Health, Wellness and Tourism: healthy tourists, healthy business ...

Health, Wellness and Tourism: healthy tourists, healthy business ...

Health, Wellness and Tourism: healthy tourists, healthy business?

Proceedings of the Travel and Tourism Research Association Europe 2010

Annual Conference 1-3 September, Budapest, Hungary

Puczkó, L. (Ed) (2010).

Health, Wellness and Tourism: healthy tourists, healthy business?

Proceedings of the Travel and Tourism Research Association Europe 2010 Annual


Dalarna, Sweden: Travel and Tourism Research Association Europe.

ISBN: 978-91-633-4666-8

The Travel and Tourism Research Association ( is an international network

of travel and tourism research and marketing professionals from a wide variety of

backgrounds. The Association provides a forum where you may benefit from meeting other

people with similar interests. It was founded in 1970 in the USA. Since 1997, the European

Chapter of the TTRA ( has been active in extending its activities in

Europe and beyond, especially with its annual conference (

The Chair of the Conference and the Organising Commitee: László Puczkó (PhD CMC MA MSc)

is a managing director and head of tourism section at 2q Tourist Research Partnership and Xellum

management consulting company; and Acting Head of the Tourism Competence Centre at Corvinus

University Budapest (Hungary). He has been a lecturer at several colleges and universities. He is a coauthor

of professional books on health and wellness tourism, the impacts of tourism, visitor

management and tourism management in historic cities. He is member of the TTRA European Chapter

Board and President of the Hungarian Association of Tourism Consultants.

Short Introduction to the Conference

Although travel has always contributed to health and wellbeing, it has often been in indirect

or passive ways (e.g. relaxation and escapism). However, many tourists are increasingly

choosing to go on trips which have the direct aim of improving their sense of wellness. On the

other hand, some destinations are now positioning themselves as market leaders in

health/medical tourism. The effects can even be long-lasting for tourists (and destinations)

and not just confined to the duration of the holiday. This can include spa tourism, which can

be medical or leisure-based; social tourism, where medical treatments are state-funded; sports

and adventure tourism, which increase physical health and fitness; occupational wellness

trips, which address work-related issues such as stress-management; and holistic or spiritual

retreats, which can balance body, mind and soul.

Many of these forms of tourism are based on changing leisure and lifestyle trends, such as

healthier nutrition, fitness regimes, or the quest for alternative spirituality. There are also

shifts in many societies from curative to preventative healthcare, which requires greater

knowledge and self-responsibility. The mainstream tourism industry is also investing heavily

in wellness products – for example the cruise industry – possibly to give a healthy ‘feel’ to a

product traditionally associated with eating too much. How can these contrasting aims be

integrated? The tourism industry is consequently responding to society’s need for holidays,

which enhance quality of life and fulfil all domains of wellness (e.g. physical, emotional,

spiritual, psychological and intellectual).

Furthermore, the link between leisure and tourism seems to be getting stronger, since wellness

and healthy/healthier lifestyle oriented customers tend to go on health(ier) trips, too.

The conference explored the relationship between health, wellness and tourism:

• Changing activities in leisure, lifestyle and travel which improve wellness and quality

of life

• Developments in medical tourism and the shift from traditional curative towards

complementary and preventative activities, or even hedonistic aspirations

• The role of well-established forms of tourism (e.g. spa, sports, social, cruise) and

newer forms of tourism (e.g. holistic, occupational, adventure) in the development of

health and wellness

• The special characteristics of investment and return in health and wellness tourism

• The special characteristics of planning, management and marketing of health and

wellness tourism


TTRA Europe would like to extend their sincere appreciation to the conference organizers,

conference chairs and keynote speakers, the dinner speaker, and the panel members and their


Conference Organizers:

László Puczkó, 2q Tourist Research Partnership


Conference Secretariat Weco Travel Ltd- Chemol Travel

Conference Chair:

László Puczkó, 2q Tourist Research Partnership

Dinner Speaker:

Dee Ann McKinney

TTRA Europe gratefully acknowledges the support of the conference:





TTRA Europe is also indebted to the members of the Scientific Committee, who reviewed

121 contributions that were submitted for participation at the conference:

Anja Touhino, Project manager, ITÄHYVÄ, Finland

Aurkene Arzua, Director, CIC tourGune, Spain

Babu George, Assistant Professor of Tourism, University of Southern Mississippi, USA

C Michael Hall, Professor, Department of Management, College of Business & Economics,

University of Canterbury, New Zealand

Edward Huijbens, Docent, Icelandic Tourism Research Centre, Iceland

Frederic Dimanche, Director, Center for Tourism Management, SKEMA, Business School

Nice - Sophia Antipolis, France

Ian Henderson, Managing Partner, TTC International Ltd, U K

Isabelle Frochot, Lecturer, CEMAGREF Grenoble & Université de Savoie

Jana Kucerova, Department of Tourism and Hospitality, Matej Bel University in Banska

Bystrica, Slovakia

Jennifer Laing, Lecturer, Tourism Research Unit, Monash University, Australia

Joseph Sirgy, Professor, Virginia Politechnic Institute &State University, USA

Kai Illing, Professor, Joanneum, Austria

Kaija Lindroth, Degree Program Manager, HAAGA-HELIA, Finland

László Puczkó, Managing director, Xellum Ltd, Hungary

Melanie Smith, Senior Lecturer, Corvinus University of Budapest, Hungary

Pauline Sheldon, Professor, University of Hawaii, USA

Rob Davidson, Senior Lecturer in Business Travel & Tourism, University of Westminster,


Roos Gerritsma, Docent, InHolland, The Netherlands

Sheila Flanagan, Director, DIT, Dublin, Ireland

Sonia Ferrari, Professor of Place, Tourism and Museum Marketing, Università della Calabria,


Tamara Rátz, Head of Institute, Institute of Tourism, Kodolányi János College, Hungary



Economist, sociologist. He has been a teacher of Budapest Business School for 15 years. He

has been a colleague of GfK Hungária Market Research Institute for 20 years, and managing

director of the company since 1993.

He earned his degrees at the College of Commerce & Catering and then at the Eötvös Lóránd

University of Budapest where he majored in Media Studies and Journalism and Sociology.

His special fields are trade, consumer panel research and the research of media use habits.

He is the president of the Hungarian Marketing Association; a member of the Board of the

Hungarian Advertising Association; a member of the Association of Professional Market

Researchers; a member of the Advisory Body of the Marketing and Media Institute of the

Corvinus University of Budapest; a member of the Advisory Body of the Budapest Business

School; a member of the Communication Sub-Committee of the National Euro Coordination

Committee; a member of National Round Table on Pensioners and the Elderly; a member of

ESOMAR’s European Marketing and Sociology Organisation. Klauzál Gábor prize winner,


He is an author and co-author of several college and university lecture notes and course books

on market research. Email:


Roger is COO of Thermarium Spa Financial Consulting based in Tyrol, Austria. Roger has

worked in spa development, operations and management for over 15-years during which time

he has built a chain of day spas and premium health clubs, worked extensively throughout

Asia and headed spa recruitment and spa operations for Steiner Leisure. Roger has been

involved in all types of spas and worked with both venture capital and angel investors for

various spa projects.

Roger is now providing experienced client dedicated financial spa planning, conceptual and

operational development to some of the most exciting spa projects in the world.



Melanie Smith is a Senior Lecturer and Researcher in Tourism at Corvinus University,

Budapest. Before this, she was Director of BA Tourism and MA Cultural Tourism

Programmes at the University of Greenwich in London. She is also Chair of ATLAS

(Association for Tourism and Leisure Education). She is co-author of Health and Wellness

Tourism (Butterworth-Heinemann, 2008) with László Puczkó and has written several journal

articles about holistic and wellness tourism. She has also recently been involved in teaching

and curriculum development in health and wellness tourism in Hungary, Estonia, and Iceland.



Kevin Turnbull is the Chief Executive of SpaFinder Europe, Middle-East & Africa, a division

of the largest spa marketing and spa gifting company in the world.

Kevin’s insight into the luxury spa market comes partly from his prior role as Director of

Mercedes Benz Luxury Car division in the UK, where he managed the ultra-luxurious

Maybach and the SLR McLaren super sports car business.

His career also saw him as CEO of the internet company Autobytel UK, a subsidiary of

Inchcape plc where he was also Global Group Director responsible for e-Commerce. Before

that he was Chief Executive of Toad plc, a technology business start-up, and played a pivotal

role in raising multi million City funding for the company and successfully floating Toad on

the London Stock Exchange. Kevin spent his early years at Ford and Nissan in sales and


Kevin received a BA (Hons) in History/Politics from Warwick University and holds an MBA

from Durham University. He is a Fellow of the Chartered Institute of Marketing, a Fellow of

the Institute of the Motor Industry and a member of the Institute of Personnel and

Development. He is a frequent speaker at industry events throughout Europe.



… started her professional career by working for a radio station and as a journalist.

Up to now 26 years experience in managing positions in tourism and hotel management.

From 2001 till June 2009 she was responsible at the State Tourist Board of Baden-

Württemberg (Southwest Germany) for marketing and advertising, for the cooperation with

tour operators and travel agencies in Germany and Switzerland.

Especially she participated in the establishment of the quality-certificate and the brand

WELLNESS STARS, which is standing for certified quality in hotels, spas and medical

wellness facilities.

Since July 2009 she’s consulting in destination-management, auditing and consulting hotels

and spas, offers spa- and marketing concepts as well as public relations. Since 2008 she is the

coordinator of the German Medical Wellness-Group.



Dr. Gerry Bodeker researches and advises on international public policy on

traditional,complementary & alternative medicine (TCAM). An Australian, he is senior

clinical lecturer in public health in the University of Oxford Medical School and research

associate at the Oxford Centre for International Development. Dr. Bodeker has been chair of

the Commonwealth Working Group on Traditional & Complementary Medicine and done

work on medicinal plant conservation for the World Bank, the Global Environment Facility

and the UN Food & Agriculture Organization. He has written extensively on traditional

medicine and is co-founder of the WHO-affiliated Research Initiative on Traditional

Antimalarial Methods (RITAM).



Elisabeth Ixmeier is co-founder of Healing Hotels of the World, an exclusive global

partnership of hotels, resorts and retreats offering holistic health and wellbeing in luxury

surroundings. The quality brand Healing Hotels of the World is based on a comprehensive set

of criteria securing holistic health and wellbeing in all areas of a hotel or resort.

Elisabeth has a PhD in philosophy and art history and is practising holistic philosophies such

as Yoga since 30 years. Being a world traveller she became familiar with the leading wellness

resorts and the development towards health travel worldwide. As the co-founder of Healing

Hotels of the World she combines her experience in tourism marketing with her enthusiasm

for personal development and healing.



Dee Ann McKinney brings 30+ years of marketing, research and advertising experience to her

current professional position of overseeing Strategic Planning and Research for the Division

of Tourism for the state of Missouri (MDT). She gained her marketing expertise with such

organizations as Southwestern Bell (AT&T), Bell South, the Cincinnati Symphony Orchestra,

regional cable networks and the Missouri Division of Tourism. She has also held media

positions in magazine, newspaper and television advertising sales.

McKinney has served on the Research Committee for the US Travel Association, the regional

(Central States) Board of the Travel & Tourism Research Association (TTRA) and the Direct

Marketing Association of St. Louis Board of Directors. Currently, as liaison to all of MDT's

research vendors as well as other state tourism offices and local, community or tourism

business organizations and other tourism research interested groups. She supervises all

research information releases and competitive analyses. For several years, she has also Cochaired

the state research directors group for the United States-- coordinating, organizing and

moderating meetings of State tourism offices twice each year.

Presently, McKinney is President of TTRA's international Board of Directors. Prior to

becoming the President, she served on the board for four years including as first and second

Vice-President. In June of 2010 she became the Chairman of the Board for TTRA.


Table of Contents

ANTUNES Joaquim Gonçalves 282

AZMAN Inoormaziah 9

BARTH Isabelle 56



BROWN Anthony 248

BROWN Graham 164

CHAN Jennifer Kim Lian 9

CHOI Hwan-Suk Chris 102

CLEEVELY Olivia 248

COLE Shu 37

CORREIA Anabela Gomes 282

DE GRANDPRÉ François 175

DEERY Margaret 38

DIMANCHE Frederic 40

DIMANCHE Christine 40

DO VALLE Patrícia 299

FORMÁDI Katalin 270

FUKUTOMI Akira 248

GERRITSMA Roos 43, 280

GICZI Johanna 203

GUSTAVO Nuno Silva 45

HALLEM Yousra 56

HANAN Katharine 248


HJALAGER Anne-Mette 67


HOWAT Gary 164

HSIEH Mei-ting (Jessica) 85

HUIJBENS Edward H. 92

İÇÖZ Onur 261


JAGO Leo 38

JOPPE Marion 31, 102

JOUKES Veronika 109

JUDIT Torday 376

KIRÁĽOVÁ Alžbeta 121

KOMPPULA Raija 144

KONU Henna 154

KONU Henna 67

LAING Jennifer 164, 378

(Quick search: Ctrl+F)


LEBLANC Marc 175


MAGGI Rico 408


MAYER Peter 270

MENDES Júlio 299

MICHALKÓ Gábor 203

MOLNAR Elisabeth 315

MUNDRUCZÓ Margit 227

NEMES Andrea 238

PARMAR Rina 248

PESONEN Juho 144

PIRNAR İge 261


PRISZINGER Krisztina 270

PUERTAS Xavier 280

QUINTELA Joana Alegria 282

RÁTZ Tamara 189, 203

RENDA Ana 299

ROWLAND Eleanor 248

RULLE Monika 309


SHEN Ching-Cheng 309, 358

STANCIULESCU Gabriela Cecilia 324

SZIVA Ivett 333

TAMÁS Várhelyi 378

TOOMAN Heli 348

TREMBATH Richard 164

TRIKI Abdelfattah 56

TSENG Tzuhui A. 315, 348

TUOHINO Anja 366

UJMA Dorota 376

VIIN Tiina 333

VOIGT Cornelia 164,


WEILER Betty 164

WENG Janet I-Jane 381

YU Ping 397

ZINS Andreas H. 408

ZOLTAN Judit 424

Health and Spa Tourism Business: Tourists’ Profiles and Motivational


Inoormaziah Azman

Postgraduate Centre


Jennifer Kim Lian Chan

School of Business and Economics,

University Malaysia Sabah (UMS),

88450, Kota Kinabalu,

Sabah, Malaysia



Health and spa tourism has increasingly become an important economic and marketing

strategy for hoteliers, resorts and tourist destinations to attract tourist visitations. Despite the

fast expansion and popular demand of health and spa services/activities by both local and

international tourists, there is little understanding of the spa and wellness consumers in the

Malaysian context. It argues that a deep understanding of consumer profiles and their key

motivations within this context is vital in order to sustain the growth of health and spa tourism

business. The paper presents a preliminary pioneering exploratory qualitative study that seeks

to understand the spa and wellness tourists’ motivation that are grounded in their own words

during their visits to spa and wellness service centers in Sabah, Malaysia. It reports the

empirical findings of spa and wellness tourists’ motivation by extending the push-pull

motivation theory that focuses on the individual’s psychological factors (motivation,

perception and attitude towards spa and wellness) and the destination’s (Sabah’s) spa and

wellness attributes. Data collection was conducted using in-depth interviews with 15 foreign

tourists in various health and spa service centres in Sabah, Malaysia. It reveals that the retired

aged group is the main category of tourists who go for health and spa services followed by the

professionals who are very health conscious and practice healthy lifestyle. The findings

revealed that health and spa tourist motivation is largely attributed to personal needs and

lifestyles, the price and the functionality/performance of health and spa service providers in

Sabah. The paper provides the broad understanding of health and spa tourists’ profiles in

Sabah, Malaysia and the key motivation factors. The finding benefits the health and spa

service providers in term of developing appropriate marketing strategies and enhanced tourist

satisfaction. The nature of the exploratory study and the type of respondent (foreign tourists)

limit the generalizability of the research findings.

Key words: health and spa, tourist profiles, motivation factors, tourist lifestyle, marketing

strategies for health and spa business


Over the past centuries, health and wellness-oriented activities have been recognized around

the world, with existing of different health practices of the people in different regions for

staying healthy, and for healing/curing remedies as well. The development of health tourism

can be resonated with the echoes of the great economic growth and major demographic shift,

occurring in most countries across the globe. Consequently, the society is aligned between the

consumer’s strong interest in health and the rising affluence, resulting in plethora of consumer

products, whether anti-aging creams or medical procedures, as everyone is in search for health

and well-being (Yeoman, 2008). Additionally, people are practicing a healthy lifestyle to keep

them fit and healthy. This lifestyle, Ryan and Travis (1981); in Kammermann et. al. (1983); in

Nahrstedt (2004), had termed “wellness” which can be described as a way of life, that an

individual create to achieve his/her highest potential for well-being, consists of actions that

the individual able to control, such as how they exercise, eat, manage stress, and perceive the

environment, and achieving a high-level wellness involves continual striving for a more

healthful way of living.

Benner, King and Milner (2004) suggested that health tourism is any pleasure-oriented

tourism which involves an element of stress relief could be considered to be a form of health

tourism. They highlighted the importance of distinguishing between health tourism and the

wide phenomenon of tourism because product perceptions on the part of both suppliers and

consumers will influence the extent to which more specialized travel experiences such as

medical treatment are promoted to mainstream market. Likewise, subsuming spa as a sub

sector of the health and wellness tourism, the spa sector is concomitantly mushrooming in the

past decades as one of the destination’s tourism offerings, especially in the hotel sector. It has

increasingly become an important economic and marketing strategy for hoteliers, resort and

tourist destinations to attract tourist visitations. McNeil and Ragins (2004) suggested that spa

participation is currently showing incredible growth, as more consumers turn to spa facilities

as venues to improve their health and well-being. Although it is luxury, it is seen as much

more necessity, and factors like, personal space, time out, escapism, retreats contribute to spa

visitation. Additionally, Smith and Puczkó (2009) stated that, in historical terms, health and

wellness practices have been very much embedded in regional and local traditions and

cultures, with available natural resources also determining the forms of wellness that were

developed. Therefore, it is arguable that there are extended key motivation factors of tourists

visitation to health/spa facilities at a particular holiday destination. Despite the expansion and

popular demand of health and spa services/activities by both local and international tourists,

there is a little understanding of the health and spa consumers in Malaysian context.

Therefore, this exploratory qualitative study attempted to understand the health and spa

tourists’ motivation that are grounded in their own words during their visits to health and spa

service centers in Sabah, Malaysia by extending the push-pull motivation theory, to provide

some insights of this popular business. The purpose of this paper is to provide a deep

understanding of tourists’ profiles and their key motivations in health and spa tourism context

which is vital in order to sustain the growth of this tourism business.

Having brief on the issue, the research is aimed at providing a starting point for understanding

Sabah’s health and spa tourism market, particularly from demand perspective, by establishing

a preliminary profile of the health and spa tourists, and identify the key motivators of these

tourists in the health and spa tourism products and services in Sabah, Malaysia. The research

objectives were undertaken in an effort to answer the following questions:

• Who are the health and spa tourists in Sabah, Malaysia?

• Why the tourists utilized any of health and spa products and services while they travel in

Sabah, Malaysia?

Literature Review

Health and Spa Tourism

In recent years, many researches have been undertaken in addressing the issues related to

population health and health tourism. Smith and Puczko (2009) suggested that health tourism

can be viewed from two different perspectives, which are medical and wellness. Spa is one of

the sub sectors of health tourism which positioned in between medical and wellness,

depending on the purposes and types of treatments received when visiting spas. There are

many studies related to health tourism, especially in the field of medical tourism, but very

limited on health, spa and wellness that can be found in tourism literature. Nonetheless, the

studies focused on the development, marketing and positioning the spa establishments – the

supply side, rather than the demand side of health and spa goers/tourists.

According to Mcneil and Ragins (2004), spa participation in the United Stated of America is

showing an incredible growth in the early 1990s when the participation in gyms and health

clubs for fitness slowed down. The researchers stated that many consumers turn to spa

facilities as venues to improve their health and well-being, and the industry continues to grow

at amazing rates and marketing opportunities abound. They highlighted the current issues and

trends in the US spa industry, which the major challenges would be; (i) to meet the

consumers’ needs effectively as a shift in paradigm in spa concept – from indulgence to

wellness, (ii) to stay abreast of the changes in the spa consumer profile; as spa facilities

nowadays are not only cater to women, but also to men, and cater to all age-group of people,

(iii) to provide a more comprehensive array of treatments, services, and activities combined in

a highly conceptualized setting, and (iv) to stay up to date with technological advances in

provision of spa information to prospective consumers. The researchers suggested the uses of

strategies and techniques that respond to consumers’ demands, in the context of target

markets and the four Ps – product, place, promotion and price. They concluded that the spa

marketers must remain flexible and adapt to changes of spa users’ wants and needs, and

continue to improve communications about the spa experience and its benefits.

In line with aforementioned, Chon and Singh (1995) provided a review of trends in marketing

the resorts in USA. One of the product development trends they highlighted was the one that

evolved health awareness – concerns about personal health and fitness which increased the

demand for health-related holidays. Consequently the resorts are adjusting their amenities and

services to accommodate the health demands on vacationer, such as fitness facilities and

health spas have been added to release stress and improve nutrition and physical conditioning.

Moreover, they also stated that the presence of spa at a resort was cited as a primary reason

for drawing them. The trend is expected to continue as more and more people travel for health

reasons to resorts and spas which provides fully monitored and individualized beauty

treatments, and health programs.

Tourist Motivation

Motivation has long been a central subject of study in psychology from varieties of ways,

including from the physiological, psychological or philosophical approaches (Petri and

Govern, 2004: 3-14). The study of motivation is widely being used in understanding human

behaviour and can be found in the literature of many disciplines. Likewise in tourism, the

concept of motivation has been used in understanding tourist behaviours and their travel

decision-making which can be indicative to tourism providers as to attract tourists and fulfil

their needs during their travel at a particular destination.

Page and Connell (2006: 63) stated that motivation as a subject is an integral part of the study

of consumer behaviour in tourism. Mountinho (1987), as cited in Page (2009), defined

motivation as a “state of need, a condition that exerts a push on the individual towards certain

types of action that are seen as likely to bring satisfaction”. It indicates the intrinsic reasons

why the individual is embarking on a particular trip (Weaver and Lawton, 2002: 189). This

psychological concept refers to tourists and the reasons why they embark on a particular trip.

It is too, directly linked to the demand for tourism, which can affected by a range of factors,

and to consumer/tourist behaviour, which does not only affect the initial purchase but also the

tourist experience as well as future decisions (Lomine and Edmunds, 2007: 125).

Consequently, motivation models and studies are seen in a variety in understanding tourist

behaviour in relation to many aspects of tourism, for example, the destination choice (e.g.

Chan and Baum, 2007; Park and Yoon, 2009), tourists’ purchase decision/spending pattern

(e.g. tourists’ souvenir purchase decision by Swanson and Horridge, 2006), and tourism

business marketing and planning strategies (e.g. Oh et. al., 1995; Bansal and Eiselt, 2004).

The results lead to a greater understanding of tourists’ behaviours and thus contributing to

effective marketing strategy in targeting the right tourist market. One of the concepts that are

considered in tourist’s motivation and purchasing process is in term of push-pull factors

which has been widely adopted in researches mostly associated with tourists’ behaviours and

segmentation, from general holiday-takings to special interest tourism, but rather in different

contexts and countries.

Push-Pull Factors of Tourist Motivation

Among the most well-known tourist motivation theory is the push-pull concept (Dann’s,

1977; Crompton’s, 1979; Iso-Ahola’s, 1982), in which activity is seen as a product of a pullpush

relationship. Dann (1981, as cited in Cooper et. al. 1993: 34) pointed out that the

destination pull in response to motivational push, which distinguishes between the motivation

of the individual tourist in terms of the level of desire (push) and the pull of the destination or

attraction. Similarly, Page and Connell (2006: 68) stated that push factors are those that

propel a desire to travel; pull factors are those that influence which destination is selected,

given the initial push, and arise from on a desire to travel. Crompton’s (1979) identified seven

psychological (push) motives: (i) escape from a perceived mundane environment, (ii)

exploration and evaluation of self, (iii) relaxation, (iv) prestige, (v) regression, (vi)

enhancement of kinship relationships, (vii) facilitation of social interaction, and two cultural

(pull) motives: (viii) novelty and (xi) education. This concept has been extensively studied

and widely accepted in tourism literature (e.g., Chan & Baum, 2007; Yoon & Uysal, 2005;

Jang & Wu, 2006; Kim, Lee & Klenosky, 2003; Oh et. al., 1995; Swanson & Horridge, 2006).

It is suggested that push-pull motivation concept is a useful approach for examining the

motivations underlying tourist and visitation behaviour. Gilbert (1991) acknowledged the

push and pull factors influencing the tourism consumer decision-making process (as cited in

Page and Connell, 2006: 68).

The idea of the push-pull model is the decomposition of a tourist’s choice of destination into

two forces, which are push and pull factors (Bansal & Eiselt, 2004). The push factors are

considered to be socio-psychological motivations that predispose the individual to travel,

while the pull factors are those that attract the individual to a destination once the decision to

travel has been made (Oh et al., 1995; Kim and Lee, 2002). This motivation concept

encompasses the push motivation factors, which are related to the tourists’ desire, and pull

motivation factors which are associated with the attributes of the destination choices (Yoon &

Uysal, 2005; Oh, Uysal & Weaver, 1995; Kim and Lee, 2002; Kim, Lee and Klenosky, 2003;

Jang and Wu, 2006).

Yoon & Uysal (2005) stated that push motivations are more related to internal emotional

aspects, while pull motivations are connected to external, situational, or cognitive aspects. On

the other hand, the push factors are origin-related, intangible or intrinsic desires of the

individual travellers, such as the desire for escape, rest and relaxation, health and fitness,

adventure, prestige, and social interaction. Meanwhile, pull factors are those that emerge as a

result of the attractiveness of a destination as it is perceived by the traveller. They include

tangible resources such as beaches, recreation facilities and historic resources as well as

travellers’ perception and expectation such as novelty, benefit expectation and marketing

image of the destination.

Chan and Baum (2007) investigated the motivation factors of ecotourists in ecolodge

accommodation by adopting the push and pull motivation factors. The findings revealed that

the eco-tourists are primarily attracted by the destination attributes (natural attractions,

wildlife, local lifestyle and eco-activities), where ecolodges are located (pull factors), and they

are also pushed by their social psychological desire to escape from their routine of normal life

(push factor). The identification of motivational factors in this study provides a clearer

account of what attracts the ecotourists to stay at ecolodges and suggested that the marketing

strategies for ecolodges should focus more on the destination attractions around the ecolodge

accommodation by positioning the ecolodges based on the unique destination attributes.

Nonetheless, conservation and protection the surrounding natural resources are important too

as these are the main motivational factors for tourists to patronize ecolodges. In contrast, Kim,

Lee and Klenosky (2003) examined the influence of push and pull factors on visitors to the

national parks in Korea. The results of a factor analysis identified four push factor domains

and three pull factor domains underlying respondents’ push and pull factor ratings. The push

factor domains suggested that the visitors to national parks in Korea considered the park to be

valuable recreational resources that provide important opportunity to appreciate natural

resources or enhance health or building friendship (consistent with results of 1999 Report of

Korean National Travel). Meanwhile the pull factor domains reflected the fact that the

national parks in Korea are relatively accessible and located close to most residential and

work areas. The study also provided the additional analyses investigated differences in push

and pull factor domains for different socio-demographic sub-groups and examined the

interrelationships among the push and pull factor domains. The study provided valuable

information in understanding Koreans’ motivation to visit national parks and the results hold

useful implication for park managers and researchers in studying how push-pull factors

impact tourists and visitors behaviour.

In line with aforementioned, it argues that the push and pull theory of tourist motivation can

be applied into health and spa tourism context. Similarly, there must be underlying factors

that motivate tourists for health and spa services while travel to a holiday destination, and

there must be certain health and spa attributes that attract the tourists to health and spa

facilities at the destination countries. Therefore, this research attempted to adopt push and pull

theory motivation concept in identifying the health and spa tourists’ motivation factors and

profiling these tourists.

The push-pull concept was utilized, with modifications being made to focus into health and

spa tourism, which is likely to be more central on the healthy lifestyles of the health and spa

goers and the holiday destination’s health and spa attributes. Accordingly, the push factors are

considered to be socio-psychological motivations that predispose the individual to travel (Oh

et. al., 1995), which evolves tourist’s personal attributes, or a demand-side approach which is

to understand tourist’s decision-making process, such as attitudes, perceptions, and learning

and motivation factors – the four major psychological factors of the individual’s purchase

behaviour (Knowles, Diamantis and El-Mourhabi, 2004: 57). Meanwhile the pull factors are

those that attract the individual to a specific destination once the decision to travel has been

made (Oh et. al., 1995). This may include tangible resources such as beaches, recreation

facilities and historic resources, as well as travellers’ perception and expectation such as

novelty, benefit expectation and marketing image of the destination (Yoon and Uysal, 2005).

Petri and Govern (2004: 20-21) suggested that some behaviour can be understood as

motivated by internal states that activate the individual to respond in genetically determined

ways. Other behaviours seem clearly the result of external information that is acted upon in

light of acquired experiences. This approach of motivation provides a dimension at which

motivation can be studied concerning the source of motivation, that is, the internal motives

versus external motives. The researchers stated that needs are commonly viewed as internal

sources of motivation that activate and direct behaviour to items in the environment that

alleviate some state of deprivation. It implies of physiological terms, and may also include

social and psychological needs. Meanwhile, the external sources of motivation are

emphasized on the motivating effects of either various goal objects or social relationship.

From this point of view, it is suggested that the motivation can be activated by changes in the

external environment.

Similarly in tourism, (Page, 2009: 90) stated that the intrinsic motivation approach recognized

that individuals have unique personal needs that stimulate or arouse them to pursue tourism

(the desires to satisfy individual or internal needs – self-improvement, self-realization, or

achieve state of happiness, and ego-enhancement). In contrast, the extrinsic motivation

approach examines the broader conditioning factors that shape individuals’ attitudes,

preferences and perceptions, but are more externally determined (the society and the culture

one lives in). Goeldner and Ritchie (2006: 254) suggested that the extrinsic and intrinsic

motivation must be able to consider that travellers are variously motivated by intrinsic, selfsatisfying

goals and at other times are motivated by extrinsic socially controlled rewards (e.g.

other’s opinions). The framework in this research integrated the individual’s psychological

factors and the destination’s health and spa attributes adopting push-pull factors motivation

concept, in order to explain tourist’s motivations in utilizing health and spa services when

they travel to Sabah, Malaysia and the key attractiveness of local health and spa to the tourists

on the other hand, by moderating the demographic variables with the push-pull dimension in

explaining the tourist motivation on health and spa services. This contributes to a better

understanding of health and spa tourists in Sabah, Malaysia and also to the development of

the sector in the coming future, as it benefits the health and spa operators in term of

developing appropriate marketing strategies and thus enhances tourist satisfaction.

Push factors

Internal motives – physiological, social and

psychological needs

(Needs that activate and direct behaviour)

Petri and Govern (2004)

Intrinsic Factors

(Unique personal needs that stimulate or arouse

them to pursue tourism)

Page (2009)

Push Factors – Psychological Factors

(Oh et. al., 1995; Yoon and Uysal, 2005; Cooper

et al. 1993: 36; Knowles, Diamantis and El-

Mourhabi, 2004)

Health-related attitudes

Health, spa and wellness perceptions & learning

Health-related motivations

Pull factors

External motives – the motivating effects of

either various goal objects or social relationship

(Motivation can be activated by changes in the

external environment)

Petri and Govern (2004)

Extrinsic Factors

(The broader conditioning factors that shape

individuals’ attitudes, preferences and

perceptions, but are more externally determined)

Page (2009)

Pull Factors – Destination Attributes

(Oh et. al., 1995; Yoon and Uysal, 2005)

Spa as a tangible resource

Unique spa treatments and experiences

(marketing image)

Health and Spa Tourists

Motivation Factors

Figure 1: The Framework for Health and Spa Tourist Motivation Factors

Health-related Tourist Motivation

Though health tourism has longevity in historical terms, health and spa tourism can be

considered at its infant stage, at which health and spa tourists’ motivation remains a

substantive interest for researches. There is generally lack of empirical studies on health and

spa tourism motivation in understanding the fundamental needs of the health and spa goers

during holiday, as there is a growing concern on health among the population at present. It is

suggested that research investigating health, spa and wellness from demand perspective is

needed as many of the available literatures (as presented above) are basically focusing on the

development, marketing and positioning studies of the health, spa and wellness


One of the available researches that directly linked to health and spa goers is of Mak and

Wong (2007), who examined the underlying factors that motivate Hong Kong travelers to

search for spa experiences while travelling away from Hong Kong. The structured

questionnaires were employed to conduct the survey and received a total of 302 responses.

The findings revealed that the Hong Kong spa goers perceived spa as a place for relaxation,

pampering, beautifying treatments, and enhancement of overall health. The motivation

factors; ‘relaxation and relief’, ‘escape’, ‘self-reward and indulgence’, and ‘health and beauty’

are the most important factors that motivate Hong Kong travelers to visit spas. The result was

found to be an integration of European spa goers health perspective and American spa goers

self rewarding perspective. The findings of their study provide researchers and practitioners in

the spa industry with useful insights into understanding the present nature of the demand of

spa in the Asian market.

On the contrary, there are studies integrating healthy lifestyle into consumer/tourists

behaviours by Gonzalez and Bello (2002) show that a strong dependency relationship

between tourists’ behaviours and lifestyle, and the segmentation of the market that emerged

makes a division into five clusters: home-loving, idealistic, independent, hedonistic and

conservative. The labels give a general idea of the lifestyle of each segment. Similarly, the

study by Hallab (2004) on healthy-living oriented lifestyle in the field of travel and tourism

show that the connection between healthy-living habits of US citizens and their travel

characteristics with respect to travel push and pull motivational factors and sociodemographics.

It revealed significant findings in regard to individuals who have a healthyliving

lifestyle and their travel behaviour and shed a light on their socio-demographic

characteristic. The researcher also suggested future researches to use more variables in

seeking to understand further the mentioned segment’s travel behaviour.

Page (2009: 88) stated that there is no all embracing theory of tourist motivation due to the

problem of simplifying complex psychological factors and behaviour into a universally

acceptable theory that can be tested and proved in various tourism contexts. In this study, the

concept of push and pull motivations is used to refer to the perceived importance of health

and spa services for international tourists during their holiday in Sabah, Malaysia. This

implies that certain reasons for health and spa services during travel may correspond to

certain benefits to the tourists that are to be valued and obtained at the destination site.

Therefore, the tourism providers, health and spa providers must understand the tourists with

regards to their health and spa perceptions, expectations and decisions; and so, matching the

destination’s health and spa attributes to the tourists’ diverse needs.

Research Methodology

Research Method and Study Site

The qualitative approach was used in this research to provide an insightful understanding of

the underlying motivation factors and perceptions that encourage the utilization of health and

spa services/facilities. Collis and Hussey (2003: 53) stated that the qualitative approach is

more subjective in nature and involved examining and reflecting on perceptions in order to

gain an understanding of social and human activities, which this research dealt with – the

tourists’ ideas, perceptions and involvement in health and spa during holiday. Moreover,

Weaver and Lawton (2002: 388) stated that the qualitative research is suited for situations

where little is known about the subject matter.

Respondents were the international tourists who stayed at four respective resorts in Kota

Kinabalu, Sabah (Shangri-La Tanjung Aru, Shangri-La Rasa Ria, Sutera Harbour, and Nexus

Karambunai) and had used the spa facilities/services provided during their stays at the resort.

The mentioned resort hotels were chosen as the study sites due to reasons; (i) they provide spa

services as part of the hotel services, (ii) they are in the same ranking – can be considered as

five-stars resort hotels, and (iii) they provide similar leisure and recreational activities and

facilities. However, due to the policy of the resort, in protecting the guests’ privacy, which is

not allowed the guests to be interviewed, the interviews were conducted at the Kota Kinabalu

International Airport (KKIA) before they depart back to their home countries or to their next

destinations. The semi-structured interview questions for in-depth interview with the tourists.

It comprised of five sections: questions related to the destination (Sabah) selection;

accommodation selection; spa and wellness experiences in Sabah; the individual’s healthrelated

perceptions and attitudes; and demographic questions. Besides that, the Englishspeaking

international tourists were specifically chose to alleviate the interview conversation

in order to maintain the genuineness of the data, and avoiding translation into other languages,

since nuances may be lost in this process possibly resulting in bias and loss of meaning.

Data Collection

In-depth interviews were conducted with 21 health and spa tourists at the Kota Kinabalu

International Airport (KKIA) from January to February 2010. Approximately 150

international tourists were approached, about 80 were staying at the respective resorts, less

than 40 of them had spa experiences at the resorts, 21 accepted to be interviewed but only 15

in-depth interviews completed (notably tourists from America, Europe and Australasia

regions) due to time constraint.

In-depth interview were conducted using recordings and lasted an average of 40 minutes.

They were conducted with the consent of the health and spa tourists on the day they were

leaving the city (Kota Kinabalu). The in-depth interviews were conducted using the interview

guide approach with a semi-structured format to enable the researcher to identify the topic and

issues in advance and therefore sequence and words the questions during the course of the

interview. The interview started with an introductory note and followed up with demographics

characteristics of the informants. The informants were first asked with questions pertaining to

their destination and accommodation selection, the purposes for coming to Sabah and reasons

to stay at the particular resort, as well as the key attracting factors of the destination and

accommodation selected. Then they were asked about their views on health-related activities

during holiday, and also their spa experience in Sabah (particularly at the resort). The final

section of the interview sought on their perceptions and attitude on health especially

pertaining to spa services and treatments during holiday in Sabah. The informants were asked

and probed for detail explanation wherever required throughout the interviews.

Data Analysis

The recorded interviews were transcribed into a written format for data analysis. The data was

revised and analyzed in three stages to identify and develop appropriate themes. First, the

sample will be profiled by socio-demographic characteristics. This is because the relative

importance of the motivational forces has been found to vary as a function of tourists’ sociodemographic

characteristics (Kim, Lee and Klenosky, 2003). Second, push and pull

motivation items will be identified by drawing out the key themes and variables relating to the

descriptive themes – push-pull motivation and push and pull forces (Oh et. al., 1995; Yoon

and Uysal 2005). It was then linked to the tourist motivation factors from the previous studies

based on push-pull motivation factors that relate to health and spa tourism. The final data

analysis was based on health, spa and wellness concept suggested in the literature (Mak and

Wong, 2009; Smith and Puczkó, 2009), at which health and spas are seen as promoting the

individuals’ health and well-being rather than cure (medically), and also the main motivations

of having health-related and spa services during travel associated with the individuals’

awareness of health and well-being. In addition, as push-pull concept was adopted in this

research, therefore, the main health and spa’s attributes were recognized. This provides an

interpretation of health and spa tourism in Sabah, Malaysia.

Findings and Discussions

Profiling Health and Spa Tourists

Table 1 summarizes the demographic profile of the study informants, who are mainly from

the America, Europe and Australasia regions. Majority of the informants were female (75%),

aged more than 30 years old (80%), worked as professionals (80%), had university degree

(73%), and annual income more than 50,000 USD (67%).

Table 1 Profiles of Health and Spa Tourists in Sabah

No Demographic variables % No. Demographic Variables %

1 Nationality (regionally) 4 Occupation

America 20 Professional 80

Europe 80 Non professional 7

Australasia 80 Housewife 13

2 Gender 5 Annual income

Male 25 50000 – 70000 USD 20

Female 75 Above than 70000 USD 47

Not given answer 33

3 Age

Less than 30 20 6 Educational Level

30 – 49 47 Self-taught 7

More than 50 33 College/University 73

Not given answer 20

By looking at the results of the demographic analysis, it can be said that informants reflected

general demographic information of health and spa tourists, who are mostly female in

professional and executive jobs; baby boomers dominate this market, which fall into the 30-

49 age group, and also the finding of younger spa goers who are less than 30 years old. These

findings indicate an encouraging interest in healthy lifestyle, health and spa tourism among

the tourists. Therefore, it can be said that tourists would likely to go to spa during holiday.

There is an absent of data from a few of informants regarding their annual incomes and

education levels including the housewives. But generally it reveals that the informants have

an annual income of more than 50,000 USD and are university graduates.

Health and Spa: Perceptions and Attitudes

Perceptions, learning and attitudes may be influential to ones’ motivation factors and thus

influence the consumer/tourist behaviours. Accordingly, the informants think that it is

important to participate in activities that contribute to ones’ health and well-being. They seek

to find balance or moderation in their lifestyles which is believed to makes ones healthy or

healthier thus ones may live longer and able to lead more enjoyable lives. The informants

seem to be health conscious, most of them claimed to have being part of the health regimes,

for examples, they do regular exercises, walking or running, Pilates and Yoga, practice

healthy eating, involve in sport activities and occasionally go to spas, have massages,

pedicure and manicure. Few informants confessed that they do not have much time to involve

in any health activities due to the nature of their works (physical jobs, a demanding work): “I

don’t do daily activities in England. No time, because of my work. My work is long, so after

work I have no time to the gym, swimming, or… (Interview informant 14)”, “I don’t do them

but I would like to do them. I don’t have time to do them. (Interview informant 15)” This

indicates that the informants are health conscious but they do not have much time for health


According to the findings, holiday seems as the best time and opportunity for the informants

to do things that they do not normally do at home to improve their health and well-being –

relaxation being part of their holiday as majority of the informants came to Sabah for holiday

and relaxation. They travelled mainly to see the wildlife (Orang Utan, Proboscis monkey, and

turtles) and natural environment (rainforest, mountain, beaches and islands) in Sabah. Other

than that, they also came because of the resorts, weather, culture, proximity to Hong Kong

(transit flights to home countries) and the range of activities like trekking up Mount Kinabalu,

golfing and water activities (snorkelling and diving). Previous travel experiences, the travel

agents’ and friends’ recommendations also influenced tourists’ decisions to come to Sabah,

especially for the first-time tourists. The travel agents and the internet were the main sources

of information for the tourists when selecting a travel destination.

In line with aforementioned, spa is not at all considered to be one of the reasons in selecting

Sabah as a holiday destination. However, when selecting an accommodation, the informants

generally consider spa as part of the resort/hotel’s facilities provided to the guests and would

have expected it if the accommodation is a 5-star resort/hotel. According to the responses, the

informants perceive spa as a place that has the ideas of relaxation, pampering, luxury, the idea

of massage and varieties of treatments, regeneration, clean and calm, tranquillity, enjoyment,

and expensive. Interestingly, there were informants associated spas with hot tubs or hot

springs. This suggests that the spa is associated with water and hot springs are the common

sources for building spas, which can be evidenced from the following quotes: “Luxury,

expensive… I think tranquil… hot tub… (Interview informant 13)” and “Different, because I

lived in Japan, so now I know the spa there was different, kinds of hot springs. So, that’s what

I initially thought about spa. (Interview informant 14)” Therefore, it is suggested that the

informants generally go on holiday for relaxation; spa is not the main reason to select a

holiday destination, but rather as part of the relaxation options/remedies during holiday.

Besides of being relaxed during holiday, the spa experience is regarded as part of the

enjoyment of holiday experience. This is reflected in the response “It is part of the enjoyment

of my holiday and it also adds to the relaxation of my holiday and the experience of my

holiday” (Interview informant 7)

Moreover, majority of the informants thought that it is important to involve in health-related

activities during holiday. They suggested that ones need healthy activities all around and not

just during holiday, or to keep moving and keep doing things even if during holiday, but it is

not the most important, the most important is relaxation; as evidenced from the following

quotes: “We try to incorporate relaxation, walking and tourism” (interview informant 12), “I

think you’ll feel better. (Health activities) It’s important but it’s not the most important. You

generally feel better” (interview informant 14), “The one thing that we try to do each day is

to go for a walk every morning, for at least it makes me energetic” (interview informant 15),

and “Relaxation is the most important, not exercise” (interview informant 18). Interestingly,

the lifestyle factor also motivates the health and spa tourists to visit spa during holiday. This is

evidenced from the quote: “When you’re away from home, and even if you’re relaxing on

holiday, where you have been, you still have to take care of your body. You still need to take

care of your face, of your nails…” (Interview informant 6). The informants thought that spa

experiences during holiday are very nice, enjoyable and relaxing as part of the holiday. To

some informants, it is one of the things that they always do on holiday which gives them the

opportunity to relax and a nice excuse for pamper, and mainly because they have time to do it

during holiday.

Health and Spa Tourists Motivational Factors

The following main themes emerged; (a) Self-satisfying/push factors: rewards after working

hard. (b) Self-fulfilment/push factors: Distress and time-out (relieve from work-stress and

take a break), unwind and rejuvenate and regeneration (busy and stressful life, distant travel

and activities involvement). (c) Spa attributes/pull factors, which consists of two sub-themes:

physical look – tangible resource (environment, atmosphere, decoration) and marketing image

of the spa (affordability, availability and accessibility, range of treatments and

professionalism). The findings are presented in Table 2.

Responses from the interviews show that the individual tourist’s wants/needs-related factors

are the main motivations for the informants to visit health-related and spa facilities during

their holiday in Sabah, Malaysia. When asked why the informants used spa and health

services at the resorts, majority of them answered for relaxation, pampering, distress, unwind,

rejuvenate and enjoyment; all that related to ones’ health and well-being in a more goaldirected

way (self-satisfying goals and self-fulfilment). Very less of mentioning the attributes

that attracts them to the spas – accessibility, affordability and the physical look of the

establishments. The informants simply answered their reasons for having spa experiences

were to relax and pamper themselves during holiday; for example: “We wanted some time-out

just to relax” (Interview informant 4), or “To relax and to get pampered” (Interview

informant 5) and “I wanted to be pampered” (Interview informant 6), “Just to relax and have

the opportunity that we don’t normally have” (Interview informant 8).

Table 2 Themes of Motivation Factors and Push/Pull Factors

Themes / Push and Pull Factors


Push factor :

Self-satisfying goal Escape - relax and pamper

Reward after working hard

Self-fulfilment Distress / Time-out

Relieve from work-stress

Take a break

Unwind / Rejuvenate / Regeneration

Recovery from tension in busy life

Distant travel / long flights

Travel activities

Pull factors :

Spa attributes Physical looks – tangible resource

Environment / Atmosphere


Spa attributes Marketing image


Availability and accessibility

Range of treatments


In addition, the reasons of having spa treatments were also related to the tiredness of being

involved in activities during holiday and the travelling itself (e.g. had long flight). This is

evidenced from the following quotes: “To distress, to relax and after playing physical sports,

it helps my muscles rejuvenate” (Interview informant 10) and “Because I come from the Sri

Lanka, from the Safari and needed to… had a long flight, and it’s good to unwind” (Interview

informant 14). Interestingly, it is discovered that notion of “escape” from daily life, which

commonly as one of the main motivators for holiday exists and related to motivation of

having health and spa experiences at the holiday destination selected. This can be reflected

from the responses: “To relax, that’s the biggest thing. When you go on holiday because you

want to get away 8-10 hours a day working high pressure, come home cook and clean. So you

want to have that spa experience, as I said, to just relax before you go back and face it again”

(Interview informant 9), and “Just to recharge my battery while I am here. So, when I go

home, I’ll feel refresh and back to routine and work” (Interview informant 15)

Clearly, the motivating factors that emerged from the responses, as shown in Table 2,

suggested that health and spa tourists were generally motivated from the individual’s

psychological aspects including variety of reasons related to relaxation during holiday (needs

and wants). From the themes and sub-themes of informants’ motivational factors, it also

suggests that informants are mainly attracted by the spa attributes such as the tangibility of the

spa itself and the marketing image it conveys which have considerate influences on the

informants’ main motivations to visit spas/have spa treatments. These factors include the

environment and decoration of the spa establishment, the affordability, availability and

accessibility of the spa, the varieties of treatments and the professionalism of the staffs.

Interestingly, the motivation factor of “culture/learning” seems exists with relation to health

and spa motivations. However, it is not at the “core” of the motivation to go to spa or to have

spa treatments on the first place, but in influencing the decisions/preferences in choosing

types of spa treatments – traditional/local types of massages.

Push and Pull Factors

It is discovered that the notion of understanding the consumer/tourists behaviours is to study

their travel/holiday motivations. These motivations often related to tourists’ behaviours and

decisions during travel and holiday. It is interesting to note that there is an existence of pushpull

motivational dimension; push factors – the real goal-satisfying and self-fulfilment in

relation to informants’ needs and wants for relaxation and pamper, either as a reward for

oneself after working hard in their careers/jobs or a relieve of stress and tension of their daily

life and works; and pull factors – the spa attributes itself that play an important role in

activating the needs and wants for spa treatments during holiday and resulting health and spa

demands at the destination country. In many circumstances, the initial needs and wants are the

unconscious motivators that are activated upon the actions (spa visitation) by the tangibility

sources of the spa itself.

Although the two different motivating factors emerged in motivating spa visitation among the

tourists, it is the push factors that have a comparative greater effect in influencing the health

and spa tourists’ behaviours to visit spas when they go on holiday. These tourists are the

people who practice generally a healthy lifestyle – involve regular exercises, healthy eating

and perhaps occasional visits to spas or health-related facilities. This indicates that the tourists

are health conscious and well-educated pertaining to their health and well-being, which

increased the demand for health-related holidays (Chon and Singh, 2005). Although some

tourists might not be a regular spa goers at their home countries (generally due to time

constraint and their nature of works), but most of the tourists would have spa treatments

during holiday which commonly related to relaxation purposes, and/or other sociopsychological

factors, which reflected the findings of Mak and Wong (2007); Smith and

Puczkó (2009). It signals the importance of viewing the tourists’ needs and wants in

developing range of products and treatments that fulfilling these needs and wants.

However, it is discovered that health and spa tourists may be conscious on their needs and

wants before their actual travel, but these sub-conscious needs and wants may be evolved or

become significant within the actual travel period. Therefore, it suggests the primary focus

and attention for health and spa providers should be on the aspects of fulfilling the tourists

health-related needs and wants – that push the individuals to go to spas during holiday. As

concluded by Mc Neil and Ragins (2004), the spa marketers must remain flexible and adapt to

changes of spa users’ wants and needs, and continue to improve communications about the

spa experience and its benefits. Apart from that, the push factors of health and spa tourists in

Sabah also reflected the wellness dimension of health tourism (Smith and Puczko, 2009).

Nevertheless, in some circumstances, the spa attributes equally play a significant role in

motivating spa visitations at the holiday destination, particularly in stimulating the “subconscious”

needs and wants. Meanwhile, to occasional or regular spa goers, there certainly

perceptions and expectation established prior to their visitation to spas at a particular holiday

destination. As spa is perceived to be a place for relaxation, with parallel to health and spa

tourists’ needs and wants, the spa establishment should be designed in a way that promote

elaxation as this is generally the main motivator for the tourists to visit spas. The spa

attributes include the physical environment and decoration of the spa itself, the reasonable

price and accessibility of the spa, the wide range of treatments or signature treatments that

blend with different/local cultures, and the professionalism of staffs. Apart from the actual spa

presentation, significantly the marketing image of the spa through media advertisement such

as brochures and resort’s websites has attracted the tourists to decide for spa visitation during

their holiday in Sabah, Malaysia. Within the framework of push and pull factors, it suggests

that these are the important elements that promote the overall spa experiences from the very

beginning of the spa visitation; at which it is perceived as an experience rather than just a

treatment, and also as part of the holiday relaxation.

Conclusion and Implications

Health and spa tourism in Sabah, Malaysia is still at an infant stage, and there is no

established definition of this growing niche tourism business which indicates an importance to

study within this tourism context. As Pearce (1989:113) stated that motivation is set of needs

and attitudes which predispose a person to act in a specific touristic goal-directed way, it is

discovered that the informants’ motivation to spas are associated with tourists’ motivation to

travel for holiday – relaxation, which this paper has explored and presented the motivational

factors of health and spa tourists in Sabah, Malaysia thus provides an insightful understanding

of what motivates health and spa tourists to visit spas during holiday in Sabah. It is clear that

both self-satisfying and self-fulfilment (push factors) and the spa attributes (pull factors) serve

as the motivational factors to spa visitation.

Moreover, the profiles of the tourists have reflected the findings of previous researches (e.g.

Mak and Wong, 2007; Smith and Puczkó, 2009). The growth of health and spa tourism indeed

affected by the major demographic shift of the world population. As previously stated,

majority of the spa goers are from the retired age group, but current findings show that there

are emerging groups of younger spa goers, within less than 30 years old. The health and spa

market also evolved among the professionals who perceive spas as a way to rest and relieve

from their work stresses, besides having the affordability for holiday and spa treatments as

indicated from their level of income. In addition, health and spa seemingly begin to be

acceptable among the male spa goers. These have directly indicated the needs for products

development to cater different groups of health and spa tourist market.

Particularly, the findings presented in this paper may indeed be significant on an international

scale, as it certainly possible that the tourists (notably from the America, Europe and

Australasia regions) to be indirectly attracted to spa attributes at the holiday destination (in

this case, Sabah, Malaysia) because their main travel motivators are mostly associated with

relaxation when holiday. This paper suggests that marketing strategies for health and spa

should focus on the individual tourist health-related needs and wants. As relaxation and

pamper are the significant motivational factors for health and spa tourists, the health-spa

providers should position their spas based on the relaxation attributes that may stimulate a

relaxing mood throughout the spa experiences – the atmosphere, the layout and decoration,

the staffs, and the spa treatments.

A major limitation of this study is due to the nature of the exploratory study and the type of

respondent (foreign tourists) which limit the generalizability of the research findings. It

suggests a comparative work in a similar context in different locations and countries would

prove beneficial for the possible validation of the findings. Additionally, the generalization of

the research findings can be extended through further research such as the use of these

motivational factors as variables in the quantitative approach in other context of health and

spa tourism – health and spa tourists’ satisfaction, spa treatment preferences, or perceptions

and expectations.


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Holidays as Health: The No Leave, No Life Campaign

Sue Beeton

La Trobe University, Australia


The current interest in health, wellness and tourism tends to focus on travel for medical reasons

(Connell, 2006; Henderson, 2003; Herrick, 2007), travel for mental and physical rejuvenation

(Mueller and Kaufmann, 2001; Smith and Puczkó, 2009) and travel connected to physical activities

that require and/or encourage certain levels of fitness. It may be a primary, secondary or even

tertiary motivator. However, taking a vacation is in itself a removal from everyday, stressful living,

and recreation leave is considered in many nations as a necessary enabler of one making a

productive and healthy contribution to society.

Furthermore, the potential financial, social and community health costs of workers not taking their

allocated annual recreation leave has been recognised for some time, with researchers and tourism

professionals calling for programs to encourage holiday taking. For example, during 2002, just

under a third of Australians did not take any holidays, and of those who did, only 30 percent took

their maximum allowance of four weeks (Woolcott Research, 2002). Close to a quarter of those

studied stated that the primary reason for not taking any leave was a sense of being too busy at work

(Woolcott Research, 2002). According to Beeton and Pinge (2003: 309), “The very conditions that

taking a break are held to ameliorate have become the reasons for not taking a break”.

Tourist commissions and other government organisations have developed programs over the years

to encourage people to take holidays, especially domestic short breaks. However, the problem of

people stockpiling their leave remains, with 123 million days of annual leave by Australian full time

employees accrued in 2009, equating to AUD$33 billion in wages (Tourism Australia, 2009a).

Consequently, the liability for companies with high levels of accrued leave on their books is

substantial, presenting two major issues in addition to the need to develop what has become a flat

domestic tourism industry: that of community health and business viability.

It is clear that workers need to be persuaded to take their recreation leave, and employers to

encourage the development of a supportive corporate culture. In 2009, the Australian government,

under the auspices of Tourism Australia, developed an innovative program to encourage workers to

take their leave and at the same time holiday in Australia. The No Leave, No Life campaign has two

core strategies:

1. To work with employers to encourage the creation of a positive leave culture in their


2. To remind employees of the personal and professional benefits of taking annual leave (and

taking it in Australia). (Tourism Australia, 2009a: 2)

This paper examines the process that Tourism Australia has adopted to achieve its desired

outcomes, with a focus on the primary employer initiatives, arguing that this model may be applied


Persuasive Communication

In any case where a change in people’s behaviour is required, it is important to understand the

barriers to participating in the desired activity. Persuasive communication theory can assist in

analysing the process and frames this particular Case Study.

According to Ajzen, “persuasive communication can produce a profound and lasting change, a goal

not easily attained by other means” (Ajzen, 1992: 6). Some years prior to that statement, Ajzen

(1988) argued that behaviour is a function of behavioural beliefs that influence a person’s attitudes

towards the behaviour, normative beliefs that determine the subjective norms (perceived social

pressures), and control beliefs that underpin perceptions of behavioural control, advancing

advanced the Theory of Planned Behaviour, outlined in Figure 1.

Figure 1. Ajzen’s Theory of Planned Behaviour

Source: Ajzen (1988: 133)

According to the theory, the intention to act precedes the actual behaviour, with intentions based on

three elements, or salient beliefs: personal attitudes towards the behaviour, one’s perception of

social pressures to undertake the behaviour (or subjective norm), and the perception of how much

personal control one has over that action (perceived behavioural control). In relation to visitor

behaviour, Fishbein and Manfredo (1992) present some strong cases supporting the role of

persuasive communication theory in affecting national park visitor beliefs, attitudes and intentions

and,, ultimately their behaviour.

The perceived control one has over one’s behaviour is significnat as it relates to a sense of personal

choice and the power to do so. This is similar to locus of control theory, which consists of two loci,

namely internal and external (McCool and Braithwaite, 1992) - where a person believes that their

future is controlled by others, they reflect a belief in an external locus of control, which is similar to

a low level of perceived behavioural control in Ajzen’s model.

While the model has three areas of salient beliefs, they are not necessarily evenly weighted, with

some being so weak at times that they are over-ridden by the most dominant belief. For example,

there are times when there may be little or no influence from attitudes and subjective norms, so

consequently a person my move directly from ‘perceived behavioural control’ to an intention to act

(Ajzen, 1988). Such differences are also reflected in the model, presenting a flexible and effective

model that has been applied many times in relation to persuading others (for some tourism and

recreation examples, see Lackey et. al., 2002, Beeton et; al., 2005).

The Case of No Leave, No Life

As noted earlier, the Australian No Leave, No Life campaign commenced in 2009, with the longterm

aim to reduce the amount of accrued recreation leave by Australians and to increase domestic

tourism. Previous attempts in the late 1980s and early 2000s to encourage local holidays by

Australians was only partially successful, with accrued leave continuing to rise and domestic

tourism growth remaining flat. In order to address this, Tourism Australia shifted from the

traditional supply focus of a Destination Marketing Organisation (DMO) to attempting to influence

demand by enlisting the employers along with the tourism industry.

Tourism Australia employed research consultants, Jones Donald Strategy Partners to undertake the

research, using Focus Groups, In Depth Interviews and Online Surveys in 2005 and 2009, along

with Single Source Surveys from 2006 to March 2009 in order to gather the required data (Tourism

Australia. 2009b). They divided their findings regarding barriers to taking leave into two groups

using ‘workplace and personal barriers’ as the differentiators.

The industry provides the domestic holiday options, while Tourism Australia developed tactical

promotions aimed at company employees through a dedicated TV travel show (No Leave, No Life)

and other collateral. The target employees are full time staff deemed to have ‘stockpiled’ over 25

days (or five weeks) of annual leave, as one in four full-time employees in Australia have that

amount of leave owing, pointing to a significant issue. Unsurprisingly, this group tend to be older

males, longer serving employees who typically manage staff, as well as parents of school aged or

older children and empty nesters (Tourism Australia, 2009b). The younger, single, child-free and

women workers did not feature, underlining the broadly accepted fact that the Australian workforce

remains dominated by men at the higher levels of organisations, and as longer-serving employees

due to the continued over-representation of women as family carers. Due to this unusual step for a

DMO to focus on changing the domestic tourism demand environment (or ‘push’ factors as

described by Dann, 1977) via employers, this paper focuses on that aspect of the campaign.

Tourism Australia has taken a three-stepped approach to working with employers, with the first

providing background data on leave stockpiling, the second suggesting some workplace strategies

to address the issue, with the third focusing on enabling employers to change the culture and

attitudes towards taking leave within the organisation through engaging with the No Leave, No Life

program. All of this material was made available via the internet as training modules and videos


In line with the Theory of Planned Behaviour, these results can be framed in the three beliefs that

Ajzen claims informs our intentions, namely attitude (towards the behaviour), (perceived)

behavioural control and subjective norms. This is outlined in Figure 2.

Figure 2. Stated Reasons for not Taking Leave


Move up corporate ladder

Prefer to work

Saving (for emergencies)

Saving (for big trip)

Hard to find things to do

Subjective Norms:

Taking leave is a sign of weakness

Cause work for others

Internal work culture

Behavioural Control:


Lack of


Support from


Job security

Source: Tourism Australia, 2009b

Will not meet targets

Hard to fit around projects

Unable to take when it suits

Lack of money

Partner’s availability

Children’s availability

Time taken planning

As can be seen, most of the salient beliefs regarding the barriers are in the ‘behavioural

control’ area, which responds directly with organisational culture. If these outweigh the

reasons for taking leave, the intention NOT to act is formed, consequently there is no action

taken. In order to shift this, Tourism Australia has adopted a strategy aimed at the demand

side of the tourism system (ie the ‘push’ factors). Their stated strategy is to ‘raise the

awareness’ of employers and employees, but they are doing more than this – they are working

to change the salient beliefs of those not taking holidays.

However, Tourism Australia has not looked at those who DO take leave, which would

provide a more holistic perspective and provide data that can be used in the Theory of

Planned Behaviour. By getting both sides and then ascertaining the strength of these beliefs in

the targe group (leave stockpilers) and range of consistent messages can be developed.

‘Strength’ does not relate to how many people believe something, but how much that belief

influence’s one’s decision to act. By ascertaining what are the strongest drivers and inhibitors,

much of the subjectivity of such research can be removed. While this may still produce a

similar outcome to what has been done, this approach would provide a more rigorous result.


The following comment from Beeton and Pinge some years ago remains true: “We need to

take holidays in order to refresh and recharge, otherwise our governments may well face

expensive community health issues in the future” (Beeton and Pinge, 2003: 320).

Tourism Australia’s strategy in relation to employers is to raise awareness of the issue, recruit

employers to the project and then assist them to create a positive leave culture. In terms of

employees, Tourism Australia aims to raise their awareness and communicate the benefits of

taking leave while encouraging them to book a domestic holiday. By analysing Tourism

Australia’s approach via the Theory of Planned Behaviour, we can see its potential for

success, as well as identify some areas that need to be watched carefully, such as the actual

influence the persuasive communications generate. Data is yet to be analysed and published

by Tourism Australia regarding this outcome.

This case demonstrates an innovative, integrated and inclusive approach to the issue of

accrued leave from the business, community and tourism perspectives that could be further

enhanced using the Theory of Planned Behaviour.


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and Applications in Recreation, Tourism and Natural Resources Management,

Sagamore Publishing, Inc., Champaign IL, pp.1-28

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Campbell National Park, CRC for Sustainable Tourism, Griffith

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report, March 2009

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safety signs in Yosemite National Park’, Final Research Report to Yosemite National

Park, Wildlife Conservation Society, New York

McCool, S.F. and Braithwaite, A.M. (1992) Persuasive Messages and Safety Hazards in

Dispersed and Natural Recreation Settings, in Michael M. Manfredo (editor),

Influencing Human Behaviour: Theory and Applications in Recreation, Tourism and

Natural Resources Management, Sagamore Publishing, Inc., Champaign IL, pp.292-326

Mueller, H. and Kaufmann, E.L. (2001) ‘Wellness Tourism: Market analysis of a special

health tourism segment and implications for the hotel industry’. Journal of Vacation

Marketing, 7(1):

Smith, Melanie K. and Puczkó, László (2009) Health and Wellness Tourism, Butterworth

Heinemann, Oxford

Tourism Australia (2009a) No Leave, No Life, Industry Prospectus, Tourism Australia, Sydney

Tourism Australia (2009b) No Leave, No Life: Employer Module 1. Analysing the Issues for

Employers, Tourism Australia, Sydney

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Research job no 5435-M. Sydney

A Case Study of Innovative Wellness Tourism: The Case of RP Vacations,


Ed Brooker

Griffith University, Australia


Marion Joppe

University of Guelph, Canada


According to Peter Drucker (1985), innovation is the specific tool of entrepreneurs, the means

by which they exploit change as an opportunity for a different business or a different service.

Entrepreneurs need to purposely search for sources for innovative opportunities, and they

need to apply the principles of successful innovation. Roompot Parks in the Netherlands

represents an example of classic entrepreneurship in that the owner sensed an opportunity to

capitalize on the renewed interest in health and wellbeing, and over time, developed an

innovative program which pulls tourists to Roompot Parks for the primary purpose of

wellness facilities and programs.

This paper highlights the findings of this single case study, which includes a semi-structured

interview with the current manager of RP Care and RP Wellness, along with previous

research undertaken by the lead author four years ago when the concepts were developing. In

so doing, the study explores the relationship between health, wellness and tourism perspective

through an entrepreneurial perspective.

Background – Roompot Parks

The Dutch are keen campers (Klemm & Rawel, 2001), and as a result, there are between 400

and 450 recreational home parks in the Netherlands. Roompot is the third largest holiday park

operator in the Netherlands and considered to be the market leader in ‘sea park’ holidays

along the Dutch North Sea coast, known for its variety of offerings that range from holiday

bungalow parks to traditional camping grounds.. The two larger companies include Pierre &

Vacances and Landal Greenparks. Pierre & Vacances, a French company, is the largest actor

in the Netherlands holiday park market, offering brands that include Center Parcs, Free Life

and Sea Spirit. Landal Greenparks have a strong emphasis on nature and space. Competition

is not limited to just the other holiday park operators. It also comes from external sources, as

new long haul and exotic destinations, often in less developed countries, attract travelers who

may be seeking alternatives (Buhalis, 2000). Roompot is keeping a close eye on the trend

towards the growth in low-cost air travel to foreign markets, realizing that these vacations

may be more affordable than a week spent at a Roompot Park. This scenario, i.e. competing

with ‘more glamorous’ international travel is also a challenge for other holiday parks, as

shown in ongoing research into innovation in Australian holiday parks.

Roompot Parks began has grown over a 45 year period from an initial local family camping

business to an enterprise that now operates 46 parks, 40 of which are in the Netherlands, and

six in Germany. Combined, the parks offer a total of 3,450 holiday bungalows, 1,800 mobile

homes, 5,950 campsites, and 400 marina slots. All the parks are positioned in the mid to

higher end of the market, attracting families and mature couples seeking quality facilities and


While the supply of accommodation had been the company’s core activity, the company had a

change in direction in 2002, focusing on being a full-service provider of all-inclusive

holidays. The strategy was designed to enable Roompot to capitalize and expand on its

existing customer base. Enlarging its product portfolio and service offering enabled Roompot

to clearly distinguish itself from its competitors. In 2010, Roompot Parks sells vacation

accommodations in over 100 resorts and campgrounds, across Europe, including 55 resorts in

the Netherlands, 50 resorts in France, 16 resorts in Germany, 5 resorts in Belgium, 3 resorts in

Denmark, and 1 resort in Poland. Locations in Italy and Spain are under current negotiation.

Roompot’s second area of expertise lies with tour operating. Roompot has developed the

capability of selling its holiday offerings through its own direct distribution channel called

Roompot Vakanties. Perspective customers can book a vacation through three channels,


1. Direct sales via Roompot’s booking centre – remains the most popular method

2. Direct sales via the Internet – increasing in popularity

3. Indirect sales channels through various intermediaries including international travel

agencies (for resale).

Innovation is not new to the company. It has been the first to develop a new product or service on

many fronts including being the first in the Dutch industry to introduce on-line reservations for a

holiday bungalow or campsite. The company is now in the unique position of being able to act as a

consultant, offering its expertise to other operators in the industry.

Introducing a new product or line of services will only benefit Roompot if it can propel the new

offerings into economic and competitive advantages (Walder, 2006). The company however

understands the lag time and effort required prior to seeing any results from its efforts. The firm

has experience with diversification, growing from its initial campground to the point where it now

offers a range of services including holiday reservations, real estate development, construction,

retail and insurance. The net financial result has seen sales almost double from EUR 68.4 million

in 2002 to EUR 118.4 million in 2004 (Bencis, 2005). Very few SMTEs can boost such growth

within such a short period of time. In 2009, Roompot Parks turned over EUR 225 million. Its

parks attracted 1.3 million guests, who stayed approximately 7 million nights.


In order to gain insights, it was essential for Roompot personnel to speak to the concept of

wellness tourism within their parks in their own words and from their individual perspectives.

This study therefore employed qualitative methodology where the research tool comprised of

a single case study based on semi-structured interviews with two individuals with specific

connections to the program. The first interview was conducted in 2006 with the visionary

staff person who was instrumental in developing the concept and a follow up interview in

2010 with the current manager overseeing RP Care and RP Wellness.

RP Care

Johannsson (2004) suggests the best chance to innovate is found in the ‘intersection’ – a

connection between two different fields. Roompot has clearly found the intersection, by merging

health care and vacations, within its existing operation. The result is known as RP Care, yet

another extension of the Roompot offering.

RP Care is an innovative modular extension of Roompot Vacations, providing guests (both

domestic and European Union) to obtain a variety of quality health and wellness services while

also enjoying a Dutch sea and sand vacation. RP Care has been established in part in response to

the international focus of health care tourism, in particular, the number of Dutch, German and

English who travel abroad in response to long waiting lines and/or electing to undertake elective

medical procedures while on vacation. Roompot felt that it could expand on its initial entry into the

health care, started five years ago with the offering of kidney dialysis at the Banjaard, a five-star

holiday bungalow park, located 10 kms from the first established Roompot Park.

The kidney dialysis service stemmed from the local hospital’s inability to service the needs of an

expanded vacation market and local knowledge, as the founder of Roompot was a member of the

local hospital board, was therefore aware of both the need for additional dialysis service and the

hospital’s desire to establish an off-site clinic. Thus in true entrepreneurial spirit, a separate

building was constructed within the park to house the dialysis service. Patients no longer had to

travel to and remain in a hospital for the procedure. Rather they have the option of visiting the

clinic three times a week, for 2 weeks, enjoying a non-sterile, relaxed but professional

environment. Appointments can be made on line through the Roompot Vacations website, with the

knowledge that the onsite medical staff are all associated with the local hospital.

The dialysis service is a radical innovation amongst holiday parks that traditionally offer

recreational opportunities to a variety of markets. However, previously, the mature market has

been viewed simply as a market opportunity based on their numbers only, as no serious efforts

have been made to alter the product mix in order to attract and retain a larger percentage of this

market. Roompot/RP Care has.

The success of the kidney dialysis service has led Roompot to extend its modular service offerings

into care and cure, augmenting the existing recreation facilities. Thus RP Care was created.

However, the creation of the service has not come without any difficulties. At first, it was a

difficult sell getting medical professionals to partner with RP Care. But Roompot’s founder

understood the value of networks, both in and outside of the business (Grulke, 2005). Based on his

relationships with external organizations, including the local hospital board, he managed to create

the necessary interest in the offering. In 2010, professional personnel from the local hospital staff

the dialysis center, but a local doctor also spends a day now visiting the park booking appointments

with park guests. Other doctors are inquiring about participating in the program.

Table 1 outlines the modular services and amenities planned for various Roompot locations within

Zeeland in partnership with local health providers. A clinic specializing in plastic surgery is

intended to be located in Goes, centrally positioned close to other Roompot parks and the regional

hospital. The location is of benefit to both doctors and patients, who will be able to convalesce in a

quality holiday setting, with family and/or friends.

The strategy to focus initially on the province of Zeeland is based in part on local knowledge of

health care providers, networks and also represents the location of Roompot’s base of operations.

The strategy can be expanded into other provinces within Holland based on local success and

learning curve.

Recreation Care Cure

• Fun stuff

• Care facilities

• Conference facilities

• Pools

• Sauna

Table 1 - RP Care building blocks

• Plastic surgery

• Cosmetic

• Orthopaedic

• Eye

• Pain reduction

• Radiology

• X-rays

• Physiotherapy

• Preventative

• Therapy

• Sauna

• Nutrition

• Acupuncture

The strength of the concept is based on various factors. First, Roompot has essentially created a

win win situation for a variety of players, including local hospitals, health insurance companies,

individuals and for its own corporate opportunity. Local hospitals can now partner with a reputable

private sector business to continue to offer its services but within a decentralized framework.

Health insurance companies benefit from the preventative nature of the services, and the solid

reputation of Roompot to deliver quality care. It eliminates the uncertainty attached with travel to

Asia or other areas of Europe. The individual benefits from the opportunity to avoid lengthy

waiting lists, select the necessary service from the extensive offering, and to recuperate in a

comfortable location, where family and friends can visit, recreate, and remain in the Netherlands.

Roompot is the other winner in this situation, using a radical approach to capitalize on disruptive

social trends. The development of RP Care capitalizes on the aging population in a manner far

removed from what the competition has considered. This competitive advantage can also be

sustained as Roompot has first mover advantages with government health care providers. In

addition, the addition of RP Care addresses the issue of seasonality head on through the

introduction of a new service line and market that may otherwise not frequent a Roompot Park.

Facilities and amenities designed for use during the busy summer months now will be occupied

and used during the spring and fall, raising occupancy rates, and creating new opportunities for

programs and events. Current estimates suggest that two to three percent of Roompot patrons

utilize RP Care services. That number is expected to grow to ten percent as a result of promotion

efforts and the demographic changes noted earlier – older population will seek out care at Holiday

Parks The addition of RP care sends a clear message to the loyal customers who have frequented a

Roompot park over several summers – we’re not abandoning you as you age. In fact, we want to

keep you as a customer, so we’ve developed new programs designed with your needs in mind.

The modularity of the three cornerstones – recreation, cure and care provide the flexibility for

application to a diverse set of circumstances. Health services can be added to a vacation or

conference. Convalescents can recover in a comfortable setting, knowing their needs are looked

after, and the care is available locally.

Roompot’s decision to capitalize on disruptive social trends, focusing on collaboration – aligning,

exchanging, and leveraging opportunities (Dvir et al, 2004) builds on a modular business model.

Such a modular approach gives the company the capability to couple and decouple service delivery

on demand, based particularly on three building blocks – recreation, cure, and care. On demand

business enables a customer to connect in a flexible manner – for instance health services to a

holiday or vice versa, contingent on his/her circumstances or personal preferences. It offers

convalescents a sense of security that they can recover in a comfortable setting, in the knowledge

that their needs are looked after in a professional manner.

The introduction of its modular business model enabled its subsidiary RP care to thrive in an

intensely competitive tourism environment. It also demonstrates Roompot’s leadership in the trade

and beyond, particularly that a radical innovation approach can bring rewards well worth the risk.

In 2010, RP Care facilitates care, cure and wellness opportunities through partnerships with

various health oriented organizations. For example, it provides facilities for disabled guests,

kidney dialysis, accommodations for people with allergies, and automated external

defibrillators at certain properties. It provides arrangements for home care, medical

equipment, and health checks for those vacationing at a Roompot Park, thereby leveraging its

strengths as a Holiday Park chain, with the wide range of health service partners.

The number of requests to capitalize on these facilities and services is growing, as noted in the

increased bookings from 2007 to 2009, illustrated in Table 2.



for adjusted

Bookings for home care and medical


Bookings from foundations and


Table 2 – Increased RP Care Bookings

2007 2008 2009

3,500 4,800 6,000

279 597 799

833 1,081 1,387

The results showcase a growth in patron response to capitalizing on the opportunities for care

and wellness facilities and services, a trend which is expected to grow as awareness of the

program is extended. The actual number of bookings may appear to be low, but the program

itself is quite unique, given that care, cure and wellness are not automatically associated with

a caravan or holiday park experience. The bookings provide opportunities for increased

business for the parks during the shoulder periods, a time when “holiday” patronage has

decreased substantially.

As with many innovations, there is a test and measure component to the implementation of

the program. Currently, five resorts within the Roompot Parks ‘chain’ have wellness centres,

two which are directly managed. The other three are parks within the RP Parks vacation

umbrella, i.e. vacation bookings. The overall success of the existing wellness programs will

impact future extension of facilities, services and partnerships. Broadly speaking, however, it

is anticipated that the program will continue to grow, given the needs of an aging population,

the opportunities to provide an enhanced visitor experience, and additional business

opportunities for the parks themselves.


RP Care represents a classic example of radical innovation in the sense that the concepts are

very unique – i.e. spending your vacation at holiday park for various care, cure and wellness

programs. The vast majority of holiday park operations shy away from introducing radical

innovation. They are aware of changes in demographics, economics, and environmental

factors, but remain hesitant to initiate new ideas. The concepts generally require a substantial

cash investment up front which, by itself, is a limiting factor for many. Initial returns are

limited, as illustrated previously with the relatively small, although increasing, number of RP

Care bookings. Radical innovation is a risky undertaking, given the longer term payback, and

non availability of benchmarks to assist with concept development.

To that end, the concepts discussed in this paper must be taken into context. The overall idea

is very novel to the industry, and time is needed for the program to expand to fulfill its

potential. Risk has been mitigated to a degree through limiting the number of parks that offer

the facilities, and through partnering with a variety of wellness associations.

Nonetheless, the concept has attracted academic interest in the areas of innovation and

entrepreneurship (Go and Israels, 2010) and practioners. A group of Australian holiday park

operators are scheduled to tour the wellness facilities in mid-September as part of their study

tour of European parks who offer health and wellness activities. Thus in keeping with Rogers

(1962) model of innovation diffusion, the concepts of RP Care may inspire strategic

innovation to take hold in other geographic regions, where it may become a norm to have

health and wellness facilities and activities in holiday parks in the future.


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Johansson, F. (2004). “The Medici Effect”. Boston: Harvard Business School Press.

Klemm, M. and J. Rawel (2001) ‘Extending the School Holiday Season: The Case of

Eurocamp’ In Seasonality in Tourism, T. Baum and S. Lundtop, (Eds). Oxford : Elsevier.

Rogers, E. M. (1962). Diffusion of innovations. New York: Free Press.

Walder, B. (2006). “Sources and determinants of innovations – the role of market forces” in

Innovation and Product Development in Tourism, B. Walder, K. Weiermair, A. Perez,

(Eds.) Berlin: Erich Schmidt Verlag.



Shu Cole

Indiana University


To date, most research on understanding travel of people with disabilities has been focused on

accessibility issues. Much of this research was a response to policies and regulations set forth

to protect the rights of people with disabilities, such as ADA in 1990. Recently, there is a call

for research looking beyond accessibility when understanding the consumer market of people

with disabilities (Yau, McKercher, & Packer , 2004; Baker, 2006). One of the reasons for this

call is because 2000 Census data show that there are approximately 50 million people with

disabilities in the U.S. Of these, about 36 million people are mobility-challenged (Ray, &

Ryder, 2003). Limited literature on travel for people with disabilities demonstrates that they

have the same desires for travel (Baker, 2005). In addition, some suggest that travel has

special meanings to travelers with disabilities. For example, Yau et al. (2004) concluded that

“being able to travel is a meaningful task through which a person with a disability can

demonstrate to others that they have recovered or started to regain their control over destiny

and to assert their future quality of life” (p.958). Findings from their study imply the potential

impact of being able to travel on the quality of lives of people with disabilities. However, the

impact of travel on the lives of people with disabilities has not been further examined and

determined in the literature. The purpose of this study was to explore the role of travel in the

quality of lives of people with mobility impairments.


Two focus group discussions were held among avid travelers with mobility impairments at the

13 th Congress of Society for Accessible Travel and Hospitality (SATH) in 2009. A total of 12

people participated in the focus groups. Two questions were asked: 1) What was the role of

travel in your life before you became mobility impaired (or “What is the role of travel in your

life?”, if the impairment is a congenital condition)? and 2)Based on your past travel

experience, has travel in general impacted your quality of life? How?

Results & Implications

Focus group discussions revealed the essential role of travel in the lives of people with

mobility impairments. Many considered travel as a basic need in life, such as food and air.

Participants confirmed the positive impact of leisure travel on their quality of lives. They

believed that leisure travel had helped them to 1) regain control of life; 2) overcome the fear

of leaving their mundane environment; 3) complete the rehabilitation successfully; 4) enhance

their relationship with family members; 5) continue learning and exploring of different

culture; and 6) keep the adventurous spirit in their lives. Findings of this study suggested the

psychological, mental, and health benefits for people with mobility impairments. Policy

makers should protect the rights of this population to travel, and business owners/managers

should make sure their facilities and services are accessible.

The Impact of Tourism on Community Wellbeing and Quality of Life: A

Longitudinal Study

Margaret Deery

Centre for Tourism and Services Research Faculty of Business and Law, Victoria University

and PO Box 14428, Melbourne City, Victoria, Australia 8001

Tel: (613) 9919 4626

Leo Jago

Centre for Tourism and Services Research, Victoria University, Faculty of Business and Law

PO Box 14428, Melbourne City, Victoria, Australia 8001

Tel: (613) 9919 1541

The Impact of Tourism on Community Wellbeing and Quality of Life: A Longitudinal

Study Introduction

Over the last few decades, substantial research has been undertaken examining the social

impacts of tourism on communities (see for example Sharma, Dyer, Carter and Gursoy, 2008;

Easterling, 2004) with the focus, often, on the level of support residents have for tourism

development. While these studies are extremely useful for tourism planners and policy

makers, they provide less information for those concerned about the wellbeing of the

community and the individuals that comprise communities. Some studies have, in fact,

examined the impact of tourism on the community and residents’ quality of life (QOL),

beginning with the early work by Milman and Pizam (1988) and Perdue, Long and Allen

(1990). More recent work by Tovar and Lockwood (2008), Andereck, Valentine, Knopf and

Vogt (2005) and Jago, Fredline and Deery (2006) have focussed on the specific tourism

impacts that either enhance or detract from the quality of residents’ lives. Much of this

research, however, is a ‘point in time’ examination of the social impacts with little or no

understanding of how perceptions of these impacts change over time. Although studies such

as that by Huh and Vogt (2007) and Getz’s (1994) study of residents’ perceptions in the Spey

Valley of Scotland have provided some insights into the changes that may occur over time,

few other studies have added to this area. This current study aims to address the paucity of

studies on the impacts of tourism on residents’ quality of life over time.


This paper examines the impact of tourism on the QOL of residents and the community as a

whole and it does so at two points in time, 2005 and 2008, using the same 3 questionnaire and

in the same location. Data were collected from host residents using a survey method based on

the instrument developed by Fredline (2002) and Fredline, Deery and Jago (2005). The

sample sizes were 420 in 2005 and 317 in 2008.


The findings show that, at the personal level, perceptions of the impacts of the benefits of

tourism had deteriorated over time and it is through the examination of the specific impacts

that a partial answer as to why this would occur can be found. Between 2005 and 2008,

respondents were statistically less positive about having more interesting things to do, that

tourism provided economic benefits and that tourism enhances pride in the town and an

opportunity to showcase the region. When examining the comments from respondents, there

were comments in 2008, not elicited in 2005, that tourism was spoiling the area and that it

was bringing unwanted activities to the region. In 2005, the comments focused on rampant

development but, three years later, there were substantial comments regarding the need for

sustainable tourism, that ‘Tourism growth should stop’. The study examines the ramifications

of these findings on the community’s QoL and provides recommendations for enhancing and

managing the wellbeing of the community.


Andereck, K.L., Valentine, K.M., Knopf, R.C. & Vogt, C.A. (2005). Residents’ perceptions

of community tourism impacts. Annals of Tourism Research, 32(4), 1056–1076.

Easterling, D. (2004). The Residents’ Perspective in Tourism Research: A Review and

Synthesis. Journal of Travel & Tourism Marketing, 17(4), 45-62.

Fredline L. (2002). Host Community Perceptions of the Impacts of Tourism on the Gold

Coast. CRC for Sustainable Tourism: Gold Coast. 4

Fredline, L. Deery, M. & Jago, L. (2005). Social Impacts of Tourism on Communities. CRC

for Sustainable Tourism: Gold Coast

Getz, D. (1994). “Residents’ Attitudes towards Tourism: A Longitudinal Study in Spey

Valley, Scotland.” Tourism Management, 15 (4): 247–58

Huh, C. & Vogt, C.A. (2008). Changes in Residents' Attitudes toward Tourism over Time: A

Cohort Analytical Approach. Journal of Travel Research, 46 (4), 446-455.

Jago, L., Fredline, L. & Deery, M. (2006). Tourism in small communities: Risk and benefits.

Tourism Review International, 10(1-2), 91-101.

Milman, A. & Pizam, A. (1988). Social impacts of tourism on Central Florida. Annals of

Tourism Research, 15, 191-204.

Perdue, R.R., Long, P.T., & Allen, L. (1990). Resident Support for Tourism Development,

Annals of Tourism Research, 17(4), 586-599.

Sharma, B., Dyer, P., Carter , J. & Gursoy, D. (2008). Exploring residents' perceptions of the

social impacts of tourism on the Sunshine Coast, Australia. International Journal of

Hospitality and Tourism Administration, 9(3), 288-311

Tovar, C. & Lockwood, M. (2008). Social Impacts of Tourism: An Australian Regional Case

Study. International Journal of Tourism Research, 10, 365-378.

Air travel and your health: Is it safe up there?

Frederic Dimanche and Christine Dimanche

Center for Tourism Management at SKEMA Business School


France ;


When considering the literature about tourists’ health, one finds three main threads: First, the

tourism literature has been mostly concerned with the benefits of travel and tourism on

visitors’ health and wellness. Discussions of medical tourism, spa tourism, wellness tourism

have particularly focused on health tourism as a market and product (e.g., García-Altés, 2005;

Henderson, 2003; Heung, Kucukusta, & Song, 2010). Second, there has been a line of

publications dedicated to managing tourist health and safety (e.g., Keystone et al., 2008;

Wilks & Page, 2003). Finally, a comparatively larger body of the literature considers

perceptions and management of risks, but not necessarily as they relate exclusively to health

(e.g., Lepp & Gibson, 2003, Sonmez & Graefe, 1998). To find specific research about the

effects of travel on travelers’ health, one has to search the medical literature. Among favorite

topics are the effects of traveling to tropical destinations, the risk of infectious diseases,

travelers and sexually transmitted diseases, and digestive disorders. The medical literature

also examines the effects of air travel on the human body.

Of particular interest to us is the impact of travel on tourists’ health and well-being. Traveling

and flying both lead to increased stress and increased risks for the traveler’s health. The

medical literature documents, for example, that business travelers experience significant stress

and file more health insurance claims than their non-traveling colleagues (DeFrank,

Konopaske, & Ivancevich, 2000; Liese, Mundt, Dell, Nagy, & Demure, 1997). It has also

been reported that there was a two- to three-fold increase in psychological claims for travelers

over non-travelers. More specifically, this paper will focus on an aspect of traveling that is

rarely considered in the literature: the impact of air travel and health and well being. Indeed,

in their edited book on managing tourist health in the new millenium (Wilks & Page, 2003),

no author examines the particular case of air travel and health, except to discuss the risk of

transportation accidents. The purpose of this paper is (1) to document through a literature

review the major risk factors and health issues, both psychological and physical, that travelers

face when flying and traveling, and (2) to suggest recommendations to help manage risk and

reduce traveler stress. Indeed, previous research has shown that travel counselors, travel

agents, or human resource departments in business firms do not properly inform and educate

travelers about the risks of flying and traveling (e.g., Lawlor et al., 2000; Lawton & Page,

1997; Welch, Welch, & Worm, 2007) and that experienced travelers had low knowledge of

travel health-related issues (Hamer & Connor, 2004). Those recommendations should be

taken into consideration by individual travelers, human resource management departments in

firms with a traveling workforce, and by travel companies, travel agents, or tour operators.


DeFrank, R. S., Konopaske, R., & Ivancevich, J. M. (2000). Executive travel stress: Perils of

the road warrior. The Academy of Management Executive, 14(2), 58-71.

García-Altés, A. (2005). The development of health tourism services. Annals of Tourism

Research, 32(1), 262-266.

Hamer, D., & Connor, B. (2004).Travel health knowledge, attitudes and practices among

United States travelers. Journal of Travel Medicine, 11, 23-26.

Henderson, J. (2003). Health care tourism in Southeast Asia, Tourism Review International,

7(3-4), 111-121.

Heung, V., Kucukusta, D., & Song, H. (2010). A conceptual model of medical tourism:

Implications for future research. Journal of Travel & Tourism Marketing, 27(3), 236-


Keystone, J., Kozarsky, P., Freedman, D., Nothdurft, H., & Connor, B. (Eds.). (2008). Travel

Medicine (2 nd ed.). New York: Mosby Elsevier.

Lawlor, D., Burke, J., Bouskill, E., Conn, G., Edwards, P., & Gillespie, D. (2000). Do British

travel agents provide adequate health advice for travellers? British Journal of General

Practice, 50(456), 567-568

Lawton, G., & Page, S. (1997). Evaluating travel agents' provision of health advice to

travelers. Tourism Management, 18(2), 89-104.

Lepp, A, & Gibson, H. (2003). Tourist roles, perceived risk and international tourism. Annals

of Tourism Research, 30(3), 606-624.

Liese, B., Mundt, K. A., Dell, L. D., Nagy, L. & Demure, B. (1997). Medical claims

associated with international business travel. Occupational and Environmental

Medicine, 54, 499-503.

Sonmez, S. & Graefe, A. (1998). Influence of terrorism risk on foreign tourism decisions.

Annals of Tourism Research, 25(1), 112-144.

Striker, J., Luippold, R., Nagy, L., Liese, B., Bigelow, C., & Mundt, K. (1999). Risk factors

for psychological stress among international business travelers. Occupational

Environmental Medicine, 56, 245-252.

Welch, D., Welch, L., & Worm, V. (2007).The international business traveller: A neglected

but strategic human resource. The International Journal of Human Resource

Management, 18(2), 173-183.

Wilks, J., & Page, S. (2003). Managing tourist health and safety in the new millennium.

Oxford: Elsevier.

“A Happy Tourist Experience”

Filep Sebastian

Victoria University


Happiness is a concept that has fascinated thinkers for centuries because it is central to

understanding the meaning of human life. Research on happiness has flourished in recent

years in many social sciences. The concept can be defined from multiple perspectives. In

positive psychology (a research field that studies wellbeing in psychology), happiness is

typically defined in terms of three main dimensions: engagement, meaning and positive

emotions. A happy person would therefore be actively involved (engaged) in his or her daily

activities, would lead a personally meaningful life (eg believe in God or contribute to a cause

that he or she believes in) and would regularly experience positive emotions of interest, joy,

contentment and love. Each of the three dimensions of happiness is measurable. Happiness is

therefore a concept that is worthy of scientific research - it can be defined and scientifically

assessed and it is a conscious state of mind.

A qualitative doctoral thesis on tourist experience and happiness was recently finalised and

awarded. In this PhD project, a study of a tourist experience of a group of study abroad

university students was conducted. The study assessed travel motivation and travel

satisfaction of the group in three phases of the students’ travel experience (anticipatory, on

site and reflective phases). Travel motivation themes were identified in the anticipatory phase;

immediate and post hoc satisfaction themes were identified in the on site and reflective phases

of the tourist experience. The students’ motivation and satisfaction themes were identified

through qualitative positive psychology approaches. An exploratory picture of a happy tourist

experience has emerged from this psychological investigation. In this picture, the three

dimensions of happiness from positive psychology – meaning, engagement and positive

emotions – are linked to the students’ travel motivation and satisfaction themes in their three

travel phases.

A series of future quantitative and qualitative studies of tourists’ positive emotions, meaning

and engagement has emerged from this micro analysis of the students’ tourist experience. The

suggested studies are important agendas for future research as the three happiness dimensions

have been linked to a range of health benefits by other happiness researchers. An example of

these health benefits is the improvement in cardiovascular health as a result of experiencing

positive emotions. Investigations of happy tourist experiences from positive psychology and

other social science perspectives therefore need to continue in tourism studies.


Roos Gerritsma

University of InHolland, Amsterdam/Diemen

The Netherlands


The presentation will mainly focus on describing the concept of urban zen and what

theoretical framework and methods of research will be applied during this PhD research.

Urban Zen – the appearance of a new cultural landscape

“The complexity and speed of modern life urgently requires counterbalancing experiences for

human beings to feel well. A health and wellness revolution is under way as individuals

attempt to redesign their lives – sometimes in superficial and sometimes in profound ways –

to achieve higher levels of physical, emotional, mental and spiritual wellness”, (Bushell and

Sheldon 2009) i .

In some western cities we can see a reflection of this revolution when we look at the increase

of a holistic ii and healthy offer, such as yoga/meditation centers, health food shops or vegan

restaurants, urban spas or hammans. We can perceive a new urban cultural landscape in which

holistic leisure activities give an extra quality or dimension to public and semi-public space.

In this research this phenomenon has been named: urban zen.

The wellness industry is rapidly growing worldwide. The first results of research amongst

wellness tourists have been documented, but not much, or hardly anything, is known about the

wellness needs and expectations of city dwellers who would like to fulfill their aim of striving

for a holistic lifestyle in their own urban environment. The following three questions are

leading during this research: What lifestyle characteristics do these citizens share and what

does this lifestyle contribute to the quality of their lives? What Western cities iii and specific

areas within these cities are playing a key role in urban zen, both economically and

symbolically? And finally, to what extent are cities marketed as places where you can find

such an cultural landscape?

Theories and methods

Several theories and methods will be applied in order to gain a clearer picture of urban zen

adepts and places. Next to structuring lifestyles characteristics, the results will be connected

with the ideas Pine and Gilmore (1999) on the transformation economy. In their study on the

experience economy, the next step after experiences is said to be the economy of

transformations. Based upon earlier research and own observations, the idea of “selling”

transformations to consumers seems to be an essential part in starting and maintaining an

urban zen lifestyle. Practicing Yoga for example, does not stop after having experienced the

weekly Wednesday evening class; it generally is just a minor marker of a long internal

process of transforming one’s attitude in life and lifestyle manifestations. The choice of

Western cities will be based upon making an inventory and a comparison of the extent of the

urban zen offer. Apart from desk research and participatory observations, in-depth interviews

with participants, practitioners, entrepreneurs and city marketeers will also be carried out.

Key words: holistic and healthy lifestyle, city dwellers/cities, methods of research, leisure

“I expect that in our hasty society there will be a rise of city spas. A place in a metropolis

where people can enjoy a moment of rest”.

(Floris Wyers, owner of


i Bushell and Sheldon, (2009). Wellness and Tourism - Body, Mind, Spirit and Place, New

York, Cognizant. Communication Books

ii There are many definitions about the term holistic. The following description seems to be the

most appropriate for this research: “According to AHHA (2007) holistic health as an

approach to creating wellness encourages you to: 1) Balance and integrate your physical,

mental, emotional, and spiritual aspects. 2)Establish respectful, cooperative relationshops

with others and the environment.3)Make wellness-oriented lifestyle choices. 4)Actively

participate in your health decisions and healing process.” – Smith and Puczko (2009).

Health and Wellness Tourism, Butterworth-Heinemann

iii Focus lies on cities in: Europe, the USA, Canada, Australia and New Zealand.

Health Tourism – The SPA Goers in Portugal

Nuno Silva Gustavo


Rua do Campo da Bola, Quinta da Raposeira, Mosqueiros

2460-203 Alfeizerão, Portugal


This paper is part of a work-in-progress PhD dissertation entitled “Tourism, Leisure and

Health – discovering the new SPAs”, the first national study in this particular field.

Having Portugal as a case study, a country in which Health Tourism was recently pointed out

as one of the ten strategic segments for tourism development, this paper aims at presenting

and discussing the new SPAs customers' profiles, as well as helping to understand how

relevant leisure and tourism moments are and how they are used in health management. The

motivations of these new SPA customers, their concerns with spa consumption and health

management in general, and the meanings of SPA consumption in global health management

are other issues focused on in this paper.

This investigation has a national spectrum and it includes about twenty-one cases studies,

including SPAs in different locations (in metropolises, cities, countryside, in and out of the

Portuguese tourism regions, day SPAs, thermal SPAs, and marine SPAs), different concepts

(e.g.: holistic), services (hydrotherapies, balneoteraphies, massages, aesthetics and natural

treatments) infrastructures, and main natural resources (tap water, sea water, spring hot water,

wine, etc.).

In the twenty-one case studies mentioned, and as the main investigation resource, a survey

was developed. This survey focused on SPA customers' consumption and on their health

management practices (the data was collected during three months with support from the SPA

Staffs). The data collected (824 surveys) was analyzed with SPSS (Statistical Package for

Social Sciences). It was map out the average profile of SPA Goers in Portugal. Different

consumer clusters were outlined with a scalable cluster analysis algorithm - The SPSS Twostep

– log-likelihood.

Keywords: Health and Body management, Leisure, Health Tourism, SPAs


With the pace of globalisation, urbanisation, state-of-the-art technologies and on-line

consumerism in 21 st century western societies, people now live out the illusion of a new

paradigm – the myth of eternal life. In the euphoria of longevity, the adoption of healthy life

styles takes on a singular importance to postmodern daily life. Founded on biomedicalisation

and promoted by neoliberal philosophies of government, health has been reinvented as a

capital to be valued and optimized, taking on a unique centrality within the lifestyle concept

(Clarke, 2003).

In the light of a new social centrality of health, that is, the growing medicalisation of western

habits, the universe of health services proliferates, a reality which manifests itself in a

growing allocation of leisure and tourism time to body care. This reality is particularly

reflected in the discovery of leisure and tourism periods as privileged opportunities for body

care and management. In accordance with the new concepts and dimensions which

circumscribe the scope of health at the outset of the 21 st century, this niche market has

witnessed a significant diversification in supply. Alongside the pathogenic view of health and

associated services, this market also currently incorporates a new range of services, now

focused on a holistic approach to the body, congregating highly disparate and different

motivations and services within the same market niches thereby expressing this new vision of

the health concept (Yeoman, 2008).

Founded on the wellness ideal (an integrated and holistic view of health), SPAs have imposed

themselves as a leading players in this new health universe as a result of the appropriateness

of their concepts and services to meeting the new challenges emerging from the globalised,

agitated and eminently urban consumer of the 21 st century. “SPAs and wellness resorts may

therefore be conceptualised in cultural/sociological terms as modern day temples where

people can experience rituals, learn to deepen their personal wellness practices, raise their

consciousness, become open to enhanced ways of being and deepen their experience of being

alive” (Cohen, 2008: 8).

The growing centrality of these spaces, expressed through the growth in supply and demand

in postmodern western societies, is the departure point for this article in which we aim to

contribute towards a greater understanding of the demand profile using Portuguese SPAs as

the case study following a nationwide data collection survey.

Literature Survey

The significance and meanderings of health in the 21 st century

Today, the meaning and the universe of health find expression in a private, lucrative and wide

ranging market of products and services where slogans and sound bites abound, such as

eternal youth, the most beautiful, the strongest or the healthiest. This is a new notion of public

health which goes beyond the paradigm of disease-free and establishes a holistic and positive

vision of health supported by a specific, socio-political environment which permeates

postmodern 21 st century societies (Minkler, 1989). In the face of growing levels of economic

prosperity, in no way comparable to those prevailing in the post World War Two boom ("The

Glorious Thirty Years”) inaugurating the model of Welfare States when the nationalisation of

the services and the social responsibility of health was taken on by national health services.

Subsequently, the development of new and contemporary, neoliberal governing principles and

policies, were complemented and articulated with the fostering of a vast private market of

health services leading to a new alternative health management model in which the individual

now plays an active and self-responsible role (Rose, 2001). In a society which is profoundly

marked by globalisation, by information technology and communication as well as by the

liberalization of markets, new “health brokers” are affirming themselves in health

management in competition with the traditional “experts”. These offer new, more

“autonomous” and more “accessible” health management products and solutions, which

circulate freely in a new and vast private health market where the laws of marketing rule.

This transfer of responsibility in the health care field, as presented in the new model, is from

the outset a reflection of a scenario marked by the growing disappointment as to the limits of

medicine and its capacity to overcome the new challenges, such as chronic illness or the

unrelenting quest (the myth) for eternal life. “A 2005 report by the WHO (…) estimates that of

all the 58 million deaths in the world in 2005, 35 million (60%) will be caused by chronic

diseases such as heart disease, stroke, cancer, chronic respiratory disease and diabetes”

(Cohen, 2008:10).

Whether we opt for more realistic scenarios, or those more visionary as regards the current

issues (EFILWC, 2004), it is clear that health faces a set of new paradigms at the outset of the

21 st century. These require ongoing analysis and reflection, conditioned by a unique scenario

of uncertainty expressed in the paradoxical perception of loss of “power” over the body in no

way consensual with human ambitions and within the scope of new self-management

practices, a hybrid and universal approach to the body and its control have been presented as

the solution.

Simultaneously and in response, a new private health market has emerged rendering new

services, many of which represent genuine technological revivalisms of health practices from

a ‘golden’ pre-scientific era, expressing a new ideological promotion of health, sold under the

holistic sign of wellness, in which the individual is morally responsible for demanding the

best physical and psychological setup able to play a determinant role in day-to-day


From Natural Hot Spring Treatments to Health Tourism

In a postmodern society, increasingly organised around globalisation vectors, as shown by the

profound political, economic and social changes which mark the beginning of this 21 st

century, “Health Tourismand the associated practices of health, leisure and tourism have

reinvented themselves and are gaining ever greater popularity as a result of new imperatives

and the greater significance attached to them. This reality is manifested in the reaffirmation of

a new leisure and tourism market, which now emerges dominated by new dimensions,

concepts, spaces and services. “In the 21 st century, wellness travel has become a global

phenomenon. (...) In response to increasing demand, traditional SPA towns around the world

are upgrading or constructing modern SPA facilities. The growth in supply is expected to

foster continuing market expansion, attract new types of customers and diversify product

offerings.” (Messerli, H. and Oyama, Y, 2004: 6)

Sustained by new holistic and wholesome offerings, the new leisure and tourism facilities and

products are today different from those of post-war Europe, then confined to the dominating

logic of classical thermal hot springs, dependent on the existence of medicinal mineral water

(a natural resource) and limited to an eminently hospitalcentric philosophy of service. Today,

supply within the scope of Health Tourism has tended to define itself as wide-ranging and

heterogenic, structuring itself according to global, holistic and health promoting parameters,

resorting to a panoply of knowledge, resources and techniques and not confining itself to mere

usage of hot spring thermal water in evasive leisure facilities (Tabbachi, 2008).

This is a distinct market, of facilities and products of a hybrid nature, where appeals are made

to unique and sometimes paradoxical fusions and interchanges such as those of the natural

and the technological, the scientific and the profane, the western and the eastern, the rural and

the urban. Despite leisure and water continuing to occupy a place of excellence in the

imaginaries of health and leisure, today this is materialised in a variety of services which

range from medical surgery in India (Medicinal Tourism) to recourse to therapeutic

techniques in a thermal facility in Europe (Therapeutic Tourism) to the simple search for

wellness by means of relaxation techniques (Wellness Tourism), thus concentrating such

distinct motivations under the umbrella of the same aims.

By associating these hydrotherapeutic techniques, irrespective of their properties or the nature

of the water used – medicinal mineral, tap or sea water, the new technologies and a service

guided by nature, the natural and ancestral (where technique, decoration and the surrounding

soundscape are examples of the essential variables of service and inherently meticulously

controlled), the rejuvenated SPA label adapts and expresses itself through this new vision of

health which is increasingly defined as healthy, vitalising, positivist, global, holistic and

symbolic. These are new ideals and imaginaries which have in the thermal facilities both their

origin and their antithesis in that, with due exceptions, a new concept of pathogenic and

functional health prevails within them. “The modern SPA is a unique combination of both

ancient traditions and up-to-date technology. The modern-day SPA is centred on holistic

healing as well as wellness philosophies, just as in ancient times. SPAs now offer a myriad of

techniques and services inspired by both Eastern and Western traditions, catering to a broad

array of individuals, each possessing different expectations and needs” (Haden, L. 2007: 9).

Faced with the expansion and privatisation of the healthcare scope, we witness the

proliferation and diversification of services and facilities where leisure and health cross paths

and which, in view of their growing relevance, have been entitled “Health Tourism” or

Health and Wellness Tourism”. This new conceptual designation not only reflects the

growing emphasis on the wellness perspective of health but also significant growth in this

niche market and its consequent specialisation. “In fact, health tourism and wellness tourism

are frequently used interchangeably. However, as this industry and its consumers become

increasingly sophisticated, discriminate use of these terms is expected” (Messerli, H. and

Oyama, Y, 2004: 10).

Today, “Health Tourism” has assumed the brand image of the original and classic

“Thermalism”, englobing an endless variety of services, which have health and leisure in

common, and where water, due to its natural relationship with the essence of the human

being, remains one of the main elements, albeit used in different ways, with different

objectives and alongside new techniques.

The SPA service supply

The new health concepts, increasingly wider in scope and resulting from the

biomedicalization trends of modern western societies, have, among other aspects, definitively

contributed to the growth of this market, as well as to its specialisation and resulting

segmentation. According to the International SPA Association (ISPA) we can currently

systematise the SPA offer into seven different types: Club SPA, Cruise Ship SPA, Day SPA,

Destination SPA, Medical SPA, Mineral Springs SPA and Resort/Hotel SPA. Nevertheless the

diversity of services in this area allows us to identify other essential variables in the

conceptualisation of this service: the philosophy of service (Holistic SPAs, Zen SPAs,

Spirituality SPAs, Romantic/Honeymoon SPAs, Luxury SPAs), or the type of therapy where in

addition to hydrotherapies (medicinal mineral water for human consumption, sea water)

therapies based on balneotherapy, vinotherapy, chocolate therapy, algotherapy, cromotherapy,

aromatherapy, to name just a few, remain common, as well as the universe of associated

services, (Mountain SPAs, Ski SPAs, Golf SPAs).

From the outset, this service range has grown both qualitatively and quantitatively. Today, the

sector tends to be dispersed worldwide, even though it continues to be closely associated with

the US health market where it developed and consolidated its current conceptual state. On the

international level, Europe also currently ranks as a preferred and growing destination for

such services.

When combining the underlying physical dimension with an integrated and holistic view,

these facilities transform themselves into veritable temples for the worship of the body

focused on the paradigm of wellness, SPAs are today a meeting point between western and

eastern views of health “The initial pioneers of the modern-day SPA concept concentrated

upon the physical aspects of wellness by providing their guest with visible results to nagging

physiological problems. (…) Over the years more and more players in the industry have

adopted holistic philosophies, and integrated Eastern and Western wellness systems into their

menus” (Haden, 2007: 1).

In the image of 21 st consumer societies, these spaces have today adopted an eminently

commercial philosophy dedicated to a clientele valuing health, the body, the environment,

social justice, personal development and sustainability. In these facilities, health continues to

be a business of an essentially liberal nature, predominantly out of medical reach and where

branding laws are sovereign. In our days, SPAs emerge as places of greater affirmation of the

ideals of self-health and of self-responsibility where individuals learn to control and monitor

their bodies by resorting to a set of specified techniques which lead precisely into a dialogue

and rediscovery of their own bodies.



It is currently impossible to quantify the universe of the SPA sector in Portugal given the

absence of a legal framework regulating SPA activities: there is only a legal framework for

hot spring thermalism, and within that, for Thermal SPAs. Thus, we must begin by

establishing minimum selection criteria. Only those SPA infrastructures which significantly

render the following services were selected: health care involving recourse to water,

specifically as regards thermal bath treatments and hydrotherapy techniques and the provision

of alternative therapies. Most of the aforementioned infrastructures are integrated into hotels.

In partnership with an expert (invited) from the National Tourism Authority (Turismo de

Portugal) so as to identify the establishments which could be classified as SPAs,

approximately 60 infrastructures were identified. In addition to the aforementioned criteria,

this selection additionally considered geographical location so as to guarantee full coverage

both geographically and the actual SPA concept thus safeguarding the representation of as

many different SPA types as possible.

29 SPAs from the resulting universe agreed to participate in this study with 20 later being

validated. Taking into consideration that a significant part of the questionnaire contemplated

variables of a clinical nature, a minimum of 30 questionnaires was established as the base

requirement for the autonomous validation of an entity. The participant Day Spas, Resort

Hotel SPAs, Destinations SPAs, Medical SPAs ensured the completion of a total of 824

questionnaires by their SPA Goers between May and August of 2009.

Procedure and questionnaire design

The questionnaire was produced within the scope of a PhD project which in its first phase

carried out a review of the available literature on themes such as health, body, leisure and

tourism. The second part of this research, of an empirical nature, first contemplated analysis

of articles and messages conveyed by the major woman’s and men’s magazines in circulation

in Portugal and later, the application of the aforementioned questionnaire. The questionnaire

was produced after analysis by experts in SPA management and involved a pre-test period of

one month. The final version of the questionnaires consisted of four parts: a first section on

SPA consumption (regularity, services used, motivations, satisfaction level and factors of

choice), a second part focused on the representation and meaning of wellness and health, and

a third on health care (practices and routines) and finally a fourth aiming to define the social

and cultural and socio-economic profile of the respondent. The questionnaire was essentially

composed of closed questions, except in the second part where open questions were preferred.

The validation of the applied questionnaire was based on a panel of experts (SPA Managers)

and on a pre-test carried out over one month in March 2009. The final version of the

questionnaire was produced in five languages (Portuguese, English, Castilian Spanish, Italian

and French). The questionnaires were applied in the form of a survey with the cooperation of

the managers and receptionists of the SPAs. Clients would be invited to participate in the

survey after their SPA session.

The statistical processing of the information was carried out using the SPSS -Statistical

Package for Social Sciences- software version 1.7. Based on a descriptive statistical analysis,

the typical profile of the SPA consumer was obtained. So as to identify possible segments in

this demand universe, grouping analysis was later applied with recourse to a TwoStep

algorithm – log-likelihood (considering the nature of the variables in question and the

questionnaire structure).

Survey Findings

Based on the sample gathered through the aforementioned questionnaire, one can immediately

present a social and cultural profile of the client who currently frequents Portuguese SPAs. As

regards age, the average SPA client is 38.5, with individuals aged between 30 and 39

representing the client age range with greatest weighting (38.7%). As for gender, women

dominate, accounting for approximately 69.8%. In the case of family structures, those without

dependents (49.5%) emerge as the main users, that is, couples (married or in common law

relationships) (24.4%) and single people without dependents (25.1%). However, the

married/common law relationship with children prevails as the single most important family

structure category with 34.6%.

The Portuguese SPA client is mostly permanently resident in Portugal (73%), despite some

being of other nationalities. Clients permanently residing in other countries represent 27% of

demand with United Kingdom residents (30%) significant in this sample. The typical area of

residence of the SPA client is also classified as being eminently urban (71.7%), be it in a city

(49.5%) or in a metropolis (22.2%).

In terms of educational levels, there is a clear domination of individuals with higher education

(73.9%), particularly honours degrees (56.1%). In line with the social and cultural profile is

also the socio-economic profile with particular emphasis on individuals engaged in

employment (91.7%) and mainly of employee status (73.2%). These individuals mostly work

in the tertiary sector (89.1%), essentially holding executive responsibilities, at corporate

management level (28.0%) or in specialised intellectual and scientific professions (37.0%).

The average monthly net salary of the family aggregate immediately reflects the sociocultural

and socio-economic level of the current population, with the vast majority earning

more than €2,000 monthly. It must also be mentioned that 48.9% of the households of

individuals attending SPAs report average monthly earnings in excess of €3,000.

The study shows that the range and frequency of SPA use is an emerging practice, despite

already being an integral part of the monthly routines of 31.2% respondents. Despite it not

being a regular practice for 40.7% of SPA service clients, it is nevertheless engaged in with a

certain regularity. This scenario is reinforced by the fact that SPA service consumers apply

their daily leisure time as preferential moments for use of these facilities (44.4%),

immediately followed by specific holiday periods (41.3%). The choice of SPAs located in

their own residential areas (28%) or an intentional journey to outside the regular area of

residence to frequent a SPA (36.5%) reinforces the routine and preferential consumption of

these types of services/facilities. In fact, 75% of the clients from our sample mentioned that

when selecting their holiday accommodation they took into consideration whether or not there

was a SPA, with 25% of clients declaring that this is a determinant factor in their final choice.

The main motive of these individuals in visiting a SPA is connected to relieving stress and/or

relaxation. Across the 824 questionnaire respondents, 74.3% mentioned this reason as very

important in their visiting a SPA. It must also be noted that improving mental and physical

health was the determinant reason given for visiting a SPA by over 50%.

From the universe of the most relevant services available at SPAs, clients clearly mention

massages (90.9%) and body treatments (including thermal water therapy – 70%) as the most

sought after. As regards the most relevant services used at SPAs, it must also be noted that

50% of the clients, did not use hydrotherapy services (vichy shower, simple immersion bath,

hydro massage, etc.) during their last visit to a SPA.

Overall and still in terms of services consumed, SPA clients classified their experiences as

positive with 64.7% saying that the services met all their expectations and 31.1% declaring

their expectations were exceeded. Only 4.2% of clients declare that their SPA experiences

globally fell short of their expectations. When deciding which SPA to visit, clients from our

sample identified the quality of treatment, service, hygiene and cleanliness, the service cost as

well as the SPA location as the most relevant factors. 78.6% declared they personally paid for

their last visit to a SPA. Worthy of note is the fact that 14.4% of SPA experiences were gifted,

namely in the form of vouchers.

In addition to the variables described thus far, the current questionnaire also focused on a set

of behaviours and health care attitudes which the SPA clients adopt in their daily lives. When

questioned globally on their lifestyles, 87.3% declared that on a merely personal assessment

they had a healthy lifestyle. The majority of SPA clients questioned declared that a healthy

life depends essentially on their personal care (53.5%), while 45.4% declared that in addition

to taking care of their health, there are also external factors which can condition that healthy

life. Only 1.1% of the sample declared that a having a healthy life does not depend on them

but solely on external factors over which they have no control, such as work, stress imposed

by the pace of daily routines, environmental quality, economic conditions or interpersonal

relationships, specifically with family members and close friends.

As for necessary personal care for a healthy life, the clients questioned transversely referred to

“food and diet” (89.4%) and “physical exercise” (82.9%) as fundamental care. “Alternative

medicine and techniques” were also mentioned as an important recourse in the universe of

personal care” (for example: meditation and pilates, tai-chi, yoga, the SPA, etc.). Other

aspects mentioned, while not as unanimous, were “relaxation” (for example: sleeping duration

patterns, searching for calm environments) “deviating behaviours” (alcohol and tobacco

consumption) “hygiene” and “recourse to monitoring by conventional medicine” (visiting the

doctor) and “associated techniques” (regular check-ups). Only in passing was a direct

reference made to (considered in the category of “others”) external factors (beyond the control

of the individual) which have implications for a healthy life. Although not as consensual in

comparison with the main personal health care factors already described, these are related to

“work” (such as the number of working hours, the workplace and conditions, relations with

colleagues, satisfactory payment conditions), with “everyday stress” (resulting from the

various timetables and obligations to comply with, traffic and the urban rhythm of life in

general) – 36.9% of those questioned mentioned they had a very stressful daily life, the

“environment” (pollution, area of residence) “interpersonal and economic constraints” (family

wellness, resources/economic limitations) are major issues. Among the “other” factors

referred, are “genetic/hereditary”, “epidemics” and “frequenting places which are also

frequented by smokers”.

When confronting those questioned with their wellness practices, on the one hand we see the

prevalence of the aforementioned set of personal care initiatives with the objective of

achieving a healthy life, such as “physical activity” (67.1%), “food and diet”, recourse to

alternative medicine and techniques and visits to SPAs – 33.7% – here, this is a systematically

mentioned and autonomous category in contrast with that initially observed, and on the other

hand, a set of practices diverse in nature. This new universe encompasses sociability practices

– 24.6% – (for example: dinner with friends, going on family outings, going out in the

evening with friends) and hobbies – 21.0% – (for example: travelling, going to the cinema or

theatre, listening to music, reading, painting, gardening, etc.). Recognition of the importance

of physical exercise and an appropriate diet for a healthy life is reinforced by the general

incorporation of these practices in lifestyles. Among those questioned 71.2% regularly

exercise or include exercise in their lifestyle, with only 28.7% of individuals never having

practised regular exercise or only now not involved in regular exercise.

As regards, special care with food and diet (for example: purchasing diet or organic products

etc.) and as mentioned, the scenario is very identical in that 70.2% of individuals regularly

watch what they eat and actually consider it an integral part of their lifestyle. Additionally,

70.1% of those questioned take or have taken food supplements, while 34.1% take or have

taken weight control products (natural or synthetic) These two care initiatives are reflected

namely in the body mass index (BMI) of those questioned (23.2 Kg/m 2 ). Overall, the sample

shows that 69.5% of SPA goers present a normal or below average BMI.

There is yet another set of practices and habits complimentary to those mentioned, for

example, the non-consumption of alcoholic drinks and/or no smoking. Among those

questioned, 51.3% do not drink alcoholic beverages outside mealtimes or do so very rarely

while 41.9% of individuals limit consumption to the weekends and special occasions. In this

sample, 69.4% of individuals are non-smokers and only 18.1% smoke. The remainder are

occasional smokers (particularly at parties or commemorative events). This series of care

initiatives is complemented by a set of monitoring practices such as simple weight watching.

This habit is common to 59.5% of those questioned, with the vast majority routinely watching

their weight at home. In addition to weight watching, 80.4% of the SPA goers who make up

our sample regularly have medical check-ups and in this particular universe 56.7% do so on

their own initiative with 43.3% acting based upon medical recommendation. This scenario

inverts only in the case of illness, upon which 66.3% resort primarily to a doctor and 33.7%

initially seek out the chemist (12.2%), self-medicate, (11.9%) or turn to alternative medicine


The use of health management equipment in the home is another common practice. Overall,

52.9% of those questioned have equipment at home, with 28.5% having medical equipment

(such as blood pressure, glycaemia or cholesterol measurement devices etc.) and 38% have

physical fitness equipment (for example: bicycle, exercise machines, etc.). These practices

incorporate yet another formative/informative dimension on health, sustained by women and

men’s magazines, which are assiduously read by 52.6% of SPA goer respondents. Here,

particular reference must be made of the women’s magazine Happy Woman (17.9%) and the

men’s magazine Men’s Health (7.8%). The internet complements this information source,

with the specific objective of obtaining information necessary to health management by

63.5% of questioned SPA goers, as well as regular reading of specialized magazines and

books on health (40.4%). Despite the overwhelming majority of those questioned being

beneficiaries of their respective national health systems (84.2%), 65.7% have also taken out

additional health insurance coverage.

Finally, and as regards specific beauty care, 78.1% of the sample regularly consume typical

beauty products and 21.0% use or have used the latest technologies to carry out plastic

surgery treatments (for example: lifting, liposuction etc.), slimming or cellulite treatments,

laser hair removal or skin rejuvenation.

When applying the TwoStep agglomeration technique, with a view to identifying clusters

within the universe of SPA consumers, we identify three clusters: Fans SPA Goers, First

Experience SPA Goers, Men SPA Goers

Figure 1 – SPA Goers by cluster in relation to the use of SPAs and other health care

responsibility uses




Health Management






Source: Author




The figure presented allows us to verify how the differences between the respective clusters

can be systemized by the regularity in SPA practices and by the responsibility as to health,

expressed in frequency and health practice categories. The Fans SPA Goers (19.8%)

demonstrate a high level of SPA practice and regularity with the frequency of SPA use and

consumption being as significant as other habits and regularities as regards health care. This

cluster has a positioning in terms of body and health management which is singular within


this universe, which is in itself already particular. In the case of the First Experience SPA

Goers (40.6%) and the Men SPA Goers (32.9%) there is a distinct positioning. In this case

health habits and care are also greater than that of the general population, although just as in

frequency of visits, lesser than that of Fans SPA Goers.


The first limitation of this study is the fact that it focuses on the reality of one single country

in matters which tend to be global in nature. It is important to stress that Portugal is integrated

in Europe, a region where the SPA sector and social significance are not as expressive as in

other parts of the world and so the phase of development of this market cannot be

underestimated. The second limitation of this study pertains to its period of application, which

for technical and financial reasons was limited to a few months when a full year of application

would have been preferable.


The development of the SPA market and the consumers associated seem to a great extent to

reflect a set of new ideals and a new vision associated to health and its management. Centred

on a positivist acceptation of health, where well-being is the dominating theme, SPAs have

reinvented themselves and have reinvented the whole ideal of health. In the SPA image,

health has also tended to diversify and conquer new domains thus transforming the universe

and the imaginary of health tourism, now sustained by a vaster range of services. This is an

evident reality in the consumer universe of -Salut per Aqua-, which goes much further than

the traditional concept associated to water in favour of new holistic techniques and services

founded on principals of relaxation and massage. This is the affirmation of a new, responsible

and proactive philosophy which is the antithesis of that which had previously prevailed.


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Customer perceived value of medical tourism: an exploratory study

The case of cosmetic surgery in Tunisia

Yousra Hallem

Doctoral student

Ecole de Management de Strasbourg/Institut Supérieur de Gestion de Tunis

Isabelle Barth


Ecole de Management de Strasbourg

Abdelfattah Triki


Institut Supérieur de Gestion de Tunis


The present study is an attempt to investigate the dimensions of customer-perceived value in

the context of a medical tourism experience. The value dimensions of the use of the Internet

will also be explored owing to the role of the Internet in the worldwide growth of medical

tourism. On the basis of the theory of consumption value developed by Sheth, Newman and

Gross (1991), the netnographic study shows that the functional dimension has a great

influence on the value perception of the medical tourism experience. The use of the Internet

essentially has functional, social and epistemic values.

Keywords: medical tourism, perceived value, netnography, Internet

Customer perceived value of medical tourism: an exploratory study

The case of cosmetic surgery in Tunisia

Medical tourism is not a modern trend. “Health tourism is a concept as ancient as prehistory

and as up-to-date as tomorrow” (Ross, 2005). What is different in the 21 st century is that

tourists are travelling farther away, to poorer countries, and for medical care that is invasive

and high-tech. (Bookman and Bookman, 2007). In recent years, medical tourism has

experienced an explosive growth; it thus seems obvious that patients moving from developed

to developing countries for care perceive value.

Researchers believe that the growth of medical tourism has been facilitated by the rise of the

Internet (Connell, 2006). Bookman and Bookman (2007) think that the Internet has opened

the doors to medical tourism in developing countries. The Internet is a huge source of

information for medical tourists, enabling them to know more about destinations, facilities,

service suppliers and procedures. It is also a primary medium for suppliers to promote their

service offers and an increasing number of informative medical tourism websites can be


We can then suppose that medical tourism is a profitable activity for developing and

developed countries. On one hand, developed countries can resolve the problem of long

waiting lists and patients can take advantage of attractive costs. On the other hand, medical

tourism is a lucrative activity for developing countries, and several of them are now tapping

into this niche. Countries are thus searching for new ways to promote their infrastructures and

skills, attract medical tourists, increase their numbers and, most importantly, improve their

satisfaction. Therefore, customer value is now a strategic weapon in attracting and retaining

customers (Woodruff, 1997; Zeithaml, 1988). As perceived value is considered as a key

component of consumers’ decision-making and behaviour (Zeithaml, 1988), countries

receiving medical tourists and practitioners should understand what is the value sought by the

customers and where they should focus their attention to achieve the market positioning

required and to best satisfy the customer. From a marketing perspective, it thus appears

interesting to look at medical tourism experiences through the concept of customer-perceived


Our research deals with medical tourism in Tunisia and more specifically with cosmetic

surgery in Tunisia. Through a qualitative study, we will investigate some research questions:

What are the dimensions of customer-perceived value in the context of medical tourism? Is

customer-perceived value only limited to cost consideration? What are the dimensions of

customer-perceived value related to the use of the Internet in the context of medical tourism?

Conceptual background

Medical tourism: a booming business

Medical tourism is a growing market catering to patients who travel to foreign countries to

obtain medical care (Deloitte report, 2008). The Tourism Research and Marketing Report

(2006) indicates that the market included approximately 19 million trips in 2005 with a

business volume of around $ 20 billion. This report estimates that the number of trips will

have reached 40 million by 2010, with a growth of 4% for the overall market volume.

Other statistics report that, in 2005, countries like Singapore ( and Thailand

respectively received between 250,000 and 1 million foreign patients. Similarly, the number

of foreign patients who took a medical tourism journey in Tunisia has more than doubled

between 2003 and 2007. Their number reached 102,000 (Tourismag, 2008) in 2007, as

opposed to 42,000 in 2003 (Lautier, 2005).

Connel (2006) states that “the biggest hurdle that medical tourism has had to face and

continues to face, is the challenge of convincing distant potential visitors that medical care in

relatively poor countries is comparable to what is available at home in terms of results and

safety”. Despite this, we can observe that a growing number of patients from developed

countries are travelling for medical treatment to regions once characterized as ‘third world’

(Herrick, 2007).

Therefore, with the increasing number of medical travellers, we can suppose that elements of

value other than financial ones may motivate their decision.

The concept of customer-perceived value

Day (1990) stated that the perceived customer value represents the difference between

“customers’ perceived benefits” and “customers’ perceived costs”. The first

conceptualizations of customer-perceived value begin with the works of Zeithaml (1988),

who defined customer-perceived value as “the consumer’s overall assessment of the utility of

a product based on the perception of what is received and what is given”.

The pioneering ideas about perceived value were based on economic theory and the concept

of utility. Despite the relevance of this one-dimensional conceptualization of customerperceived

value, it remains too simplistic and does not make it possible to grasp all of the

explanatory attributes of a purchase. In a marketing context, it has been acknowledged that

value is not restricted to aspects related to price and quality but that it also combines other

functional, emotional and social aspects (Sweeney and Soutar, 2001). Sheth, Newmann and

Gross (1991) identified five consumption values that influence consumer choices, which are

functional, social, emotional, epistemic and conditional values. Sweeney and Soutar (2001)

developed a multiple-item scale for measuring consumer-perceived value (PERVAL). Four

dimensions of perceived value emerged, which are emotional, social, quality/performance and

price/value for money.

The perceived value of the Internet

The use of IT and especially the Internet in healthcare has the potential to change the

healthcare industry worldwide in terms of infrastructure, costs and quality of services

(Wickramasinghe and Goldberg, 2004; Wickramasinghe and Mirsa, 2004). The Internet has

especially become an important medium for marketers and healthcare providers to provide

information and market a wide variety of health care services and products (Bodkin and

Miaoulis, 2007). It has been confirmed that perceived value has a big impact on the use of the

Internet as a medium for the search and procurement of goods. In general, people seeking

information related to health care may act on several motives (Williams et al. 2003). They

may be searching for information as a health care professional, as a consumer looking for a

self-diagnosis or other diagnosis, as a patient to complement information from a doctor, as a

consumer to exchange information with peers or for general interest browsing. Consumers

access online health information in three primary ways: searching directly for health

information, consulting with health professionals and participating in online support groups

(Clines and Haynes, 2001)


Through a qualitative study, we explore the concept of customer-perceived value in a medical

tourism context. We choose netnography as a research methodology because it has been

acknowledged that consumers making product and brand choices are increasingly turning to

computer-mediated communication for information on which to base their purchasing

decisions (Kozinets, 2002). Medical tourists are using forums, chat rooms and blogs to

exchange large amounts of information, share ideas, look for advice, and make contact with

other patients who have experienced a medical tourism adventure. Netnography is a research

method that taps into this huge amount of information by analyzing the exchanges of

members of online virtual communities. On the basis of the criteria developed by Kozinets

(2002), such as the high traffic of posts and the relevance and richness of the data exchanged

among members, we decided to work on the virtual community of Doctissimo. We used nonparticipant

observation, only reading the posts of members with no intervention, and

participant observation by participating in conversations and inducing new discussions.


A thematic analysis was conducted. The choice of categories to be studied was made

according to the method developed by Miles and Huberman (1991). Based on the

consumption value theory of Sheth, Newman and Gross (1991), a thematic analysis of posts 1

has allowed us to highlight different dimensions of perceived value related, on one hand, to

the medical tourism service and, on the other hand, to the use of the Internet in the same


1 We decided to keep the spelling and grammar mistakes to give more credence to the talk of participants.

Functional value

Functional value is defined as the perceived utility based on the functional, utilitarian, and

physical performance of a product (Sheth, Newmann and Gross, 1991). A study has shown

that the main functional value attributes, in the context of the purchase of a tourism product,

are the quality of the travel agency’s installations, the staff’s professionalism at the travel

agency, the quality of the tourism package purchased and the price. (Sanchez et al. 2006).

Concerning the medical tourism service, several attributes have emerged, such as the cost

differential, the skills of the surgeon and nursing staff, the quality of the equipment, the

quality of care and the importance of the recovery period.

It may seem obvious that cost is a major incentive in the medical tourism industry. In fact,

some figures show that operations in India cost 80% less than in the United States (Walker,

2006). We can observe the same relation between France and Tunisia. “This difference of

price between Tunisia and France is hallucinating, until now I could hardly believe it!!!!”

“Who said it was cheap-rate surgery?? Life over there is cheaper than here and that’s why

prices are lower than here!!”

Before deciding to get an operation, future patients spend a lot of time searching for

information about the skills of surgeons.

“Someone who listens, is attentive, calm, thoughtful and is most importantly licensed, belongs

to a medical association and is very competent!” “My motivations were a competence similar

to what is available in France for a price sharply lower than in France, following the

principle of value for money! Because if surgeons were not worth the trip, I wouldn’t go

there, even if it’s cheaper!”

Concerning the modernity of foreign hospitals, it appears that in many developing countries,

public and particularly private hospitals are well-equipped and meet international standards.

“I leave for the operating room, it’s large, I recognize the respirator… it’s the same brand we

have at home, everything is exactly the same, which goes to show that some received ideas

are wrong.”

Regarding the care, many patients appreciate the reactivity and efficiency of the medical staff.

« …I wasn’t feeling very good…, immediately the anaesthetist took care of me,

electrocardiogram, drip, regular blood tests, I felt reassured in this health care

environment.” “As someone who has gone through several operations, I can EASILY SAY

that I had never got or even seen such care at this price.”

The travelling patient aims to purchase a particular service and to achieve a defined health

goal (Bookman and Bookman, 2007). Despite the importance of the medical aspect, it appears

that non-medical services are not insignificant to the medical tourism experience. Medical

tourists especially appreciate the recovery period.

«In my opinion, the advantage of being operated in Tunisia is the rest afterward, they keep

you in the clinic for as long as it takes, after that you end your stay in a hotel, where there are

no concerns such as going shopping or doing housework or what’s for dinner tonight, or the

postman ringing and so on!!”

Bookman and Bookman (2007) asked the question of why a medical tourist picks one

destination over another. They believe that factors such as cultural similarities, distance from

home, medical specialties and reputation influence an individual to favour one country.

Travelling patients think that Tunisia is well reputed in the field of cosmetic surgery. Tunisia

also has strong cultural similarities with France and it is a country where the people speak

fluent French. Finally the geographical proximity between France and Tunisia seems to play

an important role in the choice of medical tourists.

“My first criterion was the fact that the first country to have done surgery for tourists was

Tunisia, so they are more experienced than the others, the second criterion was the proximity:

a two-hour flight is very manageable, and finally the third criterion, the language. In Tunisia,

unlike in Eastern Europe, Thailand or Brazil, all the doctors speak French! It’s important to

be able to easily discuss operating techniques, etc., without asking myself whether I was

properly understood…????”

As regards the use of the Internet, the functional value of the tool lies in its ability to ensure

remote contact between medical tourists and service providers (surgeon and/or tour operator).

Novak and al (2000) considered the ease of contact as a component of a “compelling online

experience”. Through an empirical study, Heinonen (2008) highlighted how well companies

respond to customers’ inquiries using technology such as e-mails. E-mails have the potential

to improve patients’ perception of the accessibility of their managed care organization and

healthcare providers (Moyer, 1999). Therefore, several medical tourists think that the Internet

and particularly e-mails are an efficient tool to communicate with their surgeon or tour


“Doubts, questions, I immediately send an e-mail to my surgeon who replies to me within the

day, he reassures me, tells me not to hesitate to ask any questions that pop into my head and

that it's normal to be anxious. I appreciate this permanent contact.”

Several studies have also shown the usefulness of electronic mail as a medium for patientphysician

communication, as they make it possible to gain time, and improve convenience

and access to medical care for purposes such as renewing prescriptions, communicating

laboratory results and making appointments (Sciamanna et al. 2007).

In our case, it was found that administrative issues inherent to the medical tourism package

are easily and well handled by electronic communication.

“Did you send him the pictures directly by e-mail or through the website? The surgeon has to

see your pictures to make a diagnosis and assess the cost!

Then his assistant will send an e-mail or call you, anyway, the written estimate will surely be

sent by e-mail and then to show you agree, you will need to send him the confirmation of your

plane ticket reservation!”

Other studies have found that follow-up care is among the main reasons why patients use emails

(Nelson and Stewart, 1993, Houston and al, 2004).

The same finding is observed in a medical tourism context, where the follow-up is performed

remotely. The patient sends photos of the evolution following the operation to the doctor, who

examines them and then gives advice and/or renews prescriptions to the patient.

“He remained available after I got back, by e-mail and by phone and even on live chat…!

Regarding the e-mails, it’s useful to send him photos showing the progress of healing for

example!” “I just had my surgeon on the phone a moment ago, and after observing the

photos, he thinks all the same that I have a stitch that went off under the nipple…”

In the context of our study, the Internet is not only a means used to ensure remote contact, it’s

also the main source of information for medical tourists. The Internet is a wide source of

information that allows customers to access more customized information with minimal effort

and cost (Alba et al. 1997). Through forums, travelling patients can easily get information

with minimal effort.

“Before my operation, I did extensive research on the Internet…” “So I started, I began my

search! I typed “facelift in Tunisia” on my friend Google. It gave me the names of clinics and

forums. The breaking point, but yes, the forums, what an idiot not to have thought about it

before, these things are full of information, lol…. So I signed up on 2 forums, and I visit both

of them daily, I don’t post but I read.”

Social value

Social value is defined as the perceived utility based on the association of a product with one

or more specific social groups (Sheth, Newmann and Gross, 1991).

As regards social value, the attributes most often mentioned in literature are obtaining social

approval (Cengiz and Kirkbir, 2007), improving self-image, feeling accepted and making a

good impression (Sweeney and Soutar, 2001), and finally turning to a service provider known

by many other customers (Sanchez et al. 2006). The aspects which stand out the most from

the discussions of medical tourists are related to improving self-image and to turning to a

well-known service provider.

We were able to observe that a large majority of medical tourists turn to cosmetic surgery in

order to improve their self-image and physical appearance in the aim of improving their selfesteem.

“That’s it, I’ve made my decision, after having 6 children, being “obese”, having lost 50 kilos

and reached my forties, I am going to have an abdominoplasty in Tunisia!”

Moreover, medical tourists are looking for the most famous and particularly the most skilled

service provider (surgeon and/or tour operator). We can also observe the formation of groups

supporting for example a surgeon who became famous on the forum.

“It’s true that our surgeon is very attentive to details and very thoughtful. He knows how to

reassure us…” “Our surgeon will soon need a new set of arms to operate all of us!” “What a

successful man he is!”

As regards the Internet tool, the two aspects which stand out the most are related to the

sharing of experience and the formation of groups and social connections.

In addition to seeking health information, individuals can also use the Internet to

communicate with one other in support groups (Houston and al, 2004). In fact, the advent of

the Internet has given rise to many forms of online socialization.

“Thank you for your testimony on your surgical experience in Tunisia: this will be a great

contribution for forum users… so being able to have information on your experience will

provide valuable elements to forum users…” “This forum is an important tool when one

embarks on the adventure of “cosmetic surgery” and I’ve met many people on the forum

ready to help the others.”

Forums dedicated to medical tourism foster the creation of social connections among

members sharing the same opinions and interests. In the forum under study, we can observe

the formation of groups of medical tourists, such as the group of the “lololandaises” and the

“Tunis girls”. The “Tunis girls” group is formed by women who have been operated in Tunis.

The “lololandaises” group is formed by women who have undergone breast surgery.

“Congratulations! You will become a Tunisgirl!!!” “THANK YOU all for your

encouragement!!! And for the lololandaises-to-be: GO THERE stress-free, it’s wonderful to

feel so feminine!!”

Emotional value

Emotional value is defined as the perceived utility based on the ability of a product to arouse

feelings or affective states (Sheth, Newmann and Gross, 1991). Emotional value is related to

the development of positive emotions, such as happiness, interest, and pleasant surprise, and

negative emotions, such as sadness, fear, anger, disgust, and unpleasant surprise (Borod et al.


Previous studies focused on a range of positive and negative feelings arising from a tourism

experience (William and Soutar, 2000; Sanchez et al. 2006; Petrick, 2002) and from a medical

experience (Cengiz and Kirkbir, 2007), such as fear, excitement, pleasure and happiness. In

our case, members made for example comments about being “afraid” and “excited”.

“I keep jumping around because I can’t wait! In 8 days, I’ll be on the plane at this hour!” “A

small tablet before I went to bed to feel relaxed even though I was pretty wired. Not stressed

but excited at the thought of fulfilling my dream.”

“I am supposed to go there on March 2 nd for a breast operation, and now I am really afraid

because there is no way of checking the surgeon’s skills…, I am just afraid of failure.”

Epistemic value

Epistemic value is defined as the perceived utility based on the ability of a product to arouse

curiosity, provide novelty, and/or satisfy a desire for knowledge (Sheth, Newmann and Gross,

1991). Goetzinger et al. (2007) stated that the Internet has revolutionized the way consumers

search for information and has completely changed consumers’ decision-making process,

particularly in the health care industry. In the same vein, it has been acknowledged that the

Internet provides some level of epistemic value to those who use it as a resource for health

care information (Wilkins, 1999). Medical tourists conduct several searches on:

The service providers (surgeon and/or tour operators):

“Before my operation, I had done extensive research on the Internet and I had consulted

several surgeons to be sure to have a good surgeon.”

The cost of stays:

"Are rates really more interesting than in France????”

And the postoperative care:

“Otherwise, as regards post-operation care, I clean the scar using Bétadine, by tapping

gently, without rubbing, then you put a good coat of IALUSET healing cream, all over, and

use IALUSET PLUS where it weeps, because it is a healing and disinfecting cream at the

same time!”

Conditional value

Conditional value is defined as the perceived utility based on the specific context or set of

circumstances faced by the patient. An alternative acquires conditional value in the presence

of previous physical or social contingencies that enhance its functional or social value (Sheth,

Newman and Gross, 1991).

The conditional value of the medical tourism experience finds its essence in the presence of

several contingencies which tend to improve its functional value. These contingencies are

related to the high prices applied in France, the long waiting lists at teaching hospitals and the

absence of coverage for cosmetic surgery.

“It is true that in France, it can be twice as expensive as in Tunisia! Otherwise, there are

some teaching hospitals where prices are around 2,300 euros, but for some, the waiting

periods are too long”

“Concerning coverage, it’s not the lost weight that matters, it is whether or not you have a

"deck", and I have no deck and therefore no coverage…so I’m not interested in being

operated in France”

The table below recapitulates the main findings.

Value Medical tourism service Internet

Functional -cost differential

-abilities of surgeon and nursing


-equipment quality

-quality of care

-importance of the recovery period

-assets of the Tunisian offer

(cultural similarity, geographical

proximity, reputation)

Social -turning to a well-known service


-enhancing self-image

-Maintaining remote communication

through e-mails (making the steps

prior to the service contract easier,

and facilitating post-operative


-easy and quick information


-sharing experiences

-formation of groups and social


Emotional -positive and/or negative feelings

resulting from the experience

Epistemic -information search tool regarding

service providers, costs, treatment

(before and after the operation)

Conditional -high costs in France

-long waiting lists in teaching


-no coverage for cosmetic surgery

Summary of the dimensions of perceived value in the context of medical tourism


This research shows that the medical tourism experience and the use of the Internet in this

context include a set of value dimensions. Knowing the contribution of each value dimension

to consumers’ choice, and in our case to the choice of medical tourists, gives valuable

information to managers (Williams and Soutar, 2000), enabling them to better understand the

concerns and expectations of medical tourists. Like in other studies, it thus seems obvious that

the contribution of functional value is highly significant in the perceived value (Cengiz and

Kirkbir, 2007), especially as regards costs. It is also interesting to note that despite the

importance of costs, medical tourists would not be able to overcome their apprehension if

services were of poor quality; which explains the importance of other aspects of functional

value, such as the surgeon’s skills, the quality of care and the modernity of the equipment. It

is therefore essential that health establishments undergo certification and accreditation to

enhance their reputation.

The functional value of the Internet tool lies in its ability to guarantee a permanent contact. It

is thus essential to optimize the potentialities of the tool. However, and in conjunction with

other studies (Williams and Soutar, 2000, Sanchez et al. 2006), the importance of the

functional dimension in the perception of value should not make us forget the contribution of

other aspects.

Medical tourists see in the Internet tool, and particularly in forums, an effective means of

sharing experience, finding positive stimulation, and especially of finding information on the

different aspects of the Tunisian medical tourism offer. The components listed are

respectively related to social, emotional and epistemic values.

Health care professionals can get more out of these value dimensions, for example by creating

their own blogs or forums, around which they will be able to rally real virtual communities,

thus improving access to information and creating positive word-of-mouth.

The conditional value of the Tunisian medical tourism offer is based on certain aspects of

Western health care systems, such as long waiting lists and the lack of coverage for certain

operations. It would be interesting to communicate more about these issues.

From a managerial viewpoint, the results obtained are a first attempt to enlighten managers on

the major dimensions of the value perceived by medical tourists and on the relative

contribution of each dimension to the perception of value. The goal is to better understand the

needs of medical tourists and thus to better guide their choices and marketing decisions.

From a theoretical viewpoint, these results are a first step in developing a synthetic theoretical

model incorporating the dimensions of both the perceived value in the context of a medical

tourism experience and the usefulness of the Internet in the same context. It is also a first step

towards understanding the key dimensions of perceived value and their impact on behavioural

consequences in a medical tourism context. The ultimate goal is to operationalize the

dimensions of perceived value and test their impact on satisfaction and behavioural



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Cruise Tourism - Changing Products – Improving Wellness?

Ian Henderson

TTC International

Belfast, UK


“This presentation examines the rapidly changing cruise tourism industry across the world but

notably in Europe where growth has exceeded all expectations. (NB It will not cover river

cruising). Not only is the market receiving brand new cruise ships but it is seeing a much

greater spread of products on board. One theme being promoted is that of life, health and

wellness – which may seem to conflict with the image of constant eating and drinking on

board such ships!

The image presented and the products offered may not appear to be consistent in ensuring a

total ‘wellness’ regime.

Additionally the rapid growth in cruise tourism and the need to fill ever larger ships may drive

new customers on board whose desired ‘experience’ may not always be compatible with that

of their fellow cruisers. Mixing market segments creates tensions between groups of

passengers where those who are lured by price may have a totally different lifestyle and set of

ambitions and values to those who are focusing on a more ethereal experience.

The presentation will consider the proposition that ‘wellness’ takes on many meanings to

cruise passengers and that visiting the spa and gymnasium may not be an essential part of the


Thankfully my own cruise experience 5 cruises on 3 different cruise lines has not faced that

problem because we fly to USA and avoid Southampton (where I did the highly successful

cruise tourism strategy in 2004/5).

We prefer Celebrity which is said to be four star and promotes wellness and ‘life enrichment’

and does to some extent. Good gyms and exorbitantly prices spas – plus new products that

suggest healthier eating and living on board.

Cruise Tourism Work undertaken:

Port of Southampton Cruise Tourism Strategy

Scottish Cruise Tourism Review

Economic Impact of Cruise Tourism Dover

Antigua Tourism Masterplan

St Maarten Tourism Masterplan

Limassol Cruise Terminal Feasibility

Mombassa Cruise tourism Feasibility

Dublin Cruise Tourism Feasibility

Cosmeceuticals in wellness tourism – Cases of co-branding and co-creation

Anne-Mette Hjalager

Associate professor, University of Southern Denmark, Centre for Tourism, Innovation and


Niels Bohrsvej 9, DK 6700 Esbjerg

Henna Konu

Researcher, University of Eastern Finland. Centre for Tourism Studies

Puistokatu 5,, FI-57101 Savonlinna


“Cosmeceuticals” is a combination of the terms “cosmetics” and “pharmaceuticals”.

Cosmeceuticals are supplied to the wellness facilities, and they materialize for the tourists

during treatments. Tourism research has not to any significant degree addressed the role of

cosmeceuticals in the wellness industry.

The paper provides examples of strategic alliances from the Nordic countries of co-branding.

Additionally, the producers/distributors of cosmeceuticals may become crucial partners in the

creation of the experience offered in the wellness facilities. With examples from the Nordic

countries, it is demonstrated that alliances can lead to innovation and development in

cosmeceutical enterprises, and that the collaboration can also assist the wellness industry in its

attempts to obtain inimitability. Based on innovation literature, the paper discusses models for

co-creation and factors that facilitate or hamper collaborative processes. Co-creation and cobranding

constitute strategic alleys for the wellness industry. The Nordic evidence suggests

that the opportunities are not fully exploited.

Keywords: Spa and wellness tourism; cosmeceuticals; innovation; co-branding; co-creation;

the Nordic countries.


“Cosmetics” and “pharmaceuticals” together form the term cosmeceuticals, which embrace

anti-aging creams, moisturizers, bathing salts, lip balms and many other products. When

extending the use of cosmeceuticals and applying the rhetoric of health improvements, the spa

and wellness industry is increasingly marching into domains formerly exclusively occupied

by “serious” medical professionals. Similar movements and invasions can be observed in for

example electronics where GPS-technologies have moved from restricted military use to

become an instrument for play and enjoyment, and in the clothing sector waterproof clothes

previously used mainly for military purposes or as working clothes have also disseminated

into outdoor activities for recreation and tourism (Logue 2005, Smedstad 1995).

Wellness tourism integrates body, mind and spirit. A satisfactory tourism experience depends

on the intentions, mood and adaptability of the tourist, but also on the competencies and

professionalism of the wellness staff to interpret and meet the needs of the visitor. Relations

between human beings are found to be crucial in wellness tourism (Kelly & Smith 2009).

However, wellness experiences are not only a matter of intangible procedures and services.

The delivery process is assisted by a large number of auxiliary remedies. Thus,

cosmeceuticals are supplied to the wellness facilities, and they materialize for the tourists

during treatments. As it will be further developed and explained in this article, the image and

the commercial success of cosmeceutical products depend on the interaction between the staff

and the customers in the wellness facilities. Accordingly, it assumed that there is a mutuality

of the two industries, which may or may not be fully envisaged and exploited. It is part of a

collaborative picture that cosmeceuticals are also merchandised on the premises and often part

of the décor. Thus, the role of the cosmeceuticals is, potentially, even more far-reaching in

terms of development and branding.

Although wellness tourism is a topic that attracts many tourism researchers, the role of

cosmeceuticals in the wellness industry has not been addressed too any significant degree.

Generally, it is remarkable how few research reports are generated from the “engine room” of

the wellness industry.

The geographical framework for this study is the Nordic countries, where spa tourism has

existed for a long period of time (Aho 2007, Hemmi & Vuoristo 2004, Kangas & Tuohino

2008, Konu et al. forthcoming 2010, Smith & Puczkó 2009, Suontausta & Tyni 2005). There

are many strategically sound ways for spa and wellness tourism enterprises to move in

developing their competitiveness and brands, and developing their cosmeceutical alliances

might be one of them. One assumption here is that the producers/distributors of

cosmeceuticals are crucial partners in the creation of the experience offered in the wellness

facilities. Cosmeceutical producers play a role both in terms of innovation of new products

and services and in the marketing and branding process. The terms co-creation and cobranding

are applied in the investigation of the nature of such collaborative structures.

Literature review

Wellness tourism has its roots in the long history of spa resorts, and in that sense is not a new

phenomenon. During more recent decades it has modernized and diversified into a large

variety of categories. As demonstrated by Smith and Puczkó (2009) wellness tourism includes

a high focus in facilities for medical treatments, as well as pure leisure and relaxation sites.

There are also great variations in profiles when it comes to expectations of the tourists

involvement and activity, either mentally or physically. The rapidly upcoming research

interest covers many issues, but there seems to be an overwhelming interest, for instance in

users’ profiles and in motivations, behaviours and experience. Generally, the rationale is that

there are significant growth prospects due to ageing and changed lifestyles (Bushell &

Sheldon 2009). In parallel, destination studies contribute to the wider perspectives with

evidence about local resources, sustainability fit and economic viability (Pechlaner & Fischer


In the pharmaceutical literature, the development of cosmeceuticals is given quite noteworthy

attention. There is a science based focus on the ingredients that influence the skin's biological

function and the discovery of new active agents (Draelos 2008, Tsai & Hantash 2008).

Spa and wellness facilities provide a long range of treatments. Not all of them imply the use

of cosmeceuticals. There is an ongoing development in the treatments, such as cooling and

hot stones, and vitaminized massages, as well as treatments of the extended body, and

combined mental and physical treatments. Simultaneously, there is a tandem process of

ongoing development with cosmeceuticals that can be applied in those treatments.

Manufacturers are enthusiastic to explore the uses of traditional and new raw materials in

their products. Trends for the near future are claimed to be that natural products and extracts

will replace chemical materials; additionally, plants and fermentation will replace animals as

ingredient sources.

The use of cosmeceuticals in wellness tourism is only fragmentarily covered in the research

literature, and then only in conjunction with the descriptions of the treatments provided. Smith

and Puczkó (2009) reviewed the many categories of wellness tourism, from medical to

recreational, relaxationally passive to sportily active, physical to spiritual, and focused to

holistic. Treatments where cosmeceuticals are prevalent occur in some of the categories and

not in others. The experiential cosmeceuticals do receive some anecdotal attention in the

literature, for example massages and body wraps based on chocolate. The general trend seems

to be that the inclusion of spa elements in for example hotels and sports centres increases the

profits, and that the growth rate of goods and merchandise is particularly impressive

(Mandelbaum & Lerner, 2008). In terms of treatments, Behrens (2007) points to the strong

diversification and internationalization trends, where large corporations with huge marketing

budgets tend to be the main driving forces. Those players in the wellness and spa market may

have alliances with suppliers of cosmeceuticals in the same league.

On a more general level co-branding with the tourism business and their suppliers is an upcoming,

but still novel research theme (Pechlaner et al. 2006). Co-branding is when two

companies form an alliance to work together, creating marketing synergy. In this situation, a

tourism enterprise will enhance its image by using respected and, preferably, already wellbranded

products, while the suppliers can achieve an extra marketing platform for its

products. Any wellness provider will apply scrubs, lotions, muds etc. during the treatments

and the brands of these can be made very visible and their merits included in verbal

appraisals. The spa-goers are expected to take the first step towards a loyalty to the particular

product. They can also find the same products in the shop to bring back for home treatments

and gifts. Additionally co-branding can include club memberships offers. The co-branding

can also take place on the websites of the enterprises, sometimes even including e-shopping

opportunities (Lee et al. 2006). The research literature is fairly tacit about strategic cobranding

alliances between the wellness industry and its suppliers in this field (Gibson, 2008;

Weiermair & Steinhauser, 2003). Smith and Puczkó (2009) talk about “signature products”, a

term that embraces the development of new spa products and treatments special to the place

and destination. Signature products might involve an active and mutually beneficial a cobranding

of the spa-facilities with the producer and the local community, from where an

element of the signature derives.

Co-creativity moves the issue further. In this case a wellness operator will collaborate

intensively with suppliers of cosmeceuticals in order to develop new products. The open

processes lead to cross-fertilization of knowledge. During the process of co-creation the

purpose for the supplier is also to gain new ideas and insights, which may eventually lead to

product introductions to a wider market (Möller & Törrönen, 2003). Accordingly, tourism

service providers and their suppliers are partners in an innovation process, and leading

tourism enterprises are responsive test benches for new supplies with a higher quality and

better market potential. Such innovation processes are not well illuminated in tourism

innovation literature (Hjalager, 2010).


This study combines literature reviews with brief and targeted case studies. As the research is

part of a larger project on “Nordic Wellbeing” the geographical focus is the Nordic countries,

in particular Denmark and Finland. Persons selected for interviews are managers of spa and

wellness facilities and cosmeceutical manufacturers and distributors. As tourism research is

only marginally addressing issues about co-branding and co-creation, the Internet and the

trade press has been an important supplementary source of knowledge on specific practices in

the global spa and wellness industry.

Spa Industries and their Suppliers – Cases from Denmark and Finland

The inclination to place additional weight on the spa products and the relations with the

producers and distributors of them can be demonstrated by the cases from Denmark and

Finland. The cases illustrating the strategies are far from uniform.

Table 1. Cases of co-operation and co-branding between cosmeceuticals and wellness firms.

Strategies of spa firms and cosmeceutical firms

Comwell Hotel


Development of a series of skin care products together with Matas, a retail

materialist chain. Intensive co-branding in shops and in the wellness facilities

in the hotels. Joint marketing campaigns. The “Spalosphy” series has been

very successful in the spas and as a retail product.

Vejlefjord Spa Development of private label cosmeceuticals to the spa. The products are

available in the spa and in the webshop. The suppliers of ingredients are

anonymous. The staff prepares the products in the “back office” on a regular

base, and there is a great concern about the freshness and the full and open

Queen Dorothea’s


declaration of the ingredients.

The theme of the bath is medieval, and historical line has also been chosen for

the spa product series, developed in collaboration with a local supplier of

cosmeceuticals. The concept will be developed in order to create a wider level

experience for the spa-users.

SeaWest Spa SeaWest imports an Islandic spa product series, chosen for its image of being

“clean”, and with ingredients from the Nordic natural environment. The

Anttolanhovi and


products are also available in the spa shop and on the web.

A distinct concept is the ‘wellness bar’ (following the idea of minibar), which

are found in Art&Design villas. The bars are filled with Finnish wellness

products from Lumene and Cutrin (both labels owned by LUMENE Oy). The

intention is to give customers a possibility to pamper themselves with

products with arctic ingredients.

Hotel Kalevala Hotel Kalelava uses Frantsila’s supplies, which concentrates on organically

grown and produced herbs and plants. Raw materials of the cosmeceuticals

are mainly cultivated for the purpose, but in addition some of the ingredients

are gathered from nature. All herbs and plants that are used are well known in

folk medicine, and as such used to enhance health and wellbeing and cure


Designermudder The firm is a cosmeceuticals producer diversifying into experiences and

events. The strategy to offer good and interesting skin care products, for

example coloured muds. However, additional services that enhance the

experience of the spa-user are also offered, and the specialists from the firm

are responsible for fun-events such as producing your own soap. The strategy

is also about building mutual relations with the spa facilities employees.

Guest Comfort Guest Comfort is a cosmetic supplier who acts as a creative intermediary

between cosmeceuticals and businesses in the tourism sector. It is also a

knowledge intermediary between spa facilities and the producers of

cosmeceuticals, and sees itself as a motivator for continual creativity in the


Issues in Co-branding and Co-creation

The branding literature elaborates on the many dimensions of effective co-branding. Aaker

(1996) demonstrates that the companies in collaboration must have a deep understanding of

their customers’ motivations in order to create and enhance the loyalty for more products in a

co-branding group. Furthermore, the quality levels must be comparable, and the product

character stable and unshakeable, as compromising will harm the collaborating partners. In

the cases of successful co-branding, a mutual respect and trust has been built up over time.

Suppliers are likely to be more willing to launch into risky partnerships if they have the

prospects of lasting contracts that guarantee a return from their innovation and other

investments (Crotts et al. 1998).

According to Lee and Decker (2008) there are three distinguishable effects of co-branding:

• Mutual effects which occur if there is a high degree of product fit, where the two

products are interlinked. That is the case in cosmeceuticals, as the products are directly

applied during the treatments and exposed to the customers, while the treatments take

place. If the customer gets a sense of wellbeing after the treatment, he/she will build

up a favourable attitude towards both the spa and the particular cosmeceutical.

• Extension effects happen later as a responsive consumption behaviour. By

remembering the spa-experience, the customer will also be likely to bring back gifts

from the spa gift shop and to choose the spa product during daily shopping.

• Reciprocity effects are the long term effects where the customer on a more permanent

base perceives the quality of a product in a certain manner. At this time the

collaboration between the supplier of cosmeceuticals and the spa facility can expand

their collaboration and utilize the established brand equity, for example by introducing

more cosmeceutical products or by appealing to new market segments.

In the private label case of Vejlefjord, there is of course no co-branding, and none of the

effects are materializing. It demonstrates a careful strategic choice, which coincides with for

example the strategies in professional staffing.

Other cases in this collection are examples of the harvesting of the effects of mutuality. Thus,

the Hotel Kalevala and the Seawest work with producers with a distinct image, which

supports the brand of the place as “Nordic”, “clean”, and “responsible”.

In the co-operation model of Anttolanhovi and Lumene, Lumene’s products are introduced to

different customer segments and possibly also to people that have not tested Lumene products

before. This can encourage customers to buy Lumene products also from other places, e.g.

during daily shopping. Comwell/Matas likewise expand the likelihood of extra business for

both partners, not least because the Matas shops are found in nearly all towns in Denmark.

Designermudder is an example of a supplier that has the reciprocity in mind to have products

that appeal to categories of spa goers that most spas are not yet geared to serve. The

intermediating of Guest Comfort also helps spa providers and cosmeceutical products that are

not experienced in, or capable of, exploiting the potentials of co-branding.

Generally speaking, there are several driving forces for innovation in tourism, for example the

technological developments, suppliers’ provision, market demand/customer requirements, and

governmental regulation (Hjalager, 2002). Innovative suppliers can be decisive for tourism,

due to the fact that much innovation is already embedded in technology and raw materials.

Suppliers’ innovations are “released” when integrated in the service delivery in the next step

in the value chain. Barras (1986) declare this a typical “reverse” road to innovation in

services. Cosmeceutical producers can be analysed in this logic. Eventually, the most

innovative producers of cosmeceuticals may theoretically be able revolutionize the product

that the spa facilities are offering to their customers. Seen from that perspective, spa and

wellness enterprises are in a situation where they have to consider existing and emerging

cosmeceutials not exclusively as enhancers of products, features and functions, but also as

facilitators of experiences. The case study of Designermudder exemplifies that more colourful

spa muds and scrubs can be a stepping stone for the spa experiences for new target groups,

and thereby a re-orientation or a diversification for the spa and wellness facility. Likewise,

Guest Comfort has a “push effect” on its customers in the spa business.

The literature on service design (Pine & Gillmore, 1998; Voss & Zomeijk, 2007) widely

advocates to use metaphors from the theatre in order to enhance the experience and make the

products innovative as far as the user is concerned. Producers of cosmeceuticals possess

distinct chances to contribute to the development in the spa business in a proactive way.

Systematic approaches as suggested by Edensor (2001) and Mossberg (2007) reveal that there

might be a plea for enhanced understanding of the theatrical focus in spa innovations, and the

cases in this study illustrate that co-creation with cosmeceuticals can be seen as a construction

of dramatic progressions.

• Scripting is about creating the story and the rituals. Scripting is a multifaceted process

that integrates issues about the socio-economic and educational background of the

customers and the type of business. The scripting process can reflect a range of

matters: What is the place of origin of the ingredients? What scientific evidence is

available? What auxiliary remedies? Spa ceremonies are often very rigidly scripted,

and the customers more or less know what to expect. However, spa providers are

attempting to make variations in order to create surprises. A uniqueness of the

cosmeceuticals and the producers’ contributions to the script are methods of enhancing

the period of time - before some other business is copying elements from the concepts.

The renaissance case of Queen Dorethea’s Bath is good illustration of the potentials of

a thematic script with monks and their medical herbs.

• Sceneography and stage-design. There is an ongoing architectural and ethnic

proliferation and thematic remodeling of the spa interiors. The importance of the décor

seems to increase, as the colours, shapes, sounds, surfaces etc. tend to create the

signature of the place and contribute to the overall feeling of wellbeing. The cases in

this study vary from very classical, to modern Finnish design and to the medieval

Queen Dorothea’s Bath. However, these specific wellness facilities exhibit limited

attempts to bind together and co-create the cosmecuticals and the sceneography, for

example underlining the views to pine trees outside and a Nordic ambiance with pinebased


• Casting and instructing deal with the recruiting and managing the staff who are

capable of enacting the story that is laid out in the script and embraced in the

sceneography. From the point of view of the suppliers of cosmeceuticals, it is hardly

enough that the staff are professional therapists or cosmetologists and able to apply the

products in exactly the required way. Innovating goes beyond that and includes for

example the use of costumes that are harmonized with the setting and potentially also

the image of the cosmeceuticals. Instruction also contains preferred behavior and

procedures that reinforce the image with some scope for improvisation. Innovativeness

in the field of casting and instructing is about creating norms and cultures of a place,

which contributes to uniqueness, and which creates a learning environment for the

producers of the cosmecuticals to achieve relevant and reliable feedback for their

innovation processes. Enhanced sales methods for merchandise and after sales services

are also a part of this picture and crucially relevant in terms of cosmeceuticals. The

proprietors’ interviews emphasis the need for training as part of the co-creation and

co-branding process.

• Directing the tourists’ performance. Tourists in spa and wellness establishments are

not only spectators, they are also co-producers of their own and other people’s

experience and therefore partly responsible for the success of the theatric play. There

is normally a good deal of guiding of the visitors through treatment programmes and

offers, and most customers are accepting the implicit conformism. Self-pampering

requires particular advice and encouragement, as seen in Anttolanhovi and Comwell

cases. When appealing to broader audiences, there might be a need to introduce other

ways of play directing into the spa product. Designermudder sees the opportunities in

organizing events for children where they produce their own soaps or lotions. Such

events – however in line with the objectives of both spas and cosmeceutical producers

– may require new modes of interacting with the customers.

Discussion and Implications

This study approaches a tourism niche from the point of view of the suppliers, and this is a

method that is not conventional in tourism research. By accumulating an understanding for

the business models and marketing strategies from the suppliers’ side, it is possible to broaden

the perspective in terms of innovation and knowledge transfer. Accordingly, the study unveils

that the co-branding and co-creation is taking place under quite different understandings of

boundaries of the enterprises. It is a conclusion from the cases that there are both existing and

emerging overlaps in the roles of the cosmeceutical producers and the spa wellness

enterprises. Collaboration tends to soften the boundaries and opens up inspiration and

communication, enlarging the knowledge base can contribute to the competitiveness of a firm

(Howell et al. 2003) and influence innovativeness (Tether 2005, Walsh 1996).

The cases suggest that co-branding is an emerging issue in the spa industry, and that that the

cosmeceutical industry seems to be responsive. However, in the Nordic cases there is only

marginal emphasis on creating destination/nation specific wellness cosmeceuticals.

Accordingly, the destination signature expressed through products with names of specific

locations or geographical features is generally weak. Rather, both the spa industry and the

producers tend to rely on the international practice in the business, where oils, fragrances are

acquired from all parts of the world and assimilated into the spa product. There are many very

persistent traditions in the ingredients sector, but the choice of ingredients also has an

economic background. When it come to the collection and processing of ingredients from the

natural environment where supply is distributed over large spaces in remote areas, the

obtaining of an economics of scale in countries with high labour costs becomes very difficult.

As it is illustrated by Finnish Frantsila and Lumene it is possible to create some economies of

scale in this field. It is important to envisage that particularly Lumene has experienced growth

and now the firm represents a major actor in its home market.

For those enterprises and governments who intent to proceed along the road of creating

stronger alliances or backward integration with the value chain there are a number of focus

points to be aware of and to address:

• Is there a resource base for a cosmeceuticals in the Nordic countries?

• Are “lived Nordic values” (Nordisk Råd and Nordisk Ministerråd, 2009) contributing

leads for wellness and wellbeing tourism?

• Are there supportive business structures and a collaborative network? Are the spa and

wellness industry and the cosmeceutical producers prepared to enter into collaborative

agreements and trustful interaction?

• Do the regulatory regimes challenge and support the endeavours to create Nordic

value chains?

When it comes to meanings and values the Nordic elements in spa and wellness are intrinsic,

and there is still substantial research to be undertaken when it comes to a better grasp of cobrand

management in this context (Pechlaner et al. 2006). None of the actors in this study

have yet to achieve a consistent and full-bodied co-branding and co-creation profile, and that

is not a surprise. We are talking about a discipline in tourism that is still emerging in terms of

academic research and in terms of practical implementation. Destinations still have to be

invited in to do a job.


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An exploratory study of consumer choice and motivation of medical

tourism in Thailand: A case study of healthcare consumers visiting a

private hospital in Pattaya

Miss Wanvipha Hongnaphadol

The University of York, UK


According to Gee (1997), travellers are now travelling with different expectations; rather than

going for sightseeing in different places those tourists seek more meaningful experiences.

Therefore, any country’s economy depending on the tourism sector needs to create uniqueness

in their tourism products or come up with a special interest tourism product such as cultural

tourism, adventure tourism and health tourism. Health tourism, the concept of travelling for

healthcare, has been developed for centuries since the Greek and Roman periods or, according

to Burkett (2007) and Swarbrooke and Horner (2007), since the sixteenth and seventeenth

centuries. Health tourism, in the first place, was just the utilisation of natural resources, e.g.

mineral springs, sea water, including social activity. Healthcare has been combined with

leisure facilities and entertainment since then. Later in the seventeenth and eighteen centuries,

many wealthy Europeans visited places like France for medical expertise. Yet, this can be seen

as a regional health travel. Global health travel occurred afterwards, as Swarbrooke and

Horner (2007) point out the most sophisticated recent form of health tourism is where people

travel abroad for medical treatment.

Context of the Research

Tourism in Thailand

International tourism in Thailand started its journey in the seventeenth century when

Europeans travellers began visiting the country both for commercial and sightseeing purposes

(Oppermann and Chon, 1997). More recently, tourism has played a significant role in the

growth and development of the country’s economy as the country shifted from an agricultural

base to a more industrialised and service based economy. The first five-year Tourism

Development Plan (1977-1981) was undertaken in 1976. The industrialisation of the Thai

economy resulted in the increased export value of tourism as well as textile products, rice and

rubber during the 1980s (Higham, 2000). By 1995 the foreign exchange income from

international tourism exceeded the country’s top ranking exports (TDRI, 1998). The ‘Visit

Thailand Year’ campaign in 1987 succeeded in gaining a dramatic increase in the number of

foreign tourists and the ‘Golden Decade of Thai Tourism’ followed between 1987 and 1996.

The rise of Thai tourism continued into the mid-1990s and rapidly dropped in 1997 due to the

economic recession. Overall, the number of international arrivals in Thailand has increased

from 1.2 million in 1975 to about 7 million arrivals in 1995 and risen to 14 million in 2007

(TAT, 2008).

Healthcare services in Thailand

Thailand has a market-oriented healthcare system as people have free choice in selecting a

healthcare facility (Janjaroen and Supakankunti, 2002). Although public providers play a

major role in delivering healthcare services, the private sector is significantly growing.

Regarding the health insurance system in Thailand particularly the universal coverage (UC) 2

2 The Thai government has implemented national health insurance consisting of the Civil Servant Medical

Benefit Scheme (CSMBS) – covering government officials, their parents, spouses and children, the Social

scheme, although this theoretically increases individuals’ access to healthcare and provides the

same quality health services as offered by other health schemes, it can lead to healthcare

service and provision not being equally accessible to many local people with the same quality

standards (Sreshthaputra and Indaratna, 2001). Unlike the developed countries, their public

healthcare can not only reach everyone for free, but also with good quality and standard of

care. Pachanee and Wibulpolprasert (2006) argue that the UC scheme, the incoherent health

policy implemented by the Thai government, hinders the promotion of international trade in

health services. The UC scheme has large impact on healthcare system in Thailand including

financing system, quality of care, manpower, etc. Although the UC scheme increases people’s

health security and decreases people’s healthcare expenditure (Ngosurachet and

Sornlertlamvanich, 2004), some middle- and upper-classes eligible for it decide not to use the

service because of long queues, and non-confidence in the quality and standard of care

(Sreshthaputra and Indaratna, 2001; NaRanong, 2005). Therefore, they rather visit private

hospitals. As any individual claiming for this health insurance benefit can mainly receive the

service at public hospitals, the promotion of healthcare services to medical tourists in public

medical providers is unlikely due to the existing high demand of the local people, and the

contribution of major affordable resources to firstly serve most local people. Consequently,

medical tourism business in Thailand is focused on private hospitals 3 which provide good

images of hotel-like atmosphere in medical settings and create positive attitudes towards Thai

healthcare services and medical expertise for medical tourists.

Medical tourism

Medical tourism is an emergence of a new and distinct niche market in terms of the deliberate

articulation of the healthcare and tourism industry where patients travelling overseas for

medical care – involving specific medical intervention – treatments and operations in hospital

context combined with a vacation (Cornell, 2006a; 2006b). However, medical tourism is not

considered as a new concept in terms of travelling for healthcare as evidenced since the Greek

and Roman periods. While Caballero-Danell and Mugomba (2007) agree with Connell by

shedding light on tourism experience gained from leisure activities after medical treatment,

others emphasise the cost effective medical care provision (Awadzi and Panda, 2006).

In this research, the term ‘medical tourism’ will be used to denote foreign patients travelling to

seek medical treatments and operations from the healthcare services in Thailand. However, the

participation in tourism either before or after treatment and the degree of participation is not

yet defined in the term as this can be highly diverse and really depends on the types of

treatments medical tourists have. This is yet to be investigated in the research if medical

tourism in Thailand is about tourism. Although medical tourism covers a wide range of

products and services (elective and non-elective treatments), cosmetic surgery, such as

Security Scheme (SSS) – covering employees in private companies, and the universal coverage scheme (UC or

30 baht scheme) – covering the rest who is not eligible for the first two schemes, since October 2001

(Ngosurachet and Sornlertlamvanich, 2004). Each scheme has different types of payment: fee for service on

CSMBS; capitation on both SSS and UC. With the UC scheme, the beneficiaries have to register to particular

health facilities and pay only 30 baht per hospital visit for most of diseases in public hospitals which are the

main providers. Therefore this leads to a huge workload but low pay to doctors in public providers, and to an

increasing internal brain drain of doctors to private hospitals which provide better incentives. 30 baht is about

£0.58 (51.52 baht equivalent to £1, rated on 2 August 2010).

3 Private hospitals, accredited by Thailand’s Ministry of Public Health (MoPH), deliver not only expertise in

healthcare but also excellent service. Private hospitals sometimes cooperate and liaise with ‘medical travel

agencies’, which work just like traditional travel agencies except that they specialise in medical travel services

and can help consumers make medical appointments, make arrangements for travel-related needs (e.g., flight and

accommodation bookings), and also include leisure and sightseeing activities in customer itinerary.

enhancement and beauty, will be more in focus as considering significant figures of foreign

patients travelling to Thailand for this particular purpose.

The development of medical tourism in Thailand

According to Connell (2006b), Thailand became a medical tourism destination in the 1970s

with its expertise in sex change operations and cosmetic surgery. The medical tourism industry

played an important role again due to the currency collapse and rapid devaluation of the Thai

baht 4 in the Asian Economic Crisis in 1997. Many Asian governments, including Thailand, all

promoted economic diversification, with the notion of turning round health service earnings

through attracting foreigners. They considered medical tourism as a potential growth factor of

the economy and promoted it because they foresaw its business opportunities and as a catalyst

to their economies. Thus, a big budget for improving healthcare services in these countries

was established to develop the best international standards. In support of what Teh (2007)

points out, merging medical expertise and tourism has become a government policy in many

Asian countries. The Tourism Authority of Thailand (TAT) launched a campaign to promote

Thai traditional healthcare including massage, herbs and authentic Thai food to attract more

foreign tourists. The TAT started a promotional programme for health tourism with the first

‘Thailand Health Travel Mart’ in 1999, repeated in 2000. The purpose of medical tourism at

the beginning was to generate another way of earning foreign income and to help the

hospitality business such as private hospitals and hotels during the recession. Medical tourism

thus became the new trend of Thailand’s tourism industry.

Previous studies of medical tourism research

In research on people travelling for health reasons or so-called ‘health tourism’, Goodrich and

Goodrich (1987) started by conducting an exploratory study of health-care tourism 5 with

travellers visiting hotels or resorts for healthcare treatments. In studies discussing motivating

factors of travellers seeking wellness and spa experiences, Chen, Prebensen and Huan (2008)

and Mak, Wong and Yang (2008) focused more on the motivation of wellness travellers by

addressing how visitors are motivated. While the former study revealed that cost and variety

of attractions rather than healthcare facilities at the destination were the main reasons to select

and visit the destination, the latter found that relaxation, health consciousness, and

attractiveness are among the most salient motivations attracting customers to wellness resorts

which corresponds well with the marketing schemes emphasising tranquility, enjoyment and

body pampering, in other words relaxation. Psychological benefits accordingly appear to be

the most important driving force pulling customers to wellness resorts. Although these studies

emerge from people travelling for health reasons, the settings are in a more relaxing context

i.e. hotels, resorts. Unlike the proposed study, it aims at exploring motivations for people

seeking healthcare in medical settings i.e. hospitals. However, it can be contributed to this

study as an initial guidance in exploring tourist motivations in search of healthcare as there is

little investigation of tourist motivation in relation to health seeking behaviours.

Caballero-Danell and Mugomba (2007) emphasise that little academic research has been done

on the medical tourism market due to the fact that it is a relatively new niche market.

Rittichainuwat, Qu and Mongkhonvanit (2008) additionally agree that there is little empirical


The devaluation of the Thai baht, on the other hand, provided the opportunity for hospital to attract overseas

patients due to the relatively lower charges.


“[T]he attempt on the part of a tourist facility (e.g. hotel) or destination (e.g. Baden, Switzerland) to attract

tourists by deliberately promoting its health-care services and facilities, in addition to its regular tourist

amenities” (Goodrich and Goodrich, 1987: 217).

study identifying the motivation of travellers to Thailand generally, and far less on medical

tourist motivation.

Conceptual framework

Theory of consumer motivation

The study of motivation in tourism is obviously important due to its role as a trigger to travel.

Tourism literature emphasises the significance of both push and pull factors in shaping tourist

motivation 6 (Crompton, 1979). Many scholars have worked on the definition of tourist

motivation partially by identifying the underlying reasons for travel. Each individual tourist

motivation framework may not fully explain the circumstance. According to Fodness (1994),

the most common empirical studies on tourist motivation are from the works of Dann (1977),

Crompton (1979), and Pearce and Caltabiano (1983), all of which explored push and pull

motives. Pull factors are the destination’s extrinsic forces, such as attractiveness and specific

features of the destination, perceived by potential tourists and pull people to choose that

particular destination whereas push factors are consumer’s intrinsic forces establishing the

desire to travel and push people to travel in the first place. In other words, according to Bolles

(1975), human behaviour is pulled through the perception of valuable characteristics in the

environment and pushed through the action of motivating drives. Klenosky (2002) further

suggested that a single pull factor of a particular destination can be driven by multiple push

motivational forces. People may have multiple and possibly very different push motivational

reasons for evaluating positively the same pull factor. Likewise, tourists with different

demographic profiles may have different push and pull travel motivations in visiting a

particular place.

Interestingly, according to Chen et al. (2008), no academic literature has shed light on the

types of motivation of consumers visiting medical tourism settings, therefore investigating

those different motivations will help identify the possible leading attributes influencing the

demand since tourists often possess more than one motive (Pearce, 1993, as cited in Chen et

al., 2008). Additionally, as Sangpikul (2008) points out, there is limited research on the pull

motivational factors or destination-based attributes segmentation in a Thai context. According

to Kozak (2002), the destination attributes of a particular destination or pull factors, could be

various and different from one destination to another depending on the perception of travellers

towards a particular destination. According to Lubbe (1998, as cited in Sangpikul, 2008),

travellers’ motivations to visit any particular destination begin when they become aware of

certain needs and perceive that certain destinations may be able to satisfy those needs. Thus,

the investigation of pull factors in Thailand’s medical tourism context is important in

developing a successful marketing program.

Consumer behaviour and decision making

Following Bourdieu’s (1990, as cited in Dressler, 2007) idea of medical anthropology, which

draws on the disciplines of medicine, anthropology and history (Comelles, 2002), to

understand human behaviour, requires the analysis of the intersection of social structure and

cultural construction. Understanding human behaviour in general, and human health seeking

behaviour - the intrinsically motivated behaviour (Deci, 1975, as cited in Deci, 1978) - in

6 Tourism motivation has been defined by several tourism scholars as “a meaningful state of mind which

adequately disposes an actor or group of actors to travel, and which is subsequently interpretable by others as a

valid explanation for such a decision” (Dann, 1981: 211); “a dynamic process of internal psychological factors

(needs and wants) that generate a state of tension or disequilibrium within individuals” (Crompton and McKay,

1997: 427). Crompton and McKay’s definition reflects Murray’s (1938) psychological needs as deep-seated

driving factors of motivation.

particular, thus requires the exploration of how shared cultural constructs, known as cultural

consonance in behaviour, meet social structure. As Comelles (2002) contends, it is impossible

to study health seeking behaviours without taking account of the long development of

healthcare providers which have delivered care services from the late Middle Ages to the end

of the 20 th century and cultural context.

Due to the different pattern of previous and new healthcare consumers, a consumer influence

has reflected into different levels (Hjertqvist, 2002). Previously, the healthcare provider was

not designed to serve a real consumer influence. Similarly later, in the welfare state, the

patients’ specific demands could not be fully responded as need, not demand consideration,

was the key to the healthcare provision. Western healthcare consumers today, however, seek

to influence the organisation of the healthcare system and the services provided. Apart from

being used to making complex decisions, Western healthcare consumers are also provided

with greater access to various means of information sources which they require to create

satisfying information in order to compare the providers’ quality and choices among those

offered (Borgenhammar, 1997, as cited in Hjertqvist, 2002). Freedom of choice and the use of

healthcare facilities in many countries are predominant in the current healthcare consumer’s

framework when they can benefit from shorter waiting times and better quality services.

Hence, this kind of framework promotes the development of healthcare provision both

regionally and globally. As commented by Hjertqvist (2002), the more consumers supported

by public or insurance funding cross borders, the more pressure that is exerted on providers to

offer competitive price information. Herzlinger (1997, as cited in Belien, 2000) agrees that, in

order to achieve patient empowerment or consumer-oriented healthcare, competition in

healthcare services as well as an unrestricted supply of these services, both of which create an

expansion and differentiation of services and make prices decrease, are required (Herzlinger,

1997, as cited in Belien, 2000).

Consumer/Patient Choice

Identity: patient, consumer, citizen

Patients, according to Hogg (1999: 6), are ‘people with particular health problems who may be

taking medicines or receiving treatment’. As Edwards and Elwyn (2001) point out, the term

‘patient’ tends to describe associated images of stereotypical patient with passive role seeking

and following physician advice. ‘Consumer’, on the other hand, depicts those who seek

healthcare in active role and perhaps making their own decisions and having the ability of

exercise choice. Contemporary thinking in the healthcare arena leads health professionals to

view patients as consumers.

As the role of market raises the significant issue of identity, in terms of healthcare market, the

identity of health service users is considered whether they are patients receiving services

passively, consumers shaping and controlling the receipt of services, or citizens utilising their

rights to free healthcare (Milewa, 2009). Therefore, it is essential to explore how health

service users have engaged with these identities, i.e. patient, consumer, citizen as these words

can be differently conceptualised due to different healthcare systems and the role of those

receiving healthcare, and how they are considered in terms of individual consumer (individual

identity) and independent collective mobilisations (collective identity).

Generally, the consumer’s decision to purchase a particular service involves many more risk

considerations than purchasing a product. This is because heathcare service provision is

different from other areas of economic activity, products or services due to the prevalence of

irregular, uncertain and unpredictable demand and supply in healthcare (Arrow, 1963). As

highlighted by Folland et al (2001), consumers are uncertain of their health status and need for

healthcare in any particular time. There is additionally a product uncertainty associated with

the health context as consumers may not know the expected outcomes of treatments without

their physicians’ advice. This is supported by what Arrow (1963: 302) suggests, ‘the patient is

forced to trust his physician, lacking the latter’s knowledge and experience; the customer

cannot test the product before using it; recovery from disease is as unpredictable as its

incidence; and entry into the field of healthcare is limited by professional and licensing

restrictions’. Consequently, these characteristics make the healthcare market difficult to

achieve when compared to other types of market.

In conclusion, healthcare is no longer defined by people receiving services when they are ill –

the stereotypical patient. Instead, the term ‘healthcare consumers’ engaging with healthcare

professionals as a formal equal have been used more widespread in the development in

healthcare phenomenon when mentioning people acquiring healthcare where traditionally

people sought and received healthcare in their own locality, and certainly within their own

country. However, healthcare consumers have recently challenged the healthcare seeking

patterns by travelling across country.

Consumerism in healthcare

Consumerist approaches can be categorised under the form of marketisation reforms. The idea

of consumerism was introduced in the 1980s by the British and American governments due to

its significance to people’s lives (Miles, 1998). In Britain, the ideology of consumerism

providing consumers with the rights and political citizenship is defined through charters (e.g.,

The Patient’s Charter, The Citizen’s Charter) rather than in terms of active domestic

participation. The marketisation of the welfare state represents a response to the growth of

individualism and rising consumer expectations about service delivery, which have led to calls

for more user involvement and greater consumer choice (Glendinning and Kemp, 2006). A

consumerist approach, according to Needham (2007), is possible to damage citizenship

gradually by making public services as commodities in the marketplace and putting people in

the situation of caveat emptor. Some commentators have argued that consumer-style

approaches to choice undermine the collective provision of welfare (Needham, 2003).

However, for others increasing choice is a way of ensuring that the welfare state can survive,

by making it more responsive to the needs and aspirations of those who use it (Glendinning

and Kemp, 2006). According to Cullum, Deputy Chief Executive of the National Consumer

Council (2004), it can be argued that a consumer-centred approach is important to the

development of public services as it does not concern turning the public sector into the private

sector or so-called privatization, or introducing market values onto public services. Instead, it

is the means to ensure that everybody has access to necessary services with as high standard as


Patient choice

According to Shackley and Ryan (1994), the main barrier to consumer sovereignty in

healthcare is the asymmetry of information between buyers and sellers. The nature of

healthcare is that providers of healthcare have a large informational advantage over

consumers. The existence of informational asymmetry between buyers and sellers is common

in other markets as well. In general, sellers know more about a product than buyers, e.g.

sellers will be better informed than consumers regarding the characteristics of a product and

the technology that was used to produce it. Yet this does not prevent consumers from freely

exercising their own preferences in making their consumption choices regarding the product.

The essential difference between healthcare and other commodities is that for other

commodities the consumer is more aware than the seller of what these products’

characteristics mean to him/her. They know their own needs.

The situation in healthcare, on the other hand, is quite different. The acquisition of information

is costly in terms of time and resources. There is little opportunity for consumers to learn by

experience as they will be infrequent users of the market. Doctors, on the other hand, use the

market regularly. In many instances consumers will be unaware that they actually need

healthcare, e.g. women in the early stages of breast cancer, therefore the consumer may no

longer be deemed to be the best judge of his/her own interests. Because of the complex

relationship between healthcare (which consumers do not value per se, i.e. individuals derive

no direct utility from consuming healthcare, rather healthcare is consumed in the expectation

that health status will be improved as a result) and health status, the consumer becomes very

reliant upon the much better informed provider to make the link between the consumption of

healthcare and the resultant effects on health status. Hence, there is a special relevance of the

agency (doctor-patient) relationship in healthcare.

Patients want to be treated as consumers of healthcare in the sense that they want better

information about treatment options and to be more involved in making the decision as to

which option to follow. How far patients behave as consumers depends on the severity of their

illness, the nature of the procedure involved and their individual circumstances. Most severely

ill patients face complex treatment options and many prefer decisions to be made on their

behalf by a well-informed and trusted health professional. On the other hand, they may not

want to be treated as consumers as the nature of healthcare product and service, which is

unpredictable, does not support the role of being a consumer.

However, as suggested by Appleby, Harrison and Devlin (2003), choice is not always

advantageous as it should be counterbalanced by the costs of creating it. Choice for some may

limit and impact on the choice of others. Tritter et al (2010) agree with this as greater choice

may, in fact, even add to a further health inquality burden. In summing up, choice seems

structurally associated with enhanced marketisation of healthcare provision and the arena of

the consumer tends to be based on the economic rationality of maximising personal benefits

within market-based systems. However, evidence about what is driving patients’ choices in

reality is currently limited.

In conclusion, the conceptual frameworks of push-pull, consumer behaviour, consumer choice

and consumerism in healthcare are proposed due to several important factors. According to

Snepenger et al. (2006), the push-pull theory has prevailed over other paradigms in examining

motivations underlying tourist and visitation behaviour (Dann, 1977, 1981; Crompton, 1979),

attracting most attention from several scholars (e.g. Dann, 1977, 1981; Crompton, 1979;

Klenosky, 2002; Kim et al., 2003; Kao, Patterson, Scott and Li, 2008). Due to its theory

having been used much in travel motivation research, this provides a better opportunity to

compare and contrast findings with previous studies. Consumer behaviour literature identifies

the interrelationship between needs and motivations (Goodall, 1988; Witt and Wright, 1992)

as the presence of the former constructs the latter. In other words, people’s needs for

healthcare create their motivations in searching for it. The examination of differences of

motivations between sample populations representing different cultures is important in

understanding tourists’ behaviour (Kim, 1999, as cited in Kozak, 2002). Different cultural

conditionings and different healthcare and insurance system of healthcare consumers will

influence their expectations and perception. As a result, the investigation of health seeking

behaviours and motivations of medical tourists having different cultural and social

ackgrounds is expected to accomplish in this study as they are likely to have different

motivations and perceptions in seeking healthcare services

Aims of the Study

The present research project aims to explore the reasons why consumers from major Western

countries where English is the main language travel to Thailand for their medical treatment.

The research will investigate the motivations of potential medical tourists, differences in these

motivations among different groups both from the same and different countries,

interrelationships among these motivations, consumer choices in selecting a particular

treatment in Thailand over other medical tourism destinations, and the degree of tourism

participation of those medical tourists.

Research Questions

What are the significant motives that influence the decision of medical tourists from the US

and the UK to travel to Thailand, and to Bangkok Pattaya Hospital in particular?

How are these motives different with respect to age, nationality and gender?

How does Bangkok Pattaya Hospital perceive the consumer motivation from these countries?

To what extent does Bangkok Pattaya Hospital applied perceived consumer motivation to

service provision for medical tourists? How is a healthcare provider’s service provision

related to what motivates medical tourists to visit the hospital?

What are the major keys influencing consumer choices about provider and destination? Why

does a medical tourist choose one destination over another?

To what extent do medical tourists take tourism component as a part in their decision making


Is medical tourism in Thailand about tourism? Is medical tourism likely to

utilise the tourism component?

What is it about the tourist part of medical tourism?

To what extent do medical tourists participate in tourism?

Research Rationale and Methodology

This research will consist of three stages of data collection: exploratory study (observations

and small interviews with patients in a first visit to hospital), designing the questionnaire, and

the main study (a second visit to hospital).

Rationale for selection of hospital

Bangkok Pattaya Hospital (BPH) was chosen as the study site for two principal reasons.

Firstly, it met the following parameters: segmenting foreigners as a major target market;

providing internationally standardised quality of hospital, medical treatment, facilities and

infrastructure, and management personnel to the foreign patients. Secondly, BPH’s major

target market is not expatriates only but also medical tourists both in contact with the hospital

directly and via the agents in their home countries. The major target market is medical tourists

from major Western countries such as Western Europe (e.g. UK) and US; Arabic countries

such as UAE and Oman; and Australia and New Zealand. It was thus felt that with the

resources available to the researcher, a study uncovering consumer motivation and a

healthcare provider response could adequately be tackled at this hospital.

Participant selection

Due to the researcher’s limitation of time and funding, only the medical tourist participants

from major Western countries where English is the main language, i.e. the UK and the US are

chosen as the research target. Although expatriates 7 represent a high proportion in the foreign

patient market share in private hospitals generally, they are not selected here simply because

they do not travel to Thailand for medical care and are not representative sample of actual

medical tourists. The countries mentioned are selected since they represent a significant group

of total medical tourists. Approximately 150 patients, or about 75 patients from each country

will be sought for the questionnaire study to generate a representative sample as equally as

possible in terms of nationality and gender. These countries additionally provide a

comparative study of two different continents in terms of cross-cultural study with similar

Western background in order to compare their motivations for visiting a Thai private hospital.

Questionnaire survey

Interviews with medical tourists

Piloting the questions for interview

The piloting of all the questions for actual interview with medical tourists will be first carried

out by semi-structured interviews, elaborating in-depth response, in the UK with

approximately 5 British people who have visited Thailand for some kind of medical treatment.

As supported by what Gillham (2007) mention, a proper pilot study is a reproduction of the

main study involving fewer participants who possess the same characteristics as the final

target group.

Exploratory interviews

After the piloting, the first visit to BPH will take place with about 20 patients- 10 from the UK

and 10 from the US - who will be interviewed in a semi-structured format with open-ended

questions, such as ‘what motivated you to travel to Thailand for medical care?’ As suggested

by Gillham (2007), careful semi-structured interviewing before the questionnaire being

constructed can help identify the most of the likely answers. The most frequent keywords of

travel motivations from the medical tourists’ answers will be incorporated into the


Main questionnaire study

The researcher will inform the hospital during the first study visit of the requirement to survey

150 medical tourists using the quota sampling from two different countries visiting BPH. This

sampling is proposed here because it is aimed as far as possible to include an equal proportion

of participants from two different countries and from both genders (nationality and gender

distribution) in order to address a representative sample. Medical tourists from each

nationality will be approached until quotas are filled, in other words until there are at least 75

medical tourists from each individual nationality.

7 Foreigners resident in Thailand

Understanding mature traveller’s demand and choice in spring destination

Mei-ting (Jessica) Hsieh

Lecturer, Taiwan Hospitality and Tourism College

PhD candidate, University of Lincoln, U.K.


The ageing population in Taiwan is entering 11% who were 65 years old and above by 2009.

This percentage is likely to reach 20% by 2025 and 39% in 2051. Not surprisingly, after 2010

the emerging age cohort categories of 55 starting to reach retirement, and will continue to

increase in Taiwan. Mature people undoubted have much free time from working careers and

start to concern the long-term health status. This study examines how the Taiwanese mature

spring/spa travellers’ needs affect the travel motivation to choose spring destination and what

extent demand for the particular groups in springs. 200 valid responses to the questionnaire

carried out in spring destinations of Taiwan. The factor analysis of motivation factors

revealed three underlying spring/spa destination attributes and four socio-psychological

underlying dimensions. The main spring/spa travel motivations of Taiwanese were ‘Personal

health & building relationship’and ‘commercial Internal’; which appeared to be the most

important push and pull motivations, respectively. The study also suggests that there is a

significant relationship between travel motivation and age groups effect on destination choice.

Based on the results, the findings will point out spring/spa marketing implications in

conjunction with the theoretical framework, and add to other relevant organisation.

Key words: Mature traveller, Destination choice, Spring/spa tourism, Taiwan


With rapid growth in an ageing population, baby boomers comprise a large proportion of the

world travel market. The emerging age cohort categories of 55 starting to reach retirement,

and will continue to increase in Taiwan. Mature people undoubted approach an advanced life

cycle stage (e.g. the retirement stage) and are free from working careers. Nowadays, they are

likely to have sufficient savings, ample time, more motivation to enjoy, spend more freely on

activities and concentrated on personal health. Particularly in the health tourism industry, the

marketer have started to focus differentiate segmentation on the mature groups (Silvers, 1997;

Mochis, 1997). The growth of hot spring tourism since 1900s is well-known in Taiwan

society. Spring tourism in travel market of Taiwan has been acknowledged for century as

different type of natural springs has its own specific medicinal cures for improving people’s

health. In 1999, due to the Taiwanese government’s promotional spring/spa activities, visitors

are increasingly seeking a healthier lifestyle to maintain their wellness. The spring and spa

tourism would seem that become one of the pioneer “value sectors” during the modernisation

process in Taiwan. A number of re-birth spring/spa destinations increased extremely, this

potential attraction draw people to visit spring/spa destination through diverse products.

Moreover, it also tapped the potential of a rapidly expanding market, which includes sectors

such as healthcare services and the medical wellness industry.

People travelling for health in spring/spa resorts and destinations become an attraction

phenomenon for prevention on people’s health. The broad reasons for participating in

spring/spa travel nowadays are not only on socialise, improve well-being, and physical

therapy. New senses people went to the spring/spa in a quest of spiritual events and develop a

healthy lifestyle. Hence, to develop tailor facilities product and service to meet particular

groups’ needs, and upgrading the quality of spa destination are as an important for market

segmentation. Research has paid limited attention to the mature travellers studied, or the

mode of spring/spa destination choice. It is vital to be aware that mature traveller needs are

more diverse and multifaceted than ever, and this highlights the need for innovation to meet

the demand for a variety of recreational activities.

Characteristics of mature spring traveller

According to the Taiwan Tourism Bureau (2004), the Central Geological (2002) survey that

Taiwan has over 128 nature spring destinations located in different geological areas including

plains, mountains, valleys, and oceans. It has been identified different type of springs (i.e. s

hot springs, cold springs, mud springs, and seabed springs) with different destination

attributes based on the water temperature, geology, chemistry, and mechanism.

As spring have multi functions for curative effects and medical benefits of soaking. It has

gained popularity for people to ‘taking the water’ in the natural spring/spa destination,

particularly for aged people and patients. Travelling for mineral spring therefore has become

one of most representative recreational activity in Taiwan. (Hsieh et al., 2007). This vogue

beneficial effects relevant industry growing well not only for health tourism industry but also

for medical treatments, social insurance system, and national economy. The majority of

health spa tourism in Taiwan is domestic tourism, the total number of visitors increased from

approximately 4 million in the 2002s to 15 million people (23%) to visit hot springs for

experience their therapeutic techniques and leisure activities purposes, compare with inbound

demand only 17% for hot spring tourism (Taiwan Tourism Bureau, 2004). Nowadays, people

traveling for health in spa resorts and destinations as an attraction phenomenon. Particularly

the new health spring/spa revive health tourism market, the features and potential attraction

draws people to visit particular destination.

The emerging health and spa tourism is blooming in Taiwan since the government carried out

the ‘Taiwan hot spring tourism year’ by 1999. Following the Taiwan Tourism Bureau was

allied springs festival to revive the health spring/spa industry, it is not surprising to see or hear

that the reason travel for desirable health spring/spa destination in the mass medium. It

indicates the health spring/spa tourism is not only as an important curative activity for

domestic tourists but interests overseas tourists. With this potential growth health spring/spa

market, the further developments of health tourism are crucial to the Taiwan tourism industry.

With the society transformations, a number of sociologists recognised the phenomenon of

leisure activities may create a new lifestyle to good and reenergised for mature travellers. As

different value orientation on new aged have different needs in terms of attitudes and quality

of leisure. Thus, it is possibly different approaches on the ways to travel and time to spend.

Norman et al. (2001) refers to mature market as a complex phenomenon in which of

interaction on the biological, psychological, historical and social factors. It is means that

characteristics of mature traveller are response to various activities in particular the new-age

of baby boomers entry mature travel market. As people in the modern time have more

opportunities to arrange their working hours and leisure time, in addition, life expectancy

continue to rise, it impel many people doing more physical health activities during their lives.

Health spring/spa tourism products are dependent on natural resources such as mineral water

and seaside location. Although, the broad reasons for participating in spring/spa travel are to

socialise, improve well-being, and physical therapy, the new sense in a quest of health is

spiritual events and travel for the purpose of mineral cures. Research has paid limited

attention to the mature travellers studied, or the mode of spring/spa choice. It is vital to be

aware that mature traveller needs are more diverse and multifaceted than ever, and this

highlights the need for innovation to meet the demand for a variety of recreational activities.


Study Design

The aim of research methodology was undertaken survey of mature spring/spa travellers

visiting natural springs of Taiwan. Besides, the study designed to extend the theoretical

framework for Taiwanese mature spring/spa traveller. This design was chosen because it

provides a highly accurate picture of the phenomenon under study. Questionnaire was

developed based on relevant literature review, conversations with mature spa/springtravellers,

and amendatory pilot survey. The questionnaire considered what information

would be essential related to the respondents’ needs of destination attributes in spring/spa.

Structured questions were used to gather information on natural spring/spa attributes and

socio-demographic. The sample was randomly selected from spring/spa travelers, who had an

interest in staying and visiting spring/spa destinations for particular purposes such as health,

activities, or being in a nature-based environment. The empirical evidence for the relationship

between motivation and destination choice is investigated in order to see what those factors

may mean for particular spring/spa groups, government policy reform, and market



Data for this research were collected from 33 spring/spa destinations with 15 different

geology natural springs and on cold spring region in Taiwan. The data collection phase was

conducted over a period of seven months beginning in October of 2007 and finishing in April

2008. The questions on the destination attributes are based on using internal and external

forces to represent intrinsic and extrinsic factors. It contains the real reason for visit,

companions, and geographical characteristics in the health spring/spa destination. 285 mature

spring/spa travellers were invited to fill in the questionnaire at destinations after they had

visited or stayed in the spring/spa. Analysis of numerical data was followed by data entry of

200 valid responses.

Accordingly, the statistical method of analysis was summaries of the broad category of

descriptive statistics to describe mature spring/spa traveller’s characteristics related to

motivation, and how destination feature in spring/spa tourism experiences. Following the

study used exploratory factor approach as an analysis technique to explain traveller

motivations and to explore if there are differences between demographics and destination

choice. A principal component factor analysis was used to examine the importance of push

and pull motivation factors within the spring/spa travel groups; and if there were differences

in terms of destination attributes. Subsequently, the analysis proceeded to investigate if there

is a significant difference in socio-psychological characteristics and demographic variables

that influence mature spring/spa travellers’ to a certain destination. Variables consist of

demographic traits, trip purpose, characteristics of trip, and socio-psychological factors.

Factor analysis of motivation factors revealed three underlying spring/spa destination

attributes: commercial internal, commercial external, and natural & friendly service.

ANOVA analysis revealed that the main effects of age groups effect on destination choice are


The study proceeds to find whether variations in these factors have an effect on the choice of

Taiwanese mature travellers as measured in the study. The findings will point out spring/spa

marketing implications in conjunction with the theoretical framework, will add to knowledge

of the practical spring/spa market and will highlight methodological concerns in further


Data analysis and discussion

A principal component factor analysis was used to investigate the importance push-and-pull

factors within the Taiwanese mature travel groups, the underlying motivations of travellers,

and the differences in terms of destination attributes. Independent samples T-test was used to

compare the difference between the means of two groups, such as the mean push factors of

male and female travellers in spring destination or if there are any significant differences

between two means according to the demographic characteristics.

Demographic Profile

A summary of the demographic characteristics examined is show below in Table 1. The

sample was composed of the 200 mature traveller respondents from health spring/spa

destinations. It shows that 61.5% of respondents were males 38.5% were females. The

majority of the mature travellers to spring/spa were male, compared with younger group in

which over half of younger respondents were female. 42.5% of respondents were aged

between 50 and 54, only 27.5% were over 60 years old with a mean of 57.1. The majority of

population in Taiwan was young age group (15-45), while 73.3% mature group (45-65) and a

minority (nearly 11%) aged 65 and above.

Overall the sample of Taiwanese spring/spa mature travellers was less highly educated with

college or university degree. 34.5% of respondents present that they are retired and others

state their occupation as business owner. The similarity to white-collar worker (31.5%) was

the most common occupation from respondents.

When considering aspects of individual health status, most Taiwanese mature travellers

generally replied that they perceived their own health to be good (50%) or excellent (15.5%).

Only 3% of mature travellers feel they have some health problems, and 6.5% of them feel that

they have poor health (either in physical or mental health in their daily living, including

disease, impairment, disability, and handicap).

Table 1 Travellers’ demographic profile (N = 200)

Mature travellers


Frequency (%)


Female 77 (38.5)

Male 123(61.5)


Under college 130 (65)

College above 68 (34)


Under NT$10,000 28 (14)

NT$10,001-NT$20,000 26 (13)

NT$20,001-NT$30,000 38 (19)

NT$30,001-NT$40,000 42 (21)

NT$40,001-NT$50,000 28 (14)

NT$50,001 and over 37 (18.5)


Bad 6 (3)

Poor 13 (6.5)

Fair 50 (25)

Good 100 (50)

Excellent 31 (15.5)


Blue-collar worker 47 (23.5)

White-collar worker 63 (31.5)

Professional 21 (10.5)

Retired and Others 69 (34.5)

Travel Behaviour

The result in travel behaviour shows nearly 77% of respondents indicate that they tend to a

visit spring/spa destination more than once each year, whereas the remainders visit spring/spa

destinations only annually. The vast majority of respondents (about 77%) have visited

spring/spa destinations more than once before, whereas the rest have visited spring/spa

destinations for the first time. This result indicates that Taiwanese mature travellers have

experience in purchasing spring/spa products.

The majority of respondents indicated that they usually make visit to spring/spa destinations

or stay only one night in these destinations. This suggests that mature travellers in Taiwan

generally stay for a very short time at spring/spa destinations. Nearly half of respondents

reported that they have visited natural spring/spa destinations for curative purposes.

In visiting group, more than half of the respondents (60%) were travelling with family as the

primary party, and about 30% visited spring/spa with friends and colleagues. The social

change in Taiwan increased opportunities for target marketing based on different family life

cycle stages, for example, increased economic status and leisure time combined with shorter

working hours in modern life. The notion of travelling with family members was the most

commonly reported motivation. Regarding the spending at sparing/spa destination variables

present more than 50% of respondents that they spend less than NT$10,000 (less than £200)

on spring and spa products each year whereas the remaining 39% of mature and 17% of

younger travellers spend NT$10,000-$40,000 on spring and spa products each year.

Travel motivations

Factor analysis was performed to identify the underlying dimension of travel motivations in

this study. These include 24 push and 19 pull motivation variables were initially chosen to be

factor analysed. Using the PCFA orthogonal varimax rotation was performed to reduce the

push items and pull items of Taiwanese mature spring/spa travellers’ motivations into specific

underlying constructs. In addition, by using the statistical technique is to determine the linear

combinations of motivation variables and investigate the interrelationships between. Items

were dropped from further analysis while low correlations with the overall score of the


The first step of PCFA was examining if the inter-correlation among the variables meet the

similarity variables. Followed, the latent root criterion factors were extracted only eigenvalue

greater than one. As the rules of principal components with higher variance than the

standardised original variables should be extracted. The extracted factor communality loading

greater than 0.50 was valid to include items in a factor. Regarding the reliability and validity

of factors was measured by Chronbach’s Alpha, it was calculated for each of identified

dimensions to test the internal consistencies and reliability of each specific dimension.

The PCFA technique came up with three underlying spring/spa destination attributes:

commercial Internal, commercial external, and nature & friendly services. Four underlying

push motivation factors were ‘personal health & building relationship’, ‘education &

learning’, ‘feeling good’, ‘arranged treatment’. The main distinguishing of motivation

dimensions were the ‘personal health & building relationship’ and ‘commercial external’,

which appeared has a significant differences regard to the age groups.

The results of this study suggest that at least four main motivation dimensions benefit

spring/spa tourism exist in Taiwan. In addition, it appears that mature travellers are looking

for different products and services of benefits in order to meet their needs. These imply that

the marketing segmentation should be clearly identified. Those information can be use to

guide decisions related to marketing strategies development, quality of spring/spa

environment, or social responsibility expansion.

Conclusions and implications

The mineral springs tourism is much different and beginning to change in Taiwan society.

People visit spring or spa destination can be relaxation or for curative with alternative

therapies purposes. In the new emerging spring and spa marketer start conscious that the

opportunities of the market segments; and promote different packages and services in order to

attract health travellers. One of the most important for marketing strategies is the need for a

clear of the wellness concept from the therapeutic. The findings will point out health

spring/spa marketing implications in conjunction with the theoretical framework, will add to

knowledge of the practical mature travel group, will help make improvements to government

policy, and will work towards the methodological concerns in the further research. To have a

leading edge in the competitive health tourism, spring/spa marketers need to keep in mind that

the changeable motivaions and trends for understand different spring or spa travellers’ needs.

The further recommendations are aimed in the spring/spa tourism market:

• To distinguish spring and spa travellers from spiritual and rehabilitation

• Manage the high level of qualifed staff with further training in treatment skills

• Establish good relationship and cooperate with policy makers

• Explore suitable wellness programmes to meet different group needs


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Holloway, J. C. (2004). Marketing for Tourism (fourth ed.). Essex: Prentice Hall.

Hsieh, L. F., Lin, L. H., & Lin, Y. Y. (2007). A service quality measurement architecture for

hot spring hotels in Taiwan. Tourism Management, May.

Norman, W. C., Daniels, M. J., McGuire, F., & Norman, C. A. (2001). Whither the mature

market: An Empirical Examination of the travel motivations of Neo-Mature and Veteran-

Mature Markets. Journal of Hospitality & Leisure Marketing, 8(3/4), 113-130.

Natural wellness - Health and wellness as nature-based tourism product

Edward H. Huijbens

Director,Icelandic Tourism Research Centre


This paper is set in the context of a two year research project funded by the Nordic Innovation

Centre (NICe), dealing with Nordic wellness and wellbeing. The researchers of the project

collaborate with budding health and wellness destinations, one in each of the Nordic countries

in order to establish a Nordic wellness concept and develop user-drive product improvements.

This paper deals specifically with the Icelandic case being studied under the terms of the

project and will combine nature-based tourism with that of health and wellness. Nature-based

tourism is by far the most prominent form of tourism in Iceland. Albeit vaguely defined it

entails tourism in natural settings, tourism focusing on elements of the natural environment

and tourism developed to conserve or protect natural environments. This paper looks at a

development of a geo-thermal spa, much like the Blue Lagoon, but in the NE corner of

Iceland near Lake Mývatn, a famed nature-based tourism destination in Iceland. The current

spa facility was erected in 2004. It builds on a long history of locals using the thermal waters

and steam coming from the ground for wellbeing, and is gaining steadily in visitor number per

annum. Emerging from research amongst stakeholders involved in the building up of the

Mývatn Nature Baths in NE Iceland was the role nature plays in health and wellness. Both as

a fundamental concept of being in nature and/or at one with nature, and more specifically

through health and wellness related activities in a natural setting. The paper will explore some

of the tentative product manifestations and ideas of these emerging themes and their

implications for product development in health and wellness tourism for NE Iceland.

Budapest’s thermal spas on screen

Anna Irimiás

Associate Professor, Kodolányi János University of Applied Sciences, Tourism Department.


The phenomenon of film-induced tourism has been well-documented in a number of locations

world-wide. Feature films have become one of the most powerful tourism marketing tools

offering an alternative selling method for destinations. Budapest’s famous thermal spas

several times hosted international film productions, such as Red Heat (1988) with Arnold

Schwarzenegger and I, Spy (2002) with Eddie Murphy and Owen Wilson. The Hungarian

capital, well-known for its health tourism, but not for film-tourism, is clearly identified in

these movies as a city of spas. The types of attracting qualities are as diverse as the films in

which they reside. Usually viewers attach an icon to the location they have seen in a film,

therefore locations which carry an emotional charge can easily be identified. Swimming pools

used by the Hungarian national water polo team are strongly linked to national identity. The

primary sites for the CCCP-Hungary, so called ‘blood in the water match’ in The Children of

Glory (2006) were swimming pools used by the Hungarian athletes (BVSC on Szőnyi street

and Alfréd Hajós).

In film-induced tourism literature much emphasis has been given to the significance of films

and locations in terms of its economic generation and on the motivations of visitors

(Provenzano 2008; Beeton 2005; Riley-Baker-Van Doren 1998; Toke-Baker 1996), or

recently a growing interest exists in the study of the impact of successful television

programmes on local enterprises (Connell-Meyer 2009; Irimiás 2008; Messina-Bocchioli

2008; Connell 2005). There, however, appears to be very little research on the films’ impact

on a different tourism product, like health and wellness tourism, and the role of a successful

movie production in reinforcing the image of the spa and the location.

The aim of this paper is to analyse the relationship between film-induced tourism and health

tourism and to elaborate a model of a possible collaboration. The research is based on a

questionnaire survey carried out in 2009 among foreign tourists staying in Budapest (the

collected data was analysed with SPSS), and on semi-structural interviews with Hungarian


Keywords: film-induced tourism, destination image, Budapest, spas.


Films provide the objects and subjects for the gaze of many people, and movies may induce

them to travel to the location where the film was set (Riley-Baker-Van Doren 1998). Image is

central to marketing, even more so in tourism destination marketing, which promotes an

intangible product. Destination imaging is multi-dimensional, comprising both symbolic and

tangible features (Beeton 2005). Image influences tourism related attitudes and it affects the

individual’s perception and consequent behaviour (Gallarza-Saura-Calderòn Garcìa 2001).

Moreover, image has long been considered as a primary decision-making factor in holiday

travel. The importance of tourism destination image has been widely studied and the image

has emerged as a crucial marketing concept in the tourism industry (Hall 1999).

Visual culture may influence many aspects of everyday life and the effect of film on human

behaviour has long been debated mainly in psychological and sociological studies. In some

feature films the development of a country’s identity, image and cultural representations can

be traced through popular film and television series. The Lord of the Rings saga and its impact

on New Zealand’s tourism is one of the best examples of film-induced tourism (Buchmann-

Moore-Fisher 2010; Corl-Kindon-Smith 2007).

Tourism images are developed from the stories of returning travellers as well as the media of

the day. In a wider sense, news coverage and popular culture (as in films, television programs,

and literature) can provide substantial information about a place in a short period of time.

Additionally, while watching a film, people usually are more open to all the information

because they do not feel to be targeted for selling promotion compared to traditional

advertising. Further, news and popular culture products are so deeply embedded in every day

life that they are likely to have high market penetration. Thus, portrayals of places in news

and popular culture can alter an area’s image significantly, even in a short period of time.

Motion pictures are an important element of popular culture. They may impact on many

people and few would deny that movie-going and television watching are the major leisure

activities in the Western world. Usually popular films dominate the movies for a relatively

short period, however, the impact of popular films on individual and societal beliefs and

behaviours will continue to increase as cable television, DVD use, and internet downloads

diffuse rapidly. A film may create and prolong interest in a destination. According to Butler

(1990) what is shown in movies, videos, and television will become even more important than

print media in shaping images of, and visitation to, places, due to expanding accessibility and

high credibility of these information sources. It can be affirmed that contemporary tourists

organic images of places are shaped through the consumption of film and television series

without the perceived bias of promotional material. Recognising that movies can enhance

awareness of places and affect decision-making processes, marketers are increasingly working

with film producers to promote their destinations as possible film locations (Beeton 2005;

Seaton and Hay 1998).

Tourism holds an important position in the substantial political, economic and social

restructuring processes which have taken place in Central and Eastern Europe (CEE) in the

past two decades. The ‘re’-imaging of the region faces different challenges and niche tourism

products need to be developed and marketed in response to the changing nature of tourism

demand. Similarly, CEE cities like Budapest in order to enhance their role as tourism

destinations are trying to create new and unique experiences for visitors (Rátz-Smith-

Michalkó 2008). Brand identities are based on culturally distinctive features and new tourism

trends like film-induced tourism may have a key role.

This paper is concerned with the process of image formation related to film tourism. In the

focus of the research the analysis of Budapest’s identity on feature films can be placed, with

special attention on spas and baths. The featuring of spa locations in the Hungarian and

international film productions may offer different aspects of health and wellness tourism

image formation and a co-operation between film commissions and the Hungarian tourism

authorities would be auspicious.

Budapest as film location

The power of film to motivate travellers, create new images, alter negative images, strengthen

weak images, and create and place icons is recognised by many as a major factor in tourism

promotion (Beeton 2005).

Films familiarise audiences with places and attractions featured in them. Riley and Van Doren

stated that ‘Extended exposure to attractions through the medium of film allows potential

tourists to gather information and vicarious knowledge, therefore lowering the anxiety levels

caused by anticipated risk’ (1992:269). Thus, it is proposed that observing a movie can

increase the degree of familiarity with the places it portrays.

That is, the popular view of a place offered by media may prompt that place to recreate its

own identity in this image. This recreation of place identity implicates different levels of

culture, and language, including the visual language of television, films, and other mass

media. This implication provides representations that produce meanings which may reinforce

place identity. These meanings regulate social practices, influence people’s behaviour, and

consequently might have real practical effects. In particular, movies, as visual language, have

been one of the major vehicles to construct and transmit meaning, often of places with which

people do not have first hand experience.

The Hungarian capital has recently became ‘film friendly’ with a number of film commissions

and film offices working on the promotion of the city as an ideal film location. Korda Studios

established in the nearby of Budapest offers a wide range of film locations that might be

attractive to film producers. Macionis (2004) discovered the international exposure a film can

provide a destination; a film is an advertisement potentially viewed by millions of people who

may be tempted to become film induced tourists.

Films are often not shot at the locations they purport to be, however benefits of film-induced

tourism can be traced only if the viewers can clearly identify the film location with the

destination they are interested to visit. Moreover, considering the issues of cultural identity of

a place and its role on films it seems to be clear that a film can reinforce the country’s identity

if they are interrelated.

Natural landscape or atmosphere can be featured as backgrounds in a film, however the

storyline and the characters add some emotional charge to places. This interrelationship of

cognitive and affective image components eventually determines the predisposition for

visiting a destination.

Research hypothesis and study methods

Based on the conceptual framework described in this study, two hypotheses were considered:

Ha 1: The perceived destination image of Budapest will be reinforced through the films set


Ha 2: Budapest identity as a city of spas will be reconfirmed through the films

The study was conducted using bilingual (English and Italian) questionnaires among foreign

tourists staying in Budapest. The research was carried out in March-April 2009 and 600

tourists were asked to fill in the questionnaire. Due to incomplete questionnaires a total of 67

were dropped out of the sample. Consequently, 533 usable responses were available at the end

of the research, meeting the criteria for statistical estimation for data analysis.

The questionnaire comprised 17 questions and classified the respondents by age, gender,

origin, first visit to Budapest, length of stay, whether they travelled independently or as part

of a package.

To measure the cognitive component of participants’ image of Budapest, 11 image attributes,

which were measured by five-point Likert type-scale, were included in the questionnaire.

These 11 items refer to historical attractions, atmosphere of the destination, and lifestyle of

local people. In order to measure the impact of films on Budapest tourism destination image, a

popular motion picture was defined as a film produced for the entertainment of the general

public employing plot and characters. A total of 38 film titles were selected to be included in

the questionnaire. The selection of the films was based on the film location, all the 38 was set

in Budapest, and the productions are Hungarian (17 films) and international (21 films) as


Tourists who were familiar with some of the film titles were asked to underline those films

which according to them, were set in the Hungarian capital city. They were also asked to

nominate those films that give a positive image of the city, as well as those that give a

negative image of the city in the film productions.


Budapest identity and its role in film tourism

Tourists’ perception of Budapest was measured by the 11 image attributes given in the

questionnaire. In a five-point Likert-type scale these image attributes were measured, and the

mean value 4.05 (n=533) clearly shows that those tourists who participated in the research

identify Budapest as a city of spas (Figure 1.). Budapest’s imposing baths such as Gellért Spa

Baths and Hotel on the Buda side, and Széchenyi Baths in the Pest side of the city are

considered to be the landmarks of the capital, as well as to be the leisure places preferred by


Figure 1 Perception of tourists on Budapest

Modern city

Religious city

City where is good to live

Multicultural city

Art city

Shopping city

City where is good to have holiday

Party city

Cultural city

Historical city

The city of spas












0 1 2 3 4 5

Source: data collected by the author (2009)

Usually viewers attach an icon to the location they have seen in a film, therefore locations

which carry an emotional charge can easily be identified. Swimming pools used by the

Hungarian national water polo team are strongly linked to national identity (Table 1.). The

Children of Glory (2006) Hungarian film production is a commemorative film about the

national revolution of 1956 against the Soviet ‘Empire’. The days of heroic fight and struggle

against the Soviet army on Budapest’s streets and in the major cities of Hungary coincide with

the world-famous water polo match played in the finals of the Melbourne Olympic Games. In

the film, the primary sites for the CCCP-Hungary, so called ‘blood in the water match’ were

located in swimming pools in Budapest used by the Hungarian athletes (BVSC on Szőnyi

Street and Alfréd Hajós). In certain types of place-oriented movies, viewers are offered the

opportunity to learn about the place by imaginatively participating in the place-related

experiences of the characters (Kim-Richardson 2003). These swimming pools, however not

considered as tourism attractions, may be identified as the spaces of national proud of

Hungarians and the icon attributed to the film (national proud) could be indentified as a

thematic icon. In The Children of Glory film the above mentioned water polo match against

the Soviet national team takes place in Melbourne, and the name of the athletes swimming

pools are not cited at all. The identification of the film location using the film icon related to

the place may induce film tourism only if the film viewers are aware of original place where

the film was actually set. In this case, it could be stated that The Children of Glory may not

generate any film tourism phenomenon in Budapest, however it reinforces the image of

Hungarians as heroic and proud people through a significant water polo match and film

viewers may have the opportunity to learn about the city from a different angle of view.

In the case of these two movies, Hypothesis 1 (The perceived destination image of Budapest

will be reinforced through the films set there) seems to be confirmed and film images could

be used to reinforce Budapest’s tourism destination image.

Table 1. Film icons in spa-located movie productions

Title of Film Spa-locations in



The Children of Glory 2006 BVSC Budapest National

polo team

proud, water-

Made in Hungária 2009 Csillaghegyi


Swimming Fun, youth

I, Spy 2002

In bed with the opposition 1997

Csontváry 1980

The Children of Glory 2006

Mrs Ratcliffe’s Revolution 2008

Gellért Spa Baths Aristocratic beauty, built


Hajós Alfréd Swimming National proud

The Double Life of Mrs. Mici 1962

Pool Complex

Lukács Thermal Baths Third-age love affair

Red Heat 1988 Rudas Thermal Baths Mystery

Just sex and nothing else 2005 Szécheny Spa Budapest Built heritage, human

Io e mia sorella 1987

Csontváry 1980


Source: data collection by the author 2009. Table structure based on Riley&Baker&Van

Doren (1998: 924)

Some icons, like built heritage and aristocratic beauty of the traditional spas in Budapest, can

be recurrent or continuing images within a film, highlighted by the strong marketing

communication based on these places as well. Other icons which may attract visitors can be

single exciting events (the water polo match) which viewers can identify with the space they

are interested to visit.

Film icons may not all be visual as they may be storyline themes or atmospheric background

for the plot that may become associated with locations. Example of visual icons is the

American production I, Spy starring Eddie Murphy where Gellért Spa Baths, along with the

Buda Castle district and the Chain Bridge over the Danube offer a powerful overview of the

riverside and an outstanding panorama of Budapest. Gellért Spa Baths is not featured as the

main spa and baths centre of Budapest, instead the location was used to host scenes in an

elegant and sophisticated environment. In this film, the name Budapest and the Gellért Spa

Baths are mentioned several times and film viewers may easily identify the locations.

Hungarian film productions, even if translated, have limited distribution within Europe and

even less overseas, on the contrary the I, Spy film has been broadcasted in the United States of

America and in numerous European countries as well. Major films may have more than one

icon that film tourist associate with locations. The physical icon has been illustrated above,

however a detailed research on the effects of the I, Spy film on Budapest, and even more

precise on Gellért Spa Baths still has to be done.

The above mentioned film productions are clearly linked to Hungarian culture, to Budapest

and to the spa traditions. However, in several feature films Budapest plays the role of another

European capital, and the identification process is accessible only to those who are keen to

search for the real location of the film or already has some knowledge of Budapest’s iconic

spas and baths. In the case of the Red Heat (1988) film starring Arnold Schwarzenegger,

Rudas Thermal Baths is featured in the opening scene of the film. Schwarzenegger plays the

role of a Soviet soldier searching for a cruel criminal within the spa. In a mysterious and

vaporized atmosphere created by suffused lights the film viewer is guided through different

parts of Rudas Spa, however the city plays the role of Moscow, the Russian capital.

The other case of Budapest missed identity is the example of Mrs Ratcliffe’s Revolution

(2008) in a recent film production, twenty years after the Red Heat. This comedy is about a

British family eager to move to East Germany during the years of the Cold War because they

believe in the ideal life on the Eastern side of the iron curtain. In Mrs Ratcliffe’s Revolution

Budapest plays the role of East Berlin, and mainly derelict areas of the city were used as a

film location. The Hajós Alfréd Swimming Pool is featured in the scene when Mrs Ratcliffe

tries to organise her family’s escape from ‘East Berlin’ and the only neutral place to discuss

such a crime is the swimming pool.

Budapest missing identity in several films when the Hungarian capital plays the role for

example of Buenos Aires (Evita), München (München), Moscow (Red Heat) or Berlin (Mrs

Ratcliffe’s Revolution) is evidenced also by the questionnaire research carried out among

tourist staying in Budapest. From the 38 film located in Budapest, only a few films were

linked to the Hungarian capital as the film’s location. The respondents could indentify

Budapest as the film location only in those films that can be clearly related to Hungarian

culture or history (like Sunshine, The Children of Glory, Fateless). This means that the other

films, even if successful movie productions, miss to contribute to Budapest promotion

through films because the featured sites, however being of national pride and the key tourist

attractions, for the general movie-goers can hardly be recognized and linked to Budapest.

In the second part of the questionnaire, respondents were asked to value on a scale from 1 to 4

six different statements, all related to film tourism in Budapest. In the questionnaire the

statements follow the 38 film set in Budapest in order to help association of Budapest as a

film location, and to make the participants remember the films they might have seen. The

mean value of the answers shows that those who participated in the research think the

Budapest’s thermal spas are well represented on films (2.15) and that it is interesting to know

which films were shot in Budapest (2.21). However, according to the mean value of the

answers it cannot be stated that films strongly influence tourism towards Budapest.

Table 2. The perception of Budapest as influenced by films

Item Scale Mean



The films set in Budapest contribute to the positive image of

the city.

1-4 2.25

I can know Budapest better through the films set there. 1-4 2.51

It is interesting to know which films were shot in Budapest. 1-4 2.21

A film can influence my choice of a travel destination. 1-4 2.42

If a movie map was available in my hotel, I would use it and

would visit the film locations.

1-4 2.42

I think that Budapest’s thermal spas are well represented on

films, and give a good impression about the city.

Scale: 1= Strongly Agree and 4 = Strongly Disagree.

1-4 2.15

According to the mean value of the answers given for the statements, it can be stated the

Hypothesis 2 (Budapest identity as a city of spas will be reconfirmed through the films)

cannot be reconfirmed, nevertheless several key attraction spas feature in different movies

located in Budapest. In the research it has been evidenced that Budapest’s missing identity,

her acting as other European cities, might cause some confusion in place identification.


Films have been, without a doubt a tourist inducing ingredient, turning destinations of little or

no importance into much visited tourist attractions. Even if not all films have such an effect,

nonetheless it cannot be disputed that films in general do affect the image of destination. For

that reason, it is important that a well-planned image management plan to be produced for

destinations. A tourist visiting a destination after seeing the location in a film or television

series is an emerging phenomenon and due to the momentous impacts, many films have had

their locations research into the issues relating to film induced tourism.

Film-induced tourism in Budapest is a new phenomenon and what has emerged from the

research is that tourist even if they are familiar with some films set in the Hungarian capital,

would not acknowledge a strong motivational influence on their decisional process when

selecting their holiday destination.

By understanding the film tourist phenomenon, tourism and film stakeholders can better meet

experiences, thus expanding on the positive impacts of such destinations. Tourism destination

marketing ideally requires cooperation and input from all the sectors of community –

businesses, interest groups and local inhabitants. During the planning of tourism development,

conscious destination strategies that aim to create positive images of the destinations and

imprint them in potential visitors’ imaginations are developed.

In Hungary health- and wellness tourism have become key tourism products and a strong

marketing strategy has been based on them, promoting the medical and treatment services,

leisure time in spas and baths. However, in the marketing strategy the powerful images shot in

different spa locations of Budapest are unfortunately missed out. As stated above, several

feature films, Hungarian and international productions as well, used Budapest’s flagship

attractions like Gellért Spa Baths, Széchenyi Spas or Rudas Spas as key film locations.

On screen Budapest’s spas carry a well-defined identity and emotional links to the location

may be recognised in some feature films. The meaning of a place reinforced in some movie

productions and the film-viewers familiarity with the place starring on screen could offer

unparalleled possibilities to enhance the marketing strategy based on different tourism

products. Film commissions in Budapest are already promoting and selling the unique places

of the Hungarian capital city to host films, but until now this promotion has not been linked to

tourism marketing. A possible collaboration between the film industry and the tourism

industry could reinforce Budapest’s cultural identity.


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Marion Joppe, PhD,

School of Hospitality and Tourism Management

University of Guelph, Guelph, Ontario



Hwan-Suk Chris Choi, PhD, Associate Professor

School of Hospitality and Tourism Management, Macdonald Stewart Hall, University of

Guelph, Guelph, Ontario, CANADA, N1G 2W1


Canada is a fairly recent newcomer to the world of spa tourism. According to a

PricewaterhouseCoopers study on the spa industry, undertaken on behalf of the International

Spa Association, between 1990 and 2001, the number of spa establishments in North America

went from 1400 to 10,900, of which 1300 were in Canada, and occupancy went from 40% to

an average between 70 and 80%. Instead of slowing things down, the events of September 11,

2001 actually spurred growth in this sector. By 2003, the International Spa Association

(ISPA) estimated the number of establishments to have reached 12,100 spas throughout the

U.S and 2,100 in Canada, a 26% growth in the States but 65% growth in Canada!

In North America, health has become a major societal preoccupation, since all media bombard

citizens with warnings about too sedentary a life, the health dangers of too much weight,

cholesterol and stress, too little sleep, and high tension. Foods are considered too fatty, too

sugar and salt-laden; both the air and the water is making people sick. If all that were not

enough, North Americans have been made anxious, if not downright paranoid, about

everything from possible terrorist attacks to catching SARS (Severe Acute Respiratory

Syndrome), the avian flu or H1N1. At the same time, the strong baby boom cohort is

becoming obsessed with aging, refusing to give in to wrinkles and sagging bodies. So it is not

surprising that North Americans are desperate to find an oasis, a place where it is possible to

be at peace, breathe deeply, regain one’s internal balance, re-establish the harmony between

body, mind and soul so that they can confront this fast-paced, complex and increasingly scary

world another day. Yet that older cohort is no longer prepared to make big efforts and huge

sacrifices to look and feel better, as they did just a decade previously. The time has come to

be kind to ourselves: to strive for balance, harmony but also pleasure. Spas are seen as a

means of escaping the pressures and getting re-energized” (Association Resource Centre Inc.

2006: 5).

Health is no longer considered just an absence of illness, but rather an optimum state of

physical, mental and social well-being that requires a more holistic approach and proactive

participation by the individual (Nahrstedt 2004). The World Health Organization 8 defines

8 World Health Organization (1946). Preamble to the Constitution of the World Health Organization as adopted

by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the

representa-tives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into

force on 7 April 1948.

health as “a state of complete physical, mental and social well-being”, which reflects a

preventive way of living that reduces, and even eliminates, the need for remedies. Thus,

health tourism refers to someone who has one or more medical conditions that would make

him travel to experience therapies that help to make him well - or to improve his health. On

the other hand, the concept of wellness emphasizes personal responsibility for making lifestyle

choices and self care decisions that will improve our quality of life. People who engage

in wellness tourism are generally healthy, but seek therapies to maintain this state of wellbeing.

While Europeans and Asians have recognized the benefits of “taking the waters” for

centuries, and the concept of “wellness” has been recognized as a major force in the United

States for more almost 20 years, it has really been part of the Canadian consciousness for only

about 10 years. In that time, however, a significant change in attitudes has taken place.


One of the first comprehensive assessments of travel behaviour and motivators, including

interest in vacations at health spas, was the Travel Activities & Motivation Survey (TAMS),

completed in 1999, and repeated in 2006. For both studies, Statistics Canada undertook the

survey of Canadians, using random digit dialing to obtain samples stratified by census

metropolitan area (CMA). The samples were restricted to all persons aged 18 years of age and

older in the ten Canadian provinces and full-time residents of institutions were excluded.

Travellers who took an out-of-town trip of one or more nights in the past two years were

identified via the screening telephone interview.

In 1999, the telephone survey was completed by 18,385 individuals. Respondents were

selected randomly within the household. 24,635 qualified for the mailback questionnaire. Of

these 5,490 (35.2 %) returned the questionnaire. Using gender, age, education level and

income, responses were weighted to project the results to the national level. 2.4% (470,853

when weighted to the population) of Canadians (as compared to 4% of Americans) had stayed

at a health spa during the past two years. This survey also asked about travel intentions in the

next two years, and identified 6.7% (1,314,463 of the population) of respondents as

expressing an interest in visiting a health spa.

In 2006, the telephone survey was completed by 53,150 individuals and a total of 24,692

(53.5%) travelers completed the mail-back survey questionnaires. This survey contained two

activity variables of interest: “Day visit to a health spa and wellness spa while on a trip of one

or more nights" and “staying at a health spa”. For each variable, it was possible to choose

either “On out-of-town trips of one or more nights in past 2 years” or “Main reason for taking

any of these trips”. Among 24,692 Canadian overnight travellers, 2,538 made a day visit and

1,426 stayed at a health spa. When weighted to the Canadian population (Statistics Canada,

2006), it was determined that 11.0% or over 2.23 million of Canadian overnight travelers

visited a health and wellness spa and/or stayed at a spa resort while on an out-of-town,

overnight trip of one or more nights.

In addition to analysis of the weighted data using frequency, chi-square and analysis of

variances techniques, the odds ratio was used as a measure of association. Due to the large

sample size, all results were significant at the 0.001 level or better.


Demographic characteristics of spa-goers

While only 2.4% had visited a spa during the previous two years while on an overnight trip in

1999, this percentage had increased to 11% seven years later. In addition, 34% (almost

800,000 respondents) reported that this activity was the main reason for taking at least one

trip. While only Saskatchewan showed a high participation rate in 2000 (8% of overnight

pleasure travelers), by 2006, Saskatchewan (13.6%), British Columbia (9.3%) and Quebec

(8.3%) were all above average. In 1999, women were 47% more likely to have visited a health

spa, but there was relatively little variation by age in the incidence of health spa visits, and the

levels of formal education and household income were only weakly associated with health spa

visits. By 2006, the picture had changed quite dramatically: women were 70% more likely to

have visited a health spa, and spa visitors were over-represented among those 25 to 54 years

of age and especially among Mature Couples. In addition, they were the third most likely to

have a university degree and had the highest household income of any of the culture and

entertainment activity types.

Indeed, there was a significant shift between 1999 and 2006 in the income groups that are

both staying at health spas and participating in health and wellness spa activities. Whereas in

1999 the majority of health spa goers earned $60,000 and more, by 2006 the majority earned

$80,000 and more. This middle-aged group is, however, increasingly introducing both their

parents (mainly mothers) and children (mainly daughters) to the spa experience, contributing

to the extraordinary growth in demand for facilities as well as treatments.

Segmenting the spa segment

Spa-goers made an estimated 14.1 million visits to Canadian spas. Half of these visits were

taken to spas in Ontario and four out of five spa visits in Canada were made to day spas (11.3

million). Over 40% of the Canadian adult population visits day spas while at home (Table 1):

Table 1 Frequency of Spa Visitation

During the past 12 months, how

often did you visit a day spa?

Frequency Percentage

Frequently 398,952 5.4

Occasionally 2,603,110 35.1

Rarely 4,404,814 59.5

Total 7,406,876 100.0

Source: Lang Research Inc. (2007).

It is clear that the spa segment is not a homogeneous one. In a 2006 study by The Hartman

Group, three types of spa-goers were identified, based on the frequency with which they seek

out these experiences and their attitude towards them: core spa-goers are knowledgeable

about treatments and feel that learning about and going to spas is important to their lifestyle,

while periphery spa-goers (at the other extreme) enjoy going to spas but otherwise show little

interest in them. Between these two segments is a mid-level spa-goer segment that is

interested in learning about spas but lacks the commitment and passion of the core spa-goers.

If we take a closer look at that 40-50% of spa-goers that will travel for the purpose of spa and

wellness tourism, it is probably not surprising that these tend to be more core spa-goers, who

are not only experienced, but have already tried a range of products and services and are thus

the most critical. The majority considered themselves to be in good or excellent health and of

average weight. In spite of this, they worry about their health, including what they eat and

how much exercise they get. Two-thirds of them take vitamins; and 61% limit the amount of

fat they eat. So, while relaxation is their primary motivation for choosing a spa during their

holidays (rated 2.74 on a 3-point benefit scale in terms of importance), with pampering and

stress reduction as secondary motives, a majority reported healthy meal choices to be

important in the selection of accommodations. This does not mean that spa-goers forsake

pampering: indeed, they are 2.5 to 2.7 times more likely to seek this as a somewhat to highly

important benefit compared to other pleasure travellers. But only 37% said workout facilities

were important which corresponds to their general attitude towards active involvement in

regular fitness programs (rated 2.8 on a 5-point Likert scale). Nonetheless, odds are 50%

higher than for other pleasure travelers that being physically challenged/energized is a highly

important benefit sought of their spa vacation and .

This, then, is the dramatic shift in perception we have seen from spas as “indulgence”,

providing the ultimate in luxury and pampering: today, luxury is a given at any spa, but the

“spa experience” that incorporates a tranquil, airy setting and information about health,

wellness and self- or at-home care, in order to maintain a balanced lifestyle, is seen as a

component of long- term, healthy living.

The need for quality assurance

Considering the demographic profile of spa-goers, it is somewhat surprising that no

government has felt the need so far to impose any quality standards or regulate against

possible fraudulent claims coming out of the many different treatments proposed, vitamins,

supplements and lotions used, and statements made as to the psychological and physical

improvements to be expected. Even ISPA has recognized that “as the spa industry continues

to grow and expand to mainstream consumers and their health and wellness regimes,

therapists’ credentials as well as the overall effectiveness of the spa experience (menus,

pricing, environment, “extras,” etc.) will come under greater scrutiny by all segments of

consumers.” (The Hartman Group, 2006: 3).

Indeed, one of the more recent research studies clearly indicates the quality of the treatment

and services as well as the hygiene of staff and cleanliness of the spa facilities are the top

concerns of spa goers (The Hartman Group, 2006).

Table 2 Spa Traveller Concerns with Spa Treatments

Canada USA

Quality of treatment/services 35% 47%

Cost of services 36% 41%

Hygiene of staff and cleanliness of spa facilities 41% 39%

Benefits of treatments 29% 27%

Certification/Training of personnel performing treatments

Source: The Hartman Group (2006).

25% 18%

Premier Spas of Ontario as well as its Quebec counterpart, Relais Santé, are the only industry

associations in Canada that have recognized the need to provide consumers with a guarantee

concerning both the facilities and treatments they will find at a spa, and the professionalism

and credentials of the staff. Acquiring the Premier Spa accreditation by Spas Ontario Inc. is a

comprehensive process involving application, inspection, report submission, and acceptance

by the Board of Directors. The “Insight” lays out the stringent criteria for membership which

give consumers comfort and reassurance about the professionalism and credentials of the

person or persons into whose care they are putting their body, their mind and their soul.

Relais Santé follows a similar approach. Thus, these two organizations have laid a solid

foundation to take advantage of the growth in what can be considered a ‘super-trend’ and

squarely address one of the major consumer concerns: quality assurance and consistency with

respect to the facilities, spa products, services and treatments provided. For instance, massage

therapy training in Ontario is more extensive than that found elsewhere and this province’s

therapists are controlled by a government regulated college – both go a long way to reassuring


Reaching the spa tourist

As profound as the changes in the demographic characteristics of spa-goers have been since

1999, so have the changes in information sources to which they resort. By far the most

common source of information in 2006 was websites: over 80% of people who participated in

health and wellness spa activities used them. This compares to less than 37% using the

internet in 1999. Perhaps not surprising given their profile, the most visited types of websites

involved travel (68%), entertainment (55%) and health (53%).

The only other sources of any significance that were more popular in 2006 than in 1999

included recommendations from friends and relatives (63% compared to 55%) and the

respondent’s own past experience (59% compared to 57%). Even though all other forms of

information sources have seen more or less steep declines over the years (e.g., the use of

travel agents has dropped from 61% to 51% over the seven year period), the odds are quite

high that spa-goers use them For example, spa-goers are twice as likely as non spa-goers to

use a travel agent as an information source.

Spa visitors are also very inclined to use the Internet to plan travel (89%), and rely heavily on

accommodation (67%), airline (57%), travel planning/booking (e.g., Expedia, Travelocity –

54%), and DMO websites (54%). They are also among the heaviest users of travel media, and

are particularly avid readers of health and wellness magazines and websites, city lifestyle,

fashion and beauty magazines, and watch ‘better living’ programming (Lang Research Inc.,

2007). Finally, spa-goers have always been more likely to book travel over the internet as

well: already in 1999, 29% of those who had visited a health and wellness spa booked their

trips this way, compared to 23% of those who were merely interested and 18% of those who

were not interested in visiting them. (Lang Research Inc., 2000). By 2006, fully 68% of spagoers

booked their stay over the internet, while 77.3% booked their accommodation and 76.9

% booked their airline ticket, behavior that is significantly higher than pleasure travelers in


Since spa-goers are particularly interested in “luxury resort vacations that are relaxing and

pampering, and that offer novelty, intellectual stimulation and physical challenge” (Lang

Research Inc., 2007: 1), it is important that any promotion focus on these benefits. Spa-goers

are one of the most likely segments to book their vacation experience over the internet (68%),

largely through accommodation websites (77%).

Generally speaking, “spa visitors are extremely active in both outdoor activities and in culture

and entertainment activities while on trips. They frequently exercise and jog, and are much

more likely than the average Canadian pleasure traveller to participate in strenuous winter

activities (e.g., cross-country skiing and snowshoeing, downhill skiing) and summer sports

(e.g., golf, tennis). They also frequently attend live art performances (e.g., live theatre, high

arts, comedy clubs and festivals) while traveling and exhibit particular interest in fine cruise

(e.g., wine, beer & food tastings, inn or resort with gourmet dining)” (Lang Research Inc.,

2007: 1). Indeed, there are a number of activities where the odds range from close to three to

four times as likely that they will participate compared to non-spa goers. These include: ice

climbing, dog sledding, hang-gliding, hot air ballooning, bungee jumping, horseback riding,

windsurfing, cross- or back-country skiing, playing squash and tennis, working out, attending

jazz concerts, recreational dancing, dining in restaurants with an international reputation,

shopping/browsing in gourmet food retail stores and for clothing, shoes and jewellery. They

are also three times more likely than non-spa goers to stay in a resort, whether it is located on

a lakeside/riverside, in the mountains/ski or the seaside. And they are 5.5 times as likely to

have stayed in a cooking school; indeed, over 40% of those who participated in health and

wellness spa activities also stayed in one of these schools!


The explosion in spa products for sale in almost any store that carries personal care and

beauty products is both a result of, and a contributor to, the growth in spa visits. This

“personal introduction” is likely also the reason why even first-timers seem to have very high

expectations regarding their visit. Men, who are introduced to the spa experience, often by

their spouses, will usually start with a massage as they tend to be driven by notions of “work",

i.e., improving some aspect of their body, their emotional state or their long-term spiritual and

personal dispositions (The Hartman Group, 2004). Increasingly, however, they are warming

up to manicures and facials, largely as part of the broader societal trend that has seen a return

of the acceptability of male grooming, along with greater acceptance of the gay culture and

the rise of the “metrosexual” who has many of the characteristics of his gay counterparts, but

is heterosexual.

As the spa consumer becomes more knowledgeable and educated about available treatments

and their expected outcomes, he or she will increasingly look to the spa industry to provide

ever more information about every aspect of a wellness program, and spas will be judged on

their ability to make informed decisions and provide guidance in every aspect from menu

design and implementation, to which training and treatment programs to engage in and why.

But messages must go beyond addressing the core segment in terms of communications,

menu designs and available spa treatments: even though they are the most committed, they

represent the smallest percentage of the overall spa population, and thus, to convert the midlevel

and periphery spa-goers, the messages must also address their lower level of knowledge.

It is also important to realize that visits to day spas are an activity largely undertaken by

women, but spa travel is not: 42% of the Canadian health spa resort clientele is men. Staying

at such a resort is no guarantee, however, that they will actually participate in spa-related

activities as only 37% indicated that they did so, based on 2006 TAMS study. Still, facilities

at resorts and hotels must be adapted to a very discerning, mixed clientele, by also offering

male-focused activities like golf, outdoor adventure, male cosmetic programs, and highoctane

fitness programs.

It is clear that this industry will have to place much greater emphasis on learning, by bringing

in knowledgeable speakers from both the conventional and complementary or alternative

medical fields to educate consumers who want to make informed decisions about their own

health. Especially the core spa-goers are craving this type of knowledge, and avidly pursue

their own understanding. Nutrition is already playing a much greater role as people become

more aware of health effects procured by different food items, and weigh different dietary

approaches to combat everything from obesity to medical problems. People’s anxiety over

genetically modified foods, additives and preservatives will lead them to sustain the growth in

organic foods and the popularity of farmers’ markets, regional cuisines, and traditional foods,

all of which are perceived to be more “natural” and therefore healthier.


Association Resource Centre Inc. (2006). 2006 Canadian Spa Sector Profile. Vancouver,

B.C.: Canadian Tourism Commission

Lang Research Inc. (2007). TAMS 2006: Canadian Travel Market - Visiting Spas While On


Of One or More Nights: A Profile Report. Toronto, ON: Ontario Ministry of Tourism and


Lang Research Inc. (2001). Interest in Health Spas (Profile Report), Travel Activities &

Motivation Survey (TAMS). Ottawa: Canadian Tourism Commission.

Nahrstedt, W. (2004). “Wellness: A New Perspective for Leisure Centers, Health Tourism,

and Spas in Europe on the Global Health Market” in Weiermair, K. & Mathies, C. (eds.).

The Tourism And Leisure Industry: Shaping The Future. New York: Haworth Hospitality


PricewaterhouseCoopers (2004). The ISPA 2004 Spa Industry Study. Lexington, Ky:

International SPA Association

PricewaterhouseCoopers (2002). The ISPA 2002 Spa Industry Study. Lexington, Ky:

International SPA Association

The Hartman Group (2006). Identifying the Spa Traveler: A Look at US and Canadian

Consumer Attitudes and Motivators for Spa Vacations. Canadian Tourism Commission

and International SPA Association.

The use of the internet in wellness promotion by Portuguese spas

Veronika Joukes

Professor Auxiliar, DESG, CETRAD (ECHS),

Universidade de Trás-os-Montes e Alto Douro (UTAD),

Avenida Almeida Lucena 1, 5000-660 Vila Real, Portugal.


Until 2004, Portuguese spas were traditionally thought of as establishments in which noninvasive

therapies based on naturally-occurring sources of mineral water are provided under

professional supervision. With the publication of the Decree-Law Nº 142/2004, Portuguese

legislation regulating spas changed quite drastically: from that moment on, spa-owners,

numbering some 40 establishments countrywide, were allowed to open up what had hitherto

been a strictly health-orientated sector. Since then much has changed in the Portuguese

mineral springs spa market: one of the main innovations has been the introduction of a large

variety of services that may be termed “wellness treatments”, i.e. therapies not strictly related

to pre-existing health conditions. These are now being offered as a product range in its own

right along with traditional medical treatments, thus diversifying the services provided, all

based on the same highly therapeutic naturally-occurring mineral water. Thus spa services are

no longer just a health product, but have also become a tourist attraction, thereby legally

formalising something that, to a limited extent, had always been the case. With the change in

the services offered, the typical customer profile has also changed significantly: users of

today’s spa facilities are younger (between 25 and 45 years of age) than in the past, from the

middle to middle-upper socio-economic stratum, live in a large urban centre, have a

reasonably high level of education, and could be either male or female. Such clients prefer

making various short trips over the year to test out different destinations, and choose

registered hotels with 3 or more stars for their stays. The changing client profile has meant

changes in the means employed by firms to establish a growing and loyal client base. Indeed,

over the past five years, a large majority of Portuguese spa service providers have

significantly upgraded not only their services and infrastructures, but also their use of internet

sites. With these changes in mind, the study reported on here 9 aimed to analyse the way such

firms currently communicate with prospective clients using the web. The existing sites were

therefore systematically screened during the Spring of 2009 (30 sites) and 2010 (34 sites),

with a view to finding answers to the following questions: (i) how do they position their

medical/wellness products? (ii) to what kind of public do they address their internet-based

marketing efforts (iii) do they only mention their own services or do they also provide

prospective clients with links that give information on other service providers, such as travel

experts, sports organizations or nature guides? (iv) do the online marketing tools used by

these spas stimulate user-communities? The results of this study may offer not only

Portuguese but also spas in other locations the opportunity to further improve their dialogue

with current and potential spa-goers.


In Portugal, the supply side of health and wellness tourism consists of traditional spas based

on natural mineral water springs (that have existed since Roman times at least), some

9 This preliminary study was undertaken on our own initiative but the intention is to convert it into an

international comparative project furnishing results that may be applicable to the sector under consideration.

thalassotherapeutic establishments (registered from 1990, and using therapies exclusively

based on sea water), as well as a fast growing number of non-mineral water spas (established

since the beginning of the 21st century, based on water from the public supply network). In

numerical terms this situation translates into the following structure of suppliers: 38 mineral

springs spas that, in 2008 10 , were open to the public (Turismo de Portugal, 2009b); fewer than

10 sea-water units functioning in 2010 (Fernandes, 2006; Turismo de Portugal, 2009a); and

approximately 130 hotels with spa facilities reported by the Portuguese Hotel Association

(AHP) for the same year, which corresponds to an increase of more than 1500% over the last

8 years in the number of functioning “spa hotels” (Turismo de Portugal, 2010a). Meditative

and holistic retreats (on the one hand) and medical tourism focusing particularly on

aesthetic/cosmetic, dental and surgical treatments (on the other hand) are still in the

introductory stage of their life cycle and consequently it is impossible to quantify their current

share of the market – either because they are not yet the object of intensive promotion efforts

and/or because these subsectors' activities still remain largely unstructured.

This paper focuses on the spas that are based on mineral springs, commonly referred to in

Portuguese as termas (the local adaptation of the Latin thermae, meaning hot springs/baths).

In order to avoid misunderstandings and to emphasize the unique Portuguese context, it

should be underlined that for the Portuguese consumer the concept of “going to the termas”

has long meant undergoing therapy based on mineral water springs, i.e. only those who were

ill would “take the waters” and, consequently, mineral springs spa facilities were sought only

by the unhealthy and elderly. However, the number of spas nowadays greatly exceeded the

number of termas and recent massive marketing and awareness campaigns have facilitated the

introduction of the spa concept in Portugal, where the latter is now understood as a place (in

an urban/rural environment, in a hotel/fitness complex, in a beauty centre or even in the

traditional termas) where one can be pampered, but not necessarily with (mineral) water

treatments. We have to stress another difference, important for the development of tourist

products, between spa hotels and termas: the latter normally do not offer accommodation. On

the other hand, the traditional termas are no longer seen as mere therapeutic infrastructures

but also, and increasingly so, as places of leisure, recreation and relaxation. While, in

principal, the two dimensions – therapy and recreation – are two facets of nowadays spas that

can coexist in perfect harmony, the services provided by the emerging wellness tourism

market in Portugal are still thought of as being quite separate from those offered by the

turismo termal market (spa-based medical tourism), since Portugal has a much longer

tradition in the latter field (Lapa, 2009).

The main reason for finding these spas of analytical interest is the fact that they (i) are owned

by relatively small public or private investor’s groups, (ii) are typically autonomous rather

than part of a major grouping or conglomerate and (iii) are experiencing a phase of significant

adaptation that obliges them to market their services more directly and aggressively.

Based on a previously-conducted literature review, the empirical research analysed half of the

existing spa websites in order to find out (i) how the termas position and promote both their

traditional and new products, (ii) what kind of public they appeal to, (iii) whether they only

mention their own services or also provide information on complementary service suppliers,

such as travel experts, sports organizations or nature guides, to which potential clients are

redirected, and (iv) whether they use interactive techniques. However, before presenting the

results of this survey, the general context in which these mineral springs spas have evolved

will be described.

10 The most recent official statistics referring to the sector date from 2008.

The main characteristics of Portuguese mineral springs potential

In Portugal 408 springs with mineral water are reported to have therapeutic properties, and

three quarters of them (300) are recognised by the local population as having curative

properties (Sousa, 2006). In the spring of 2010 already 44 such spas were officially being

exploited. However, only 39 were open to the public, two more than in the previous year. The

Central region of Portugal has 20 spas (or 45% of the total), the North has 18 (41%), while

only 14% of the total number of termas are located in the remaining four regions – three in

the Alentejo and one each in Lisbon, the Algarve and the Azores (ATP, 2010; Turismo de

Portugal, 2009b).

It is not compulsory for spas to be registered members of the Associação das Termas de

Portugal, the organisation that defends the interests of the country’s subscribing mineral

springs spas. However, most spas are in fact members, with only the northern termas of

Moledo, Eirogo and Carlão never having joined the ATP. These 3 independent spas (indicated

in blue) and the limits of the NUTS II sub-regions (in green) are also indicated on the map

below. Figure 1 shows the geographical spread of ATP-member spas across the country.

In the Central region, as a matter of fact in São Pedro do Sul, the largest Portuguese termas

are to be found with 17.017 medical spa goers in 2008. The second largest facility with regard

to this kind of public, Termas de Chaves, another municipal company, however, handled

6.374 medical attendants over the same period, only a little more than one third of the number

TERMALISTUR reached. This considerable discrepancy explains why the North only served

25.814 mineral springs spa goers in 2008 and the Centre more than double (58.870) (Turismo

de Portugal, 2009b).

It is also important to note that of the 44 units under consideration (41 ATP members and 3

independent ones), 21 (48%) already renovated their premises since 2000 and that another 5

(11%) will reopen within a short span of time. This year the brochure Saúde & bemestar, in

which 20 innovative and differentiating qualification projects sponsored by Turismo de

Portugal over the last decade are listed in an appealing way, included mineral springs spa

(along with spa hotel) renovation projects with a total investment value between 470.000€ and

20.900.000€ (Turismo de Portugal, 2010b).

Figure 1. Geographical spread of Portuguese mineral springs spas in 2010

Termas (Nº indicates District Region Figure

location on map)



04 Caldas de Chaves Vila

05 Termas do Vidago

06 Águas Santas de


09 Termas de Pedras


001 Caldas de Moledo

003 Caldas do Carlão

14 Caldas de Aregos


01 Termas de Viana



02 Caldas de Monção Castelo North

03 Termas do Gerês Braga

002 Termas de Eirogo


07 Termas



08 Caldas das Taipas

11 Termas de Vizela

12 Termas


de S.

10 Caldas da Saúde

13 Termas de Entreos-Rios



16 Caldas de S. Jorge

21 Termas do Vale da

25 Termas da Curia

26 Termas do Luso




17 Termas


do Viseu


20 Termas de S.

Pedro do Sul

22 Caldas



23 Termas



24 Termas




15 Termas


de Guarda

18 Caldas da Cavaca

19 Termas



27 Caldas


28 Caldas do Cró



29 Termas de Unhais

da Serra

30 Termas de


31 Termas de Ladeira

de Envendos

32 Termas de Monte


33 Termas das


34 Caldas da Rainha

35 Termas do








39 Termas do Estoril Lisbon Lisbon

36 Termas de

Fadagosa de Nisa

37 Termas de Monte

da Pedra

38 Termas de Cabeço

de Vide

40 Caldas de






Faro Algarve

41 Termas das Furnas Azores Azores

Source: Mapped by the author (based on ATP, 2010; INETI, 2004; Turismo de Portugal,


The data presented in Table 1 show that exactly half of the units are publicly-owned and the

other half are in private hands. Contrary to what we might expect, 62% of the 21 renovation

projects so far executed were initiated by publicly-owned companies. Of the 5 that still have

to reach their final stage, however, 80% are private. Of the 18 establishments where nothing

has been undertaken yet, in turn, 44% are publicly-owned.

Table 1. Renovation of publicly- and private-owned termas in 2010

Publicly-owned termas Private termas Total

Renovation projects (concluded) 13 8 21

Renovation projects (in progress) 1 4 5

Without renovation projects 8 10 18

Total 22 22 44

Source: Elaborated by the author based on the termas websites (see list and respective

addresses in Table 2 below) and on the following publications: (ATP, 2010; Medeiros &

Cavaco, 2008; Turismo de Portugal, 2009b).

We also noted that the smaller the unit is, the less probable it is that it will be quickly

renovated. Of the 15 termas that had less than 1.000 medical clients in 2008, 7 remain in

exactly the same physical state as in 2000, 2 are under reconstruction and 6 have already

concluded their renovation work. In contrast, the 10 termas with the best sales figures all had

concluded such projects by 2010.

Further calculations indicated that ownership of spa hotels tends to be private (78%): of 18

such hotel units, 2 are owned by INATEL (a public body) and only those at Carvalhal and

Monção are run by the local municipality. Of the balneários (spas without residential

facilities), one-third have private owners and two-thirds are in public hands.

Today’s typical spa goer

In this section, in order to concentrate on “new” spa goers, “traditional” spa-goers (by which

is meant elderly persons with medical conditions that require curative treatments, with very

limited purchasing power, and with low expectations as to the quality of spa and lodging

facilities that function only during the warmer months of the year) have been disregarded

(Medeiros & Cavaco, 2008). Nowadays not only the mineral springs spas, but all the other

types of spas want to widen their clientele and for this reason increasingly use websites as a

means of attracting new clients to this niche market. Gustavo (Gustavo, 2009), drawing on his

ongoing doctoral research, argues that spas occupy a privileged market position not only

because they are associated with the principles of both health and well being, but also – and

probably mainly – because they are able to reinvent themselves in line with a global and

hybrid philosophy that mirrors the world in which we currently live.

In order to discover clients’ motivations, the kind of services they prefer during a spa

visit/stay and their daily health care practices at home, Gustavo collected responses from 824

clients during May to August 2009 in 21 “classic” and “new” hydrotherapeutic leisure spaces.

His results led him to conclude that the typical spa-goer today is predominantly female (70%),

in their thirties (average age 39, with 40% of the sample between 30 and 39), has a degree

(74%), with those in a stable conjugal relation being equal in number to single persons (24%

and 25% respectively), many without children, living in an urban area (72%), in Portugal

(73%); the vast majority (92%) are in employment, predominantly in high level managerial or

technical capacities, 89% of the employed having jobs in the service sector. In almost half of

the cases, the family net income exceeds 3.000€ per month i.e. more than six times the 2009

Portuguese guaranteed minimum income of 450€/month. These clients are most likely to visit

a spa facility during the week (45%) or to integrate it into a (short) holiday break (41%).

Those interviewed by Gustavo regularly visit spas (31% of them once a month) in order to

relieve stress or to relax (74%) and/or to upgrade mental and physical health (50%). Massage

and body treatments are the spa services with most demand. Notwithstanding the dominant

historical and cultural influence of the classical termas, nearly 50% of the clients said they

had not undergone hydrotherapeutic treatments during their last spa visit.

The same survey also revealed that future clients consider the quality of treatment, the quality

of customer service, hygiene and cleanliness, the cost of services and the location of the spa

as the most relevant factors influencing their decisions to visit or revisit particular sites.

Another important conclusion to draw is that spa clients are essentially healthy people: 87%

of those surveyed consider their routines as healthy, stressing the importance of food (89%)

and physical exercise (83%) and their personal attitude in favour of a healthy lifestyle tout

court (54%). 42% only consume alcohol at the weekends or on special occasions, while 69%

are non smokers. They undergo annual medical check-ups every year on their own initiative.

70% of the sample has a normal or below average Body Mass Index. For marketing purposes,

finally, it is relevant to bear in mind that 14% of those answering the questionnaire were in

the spa at the time as a result of having received a gift voucher.

Portuguese spa managers may also find the annual SpaFinder forecasts a source of inspiration

in defining their marketing strategies: these reports are compiled by “a team of experts who

visit thousands of spas”, interview top industry analysts and research organizations, and do

ongoing consumer and industry research in the spa, travel, wellness, and beauty sectors. In

December 2009, the Top 10 Global Spa Trends to Watch in 2010 was launched, identifying

global spa trends that will influence spa experiences for both consumers and the industry in

2010 and for years to come. They argue, for example, that prevention is the new “P”-word

(substituting its predecessor – “pampering”) and claim that belonging to a spa, rather than just

visiting it, increases one's emotional health. They defend that, while the spa industry’s virtual

presence will continue to grow, room has to be made for “wellness tourism”; and they also

foresee an era of integrated spa, fitness, health, spiritual, wellness and beauty facilities

(SpaFinder’s Seventh Annual “Top 10 Global Spa Trends to Watch in 2010” (Press Release),


Since prior knowledge of the customer is so important, greater adherence on the part of spa

managers to the SPA & Thalasso Monitor, launched by the Portuguese Hotel Association

(AHP) in May 2009, would seem appropriate. All participating hotel units in the sector are

provided with free access to this benchmarking system that produces operational management

information relevant for this market. The Monitor is supported by software that allows, at any

time, all member businesses to review their (historical) data and weigh the position of their

own unit relative to others in the same or in different regions of Portugal. It fills a serious

lacuna in technical information available on this segment, making accessible monthly-updated

operational indicators as well as data on market activity, providing a business management

tool, and guarantees that public tourism officials (local, regional and national) can access

whenever necessary, reliable information relative to their geographical area (AHP, 2009;

Mourão, 2010).

Principal results of the analysis of 15 mineral springs spa websites

It is not only those who want to decide how they are going to pamper themselves who take

advantage of the internet, but also those active on the supply side. The internet constitutes the

only medium capable of furnishing round-the-clock, “instant” and up-to-date information on

new techniques, products and services. This makes it easy for service providers to innovate,

reinvent and promote service packages and incentivise termas to continuously develop their

communicative capacities and to explore the marketing techniques to the limit in the context

of a market niche of substantial commercial interest (Gustavo, 2009).

So far no research has been undertaken in Portugal into the internet marketing strategies of

spas, neither have their websites been analyzed in any systematic way. The study reported on

here concentrated on the years 2009 and 2010: one year ago, 37 termas were open to the

public and 30 of them had a website, while in 2010 two more termas (39) were functioning, of

which 34 promoted their services through the internet. In the two years under consideration,

the arguments firms advanced for not employing a website were: (i) that the firm was in a

remodelling phase and therefore there would be few if any returns deriving from an internet

site; or (ii) that the firm’s main clients were principally local elderly customers, the spa

facilities were limited, and only open during a short period of the year and therefore there was

little hope of attracting new segments of spa goers. Only Moledo and Eirogo, two of the three

independent spa units, are examples of the latter situation, while the other cases fit into the

first group. As a matter of fact, in three (Almeida, Monte Real and Nisa) of the four cases of

new websites created in 2010, the website launched coincided with the reopening of the

premises after renovation, while the creation of the Taipas website has to be interpreted as

part of the 2010-2013 plan of its newly elected board that, amongst other objectives, intends

to redefine its public and modernize the spa (Taipas Turitermas, 2010).

In the same period, 9 termas merely offered basic information posted on the website of an

umbrella institution (the Carvalhelhos spa on the website of the bottled water firm of the same

name; those of Entre-os-Rios and Manteigas are to be found on INATEL’s website; Almeida,

Vale da Mó, Sangemil, Cró and Cabeço de Vide on the website of the municipality that owns

them; and Caldas da Rainha on the Ministry of Health’s website). With the exception of

Cabeço da Vide, the termas with over 2.000 medical spa goers per year (corresponding to 1/3

of the termas with a website link) have their own appealing websites, whereas of the 15

smaller spas (receiving less than 1.000 visitors in 2008), 4 have no website at all and 4 only

furnish the most basic details through an umbrella website. The internet presence of termas

open to the public and with accommodation is 100% and 85% of those without integrated


In order to find out how the termas use the internet to sell their services, it was decided to

focus on those that had created their own web page (excluding those with information inserted

on an umbrella site) and that had been functioning in 2009 and 2010. This universe of spa

units (i) was representative of the regional distribution of spas, (ii) included both private and

public initiatives, (iii) took in both well-visited and less-visited businesses and (iv)

incorporated both spas functioning without accommodation (balneários) and mineral springs

spa hotels. As there were only 2 eligible sites in the South of Portugal, the sample taken from

this universe was adjusted so as to include 7 sites in the Centre of the country and 6 in the

North, respecting the 14% - 45% - 41% spatial distribution ratio referred to above, as can be

verified in Table 2 below.


Table 2. Spa websites analysed

São Pedro

do Sul




g Nº of



Nº of




Centre 1 17.017

Chaves North 2 6.374

Felgueira Centre 4 4.511


d during




(Sept) -







São Jorge North 6 3.655 2003


n holder

in 2010













Website address

Private hotel



Gerês North 8 3.443 2007 (Jan) Private



Centre 10 2.358

Saúde North 15 1.326



North 16 1.258











Private hotel




Private hotel

Luso Centre 18 1.176 2010 Private hotel

Longroiva Centre 21 1.004 2009 (Oct) Municipali





Vimeiro Centre 22 637 none Private hotel





23 621



Aregos North 24 604 2009

Cavaca Centre 28 421



Private hotel

Municipali balneári

ty o

Municipali balneári

ty o


Furnas Azores no data no data 2008 (Oct) Private hotel

Source: compiled by author, based on the websites listed, INETI, 2004 and Turismo de

Portugal, 2009b.

As mentioned above, modernisation efforts on the part of the owners of mineral springs spas

did not stop at infrastructural renovation projects: many also established internet sites, on

which they placed and managed different types of information. Some of the more interesting

aspects of the internet sites encountered in the survey are presented below.

Almost all sites (Aregos and Longroiva being the only ones that offer only classic treatments)

use different subpages to recommend both medical and wellness products. However, the

degree of detail in the information provided is variable, with the Furnas site being the least

impressive example, referring to nothing more than the installations where the treatments take

place. In the majority of cases, sites not only summarise the treatments available, but also

explain them: Three do so with photos and the São Jorge site supplies a glossary of almost 30

terms. Only a small group bring together frequently asked questions in a dedicated “FAQ”

sub-page. All units, apart from Furnas, present a detailed price-list; however, it is only on rare

occasions that potential clients are informed of the time needed for each treatment. Almost all

termas differentiate their prices following one or more of the following criteria: (i) the longer

the stay and/or the more treatments acquired, the cheaper the unit price; (ii) prices vary

according to whether the visit is made in the low, middle or high season; (iii) returning

customers receive discounts; (iv) group bookings pay less; (v) in spa hotels, prices change

according to whether the treatment is bought with or without accommodation.

None of the termas created a subpage with general tips on healthy lifestyle, although some do

mention that they have a staff nutritionist and it is in this context that certain advice is given.

None of the termas elaborated a code of ethics, but São Jorge does mention a small list of

commitments regarding the quality of the services offered. None of the termas explicitly

mentions its concern for the principles of sustainability and local development. Implicitly,

some display pro-nature values, describing the spa’s healthy surroundings in their

introductory texts or including “green” pictures on the opening page of the site or in the site’s

photo gallery. Only on the São Pedro do Sul site is there a subpage entitled “quality and

environment” that includes a manual of environmental good practices («Boas práticas


The way the termas address their public is still very general. However, there are exceptions to

the rule. The São Jorge, São Pedro do Sul, Felgueira and Monchique units let us know in a

more or less obvious way that they welcome children: Felgueira provides them with a junior

passport and has created the mascot Felgui, following the example of the São Pedro do Sul

termas that uses the frog Afonsinho and the squirrel Amelinha. Monchique has a Kids’ Club.

Monfortinho to some degree focuses on clients in the area for the hunting, while Monchique

does something similar to attract the sailing community and Vimeiro targets horse riders and

golf players. Águas do Gerês hopes to conquer nature tourists, mentioning its unique

localization in the Peneda-Gerês National Park.

Only the Caldas de Aregos site had the Web Access Symbol for people with disabilities (a

blue globe, marked with a grid, tilted at an angle with a yellow keyhole in the middle) at the

bottom of its main page. There is no guarantee that a site using this symbol will be 100%

accessible, or was even designed according to the guidelines: it is the responsibility of website

users to “let the webmasters know when a site is or is not accessible to the disabled, and to

offer suggestions for greater accessibility. Those who use the symbol should do so at their

own discretion, understanding the goals of the growing group of people dedicated to making

the Web useful for all” (Web Access Symbol, [S.d.]).

Two-thirds of the websites consulted try to retain the loyalty of their clients by offering them

the possibility of subscribing to their newsletter. It should be noted that, in most cases,

prospective clients will not receive a real newsletter, but be notified of all the promotion

actions of the enterprise. Eight websites used the main page of their website as an alternative

way of announcing these kinds of special promotional campaigns.

São Pedro do Sul is the only termas that can afford the luxury of investing in a year round

programme of events and activities for its guests. The monthly programme can be

downloaded from the internet. Smaller units like Chaves, São Jorge and Monchique only

produce this kind of programme in the high season. In most cases though, future clients are

not informed or are only informed in a very brief and vague way about complementary tourist

activities in the surrounding area. São Pedro do Sul and Chaves, owned by the municipality,

limit themselves to inserting links to other organisations patronised by the municipality. No

more than a handful of links were oriented towards “independent” companies offering

specialised tourist activities: Aregos links to “Douro à Vela” a company specialising in river

trips, São Jorge has a link to the Lourosa Zoo and to the “Visionarium” Science Museum and

the Monfortinho unit has a link to the “Naturtejo” Geopark. Monfortinho is also an exception

inasmuch as it mentions direct competitors, be it Vimeiro (which belongs to the same group)

and the Portuguese Spa Association (which can also be accessed via the website of São Pedro

do Sul). All the spas that are integrated into hotels refer to their own lodging facilities, while 6

balneários mention the addresses of local lodgings, and Longroiva and Cavaca also list local


All the termas bet on being reachable by internet, offering the possibility to open an emailbox

by clicking on their e-mail address. 1/3 offers the possibility to fill out an online

“message” form. More than half offer online reservation possibilities, although in 3 cases this

is limited to a hotel reservation. São Jorge and Felgueira give their clients on top the

possibility to telephone them for free.

With regard to other aspects of online interactivity, scores are still very low: no unit has set up

a discussion forum; only São Jorge has a website poll question, with questions such as: “Are

you aware that a spa cure can benefit from refunds from the national health service?” Five

spas give customers’ opinions, albeit in a partly “censored” form; São Jorge is connected to

Twitter, São Pedro do Sul and Felgueira to Facebook, and Felgueira created a blog in January

2010. São Pedro do Sul and Felgueira offer merchandised products. In the former case they

can be individually ordered online and paid for in the traditional way (by cheque, ATM or

bank transfer); in the latter case an online shopping option (with a cart) is to be established,

but was not working at the time of the survey. Of the three units that offer vouchers, São

Jorge’s facilities are the most elaborate.


Having noted that the large majority of the mineral springs spa service providers have been

significantly upgrading not only their services and infrastructures, but also their websites over

the past five years, the survey analysed the way they currently communicate with their

(prospective) clients through the internet. We conclude that the Decree-Law Nº 142/2004 has

brought about real changes: the majority of Portuguese mineral spring spas now offer medical

along with wellness services and inform prospective clients correctly and honestly about what

to expect. Nevertheless, here are still numerous opportunities for spas to improve their

internet presence in many directions: by putting more (and more accurate) information on

their sites, they will be able to target special groups and market segments, redirecting

prospective clients to complementary tourist activities and expressing their concern over

environmental, sustainability and local development issues. Termas would be well advised to

develop their interactivity by creating discussion forums, making their sites more accessible,

offering more online shopping possibilities, taking more advantage of social networks or

creating more transparent subpages in which clients’ opinions can be expressed. Our sample,

moreover, provides evidence that the more content and links are put on the internet, the better

informed clients will become and the more likely it will be that (potential) clients will be

attracted by the product under consideration. We are also convinced that even “extremely

small” spa units can benefit from developing focused and functional websites.

In our opinion the results of this study offer not only Portuguese mineral springs spas but spas

in general the chance to further improve their internet dialogue with current and potential spagoers.

In conclusion, researchers in this field are encouraged to develop a more comprehensive

international comparative study of spa websites in order to work out guidelines for common

best practices.

I would like to thank Barrie Abbott, Louis Joukes and, most of all, Chris Gerry for their

contributions to the final form of this text and also the first year students of UTAD's Tourism

degree (Ana Carina Lima, Ângela Silva, Carla Machado, Cátia Rodrigues, Marta Mota,

Natércia Lourenço, Rita Teixeira, Sara Rebelo, Sara Teixeira, Sónia Ala, Telma Castilho,

Telma Guerra, Teresa Gonçalves and Tiago Araújo) who assisted in the collection, during

February of 2009, of some of the data necessary for this paper.


AHP (2009). Como aderir ao SPA & Thalasso Monitor. Retrieved 03-02-2010, from

ATP (2010). Turismo de saúde e bem-estar. Health and wellness tourism. Lisboa: ATP.

Decreto-lei n.º 142/2004, de 11 de Junho. (2004). Diário da República, pp. 3632-3641.

Fernandes, J. V. (2006). Thalassa, Thermae, SPA – Salute per Aqua. Lisboa: Plátano


Gustavo, N. (2009). Turismo de saúde. Uma abordagem à luz dos desígnios do século XXI. In

J. M. Simões & C. C. Ferreira (Eds.), Turismos de nicho. Motivações, produtos,

territórios, pp. 191-204. Lisboa: CEG.

INETI (2004). Termalbase. Retrieved 21-02-2010, from

Lapa, V. N. P. M. J. (2009). Águas, elites e desenvolvimento. A exploração das águas

minerais naturais do concelho de Chaves pela Câmara Municipal (1892-1948).

Unpublished PhD-Thesis, UTAD, Vila Real.

Medeiros, C. L., & Cavaco, C. (Eds.) (2008). Turismo de saúde e bem-estar. Termas, spas

termais e talassoterapia. Lisboa: CEPCEP da Universidade Católica Portuguesa.

Mourão, L. P. (2010). SPA & Thalasso Monitor. [PowerPoint presented on the international

conference which opened BTL on 13-01-2010]. Lisboa: Turismo de Portugal.

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SpaFinder’s Seventh Annual “Top 10 Global Spa Trends to Watch in 2010” (Press Release)

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Taipas Turitermas (2010). Taipas Turitermas. Plano de Actividades 2010/2013. Retrieved 10-

01-2010, from

Turismo de Portugal (2009a). Portugal e talassoterapia. Retrieved 05-02-2009, from


Turismo de Portugal (2009b). Termas em Portugal. A oferta e a procura em 2008. Lisboa:

Turismo de Portugal.

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Projectos financiados pelo Turismo de Portugal. Lisboa: Turismo de Portugal.

Web Access Symbol ([S.d.]). Retrieved 08-03-2010, from

Health Spa and Wellness – Competition or Supplement?

The Czech Republic Case

Alžbeta Kiráľová

Vysoká škola obchodní v Praze/ University of Business in Prague, Prague, Czech Republic


This paper examines the relations between health spa and wellness in the Czech Republic.

While the importance of health spa to the Czech economy is generally acknowledged wellness

is often seen as a second-rate activity with no or very low effect on health because of the

average length of stay and lack of treatments complexity.

The Czech Republic combines a number of important attributes as a destination for health spa

tourism, with a long lasting tradition of health spa culture. It offers climatic spas, healing hot

and cold springs, healing torf and mud - all for treatment and recuperation and a high standard

of services for medical and wellness tourism at cost–effective rates. The paper starts with a

short introduction of tourism in the Czech Republic followed by health state and aging

characteristic of the Czech Republic and implications for tourism. Together with the

introduction of the Czech health spa industry the place of wellness in the Czech Republic

tourism industry is explored and complements this with simple statistics.

It reports about an exploratory case study that looked at the relation between health spa and

wellness in the Czech Republic from the point of view of tourists. The aim of the study was to

explore the relation of both and to consider the expectations of tourists in this field.

Accordingly, the management of facilities has been contacted individually; tourists were

investigated through a survey. The concluding sections discuss options in attracting tourists to

motivate them to frequent health spas and wellness visits.

Keywords: Tourism, Health Spa, Wellness, Czech Republic


The Czech Republic is a landlocked country, situated in Central Europe with the total area of

78.866 sq km. Its total boundaries are 1.881 km (border countries: Austria 362 km, Germany

646 km, Poland 658 km, Slovakia 215 km). Climate is temperate, affected by the interaction

of oceanic and continental effects.

Map of the Czech Republic Picture 1

Source: Downloaded from:

(last accessed 7 March 2010)

The number of population of the Czech Republic is 10.230.000. The Capital of the Czech

Republic is Prague. The Czech Republic joined NATO in 1999 and the European Union (EU)

in 2004.

The Czech Republic is one of the most stable and prosperous of the post-Communist states of

Central and Eastern Europe. 11 The per capita GDP reached 25.100 USD (2009 est.), the

inflation rate is 1.1% (2009 est.), the unemployment rate is 9.3% (2009 est.), and 56.2 % of

labor is employed in services. 12

The conditions for tourism development are excellent – there are twelve historical monuments

on the UNESCO Heritage list, 13 over 2.000 castles, chateaux and monuments, and more than

40 protected historical towns and cities in the Czech Republic.

Four national parks 14 were established to protect the country´s most rare and valuable nature,

8 mountain ranges, and over 1.200 protected landscape areas and natural spots are covering

more than 10 % of territory of the Czech Republic offering 38.500 km walking trails, 19.024

km cycling routes, 1.240 km skiing tours to visitors. The country is dotted with over 20.000

lakes and ponds and more then 40 water basins.

11 CIA. The World Fact Book – Czech Republic. Downloaded from: (last accessed 7 March 2010)

12 CIA. The World Fact Book – Czech Republic. Downloaded from: (last accessed 7 March 2010)

13 The historic centre of Prague, Český Krumlov, Telč, and Kutná Hora, the pilgrimage church of St. John of

Nepomuk on Zelená Hora at Žďár nad Sázavou, South Moravia´s Lednice-Valtice Chateau and landscape area,

the Archbishop Chateau in Kroměříž with Květná and Podzámecká gardens, South Boheniam village of

Holašovice, Litomyšl Castle, the Baroque Holly Trinity Column in Olomouc, Villa Tugendhat in Brno, and the

Jewish Quarter and cemetery and the St. Prokop Basilica in Třebíč. Downloaded from: (last accessed 7 March 2010)

14 Krkonoše, Šumava, Dyje, České Švýcarsko. Downloaded from: (last

accessed 7 March 2010)

The Czech Republic is rich in spas (over 30), some of them with abundant tradition e. g.

Karlovy Vary, Mariánske Lázně, Luhačovice, Teplice. 15

Spas in the Czech Republic Picture 2

Source: Downloaded from:

(last accessed 7 March 2010)

Wide range of accommodation facilities, e. g. 41 five-star and 360 four-star hotels, 4.082

other hotels and boarding houses, 509 tourist campsites, 941 holiday chalets and 1.772 other

accommodation facilities are at disposal of the visitors. 16

Tourism has grown to be an activity of high importance and significance in the Czech

Republic. Above all after 1989 it becomes an important social and economic force in different

regions of the country.

The development of direct share of tourism on GDP as showed in Table 1 had a positive

tendency up to 1996 when reached its maximum (7.1%) followed by decrease to 3.5 % in


The share of tourism receipts on export reached its maximum in 1997 and 1998 respectively

as showed in Table 1. From 1999 decreasing tendency can be observed as a result of

increasing export incomes.

The share of foreign exchange receipts from tourism on the foreign exchange receipts from

services reached its maximum in 1997 and 1998 respectively as can be observed in Table 1.

Decrease can be seen from 1999 (44.8%), followed by drop to 41.7% in 2002. A light

increase to 45.8% is evident in 2003 followed by drop to 34.7% in 2008.

15 Spa & Wellness Catalogue. Downloaded from:

(last accessed 7 March 2010)

16 Tourism in the Czech Republic. Facts and Figures 2008. Downloaded from: (last accessed 7 March


Share of Tourism on National Economy Table 1


Share of tourism

receipts on GDP (in


Share of tourism

receipts on exports

(in %)

1993 5.0 11.0 33,0

1994 5.5 14.0 43,2

1995 5.6 13.4 42,8

1996 7.1 18.6 49,8

1997 6.9 16.3 50.9

1998 6.8 15.0 50,6

1999 5.8 12.0 44,8

2000 5.9 10.3 43,5

2001 5.5 9.3 43,8

2002 4.2 7.7 41,7

2003 4.2 7.3 45,8

2004 3.8 6.2 43.4

2005 3.7 6.8 39.7

2006 3.9 5.8 39.7

2007 3.8 5.4 38.7

2008 3.5 5.5 34.7

Source: Downloaded from: http// (last accessed 7 March 2010)

Share of tourism

receipts on service

receipts (in %)

Tourism as one of the largest international industries has also a noticeable impact on the

balance of payments of the Czech Republic. The development of the foreign exchange

receipts and expenditure could be divided into two main stages – in the first stage, the

receipts increased and reached its pick in 1996 with 4,1 bn USD, decrease of receipts is

typical to the second stage, especially 1999, followed by 2000. Table 2 shows a light increase

in 2001 but the situation after September 2001 and the floods in 2002 resonated in decrease of

tourism receipts in 2002. The following years – 2003 - 2008 show increase in receipts again.

Foreign Exchange Receipts and Expenditure Table 2




Receipts Expenditure Balance

1992 1.1 0,5 0.6

1993 1.6 0.5 1.1

1994 2.2 1.6 0.6

1995 2.9 1.6 1.3

1996 4.1 3.0 1.1

1997 3.6 2.4 1.2

1998 3.9 1.9 2.0

1999 3.2 1.5 1.7

2000 3.0 1.3 1.7

2001 3.1 1.4 1.7

2002 2.9 1.6 1.4

2003 3.6 1.9 1.6

2004 4.2 2.3 1.9

2005 4.7 2.4 2.3

2006 5.5 2.8 2.8

2007 6.6 3.6 3.0

2008 7.7 4.6 3.1

Source: Downloaded from: http// (last accessed 7 March 2010)

The survey “Incoming Tourism – Number of Visitors and Their Expenditure in the Czech

Republic” was carried out in January 2008 – December 2008. 17 The main objective was to

find out the number of foreign visitors coming to the Czech Republic and their consumer

behavior. Data were collected at selected border crossings, the Ruzyně airport in Prague and 2

railway stations in Prague. 18

According to the survey the main reason for visiting the Czech Republic for foreign tourists

was recreation and entertainment (52.4%), visiting friends and relatives (22.1%), business trip

(20.7%), and others (2.9%).


Tourism the Czech Republic - Facts & Figures 2008. Research by STEM/MARK for Ministry for Regional

Development. Downloaded

from: (last accessed 7

March 2010)


Tourism the Czech Republic - Facts & Figures 2008. Downloaded from: (last accessed 7 March


The main purpose of the one-day visitors coming to the Czech Republic was shopping

(73.7%), business trip (11.5%), recreation and entertainment (6.6%) and visiting friends and

relatives (6.4%).

Health State and Aging - Implication for Tourism

The World Health Organization (WHO) defines health as ‘a state of complete physical,

mental, and social well-being and not merely the absence of disease, or infirmity’. This broad

definition can be applied equally to developed and developing countries and to both genders.

Health is a cumulative state, to be promoted throughout life in order to ensure that the full

benefits are enjoyed in later years. Good health is vital to maintain an acceptable quality of

life in older individuals and to ensure the continued contributions of older persons to

society. 19

Health state is an important part of the standard of living and quality of life of inhabitants of

each country and is perceived as country´s development criteria. Healthy life expectancy

(HALE), defined by WHO as „Average number of years that a person can expect to live in

"full health" by taking into account years lived in less than full health due to disease and/or

injury“ 20 is a indicator which is monitored also in the Czech Republic.

One of the common characteristic features of most European countries is demographic

ageing: it occurs mainly as a result of decreasing or low and stagnant natality, along with

decreasing mortality and related increasing life expectancy. 21 The share of children in the

population diminishes while the share of persons at ages 65 years or more grows. The age

preference index used for comparison of population age structures exceeds the value 100 (i.e.,

the number of persons over 64 years exceeds the numbers of children) 22 in increasing

numbers of countries including the Czech Republic (102.4 in 2007 and 105.1 in 2008). Due to

a marked decrease of natality in the early 1990s it has low proportion of children up to 15

years old (14.2 % in 2008), but it still belongs to countries with relatively low proportion of

persons in the age group of 65 or more years (14.7 % in 2008). The latter proportion will

further increase as the age limit 65 is crossed by the strong generation born after World War


Another common characteristic of all European countries is the decreasing natality that

dropped also in countries where it was traditionally high. In several countries including the

Czech Republic a slow increase can be observed as the number of live born children steadily

grows since 2002, in 2006 the number of live born children per 1 000 inhabitants exceeded

again the value 10 and the value 11 in 2007. 23

The indicator of total fertility, i.e., the average number of children live born to one woman

during her reproductive period, does not reach the limit of simple replacement, i.e., the value

2.1 children per one woman, in any European country including the Czech Republic where

19 Ageing – exploding the myths. Ageing and Health Program (AHE). Geneva WHO, 1999, p. 1–21

20 WHO Statistical Information System (WHOSIS). Healthy life expectancy (HALE) at birth (years).

Downloaded from: (last accessed 7 March 2010)

21 European Health for All Database. Downloaded from: (last accessed 7 March


22 The index is defined as the number of persons aged 65 years or more per 100 children aged 0–14 years.

23 European Health for All Database. Downloaded from: (last accessed 7 March


the total fertility exceeded the value 1.3 in 2006, for the first time since 1994, and in 2007 and

2008 it reached the values 1.44 and 1.50. 24

The increasing ages of first marriage and childbirth are also common trends in all Europe.

Nevertheless, differences between countries of central and Eastern Europe and those of

western, northern and southern Europe still persist. Women in Central and Eastern Europe

begin their reproduction earlier, the trend of postponed childbirth started only in the 1990s. 25

Decreasing mortality connected with growing life expectancy are additional common features

of most European countries. However, marked differences still persist between mortality

levels in Western Europe and in countries of Eastern and Central Europe. Mortality began to

improve gradually in most post-communist countries in the 1990s, along with increasing life

expectancy. The average value of standardized death rate (SDR) shows a long-term

decreasing trend in European Union while the Czech Republic still has higher SDR values

both for men and women than the averages of the whole EU. The most frequent groups of

causes of death are circulatory system diseases. 26

The position of the Czech Republic in Europe remains unchanged, in spite of the fast growth

of life expectancy in the 1990s. Behind countries with the highest life expectancy at birth,

Czech men lag by about 6 years and women by 4 years. The Czech Republic with 3.1 and 2.8

per mille in 2007 and 2008 attains a foremost position in Europe and in the world. 27

Common features of most European countries are decreasing natality and improving situation

of mortality connected with growing life expectancy. This trend results in demographic

ageing of the population. Europe became the oldest-age continent.

The most dominant factors impacting upon the growth of the health spa and wellness industry


• Increasing number of aging “Baby Boomers”– their interest and desire for travel

opportunities that also meet their health needs is becoming a market force that greatly

influences the development of health spa and wellness market. These “new seniors” no

longer conform to the stereotype of an elderly stay-at–home. They are well educated,

independent, able to enjoy life on their own terms, eager to make choices, excited to

learn, living a fast-paced lifestyle, experiencing a sort of personal awakening. 28

• Fascination with fitness and alternative therapies and their use for promoting and

enhancing health and healing; 29 for healthy lifestyle education; for nutrition

counseling; for preventative medicine; for solving personal problems like stress or

depression; for holistic, naturopathic, alternative or eastern medicinal

practices/therapies. 30

24 Ibid.

25 European Health for All Database. Downloaded from: (last accessed 7 March


26 Ibid.

27 Ibid.

28 Péloquin, C.: Are Senior Travelers Really so Different? Downloaded from: (last accessed 7 March


29 Ross, K.: Health Tourism: An overview. In: HSMAI Marketing Review December 2001. Downloaded from:


30 Verschuren, F.: Spa, Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism

Commission. CTC 2004, p. 5.

• Seeking something new and different in a holiday experience. Customers often want

something educational or experiential, and many aspects of health and wellness

tourism also fulfills those requirements.

The Czech Health Spa Industry

There are just a few other activities that can better characterize the economic, cultural and

social development of the Czech Republic in the last decades as health spa industry. Service

development boomed in the last 20 years in the Czech Republic, and health spa industry as an

integrated part of wide service industry boomed as well. The biggest changes can be seen in

privatization and inflow of foreign investment. The role of state toward health spas has

changed indeed although it keeps still its important legislative role.

The Czech health spa industry is an integral part of the European health spa industry history

of which starts in ancient Rome and Greece. It is a matter of fact that in south Moravia the

Romans operated the first spa in the city of Carnuntum in the 3rd century A. D.

The history of Czech health spas development can be sectionalized as follows: 31

• Before 1800 – small number of spas, guests from high society only, little influence of

scientific progress, high social prestige of spa visits.

• 1800 – 1918 – dynamic development, which reached its peak before the World War

1 st , fast growth of number of visits, improvement of transport infrastructure especially

railways, positive impact of science especially medicine, physics, chemistry, changes

in structure of guest with focus on high society, spas are mostly under German


• 1918 – 1945 – health insurance companies as a new element in spa development, spas

are opening themselves to underprivileged. The further development has been

influenced by economic and political situation, post-war restoration, the economic

crises, the 2 nd World War), some of the spas get under, and new substitutes to spa are


• 1945 – 1989 – spas are nationalized (in 1945), more spas get under, changes in

financing system (state and labor union´s influence), most of the spa guests utilize spa

treatments as a part of complex spa care, changes in incoming spa guests´ structure

(most of them came from the socialist countries), high level of spa treatments,

problems in service quality, obsolete spa infrastructure, the average length of stay is

about 25 days, the remedial function of spas are preferred prior to other.

• After 1989 – privatization, direct influence of state failed, but continued in legislation,

quality and variety of services are improved, number of commercial and foreign

guests increased.

The International Spa Association (ISPA) defines spas as places devoted to overall well-being

through a variety of professional services that encourage the renewal of mind, body and

spirit.“ 32

ISPA presumes combined utilization of ten following healing elements: 33

31 Attl. P., Nejdl, K.: Turizmus I. VSH, Praha 2005, ISBN 80-86578-37-2, p. 75

1. Waters - the internal and external use of water in its many forms.

2. Nourishment - food, herbals, supplements and medicines.

3. Movement - vitality and energy through movement, exercise, stretching and fitness.

4. Touch - connectivity and communication embraced through touch, massage and


5. Integration - the personal and social relationship between mind, body, spirit and


6. Aesthetics - concept of beauty and how botanical agents relate to the biochemical

components of the body.

7. Environment - location, placement, weather patterns, water constitution, natural agents

and social responsibility.

8. Cultural Expression - the spiritual belief systems, the value of art and the scientific and

political view of the time.

9. Social Contribution - commerce, volunteer efforts, and intention as they relate to wellbeing.

10. Time, Space, Rhythms - the perception of space and time and its relationship to natural

cycles and rhythms.

Because of the different perception and different historic experience, spas are handed out by

ISPA into seven categories: 34

1. Club Spa - a facility whose primary purpose is fitness and which offers a variety of

professionally administered spa services on a day-use basis.

2. Cruise Ship Spa - a spa within a cruise ship providing professionally administered spa

services, fitness and wellness components, and spa cuisine menu choices.

3. Day Spa - a spa offering professionally administered spa services to clients on a day

use basis.

4. Destination Spa - a spa whose sole purpose is to provide guests with lifestyle choices

improvement, and health enhancement through professionally administered spa

services, physical fitness and exercise, educational programming, such as nutrition and

stress management and a sense of community through such features as on-site

accommodations. Spa cuisine is frequently exclusively served.

5. Medical Spa - a spa whose primary purpose is to provide comprehensive medical and

wellness care in an environment which integrates spa services, as well as conventional

and complementary therapies and treatments.

6. Mineral Springs Spa – a spa offering on-site natural mineral, thermal, or seawater

baths, which are used in professionally administered hydrotherapy treatments.

7. Resort/Hotel Spa - a spa within a resort/hotel that provides professionally administered

spa services, fitness and wellness components and spa cuisine menu choices.

The European Spa Association (ESPA) divides spas according naturally occurring local

remedies, which are the basis for differentiation between several types of spas and health

resorts such as:


International SPA Association's Global Best Practices for the Spa Industry. Downloaded from: (last accessed 7 March 2010)


Ten Spa Domains. Downloaded from:

accessed 7 March 2010)


ISPA Bylaws. Downloaded from:; Verschuren, F.: Spa,

Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism Commission. Canadian

Tourism Commission, Vancouver 2004 (last accessed 7 March 2010)

• Mineral spas;

• Brine spas;

• Thermal spas;

• Peloid spas;

• Spas at the seaside and in a healthy climate;

• Kneipp spas.

According to ESPA „despite common EU law there are still considerable differences in the

use of these remedies depending on the country - definitions, parameters or legal basic

conditions have been developing from different traditions. 35

This overview shows that the ISPA´s perception of spas is wider than the European classical

one – the closest approach to European approach is a destination spa, medical spa and mineral

spring spa. The other categories represent more or less combinations of wellness and fitness

with catering services, or ambulatory services only.

Based on specification above and with focus on European specifics, the Czech health spa

industry can be defined as one which is based on:

• Utilization of natural resources, which are locally bounded, specific and unique;

• Medical character of services and high expertise of the staff, including medical doctors

and medical staff;

• Complex effect of the elements of environment, as a result of mutual action of natural,

cultural, social, architectonic and esthetic elements;

• Traveling to and staying in places outside usual environment what is necessary for

enrichment of the medical treatment;

• Remedy, after-treatment, precaution (especially remedy makes a difference between

health spa and wellness);

• Long lasting beneficial effect of all the above mentioned elements on the guest.

Health spas are classified according to indications - treated diseases in the Czech Republic.

The list of indications is prepared by the Ministry of Health: 36

• A - oncologic diseases;

• B - circulatory diseases;

• C - digestive diseases;

• D - metabolic diseases;

• E - respiratory diseases;

• F - neurological diseases;

• G - musculoskeletal diseases;

• H - urinary diseases;

• I - mental diseases;

• J - dermatological diseases;

• K - gynecological diseases;

• L - Functionally infertile;

• M - Obesity and overweight;

35 Credo of the European Spas Association. Spas and Health Resorts in Europe. Downloaded from:,en/ (last accessed 7 March 2010)

36 Downloaded from: (last accessed 7 March


• N - Postoperative and posttraumatic conditions and convalescence.

Spa care has been traditionally perceived as a part of health and social care system and one of

the 3 pillars of medical treatment in the Czech Republic (besides hospital care and ambulatory

care). The Czech health spa care system consists of:

• Sequential professional spa care;

• Professional spa care for chronic patients;

• Professional ambulatory spa care;

• Professional preventive spa care.

From the point of view of tourism, one of the most important characteristics of health spa care

system is reimbursement of costs. There are four different approaches applied in the Czech


• Complex spa care - fully covered by health insurance companies (excluded travel


• Allowance spa care - medical treatments costs are partly covered by health insurance

companies, catering and accommodation is covered by guests;

• Commercial spa care – all costs are fully covered by guests;

• Ambulatory spa care – guests are staying at their homes and are regularly visiting spa

treatments without utilizing catering and accommodation services. 37

The fundamental economic unit of output in health spa is a nursing day with following


• Investigation and treatment

• Accommodation

• Catering

• Cultural, sport and supplemental activity. 38

The health spa industry is perceived as an important branch of economic activities with long

history. It is a part of the traditional and successful economic activities with positive social,

health, economic, ecological and regional effects.

UNWTO stated spa care as one of the basic motivators in tourism, as it is defined as „the

activities of persons traveling to and staying in places outsider their usual environment for not

more than one consecutive year for lemure, business and other purposes” 39 , but there is still a

discussion among a number of medical doctors and tourism stakeholders in the Czech

Republic on relation and/or interconnection of tourism and health spa.

37 In 2008, as in the preceding years, the predominant part of health expenditure was financed by the system of

public health insurance that covered 76.4 % of the expenditure in the Czech Republic. The State and territorial

budgets covered 7.0 % of the total and private expenditure covered 16.6 %. The relative proportions of these

components remained roughly the same in recent years faster increase is only registered in private expenditure

consisting mainly of expenses of households. Total expenditure on health increased from 2007 by 20 710

mill.CZK and in 2008 their absolute value was 262.645 mill. CZK (i.e. 25.182 CZK per inhabitant). This total

expenditure on health represents 7.12 % of the GDP in 2008. Public expenditure, i.e., that of the public budgets

and of the public heath insurance system, was 219.119 mill. CZK, by 12.554 mill. CZK more than in the

preceding year. The average expenditure of the public health insurance system per 1 client was 19.353 CZK. In:

Czech Health Statistics. ÚZIS ČR 2009. ISSN 1210-9991, ISBN 978-80-7280-845-8

38 This indicator can be used only when the health spa guest employ all above mentioned services.

39 WTO Ottawa Conference on Travel and Tourism Statistsics, 1991. In: Collection of Tourism Expenditure

Statistics. Technical Manual No. 2. WTO, 1995 p. 1, ISBN 978-92-844-0106-2

There is a “rigid medical” approach, a very conservative and protective one which does not

tolerate the coexistence of different forms of health tourism and does not consider health spas

as a part of tourism.

The second, more open approach considers health spa as one of dynamically developing

forms of tourism.

Globalization creates a big pressure to health spa industry as well as the international

competition and the substitutes - there are about 850 spa companies in more than 500 biggest

spa places in Europe.

Czech health spas are visited by 600.000 guests every year. The rate of foreign guest to

residents in spa accommodation facilities was close to one to one in 2008 with a moderate

change for the benefit of residents in 2009 as can be seen from Table 3. About 50% of

international guests come from Germany the second biggest market is Russia, followed by

Austria, Slovakia, the USA, Poland and Israel (Table 3). 40 Guests coming from Germany,

Slovakia and some other countries are often taking advantage from Czech allowance spa care

as the health care system in their home countries allows them to travel for health spa care

abroad and it covers their medical treatments costs.

40 Lázeňský cestovní ruch – komparace zemí střední a východní Evropy. Downloaded from: (last accessed 7 March 2010)

Foreign guests at accommodation facilities (spa): by country

Table 3

Number of guests Index % % Average Number

2009/200 share share length of of nights

2 008 2 009 8 2008 2009 stay

Guests Total 674 313 647 568 96% 11.5 6 689 216

Residents 337 392 341 520 101% 50.03


52.74% 12.8 4 031 776

Foreign Guests 336 921 306 048 91% 49.97 47.26% 10.1 2 657 440



1 Germany 193 799 176 560 91% 57.52


57.69% 9.3 1 471 844

2 Russia 68 237 54 102 79% 20.25


17.68% 13.7 685 800

3 Other Asian 21 699 22 535 104% 6.44% 7.36% 7.2 139 052



Ukraine 7 893 6 456 82% 2.34% 2.11% 13.3 79 433

5 Austria 5 396 5 515 102% 1.60% 1.80% 6.9 32 294

6 Israel 4 339 4 466 103% 1.29% 1.46% 13.8 57 215

7 Other



4 822 4 365 91% 1.43% 1.43% 9.9 38 676

8 Slovakia 3 594 4 345 121% 1.07% 1.42% 5.1 17 999

9 U.S.A. 3 315 3 304 100% 0.98% 1.08% 9.8 29 183



Poland 3 301 3 012 91% 0.98% 0.98% 4.6 10 981



France 1 847 1 907 103% 0.55% 0.62% 4.5 6 666



Italy 1 474 1 802 122% 0.44% 0.59% 5.3 7 806



UK 1 692 1 592 94% 0.50% 0.52% 4.6 5 708

1 The

1 531 1 421 93% 0.45% 0.46% 6.8 8 225

4 Netherlands



Switzerland 1 246 1 252 100% 0.37% 0.41% 5.3 5 347



Belgium 741 1 124 152% 0.22% 0.37% 5.1 4 602



Sweden 878 1 081 123% 0.26% 0.35% 5.1 4 478



Hungary 1 252 1 081 86% 0.37% 0.35% 3.8 3 048



China 1 014 1 044 103% 0.30% 0.34% 2.2 1 223

Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8

Table 4 shows a systematic increase in number of guests and number of nights from 1997, but

decrease in average length of stay although it is still quite high – 10.1. This average length of

stay is motivated by focus on health spa care as a remedy and by cost reimbursement of spa

care by health insurance companies.

Foreign Guests at Health Spa Accommodation Facilities Table 4

Year Number of Guests

Average Length of


Number of Nights

1997 98 054 10.9 968 576

1998 119 772 11.6 1 269 054

1999 117 635 11.3 1 207 287

2000 114 975 11.8 1 238 579

2001 128 244 12.1 1 425 347

2002 125 936 12.8 1 485 997

2003 123 242 12.9 1 465 567

2004 131 476 12.2 1 473 570

2005 228 110 10.9 2 265 149

2006 295 911 10.3 2 831 269

2007 317 023 10.2 2 904 923

2008 336 921 10.1 3 059 764

Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8

Table 5 shows that the occupancy of health spa accommodation capacities is increasing

systematically from 2000 for the benefit of residents. The similar development can be seen in

the number of overnight stays.

Occupancy in Health Spa Accommodation Facilities in the Czech Republic Table 5

Czech Republic Total

Year Number of




Number of





1=2+3 2 3 4=5+6 5 6

2000 437 308 176 387 260 921 5 709 748 1 658 234 4 051 514

2001 435 200 203 166 232 034 5 983 085 2 028 945 3 954 140

2002 451 505 201 028 250 477 6 431 035 2 139 202 4 291 833

2003 450 346 202 126 248 220 6 509 168 2 198 472 4 310 696

2004 481 120 217 134 263 986 6 538 058 2 215 747 4 322 311

2005 497 248 234 141 263 107 6 557 320 2 336 223 4 221 097

2006 571 101 295 911 275 190 6 743 893 2 831 269 3 912 624

2007 650 667 317 016 333 651 7 163 718 2 904 912 4 258 806

2008 674 313 336 921 337 392 7 045 620 3 059 764 3 985 856

Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8

Table 6 shows the number of guests in health spas according to costs reimbursement. It is

visible that the number of complex spa care guests as well as the allowance spa care guest is

decreasing for the benefit of commercial spa care guests in both groups – residents and nonresidents

as well.

Number of Guests in Health Spas According to Costs Reimbursement Table 6




2004 2005 2006 2007 2008

Complex Spa


112.670 105.324 94.429 92.605 91.488


Spa Care


19.147 18.253 18.572 15.708 15.149

Spa Care 45.282 55.853 66.688 91.896 112.987






117.003 119.929 134.518 133.761 153.704


Total 294.102 299.359 314.207 333.970 373.328

Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8

While the minimum length of stay for complex and allowance spa care was traditionally 21

days, the average length of stay decreased to 18.4 days in 2004 followed by additional

decrease to 14.8 days in 2008 in the Czech Republic.

There is no official statistics on age structure of health spa visitors in the Czech Republic. The

only research in this field was conducted by the agency Psyma in 2002. As it can be seen from

Table 7 the most important group is a group of 60 years old guests (53.06%), the second

important group is the one of 30 – 44 years old guests (10.88), followed by the group of 45 –

59 years old guest (3.25%). It is assumed that the number of guests in the group of 45 – 59

years old increased in the last decade.

Age Structure of Health Spa Visitors in the Czech Republic Table


Country of


Age Structure in %

0 -14 15-29 30-44 45-59

60 and


Unlisted Total

Germany 0.22 1.29 6.58 21.25 68.72 1.94 100.00

Russia 1.25 0.83 18.67 50.62 17.01 11.62 100.00

Israel 0.00 5.63 8.45 39.44 46.48 0.00 100.00



0.00 0.00 19.05 31.75 47.62 1.58 100.00

Netherland 0.00 0.00 12.50 18.75 68.75 0.00 100.00

Switzerland 0.00 0.00 14.29 42.86 38.09 4.76 100.00



0.00 3.03 18.18 60.61 18.18 0.00 100.00



0.00 0.76 21.21 63.64 14.39 0.00 100.00



0.00 9.37 9.37 15.63 62.50 3.13 100.00

Total 0.31 1.44 10.88 3.25 53.08 3.06 100.00

Source: Psyma, Prague 2002

The CzechTourism agency conducted a visitor monitoring in Western Spa Region in summer

and winter seasons 2005. 41 According to this monitoring 65% of all summer visitors are

residents, 58% of foreign visitors come from Germany, 6% from Russia. Two third of visitors

reached the destination by car, 28% of them arrived from places more than 100 km remote

from the destination. The average length of stay of 1/5 of visitors is 7 days, 2/3 of them stay

longer than 1 day and 2/3 are frequent visitors. 45% of visitors prefer to stay in hotels and

43% prefer to eat in restaurants. Among the main motives visitors indicated was learning

about new places (30%), relax (15%), and health (15%). 95 % of all respondents were looking

for information in tourism guides and Tourism Information Centers.

Sixty eight per cent of all winter visitors are residents, 67% of foreign visitors come from

Germany. Two thirds of visitors reached the destination by car, 48% of them arrived from

places more than 100 km remote from the destination. More than 55% of all visitors stay in

the destination longer than 1 day, the average length of stay of 18% of visitors is 7 days. 45%

of them prefer to stay in hotels and 36% prefer to eat in restaurants. Among the main motives

winter visitors indicated was learning about new places (21%), visiting family (15%), and

health (11%). 89 % of all respondents were looking for information in tourism guides and

Tourism Information Centers, 55% used Internet as information tool.

The Place of Wellness in the Czech Republic Tourism Industry

The term “wellness” was originally used by Halbert L. Dunn in the book “High Level

Wellness” released in 1961 42 when he connected the word well-being with the word fitness.

41 Monitoring of Visitors in Czech Republic Regions – Profiles of Tourism Regions. Downloaded from: (last accessed

7 March 2010)

42 Ardell, D.: What is Wellness. 2000. Downloaded from: (last accessed 7 March 2010)

M. Zuckerman defines wellness as programs devoted to an individual’s health and fitness,

designed to make the guests feel significantly better than when they arrived. The combination

of fun, exercise, a healthy and balanced diet, pampering relaxation, and education on

managing stress offers magnificent chance for renewal. According to Zuckerman a spa is a

comfortable environment in which guests learn how to use the tools of life enhancement and

get motivated to go back into the real world and practice what they have learned. 43

M. Joppe emphasizes the holistic aspect of wellness products and identifies some of the daily

stressors that drive users to access these services. 44

Some researchers propose that there are four essential ingredients associated with wellness:

• A lifelong approach emphasizing permanent lifestyle changes;

• Taking responsibility for one’s own actions;

• Adding to the quality of one’s life, not simply extending the length of life;

• Making choices that improves an individual’s position on the lifestyle continuum. 45

According to German experts, numerous definitions of wellness share common features: the

importance of life style, self-responsibility for health, and the exploitation of a person’s

potential for a better quality of health. 46

By many accounts, wellness can be seen as a state of health featuring the harmony of body,

mind and spirit with physical fitness, healthy nutrition and diet, relaxation, meditation, mental

activity/learning, environmental sensitivity and social contacts, a process in which an

individual makes choices and engages in activities in a way that leads to health-promoting

lifestyles, which in turn positively impact the multiple dimensions of the individual’s well

being. 47

Wellness is a dynamically developing industry in the Czech Republic with start-up around

2000. There is no widely accepted definition of wellness and the way how it is perceived is

very different. There are three main views on wellness in the Czech Republic:

Wellness is a heterogeneous element which does not come under spa care and had not

had to be a part of health spa facilities or of spa destinations.

Wellness is an appropriate supplement to spa care which can under the correctly

defined condition be a part of spa destinations but not a part of health spa facilities

(some experts accept wellness as a part of health spa facilities).

Wellness is a part of all health spa facilities, with no contradiction between spa care

and wellness.


Verschuren, F.: Spa Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism

Commission, Canadian Tourism Commission, Vancouver 2004.


Joppe, M.: The Impact of the Wellness Revolution on the Spa Industry. 2003


Adapted from: Cardinal, B. J., Krause, J. V.: Physical Fitness: The Hub of the Wellness Wheel. Dubuque:

Kendell Hunt Publishing 1989.


Mueller, H., Lanz Kaufmann, E.: Wellness Tourism: Market analysis of a special health tourism segment and

implications for the hotel industry. University of Berne, Switzerland: Research Institute for Leisure and Tourism

2004. Downloaded from: (last accessed 7 March



Finnicum, P., Zeiger, J. B.: Tourism and wellness: A natural alliance in a natural state. Parks and Recreation.

Vol. 31, Issue 9/1996, p. 84

The above mentioned conditions are defined by the German Health Spa Association as


• The wellness facility is managed by a medical doctor;

• The medical doctor is at the disposal of the guests;

• The staff is qualified;

• Integrated concept;

• Stability of offer;

• High quality of equipment;

• Documented quality management. 48

Some experts define “wellness tourism” as a “the sum of all the relationships and phenomena

resulting from a journey and residence by people whose main motive is to preserve or

promote their health.” 49

Wellness tourism activities prevent illness and preserve, promote or enhance overall health

and well being of people and their desire to prevent problems so they stay well, both

physically and mentally.

Based on the above remarks, it can be stated that health spa and wellness are two different

products although there is a lot of overlap between them, especially in terms of their markets

and in terms of the range of services offered.

Tourists who are generally healthy are motivated to travel so that they can experience

therapies and activities that will promote, enhance, and otherwise maintain a sense of well

being. Tourists with various medical conditions are motivated to travel so that they can

experience therapies that will help to make them well or to improve their health.

To be able to consider complementary or competitive relation between health spa and

wellness in the Czech Republic, a field study took place in November 2009. The field study

comprised a survey consisting of in-depth face-to-face interviews of 25 health spa and

wellness managers and other stakeholders including 50 guests. The management has been

contacted individually. Interviewees were contacted during regular operation days. Each

interview took 25 minutes and was conducted in a structured fashion. Each of the topics was

introduced by an open-ended question.

Given the qualitative nature of most of the information gathered and the size of the sample,

the survey responses were not amenable to statistical analysis. The findings are, therefore,

generally qualitative and descriptive.

The main problem in the field of health spa and wellness coexistence, seen by interviewed

managers, is in perception of both by medical doctors managing health spas. Traditionally, a

health spa manager had to be an experienced medical doctor responsible for all parts of

nursing day.

48 Medical Wellness. Gemeinsame Erklärung bzw. Letter of Intent. Deutcher Heilbäderverband. Downloaded

from: (last accessed 7

March 2010)

49 Iibid.

Today´s health spa hotels are mostly managed by managers graduated from business or

tourism schools but the investigation and treatment part of the hotel is managed by medical

doctors. Most of them represent the conservative approach on health spa and they do not

tolerate the coexistence of different forms of health tourism and do not consider health spas as

a part of tourism. Their view on wellness as a heterogeneous element which does not come

under spa care and had not had to be a part of health spa facilities or of spa destinations is at

the same time a very rigid one.

Managers, who consider health spa as one of the dynamically developing forms of tourism,

understand also the role of wellness as well as an appropriate supplement to spa care or even a

part of health spa facilities.

From the point of view of both approaches there is a difference among complex spa care

guests, allowance spa care guests and commercial spa care guests. The complex spa care

guests must fully regularize themselves to complex spa arrangement. The allowance spa care

guests have more free scope in the field of accommodation and catering, as well as cultural,

sport and other services. They can make changes in treatments with permission of the health

spa medical doctor. Commercial spa care guests are independent guests who have free scope

in the field of accommodation and catering, as well as cultural, sport and other services. All

changes in treatments must be discussed by a medical doctor.

Health spas managed by medical doctors are strongly oriented on particular components of

health spa care system and wellness components are incorporated into product offered to

guests as sport activities only. According to diagnosis guests always receive tailored treatment

with the possibility to order additional treatments on a commercial basis.

Managers, who consider health spa as one of dynamically developing forms of tourism,

understand also the role of wellness as an appropriate supplement to spa care or even a part of

health spa facilities. They are regularly innovating products offered to customers and looking

for new opportunities as wellness which they incorporate into their offer.

Such health spa facilities offer different types of massages (e. g. thai, reiki, chocolate, honey,

stone, and alike) meditation therapies, drum circles, beer or wine bath, salt caves, Nordic

walking, yoga, oxygen therapy, crymotherapy, Finish sauna, Russian bath, Turkish bath,

phototherapy, sound therapy, special food arrangement, possibilities to learn about nutrition

and healthy food preparation practices and alike.

Managers observe some trends in health spa which bring health spa close to wellness and can

be defined as follows:

• Shorter length of stay (the most common is a long weekend stay – 3 nights);

• Higher number of frequent visitors (visiting a spa 3 or more time per year);

• Increasing number of guest from 25 – 40 age group;

• Demand for special packages (Eastern, Christmas, New Years Eve, etc.);

• Demand for special events in spas (wedding party, birthday party, etc.);

• Demand for special targeting packages (weight-loosing, anti-stress, managerial,

women, etc.);

• Demand for special/exotic treatments (massages, catering, training, etc.);

• Demand for additional services e. g. cosmetics, manicure, pedicure, visage,


• Demand for some plastic surgery treatments e. g. botulotoxine, hyalurone acid, laser

therapies, chemical scrubbing, etc.

Based on of visitor survey (commercial health spa care guest have been asked) the following

results can be presented:

• 84.2 % of guest were satisfied with the quality of accommodation services;

• Satisfaction with quality of catering services was pointed out by 81.5 % of guests;

• 78.3 % of guests were comfortable with medical treatment;

• 82.6 % of guest were happy with quality of professional medical staff;

• The health spa environment was satisfactory for 82.7 % of guests;

• 82.9 % of guests were pleased by service staff quality;

• Cultural offer was satisfactory for 58.9% of guests;

• Sport offer was treated as satisfactory by 48.8 % of guests;

• 63.8 % of guests consider shopping facilities as satisfactory;

• Tourist information services were satisfactory for 69.4 % of guests;

• Tourists attractions were consider by 69.1 % of guests as satisfactory;

• Supplementary services were perceived by 59.8 % guest as satisfactory;

• 72.7 % of health spa guests were happy with services as a whole.

To the most frequently indicated remarks belong those on sport, culture, information,

attraction, shopping, and supplementary services offer. Today´s guest visiting a health spa

want to combine spa treatment, fun, exercise, a healthy and balanced diet, education on

managing stress, education on relaxing methods, rejuvenation, image and visage counseling,

personal couching, etc.

Based on the results of exploratory research and well-founded with showed statistics it can be

stated that there is no competition between health spas and wellness in the Czech Republic.

Wellness is a complement to health spa and in some ways both blend together.

Through industry research ISPA has pinpointed the following spa trends for 2010: 50

• Social Media – Twitter and Facebook are used by health spa and wellness industries to

attract visitors.

• Customer Service - Consumers are more aware of every coin spent, and with that

comes higher expectations on the level of service they receive. Spas will respond by

providing exceptional service and making each visits a customized experience for the

guest. Implementation of customer feedback mechanisms and customer loyalty

programs should help to win frequent visitors.

• Spa Sampling Menu - Mini services at lower price points are popular ways to get a

taste of treatments offered at health spas and wellness as well.

• Preventive Care - According to the World Health Organization, by 2020 the top five

diseases will all have the underlying contributing factor of stress. Spa treatments like

massage, acupuncture and meditation have been proven to aid in stress reduction and

recovery time for pre and post-op patients.

• Spa Partnerships - Spas are becoming more accessible through partnerships with

established franchises, hotels and local businesses. Popular partnerships include:

developing wellness programs at local hospitals, accommodating guests at local hotels

50 2010 International SPA Association Trend Watch. 11/17/2009. Downloaded from: (last accessed 7

March 2010)

without spa facilities and service discount trades between spas and local business


• Cell Phone Applications - Spa-ing is easier than ever with the convenience of doing it

from cell phone. Internet application allows customers to browse health spa or

wellness services and check room availability.

• Giving Back - Spas are offering promotions and free services to people who serve the

community such as teachers, hospice workers and military personnel. Some spas are

teaming up with local hospitals and providing wellness education to help educate

consumers on the spa lifestyle. Community outreach is a great way to generate

business and show how easy it is to incorporate spa into once life.

• The Millennials Take Over - This group now outnumbers the baby boomers. They

grew up in a culture where taking care of themselves, learning proper grooming

techniques and leading a healthy lifestyle were not options, but the norm.

• Simplified Spa Menus - Everyone is cutting back and spa menus are no exception. The

No. 1 spa treatment that people seek out world wide is massage because of its healing

and stress-reducing benefits. And, the No. 1 reason people go to the spa is to

relieve/reduce stress and relax.

• Beauty Rest - The spa makes rest a priority by offering treatments targeted to get guest

some shut eye. They can actually book time to sleep at the spa or stay after a

treatment to take a nap when they are feeling relaxed.


The Czech Republic combines a number of important attributes as a health spa destination

with a long lasting tradition of health spa culture. More than 30 health spas including climatic

spas, healing hot and cold springs, healing torf and mud - all for treatment and recuperation

and a high standard of services at cost–effective rates makes the Czech Republic an attractive

destination for health spa visitors.

Wellness as a part of tourism industry has a shorter tradition in the Czech Republic but

develops fast. It is an important supplement to health spas with a wide spectrum of treatments

and services offered to visitors often making each visit a customized experience for them.

The Czech health spa industry is an important part of Czech tourism industry with a wide

potential of development including wellness as a complement to health spa care. Relaxation

and stress reduction, healthy lifestyle, self-responsibility for health are reasons why people

visit health spas and wellness. Health spa and wellness is not a luxury; it is a necessity to a

healthy lifestyle.

Today´s health spa and wellness visitor seeks to look and feel better; to lose weight; to slow

the effects of aging; to relieve pain or discomfort; to manage stress or depression; to improve

fitness level; to experience holistic, naturopathic, alternative, complementary or eastern

medicinal practices and/or therapies. Treatments like massage, acupuncture and meditation

often belong to standard spa and wellness offers.

Health and wellness are all-season activities for visitors. They are booking their stay during

all seasons including off seasons which greatly contributes to making the health spa and

wellness industry available any time of year.


2010 International SPA Association Trend Watch. 11/17/2009. Downloaded from:


Ageing – exploding the myths. Ageing and Health Program (AHE). Geneva WHO, 1999

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Finnicum, P., Zeiger, J. B.: Tourism and wellness: A natural alliance in a natural state. Parks

and Recreation. Vol. 31, Issue 9/1996, p. 84

ISPA Bylaws. Downloaded from:;

International SPA Association's Global Best Practices for the Spa Industry. Downloaded


Joppe, M.: The Impact of the Wellness Revolution on the Spa Industry. 2003

Lázeňský cestovní ruch – komparace zemí střední a východní Evropy. Downloaded from:

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Monitoring of Visitors in Czech Republic Regions – Profiles of Tourism Regions.

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Mueller, H., Lanz Kaufmann, E.: Wellness Tourism: Market analysis of a special health

tourism segment and implications for the hotel industry. University of Berne,

Switzerland: Research Institute for Leisure and Tourism 2004. Downloaded from:

National Parks in the Czech Republic. Downloaded from:

Péloquin, C.: Are Senior Travellers ReAlly so Different? Downloaded from:

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Ross, K.: Health Tourism: An Overview. 2001. Downloaded from:

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Tourism Commission. Vancouver CTC 2004, p. 5.

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Raija Komppula, professor

Juho Pesonen, researcher

Centre for Tourism Studies

University of Eastern Finland

P.O.Box 86



The aim of this paper is to compare rural tourism motivations with the motivations of

wellbeing tourists, and investigate, if rural tourism could be seen as a form of wellbeing

tourism. A questionnaire was developed based on literature on wellness and rural tourism

motivations. Data were collected on a Finnish rural tourism website during summer 2009.

Altogether 727 responses were analysed using K-mean cluster analysis to create segments.

The results show that among Finnish rural tourists a segment of rural wellbeing tourists can be

distinguished. The segment values significantly more such factors as relaxing away from the

ordinary, escape from a busy everyday life, hassle-free vacation, getting refreshed, having a

sense of comfort, and having an opportunity for physical rest than the other segments. A

typical rural wellbeing tourist is a 45-54 year old female, who has lived her childhood in the

countryside. She travels with her spouse less than once a year to a rural destination.

Key words: wellness tourism, wellbeing tourism, rural tourism, tourist motivation, tourist



Although wellness tourism is one of the most ancient forms of tourism, there has been an

exponential growth in the pursuit of wellness in the history of tourism in recent years (Smith

and Kelly 2006). Centuries ago tourism destinations developed around unique natural features

such as mineral healing waters, beach and mountain resorts and sacred sites (Sheldon & Park

2009). Today wellness tourism comprises a broad range of tourist motivations and benefits of

the product. A categorization of Sheldon and Bushell (2009) suggest six types of wellness

tourism: medical, health, sport and fitness, adventure, wellbeing and transformation.

According to Smith and Puczkó (2009) the concept of wellness contains elements of lifestyle,

physical, mental, and spiritual wellbeing, and one’s relationship to oneself, others, and the

environment. Several concepts, such as well-being, happiness, quality of life, holistic practice

and spiritual beliefs relate to the concept of wellness. (Smith and Puczko 2009, 12)

Tourists are pushed by their own motivation towards the places where they expect their needs

will be satisfied (Leiper 1990). The push motivations have been seen to be useful in

explaining the desire for travel, as they are recognized as the starting point of understanding

tourists’ behavior (Crompton, 1979). Pull factors are those that attract people to a specific

destination once the decision to travel has been made. They are destination-specific attributes,

such as natural attractions, food, people, recreation facilities, or activities, which determine

whether the traveler will go to destination A or B, if both destinations fulfill the expectations

derived from the push factors. The aim and desired outcome of the tourist product for the

customer is value, which at each given time is a subjective experience (e.g. Gunn 1994).The

basis for value expectancies in tourism can be derived from the person’s underlying holidaytaking

motivations (e.g. Ryan 1997, 28).

In terms of push factors, wellness tourists are likely to be ’Active Health Seekers’ who are

highly motivated and determined to play a role in their own health. Smith and Kelly (2006)

present dimensions of wellness tourism, where various motivations refer to different kinds of

wellness tourism locations and activities, which refer to pull factors. According to Smith and

Kelly (2006) the destination in wellness tourism is often an alternative space in which one can

engage in self analysis without the stresses and distractions of home. For example, tourists

motivated by escapism and relaxation may prefer beach, spa and mountains, and those with

existential and psychological motivations may be interested in holistic centres focused on self

development and philosophical contemplation. According to Kulczycki and Lück (2009) a

substantial number of tourists highlight the importance of a specific location on their travels.

As wellness tourism is usually connected to luxury products and five-star hotels, in Finland

the concept of well-being tourism is often used instead, containing products and services from

a wider scale than the concept of wellness. It can include pampering, activities and

experiences of luxury, but is does not necessarily require high-class hotels (Konu et al. 2010).

According to Park and Reisinger (2009) luxury may refer to uniqueness, excellency,

sensuality, dream or superior quality and high price, but it may also refer to as difficult to

obtain, a means to reach happiness, personally rewarding, providing emotional benefits or

intrinsically rewarding. It must also be noted that luxury is dependent on the subjective and

situational perceptions of consumers, and is also understood differently across cultures (Park

& Reisinger 2009). Wellbeing tourism is mentioned also by Sheldon and Bushell (2009) as

being one of the types of wellness tourism. Wellbeing refers to a connection with community

or nature, inner and outer beauty therapy, massage, spas, sauna, relaxation, energy balancing,

art, music and diverse treatments (p. 10). Nevertheless, Sheldon and Bushell do not discuss

the level of quality, price or luxury of the offering in their typology.

According to Konu et al. (2010), the positioning of Finnish wellbeing and wellness tourism

should necessarily be based on the best natural resources, namely the lakes. The Lakeland

Finland, Eastern part of Finland, is an area where rural tourism is a predominant form of

tourism offering. Rural tourism typically refers to tourism outside densely populated areas and

tourism centres. In some countries, the term farm tourism (agritourism, agrotourism) is

synonymous with rural tourism. In many countries, rural tourism is understood to be more or

less synonymous with nature tourism or at least travelling in nature (Komppula 2007).

A typical Finnish rural holiday includes accommodation in a cottage, local food, sauna and

some kind of nature activities: swimming, rowing and walking in the forest. Rural tourism

establishments are often located in remote countryside, far away from neighbors. Villages and

services (shops, restaurants etc.) are often in a distance of several kilometers from the site.

Most common is a holiday in a self catering cottage, but also accommodation in B&B

establishments is available as well as half board or full board holidays with versatile services.

The largest intermediary of rural holidays is Finnish Country holidays Ltd, which has around

2700 cottages for rent. Nevertheless, a significant part of around 4000 rural tourism

enterprises sell and market their services directly and together with regional tourism

organizations to the potential customers.

According to several studies on rural tourism, many of the rural tourists are motivated by the

same factors as wellbeing tourists: they seek relaxation, escape from busy job, peace and

quiet, sports, and healthy gastronomy. A rural holiday as a product means peace and quiet, an

easy-going and warm atmosphere, nature, scenery and activities related to nature.

Interestingly, a new Finnish website (wellbeingtourism) presents

a wellbeing tourism network of one traditional spa and a fitness centre, one college of

physical education and five rural tourism enterprises. This is an example of the growing

interest of rural tourism enterprises in developing their services towards wellbeing offering.

Because of this growing interest of rural tourism sector in Finland in developing wellbeing

services there is a need for understanding customer needs and expectations. In this paper, our

aim is to compare rural tourism motivations to the existing research on motivations of

wellbeing tourists. The purpose is to investigate if there are similarities in motivations of rural

and wellbeing tourists and if rural tourism could be seen as a form of wellbeing tourism.

Motivations of wellbeing tourists

Despite the remarkable interest in wellness tourism, motivations influencing consumers’

desire to make a wellness holiday is almost an unexplored phenomenon (Bushell and Sheldon

2009, Chen and Prebensen 2009). Studies showing empirical evidence of wellness tourist

motivations are few, mostly referring to spa goers or spiritual tourists (Smith and Puczkó

2009). Out of the 17 wellness tourism case studies in the book of Smith and Puczkó (2009)

the great majority is about spas. Also their profiling of wellness visitors has a strong

emphasis on spa goers, differentiating types of wellness into four different types of spas

(traditional spas, hotels and day spas, purpose built recreational spas, seaside resorts and

thalassotherapy centres) and five other types of wellness, namely holistic retreat centres, yoga

centres, meditation retreats and medical centres (p. 134).

A study of Mak et al. 2009 examines the underlying factors that motivate travelers to search

for spa experiences. Based on the findings from a focus group interview and a review of

literature, an instrument consisting of 21 motivating items was developed and used in a survey

of Hong Kong spa-goers. From the individual items Seek physical relaxation, Pamper oneself,

Reward oneself for working hard, Seek mental peacefulness, Get away from the pressures of

work and social life and Improve overall health were the most important motivators.

According to Mak et al. (2009) luxury does not seem to be an indispensable attribute of a spa

experience, since Indulge in luxurious experience was rated only the 10 th important

motivating factor after Seeking spiritual refreshment and Getting away from daily routine.

Items relating to family togetherness or fostering friendship ties were rated as less important

factors, and the least important were factors relating to loosing weight and being fashionable.

Of the five factors identified, Relaxation and relief had the highest mean score and was

considered as the most important of the motivating factors of spa goers. The Escape factor got

the second highest grand mean. This factor was comprised of the items Get away from the

pressures of work and social life and Get away from daily routine.

In a study conducted by Koh, Yoo and Boeger (2010) the purpose was to identify market

segments among spa goers, based on a set of 21 important reasons for visiting a spa. These

benefit variables were identified through a three-stage process and a pilot study. Four factors

were identified, namely Social, Relaxing, Healthy and Rejuvenating. Social factor illustrate

the desire to share a special, pleasant experience with family and friends while relaxing and

meeting other health-conscious people in a spa setting. The factor Relaxing indicates the

desire to relieve stress in a tranquil setting and to escape the daily routines. Healthy equates

the spa experience with improving mental and physical health, and Rejuvenating focuses on

experiences that renew the spirit. The results of a cluster analysis showed that spa goers could

be grouped into three distinct segments according to benefit variables. One group was named

hedonists due to their extreme responses: for this group “social” rated 4.36, relaxing 4.78

healthy 4.65 and rejuvenating 4.78 on a five point Likert scale. In contrast, Escapists want to

relax and rejuvenate. The third group, Neutralists, only want to relax and are not concerned

with socializing, improving their health or rejuvenating.

The results of Chen and Prebensen’s (2009) study in three upscale Taiwanese wellness resorts

showed that beyond body pampering, wellness seekers are interested in pursuing other leisure

activities as well. Relaxation, recreation and experiencing nature were popular motivators for

Taiwanese wellness tourists. In addition, Smith and Puczkó (2009) present a review on few

findings about motivations of holistic tourists, yoga tourists, New age tourists, spiritual

tourists and medical tourists. They conclude that there is a clear need for more research on

various sub-sectors of wellness tourism.

Motivations of rural tourists

Studies on motivations of rural tourism are more common than those of wellness tourism.

According to Cai and Li (2009) several earlier studies indicate that rural tourists are most

often motivated by opportunities to learn and explore nature or different cultures, participate

in outdoor activities or search for peace and solitude. They may expect peace and quiet,

friendly reception, change from routine and good food. In a study of Frochot (2005) in two

Scottish locations one of the four rural tourist segments, which were based on the desired

benefits, was Relaxers, who were mainly seeking relaxation and had a lower participation rate

in most activities. They took shorter holidays than the other segments but had a higher

recurrence of countryside holidays. These findings are also supported by Royo-Vela’s (2009)

results in Spanish context.

According to the results of Park and Yoon (2009) in Korea rural tourism is an extremely

diverse sector leading to a wide range of visitors’ needs and expectations. Relaxation

represented a central distinguishing motivational theme among rural tourists, reflecting an

intrinsic emotional element. Relaxation factor consisted of items like getting refreshed, escape

from a busy job, relaxing away from the ordinary, having no rush, being physically active,

and feeling at home away from home. Also Molera and Albaladejo (2007) share the notion of

rural tourists being a heterogenous segment with diverse motivations. In their study push and

pull motivations were included in the same factor analysis. Items like calm atmosphere, non

crowded place, relaxation, attractive landscape, and independency and flexibility formed the

factor Nature and peacefulness. In their cluster analysis 25 % of respondents put a high value

on this factor, giving a low value to activities. This result is congruent with the findings of

Frochot (2005).

According to Komppula (2005) also Finnish rural tourists expect to have a peaceful, quiet and

rush-free country holiday. For Finns, nature, particularly lake and forest scenery, is a selfevident

part of a rural vacation. For both target groups, families and those travelling with

other adults, the destination should be such that it is possible, on the one hand, to enjoy peace

and quiet on one’s own, and, on the other hand, to have interaction with the other visitors. The

choice of rural tourism as the type of holiday seemed to be related to the respondent’s own

background: the countryside was felt to be part of one’s own roots and the countryside

brought back positive childhood memories in the respondents (Komppula 2005). Zamora et

al. 2004 also propose that the rural origin of a tourist has a positive effect on his willingness to

pay for a rural holiday, despite the current settlement in the city.

Method and data

In several studies these factors have also been identified as motivators of rural tourists. In our

empirical study the aim is to find out if it is possible to distinguish a special wellbeing

segment among customers interested in rural tourism in Finland. The target group of the study

was potential rural tourism customers in Finland, which were supposed to be found among

visitors of the website of Finnish Cottage Holidays, the oldest, biggest and best known

intermediary organisation on rural tourism services in Finland.

Data were collected on the Finnish Cottage Holidays website during

summer 2009. Respondents were asked to state their interest in rural holidays and provide

information on what kind of rural holiday they are planning to have or would like to have.

Also a wide range of questions on travel motivation were asked. Altogether 1043

questionnaires were completed by users of the website, of which 316 had to be deleted

because of missing answers. That left 727 filled questionnaires which were suitable for the

analysis methods used in this study.

This study uses k-mean cluster analysis to create segments based on 31 motivation statements

(scale: 7-point Likert, ranging from not at all important to very important) based on the

literature on tourist motivation and customer value in tourism, especially in rural tourism

context. The respondents were asked to assess, how important they find the statements when

considering a holiday in the countryside. The variables were based on a literature review on

rural tourism segmentation studies (Frochot 2005, Molera and Albaladejo 2007, Park and

Yoon 2009, Pesonen, Komppula and Laukkanen 2009, Royo-Vela (2009) as well as studies

on customer value, and experiences in tourism (Otto and Ritchie 1996, Tapachai and

Waryszack 2000, Williams and Soutar 2000, Duman and Mattila 2003, Komppula 2005,

Sánchez, Callarisa, Rodríguez and Molinar 2006, Gallarza and Gil 2008).

Typical problem with cluster analysis has been that respondents’ answering pattern affects the

formation of clusters (see e.g. Laukkanen 2007). To avoid this, average mean score across all

motivation statements was calculated for each respondent and it was used to calculate relative

importance of each item for each respondent. Final number of clusters was determined by

examining graphical results (dendogram) and the best discrimination result between the

groups. Clusters were compared using ANOVA. Because multiple tests were computed based

on the same data sets, p-values had to be Bonferroni corrected (Boksberger & Laesser 2009).

In this analysis in hand, attention was paid to motivations usually connected with wellbeing

tourism, namely items that refer to family togetherness, hassle-free time, escape from a busy

everyday life, getting refreshed and pampered, relaxing away from the ordinary, having

opportunity to physical rest and activities, having sense of comfort, and having chance to

meet interesting people.


Different cluster solutions using k-means clustering were used to find the correct number of

segments. Trials with two to seven clusters were executed. Final cluster solution of four

clusters proved to be the most meaningful based on the results of the cluster formation and

discriminant analyses.

Results of the discriminant analysis reveal that the travel motivations I would like to relax

away from the ordinary, I would have a feeling of romance and I could visit places my family

comes from have most discriminating power between all clusters (in descending order). Three

discriminant functions were generated. Function 1 explains 72.3 % of variance with

eigenvalue 3.668, function 2 explains 18.2 % of variance with eigenvalue 0.924 and function

3 explains 9.5 % of variance with eigenvalue 0.481. Based on the classification matrix, 95.0

% of all cases are correctly classified.

The results of the cluster analysis are presented in Table 1. Two motivations, I would have a

feeling like I was being pampered and I would have an opportunity to be physically active do

not differ statistically across clusters. The other wellbeing motivations however do differ.

Cluster B clearly values wellbeing related motivations more than other segments, not

including statements I would have a chance to meet interesting people, which segment A

values more than any other segment. Member of clusters C and D also think wellbeing related

motivations to be important, but not as much as respondents in cluster B, which is the third

biggest segment, containing 22.6 % of all respondents.

Table 1. Cluster analysis results

Travel motivation Overall






2.256 A,C,


Cluster F-value




1.549 A,





That I would have a

hassle-free vacation

1.204 0.402

0.891 A


That I would like to

escape from a busy

everyday life

1.143 0.505

2.281 A,C,


1.401 A,

D 0.921 A That I would have a



feeling like I was being


0.081 0.148 -0.079 0.164 0.079 1.090

That I would get


1.400 0.792

2.268 A,C,


1.509 A,

D 1.253 A 106.18


That I would have an

opportunity for physical


0.979 0.397

1.860 A,C,


1.259 A,

That I would have an

D 0.673 56.978

opportunity to be

physically active

-0.121 -0.274 0.049 -0.045 -0.153 2.153

That I would like to have

a sense of comfort

1.369 0.674




A,D 1.222 A 171.67


That I would like to relax

away from the ordinary

1.598 0.862

2.6463 A,


1.820 A,

D 1.362 A 253.10


That I would have a

chance to meet

interesting people


0.482 B,C,

D -1.366 -0.944 B


0.238 B,



Superscript in the mean value of a cluster denotes those clusters that have significantly lower

mean score

Profile of rural wellbeing tourists is presented in Table 2. A typical representative of the

segment is a female in the age of 45-54 with a college level degree. She has lived her

childhood in a rural area. The annual income of her household is 30 000- 45000 euro, which

can be regarded as an intermediate level. She travels with her spouse less than once a year to

a rural destination.

Table 2. Profile of wellbeing segment

Age Who would you travel with?

Under 25 5 (3.4%)

Spouse 67


25-34 33 (22.4%)

Family with children under 12




35-44 39 (26.5%)

Family with children in several age




45-54 46 (31.3%)

Friends 18


55-64 21 (14.3%) Alone 7 (4.3%)

65 or older 3 (2.0%) Other 11 (6.7%)


Number of annual visits to rural

holiday destinations

University degree 40 (24.8%)

Less than once a year 68


Technical / Trade school /


94 (58.4%)

Once a year 58


Upper secondary school 11 (6.8%)

Two or three times a year 36


Elementary school 16 (9.9%) More than three times a year 2 (1.2%)

Annual income of the


Rural origins

Less than 15 000 € 8 (5.1%)

I lived during my childhood and/or

adolescence in a rural area

I did not live during my



15 000 – 29 999 € 39 (24.7%)

childhood/adolescence in a rural

area, but I visited rural areas often

to see my relatives



30 000 – 44 999 € 40 (25.3%) I have no roots in the countryside



45 000 – 59 999 € 30 (19.0%) Gender

60 000 – 74 999 € 25 (15.8%) Male 15 (9.3%)

75 000 – 89 999 € 11 (7.0%) Female



At least 90 000 € 5 (3.2%)


The results show that among Finnish rural tourists a segment of rural wellbeing is clearly to

be distinguished. For them the motivating factors relaxing away from the ordinary, escape

from a busy everyday life, hassle-free vacation, getting refreshed, having a sense of comfort

and having an opportunity for physical rest represent a significantly higher value than for the

other segments. The profile of the segment shows that this group is quite homogenous in two

aspects, namely 91 % of the segment members are female and 85 % have spent a remarkable

part of their youth in a rural environment. It can be argued that this segment may have a rural

place identity, which refers to dimensions of self that define the individual’s personal identity

in relation to a physical environment (Kulczycki and Lück 2009, 172)

The results of this study support the findings of Park and Yoon (2009) as well as Molera and

Albaledejo (2007) by confirming the notion of rural tourists being a heterogeneous target

group with diverse motivations, needs and expectations. It also supports earlier results of

Frochot (2005) and Royo-Vela (2009) by showing that among rural tourists there may be a

special segment searching for a “lazy” relaxing holiday without an emphasis on any special


Bushell and Sheldon (2009) call for further research on motivations behind wellness tourism.

They distinguish between luxury forms of wellness tourism and more holistic attempts to

create wellness for the individual. (p. 221). We argue that there are several sub segments in

wellness as well as in rural tourism. We assume that people seeking to escape and relax in

luxury are a separate segment from those pampering themselves with lazy holiday in a rural

environment. They may be same people but behave in a different way depending on their life

situation, and other internal and external situational factors.

Both wellness and rural tourism concepts clearly mean different things in different contexts

and countries. Nevertheless, one conclusion can be drawn from this study: rush free rural

settings with nature and beautiful landscapes offer an ideal environment for a wellbeing

holiday motivated by search for relaxation, comfort and escape, not including any material

luxurious elements. Further research is needed on the characteristics of the segment as well as

their pull motivations.

In the end it can be said that rural tourism indeed is a form of wellbeing tourism, but not for

everyone. In this study one of the four segments, namely segment B, clearly values wellbeing

related motivations more than any other segment. On the other hand members of an another

segment, segment A, do not go for a rural holiday in sake of their wellbeing but are motivated

by other factors not examined in this study.


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Predicting factors of tourists’ interest towards wellbeing tourism

holidays – A Finnish case

Henna Konu,

University of Eastern Finland,

Centre for Tourism Studies

P.O.Box 86,

FI-57101 Savonlinna, FINLAND

Tommi Laukkanen,

University of Eastern Finland,

Department of Business

P.O. Box 111,

FI-80101 Joensuu, FINLAND


Many studies about motivations and profiles of health and wellbeing tourists have focused on

different sub-sectors of health, wellness and wellbeing tourism but more general research,

concerning wellbeing tourists, has been quite rare. This study aims to investigate tourist

motivations as predictors of tourists’ interests in wellbeing tourism holidays as opposed to

tourists that are not interested in wellbeing holidays.

Data is collected in Finnish Travel Fair in January 2009. In total 406 effective responses were

used. To evaluate the predictive influence of push and pull factors, the data was analyzed by

using logistic regression analysis with backward stepwise method.

Results show that the previous experience of wellbeing holidays, number of annual holiday

trips, together with pull factors “water park and/or spa”, “natural sights” and “accessibility in

destination”, and push factors “refreshing myself”, “experiencing fashionable/trendy places”

and “aesthetic experiences” significantly increase the odds of tourists’ interest to make

wellbeing holidays.

Keywords: tourist motivations, push and pull factors, previous travel experience,

wellbeing/wellness tourism, Finland


The demand of wellbeing and wellness (tourism) services has increased while many people

are stressed of living in work-obsessed, time-pressured, materialistic and over-individualistic

societies (Laing & Weiler 2008, Sheldon & Bushell 2009, Smith & Puczkó 2009). People are

seeking more often balance in their busy lives and wellbeing and wellness services are

thought to be helpful in achieving this balance. For example, it is estimated that in spa tourism

(sub-sector of health and wellbeing tourism) there are nearly 100 million active spa-goers

worldwide (ISPA 2007).

There are several wellness and wellness tourism definitions some being very wide-ranging

(e.g. Müller & Lanz Kaufmann 2001) and some more limited (e.g. Connell 2006). Sheldon

and Bushell (2009, 11) have defined wellness tourism as follows: “Wellness tourism is a

holistic mode of travel that integrates a quest for physical health, beauty, or longevity, and/or

a heightening of consciousness or spiritual awareness, and a connection with community,

nature, or the divine mystery. It encompasses a range of tourism experiences in destinations

with wellness products, appropriate infrastructures, facilities, and natural and wellness

resources.” All in all there is not one widely accepted definition. In the Finnish language the

words wellness and wellbeing are complex, especially in the tourism context. Reason for this

is that both words are translated into ‘hyvinvointi’ which causes confusion and misuse of the

words. In marketing point of view wellness tourism is usually connected to luxury products

and five-star hotels. However, wellbeing tourism can contain products and services from a

wider scale as it can comprise pampering, different (sport and fitness) activities and

experiences of luxury. The concept of wellbeing tourism suits better in Finnish context

because the wider content and description highlights better the Finnish understanding of

‘hyvinvointi’. (Kangas & Tuohino 2007, Konu et al. 2010.) Altogether, the definition of

Sheldon and Bushell (2009) is suitable for this study as it includes widely motivation factors –

more detailed both push and pull factors.

The motivations and profiles of health and wellbeing tourists have been studied rather little.

Some studies have focused on different sub-sectors of health, wellness and wellbeing tourism

– such as spa tourism or spiritual tourism (Lehto et al. 2005, Mak et al. 2009, Smith & Puczkó

2009) – but more general research, concerning wellbeing tourists in general, has been quite

rare. In addition, most of the studies concentrating on examining wellbeing tourism

motivations have focused on push factors (internal motivations) and have ignored the

importance of pull factors. It is necessary to understand both push and pull motivations and

their relationship to market efficiently a particular destination (Baloglu & Uysal 1996).

This study aims to enhance the rather slim body of knowledge on wellbeing tourism by

providing information about the push and pull factors that can explain the interest towards

wellbeing tourism holidays. Goal is to investigate possible predictors – push and pull factors,

socio-demographical factors and previous travel behaviour – of tourists’ interests in wellbeing

tourism holidays as opposed to tourists that are not interested in above mentioned holidays.

Tourist Motivations – Push and Pull Factors

Motivation has for long been a major topic in tourism research (Crompton 1979, Dann 1981,

Mak et al. 2009, Nowacki 2009, Park & Yoon 2009, Pearce 2005). Backman et al. (1995)

emphasised that motivations are interconnected with individuals’ basic needs for developing

preferences, participating diverse activities, and expecting satisfaction. The motivations of

wellbeing and wellness activities, participating in wellbeing holiday or purchasing wellbeing

and wellness products and services are also connected to customers’ needs and interests.

The push and pull model (Crompton 1979) is one of the most popular typology of tourist

motivation. The model emphasizes that tourist’s choice of a travel destination is influenced by

two forces – push and pull factors. Push factors are underlying individual motivations that

push individuals from home, and pull factors are attributes and features of a destination,

service or a product that pull individuals toward a destination. That is to say, people travel

because they are pushed by their internal motives and pulled by external forces of a travel

destination (Lam & Hsu 2006). It has been remarked that most push factors derive from

individual’s intrinsic or intangible desires, for instance, from dream fulfilment, rest and

relaxation, health and fitness, desire for escape, adventure seeking, novelty seeking, prestige,

and socialization (Chon 1989, Lam & Hsu 2006, Uysal & Jurowski 1993). Pearce and Lee

(2005) identified in their study 14 factors of general tourist motivation. These factors were

novelty, escape/relax, relationship (strengthen), autonomy, nature, self-development (host-site

involvement), stimulation, self-development (personal development), relationship (security),

self-actualise, isolation, nostalgia, romance and recognition. The push motivations are noticed

to be useful in explaining the desire for travel, as they are recognized as basis of

understanding tourists’ behaviour (Crompton 1979, Kim et al. 2008). Pull factors are more

tangible and they are related often to attractiveness of a destination (e.g. Baloglu & Uysal

1996, Bowen & Clarke 2009). Pull factors can be diverse destination attributes (e.g. spa

facilities, high quality accommodation, amusement parks, national parks) and activities (e.g.

outdoor activities, courses, excursions) that tourists are interested in.

There are only few studies that have concentrated on wellness and wellbeing tourism

motivations. These studies are mainly focused on sub-sectors of wellness tourism, such as spa

or spiritual tourism (Koh et al. 2010, Lehto et al. 2005, Mak et al. 2009) or on the push factors

(internal motivations) (Chen & Prebensen 2009, Koh et al. 2010, Mak et al. 2009) and Asian

(see Chen & Prebensen 2009, Mak et al. 2009) or US target groups (Lehto et al. 2005).

Mak et al. (2009) have studied underlying motivations for spa visits. They found five

motivation factors among Hong Kong spa-goers. These factors were friendship and kinship,

health and beauty, self-reward and indulgence, relaxation and relief, and escape. The top five

motivations (mean over 3 on five-point Likert scale) were ‘to seek physical relaxation’, ‘to

pamper oneself’, ‘to reward oneself for working hard’, ‘to seek mental peacefulness’ and ‘to

get away from the pressures of work and social life’. Koh et al. (2010) have segmented spa

goers using benefit segmentation. The benefit attributes they have used are very similar to

motivation attributes used in different studies. They identified four motivation factors: social,

relaxing, healthy, and rejuvenating. They also grouped spa goers valuating similar benefits

into three clusters – escapists, neutralists and hedonists. For instance, escapists were interested

in improving their health (mean 3,95 on five-point Likert scale) and rejuvenating themselves

(mean 3,99). Hedonists were interested the most in relaxing and rejuvenating (means in both


Lehto et al. (2006) examined motivations of yoga tourists by using 18 motivation statements.

They identified four motivation factors in their study 1) seeking spirituality, 2) enhancing

mental wellbeing, 3) enhancing physical condition, and 4) controlling negative emotions.

They found out that the top five motivations (measured using five-point Likert scale) were to

renew myself (mean 4,46), to relax (mean 4,46), to be more flexible in body and mind (mean

4,42), to let go of stress from a busy life (mean 4,41), and to help me gain a sense of balance

(mean 4,38). Kelly and Smith (2009) also found out in their case study that the focus of retreat

holidays is “the self”.

Chen and Prebenson (2009) have studied wellness motivation attributes for Taiwanese tourists

by using 16 different variables: health consciousness, physical therapy, social activity,

recreation, enhancement of quality of life, effortless activity, affordable activity, pursuing

multiactivities, relaxation, business engagement, word of mouth, curiosity, mental therapy,

attractiveness, experiencing nature, and meditation (measured using 7-point Likert scale).

They found out that the most important motivation factors were relaxation (mean 5,40),

pursuing multiple activities (mean 5,24), recreation (mean 5,16), and experiencing nature

(mean 5,04). The results show that a stay in a wellness destination or resort is not just for

being pampered, and tourists are interested in doing also different activities during their

wellbeing holiday (Chen & Prebenson 2009). Smith and Puczkó (2009, 262-263) have also

listed reasons in more general level, why people are travelling and going to spas and wellness

centres. For instance, one of the main motives is stress relief. They also highlight that fitness

and exercise have a very important role in wellbeing and wellness too. Smith and Puczkó

(2009) emphasize as well that trends and reasons of individuals of participating wellbeing and

wellness activities vary considerably, and these trends are connected closely to leisure

patterns. Konu and Laukkanen (2009) identified in their study that motivation factors

connected to health and physical activity and self-development were affecting the most to

intention to make a wellbeing trip. Based on the studies presented above, it can be stated that

the main push factors in wellbeing tourism sector seem to be things such as relaxation,

rejuvenation, pursuing multiple activities, experiencing nature, escape, health and beauty.

Many studies are highlighting the importance of environment in wellbeing tourism (Kelly &

Smith 2009, Smith & Puzckó 2009). Some of the wellbeing tourism concepts, such as Alpine

Wellness (Pechlaner & Fisher 2006) and Lake Wellness which is under development (Konu et

al. 2010) base strongly on the natural resources of the destination. In addition, some of the

wellbeing and wellness services are depend on natural resources. Good examples are hot

springs and mineral waters that are believed to have healing powers (Erfurt-Cooper & Cooper

2009). However, it is very difficult to find studies that have actually empirically tested the

importance of pull factors of wellbeing tourism.

In this study more general motivation factors (push and pull) are used as the questionnaire is

directed to potential wellbeing tourists, and as the aim is to find out the motivational

differences between tourists who are interested in wellbeing holidays, and tourists who are

unsure/not interested in wellbeing holidays.

Demographic Variables, Travel Experience, and Past Wellbeing and Wellness Tourism


Some studies have concentrated on describing demographic profiles of wellbeing and

wellness tourists. Studies have shown that most of the wellbeing and wellness tourists are

female (Koh et al. 2010, Lehto et al. 2006, Smith & Puzckó 2009), approximately over 30years-old

(Koh et al. 2010, Lehto et al. 2006, Smith & Puzckó 2009), and highly educated

(Koh et al. 2010, Lehto et al. 2006). In addition, studies that have examined different subsectors

of wellbeing and wellness tourism highlight, for instance, that spa-goers (Koh et al.

2010) as well as yoga tourists (Lehto et al. 2006) have high average income.

Pearce (2005, see also Pearce & Lee 2005) has discussed the relationship between past

experience and tourist motivation when he developed travel career patterns (TCP) concept.

Pearce argues that all travellers are influenced by the most important travel motives (e.g.

escape/relax and novelty) as well as less important motives (e.g. social status and isolation).

He also claims that when tourist’s travel career level develops (tourists grow older, pass

certain stage in life-cycle and gain more experience) the moderately important travel motives

will change from internally-oriented needs to externally-oriented needs. Mak et al. (2009)

studied the relationship between past spa experience and tourist motivations. They found out

that spa-goers who had visited spa two to five times during last two years were more

motivated by attributes connected to escape than spa-goers that had visited a spa only once.

Thus, it can be assumed that demographical factors, travelling habits (travel experience) and

past wellbeing tourism experiences can have roles as explaining factors of wellbeing holidays.

Data and Methods

To examine tourist motivations (push and pull factors), a computer aided survey was

conducted to potential Finnish tourists in Matka 2009 travel fair in Helsinki, Finland.

Altogether 32 push factor statements (mainly Pearce 2005, Pearce & Lee 2005) and 20 pull

factors including statements covering the six As (attractions, accessibility, amenities,

available packages, activities, ancillary services) defined by Buhalis (2000) were adapted

from the earlier studies. For the purposes of this study, a total number of 406 effective

responses without missing values were used. The data is divided into two groups using an apriori

segmentation based on the interest respondents have towards wellbeing holidays.

Logistic regression analysis with backward stepwise selection procedure was used, with the

cut-off statistical significance selected at the 0.10 level. The target (dependent) variable is a

binary/dichotomous variable in which 0 = unsure/not interested in wellbeing holidays, and 1 =

interested in wellbeing holidays. The independent variables included push and pull factors,

demographic factors, travelling habits (how many short and long trips taken during last 12

months), and past wellbeing tourism experiences. Age as a demographic variable was

excluded from the analysis due to a large number (24%) of missing values.