and impact their performance positively.

On the development front, medical tourism in Tunisia has a direct effect on the economy and creation of jobs. It is a billion a year business, and that is why other business divisions associated with it such as hospitality business, transport business, and wellness services can survive (Medical Tourism Business, 2024). Interviews verify that providers also view themselves as players in the wider economic development plan of Tunisia, rather than as clinicians. This is similar to outcomes in Asia where governments in Malaysia, Thailand, and Singapore are actively encouraging health tourism as a way to develop their nations (Ormond and Sulianti, 2017; Henderson, 2004).

Convergence and divergence are also brought out in a cross-cultural comparison. Similar to Asia, Tunisia competes based on cost efficiency, destination branding and integration with cultural tourism. However, it is different in Tunisia due to distance to European markets, Mediterranean identity and great connections with francophone. Where the Asian providers tend to emphasize luxury and technological innovation, the Tunisian providers are emphasizing affordability, safety, and familiarity with the culture as their selling points. The presented objection indicates that the institutional, cultural, and market-specific determinants precondition entrepreneurial approaches to healthcare tourism.

Even though the application of the digital strategy was done through a consultancy, they gain profit from its outcome randomly. Indeed, it was observed that all respondents agreed on the importance of the digital presence of their business to survive.

The new trend in the medical industry has seen a real transformation for the senior segment; from purely medical intervention to aesthetic interventions to beautify and rejuvenate the look. The new digital platforms reflect new medical trends for seniors. Indeed, since the percentage of the access of seniors to social media has increased, cosmetic surgery for seniors has also increased. These digital platforms become a resource for content creation, they are used to educate people about the different medical offers, the skills of doctors, and mostly about the brand. They even become a platform for virtual consultations.

The medical sector is changing the stereotype of beauty and helping to improve not only the physical but also the psychology of older adults, even though, our clinics are still in the digital transformation phase. At this time, these clinics are taking advantage of social media as a positive consequence made without effort. In other words, when seniors shared their experience or their perfect images on these digital platforms, other seniors feel concerned and become obsessed with the new looks and voluntarily become engaged with the beauty surgery. Indeed, since the digital explosion, there is more and more value for the image, and the "physical appearance", whether compared to what people see on social networks or what they want to show.

Especially for seniors who are likely to maintain their physique affected by aging. They find themselves in front of social media showing the perfect silhouettes, and the beautiful faces, which stimulate them and influence them to make some improvements to hide their imperfections. In addition, following selfies published on social media, people have an increased awareness of what they look like over the years, especially around the eyes and neck. These digital platforms have created a revolutionary image that promotes health, beauty, and fitness which is in favor of cosmetic surgery.

Most of the research indicates that patients benefit psychologically from aesthetic procedures, reporting improvements in their appearance and body image despite the that a minority had experienced some kind of "emotional turbulence" (Bion, 1976). Plastic surgery produces long-term positive psychological benefits and a better quality of life for older adults who often report the development of confidence after the procedure. They feel good and look good. This confidence often gives them the motivation they need to set new goals, be more adventurous, more sociable, and feel more comfortable in their own skin.

Indeed, in parallel with physical rejuvenation, a large majority of these patients admit feeling a second bodily youth. Their new reflection in the mirror seems to indicate to their brain that their bodies have also been rejuvenated. It is often believed that plastic surgery seemed to guarantee only cosmetic improvements, it is a recurring mistake, especially in the case of the old adults. Before any final conclusions, a few issues must be assigned. One of the common problems with interviews is that respondents intend to give desirable replies. Yet, this technique provides us with a large amount of valuable information.  We highly recommend the use of social media as a long-term strategy not as a tool. Indeed, given the power of digital communication, marketing managers should recognize the influence of social media on people’s self-perception.

We also recommend firms in the medical sector go beyond the share of images and engage their target to be part of the brand, they can use tools like transmedia storytelling. Engagement can also be creatively stimulated through an emotional connection with the target such as using causes that are important for the patients (Mangold & Faulds, 2009). Despite its rank as the second destination for medical tourism and especially cosmetic surgery, Tunisia remains behind Turkey and Egypt in terms of digital communication. We highly recommend an extra effort in this field so the country could internationally benefit from their high service quality.

Besides communication, providers have become entrepreneurs who constantly revise their businesses through digital innovation, patient-centered care packages, responsible marketing conducts that recognize the frailty of seniors. Trust and reputation of the destination are included and strengthened by the transparency principle of CSR and ethical advertisement and long-term well being of the patients.

Concurrently, this work adds to the literature regarding sustainable entrepreneurship in healthcare tourism as it demonstrates that in Tunisia, the providers are not just clinicians but also entrepreneurs. They are changing their business models, implementing digital tools, and aligning their services and responsible marketing practices to seniors. Providers facilitate their international competitiveness and protect vulnerable populations by integrating the CSR principles of transparency, patient well-being, and ethical communication.

Regarding the societal aspect, medical tourism also results in inclusive development, creating local jobs and spillovers to the hospitality, transport, and wellness sectors. As witnessed in Tunisia, the middle-income state can strategically position itself as a sustainable healthcare destination, not only on the affordability dimension, but also on the ethical stewardship dimension.

Last, the connection between healthcare entrepreneurship and sustainability could be further developed in future studies, such as exploring how providers can achieve profitability and social responsibility, environmental consciousness (e.g., green hospitals), and equitable access of care. It is processes such as these that will not only make the medical tourism a highly profitable business domain, but also a feasible development and an ethically viable internationalization.

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