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<strong>Health</strong>, <strong>Wellness</strong> <strong>and</strong> <strong>Tourism</strong>: <strong>healthy</strong> <strong>tourists</strong>, <strong>healthy</strong> <strong>business</strong>?<br />

Proceedings of the Travel <strong>and</strong> <strong>Tourism</strong> Research Association Europe 2010<br />

Annual Conference 1-3 September, Budapest, Hungary<br />

Puczkó, L. (Ed) (2010).<br />

<strong>Health</strong>, <strong>Wellness</strong> <strong>and</strong> <strong>Tourism</strong>: <strong>healthy</strong> <strong>tourists</strong>, <strong>healthy</strong> <strong>business</strong>?<br />

Proceedings of the Travel <strong>and</strong> <strong>Tourism</strong> Research Association Europe 2010 Annual<br />

Conference<br />

Dalarna, Sweden: Travel <strong>and</strong> <strong>Tourism</strong> Research Association Europe.<br />

ISBN: 978-91-633-4666-8<br />

The Travel <strong>and</strong> <strong>Tourism</strong> Research Association (www.ttra.com) is an international network<br />

of travel <strong>and</strong> tourism research <strong>and</strong> marketing professionals from a wide variety of<br />

backgrounds. The Association provides a forum where you may benefit from meeting other<br />

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

Chapter of the TTRA (www.ttra-europe.org) has been active in extending its activities in<br />

Europe <strong>and</strong> beyond, especially with its annual conference (www.ttra-europeconference.com).


The Chair of the Conference <strong>and</strong> the Organising Commitee: László Puczkó (PhD CMC MA MSc)<br />

is a managing director <strong>and</strong> head of tourism section at 2q Tourist Research Partnership <strong>and</strong> Xellum<br />

management consulting company; <strong>and</strong> Acting Head of the <strong>Tourism</strong> Competence Centre at Corvinus<br />

University Budapest (Hungary). He has been a lecturer at several colleges <strong>and</strong> universities. He is a coauthor<br />

of professional books on health <strong>and</strong> wellness tourism, the impacts of tourism, visitor<br />

management <strong>and</strong> tourism management in historic cities. He is member of the TTRA European Chapter<br />

Board <strong>and</strong> President of the Hungarian Association of <strong>Tourism</strong> Consultants.<br />

Short Introduction to the Conference<br />

Although travel has always contributed to health <strong>and</strong> wellbeing, it has often been in indirect<br />

or passive ways (e.g. relaxation <strong>and</strong> escapism). However, many <strong>tourists</strong> are increasingly<br />

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

other h<strong>and</strong>, some destinations are now positioning themselves as market leaders in<br />

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

<strong>and</strong> not just confined to the duration of the holiday. This can include spa tourism, which can<br />

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

<strong>and</strong> adventure tourism, which increase physical health <strong>and</strong> fitness; occupational wellness<br />

trips, which address work-related issues such as stress-management; <strong>and</strong> holistic or spiritual<br />

retreats, which can balance body, mind <strong>and</strong> soul.<br />

Many of these forms of tourism are based on changing leisure <strong>and</strong> lifestyle trends, such as<br />

healthier nutrition, fitness regimes, or the quest for alternative spirituality. There are also<br />

shifts in many societies from curative to preventative healthcare, which requires greater<br />

knowledge <strong>and</strong> self-responsibility. The mainstream tourism industry is also investing heavily<br />

in wellness products – for example the cruise industry – possibly to give a <strong>healthy</strong> ‘feel’ to a<br />

product traditionally associated with eating too much. How can these contrasting aims be<br />

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

which enhance quality of life <strong>and</strong> fulfil all domains of wellness (e.g. physical, emotional,<br />

spiritual, psychological <strong>and</strong> intellectual).<br />

Furthermore, the link between leisure <strong>and</strong> tourism seems to be getting stronger, since wellness<br />

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

The conference explored the relationship between health, wellness <strong>and</strong> tourism:<br />

• Changing activities in leisure, lifestyle <strong>and</strong> travel which improve wellness <strong>and</strong> quality<br />

of life<br />

• Developments in medical tourism <strong>and</strong> the shift from traditional curative towards<br />

complementary <strong>and</strong> preventative activities, or even hedonistic aspirations<br />

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

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

health <strong>and</strong> wellness<br />

• The special characteristics of investment <strong>and</strong> return in health <strong>and</strong> wellness tourism<br />

• The special characteristics of planning, management <strong>and</strong> marketing of health <strong>and</strong><br />

wellness tourism


Acknowledgements<br />

TTRA Europe would like to extend their sincere appreciation to the conference organizers,<br />

conference chairs <strong>and</strong> keynote speakers, the dinner speaker, <strong>and</strong> the panel members <strong>and</strong> their<br />

facilitator:<br />

Conference Organizers:<br />

László Puczkó, 2q Tourist Research Partnership<br />

&<br />

Conference Secretariat Weco Travel Ltd- Chemol Travel<br />

Conference Chair:<br />

László Puczkó, 2q Tourist Research Partnership<br />

Dinner Speaker:<br />

Dee Ann McKinney<br />

TTRA Europe gratefully acknowledges the support of the conference:<br />

GOLD SPONSOR:<br />

SILVER SPONSORS:<br />

www.hungary.com<br />

www.kjf.hu<br />

www.budapestinfo.hu


BRONZE SPONSORS:<br />

MEDIA SPONSORS:<br />

www.spasbudapest.com<br />

www.danubiushotels.com<br />

www.kastelyszanatorium.hu<br />

www.omorovicza.com<br />

www.raczhotel.com<br />

www.thermarium.com<br />

www.xellum.hu<br />

www.turizmus.com<br />

www.eumta.org<br />

TTRA Europe is also indebted to the members of the Scientific Committee, who reviewed<br />

121 contributions that were submitted for participation at the conference:<br />

Anja Touhino, Project manager, ITÄHYVÄ, Finl<strong>and</strong><br />

Aurkene Arzua, Director, CIC tourGune, Spain<br />

Babu George, Assistant Professor of <strong>Tourism</strong>, University of Southern Mississippi, USA<br />

C Michael Hall, Professor, Department of Management, College of Business & Economics,<br />

University of Canterbury, New Zeal<strong>and</strong><br />

Edward Huijbens, Docent, Icel<strong>and</strong>ic <strong>Tourism</strong> Research Centre, Icel<strong>and</strong><br />

Frederic Dimanche, Director, Center for <strong>Tourism</strong> Management, SKEMA, Business School<br />

Nice - Sophia Antipolis, France<br />

Ian Henderson, Managing Partner, TTC International Ltd, U K<br />

Isabelle Frochot, Lecturer, CEMAGREF Grenoble & Université de Savoie<br />

Jana Kucerova, Department of <strong>Tourism</strong> <strong>and</strong> Hospitality, Matej Bel University in Banska<br />

Bystrica, Slovakia<br />

Jennifer Laing, Lecturer, <strong>Tourism</strong> Research Unit, Monash University, Australia<br />

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


Kai Illing, Professor, Joanneum, Austria<br />

Kaija Lindroth, Degree Program Manager, HAAGA-HELIA, Finl<strong>and</strong><br />

László Puczkó, Managing director, Xellum Ltd, Hungary<br />

Melanie Smith, Senior Lecturer, Corvinus University of Budapest, Hungary<br />

Pauline Sheldon, Professor, University of Hawaii, USA<br />

Rob Davidson, Senior Lecturer in Business Travel & <strong>Tourism</strong>, University of Westminster,<br />

UK<br />

Roos Gerritsma, Docent, InHoll<strong>and</strong>, The Netherl<strong>and</strong>s<br />

Sheila Flanagan, Director, DIT, Dublin, Irel<strong>and</strong><br />

Sonia Ferrari, Professor of Place, <strong>Tourism</strong> <strong>and</strong> Museum Marketing, Università della Calabria,<br />

Italy<br />

Tamara Rátz, Head of Institute, Institute of <strong>Tourism</strong>, Kodolányi János College, Hungary<br />

KEYNOTES<br />

ÁKOS KOZÁK<br />

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

has been a colleague of GfK Hungária Market Research Institute for 20 years, <strong>and</strong> managing<br />

director of the company since 1993.<br />

He earned his degrees at the College of Commerce & Catering <strong>and</strong> then at the Eötvös Lóránd<br />

University of Budapest where he majored in Media Studies <strong>and</strong> Journalism <strong>and</strong> Sociology.<br />

His special fields are trade, consumer panel research <strong>and</strong> the research of media use habits.<br />

He is the president of the Hungarian Marketing Association; a member of the Board of the<br />

Hungarian Advertising Association; a member of the Association of Professional Market<br />

Researchers; a member of the Advisory Body of the Marketing <strong>and</strong> Media Institute of the<br />

Corvinus University of Budapest; a member of the Advisory Body of the Budapest Business<br />

School; a member of the Communication Sub-Committee of the National Euro Coordination<br />

Committee; a member of National Round Table on Pensioners <strong>and</strong> the Elderly; a member of<br />

ESOMAR’s European Marketing <strong>and</strong> Sociology Organisation. Klauzál Gábor prize winner,<br />

2008.<br />

He is an author <strong>and</strong> co-author of several college <strong>and</strong> university lecture notes <strong>and</strong> course books<br />

on market research. Email: akos.kozak@gfk.com<br />

ROGER ALLEN<br />

Roger is COO of Thermarium Spa Financial Consulting based in Tyrol, Austria. Roger has<br />

worked in spa development, operations <strong>and</strong> management for over 15-years during which time<br />

he has built a chain of day spas <strong>and</strong> premium health clubs, worked extensively throughout<br />

Asia <strong>and</strong> headed spa recruitment <strong>and</strong> spa operations for Steiner Leisure. Roger has been<br />

involved in all types of spas <strong>and</strong> worked with both venture capital <strong>and</strong> angel investors for<br />

various spa projects.<br />

Roger is now providing experienced client dedicated financial spa planning, conceptual <strong>and</strong><br />

operational development to some of the most exciting spa projects in the world.<br />

Email: rallen@thermarium.com, www.thermarium.com<br />

Dr. MELANIE SMITH<br />

Melanie Smith is a Senior Lecturer <strong>and</strong> Researcher in <strong>Tourism</strong> at Corvinus University,<br />

Budapest. Before this, she was Director of BA <strong>Tourism</strong> <strong>and</strong> MA Cultural <strong>Tourism</strong><br />

Programmes at the University of Greenwich in London. She is also Chair of ATLAS<br />

(Association for <strong>Tourism</strong> <strong>and</strong> Leisure Education). She is co-author of <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong><br />

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


articles about holistic <strong>and</strong> wellness tourism. She has also recently been involved in teaching<br />

<strong>and</strong> curriculum development in health <strong>and</strong> wellness tourism in Hungary, Estonia, <strong>and</strong> Icel<strong>and</strong>.<br />

Email: melanie.smith@uni-corvinus.hu<br />

KEVIN TURNBULL<br />

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

of the largest spa marketing <strong>and</strong> spa gifting company in the world.<br />

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

Mercedes Benz Luxury Car division in the UK, where he managed the ultra-luxurious<br />

Maybach <strong>and</strong> the SLR McLaren super sports car <strong>business</strong>.<br />

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

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

that he was Chief Executive of Toad plc, a technology <strong>business</strong> start-up, <strong>and</strong> played a pivotal<br />

role in raising multi million City funding for the company <strong>and</strong> successfully floating Toad on<br />

the London Stock Exchange. Kevin spent his early years at Ford <strong>and</strong> Nissan in sales <strong>and</strong><br />

marketing.<br />

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

from Durham University. He is a Fellow of the Chartered Institute of Marketing, a Fellow of<br />

the Institute of the Motor Industry <strong>and</strong> a member of the Institute of Personnel <strong>and</strong><br />

Development. He is a frequent speaker at industry events throughout Europe.<br />

Email: kevin@spafindereurope.com<br />

KATHRIN SPILLER<br />

… started her professional career by working for a radio station <strong>and</strong> as a journalist.<br />

Up to now 26 years experience in managing positions in tourism <strong>and</strong> hotel management.<br />

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

Württemberg (Southwest Germany) for marketing <strong>and</strong> advertising, for the cooperation with<br />

tour operators <strong>and</strong> travel agencies in Germany <strong>and</strong> Switzerl<strong>and</strong>.<br />

Especially she participated in the establishment of the quality-certificate <strong>and</strong> the br<strong>and</strong><br />

WELLNESS STARS, which is st<strong>and</strong>ing for certified quality in hotels, spas <strong>and</strong> medical<br />

wellness facilities.<br />

Since July 2009 she’s consulting in destination-management, auditing <strong>and</strong> consulting hotels<br />

<strong>and</strong> spas, offers spa- <strong>and</strong> marketing concepts as well as public relations. Since 2008 she is the<br />

coordinator of the German Medical <strong>Wellness</strong>-Group.<br />

Email: kathrin.spiller@wellness-stars.de<br />

GERARD BODEKER, Ph.D.<br />

Dr. Gerry Bodeker researches <strong>and</strong> advises on international public policy on<br />

traditional,complementary & alternative medicine (TCAM). An Australian, he is senior<br />

clinical lecturer in public health in the University of Oxford Medical School <strong>and</strong> research<br />

associate at the Oxford Centre for International Development. Dr. Bodeker has been chair of<br />

the Commonwealth Working Group on Traditional & Complementary Medicine <strong>and</strong> done<br />

work on medicinal plant conservation for the World Bank, the Global Environment Facility<br />

<strong>and</strong> the UN Food & Agriculture Organization. He has written extensively on traditional<br />

medicine <strong>and</strong> is co-founder of the WHO-affiliated Research Initiative on Traditional<br />

Antimalarial Methods (RITAM).<br />

Email: gerrybodeker@gmail.com


ELISABETH IXMEIER<br />

Elisabeth Ixmeier is co-founder of Healing Hotels of the World, an exclusive global<br />

partnership of hotels, resorts <strong>and</strong> retreats offering holistic health <strong>and</strong> wellbeing in luxury<br />

surroundings. The quality br<strong>and</strong> Healing Hotels of the World is based on a comprehensive set<br />

of criteria securing holistic health <strong>and</strong> wellbeing in all areas of a hotel or resort.<br />

Elisabeth has a PhD in philosophy <strong>and</strong> art history <strong>and</strong> is practising holistic philosophies such<br />

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

resorts <strong>and</strong> the development towards health travel worldwide. As the co-founder of Healing<br />

Hotels of the World she combines her experience in tourism marketing with her enthusiasm<br />

for personal development <strong>and</strong> healing.<br />

E-mail: E.Ixmeier@healing-hotels.com, www.healinghotelsoftheworld.com<br />

DEE ANN MCKINNEY<br />

Dee Ann McKinney brings 30+ years of marketing, research <strong>and</strong> advertising experience to her<br />

current professional position of overseeing Strategic Planning <strong>and</strong> Research for the Division<br />

of <strong>Tourism</strong> for the state of Missouri (MDT). She gained her marketing expertise with such<br />

organizations as Southwestern Bell (AT&T), Bell South, the Cincinnati Symphony Orchestra,<br />

regional cable networks <strong>and</strong> the Missouri Division of <strong>Tourism</strong>. She has also held media<br />

positions in magazine, newspaper <strong>and</strong> television advertising sales.<br />

McKinney has served on the Research Committee for the US Travel Association, the regional<br />

(Central States) Board of the Travel & <strong>Tourism</strong> Research Association (TTRA) <strong>and</strong> the Direct<br />

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

research vendors as well as other state tourism offices <strong>and</strong> local, community or tourism<br />

<strong>business</strong> organizations <strong>and</strong> other tourism research interested groups. She supervises all<br />

research information releases <strong>and</strong> competitive analyses. For several years, she has also Cochaired<br />

the state research directors group for the United States-- coordinating, organizing <strong>and</strong><br />

moderating meetings of State tourism offices twice each year.<br />

Presently, McKinney is President of TTRA's international Board of Directors. Prior to<br />

becoming the President, she served on the board for four years including as first <strong>and</strong> second<br />

Vice-President. In June of 2010 she became the Chairman of the Board for TTRA.<br />

Email: deeann.mckinney@ded.mo.gov


Table of Contents<br />

ANTUNES Joaquim Gonçalves 282<br />

AZMAN Inoormaziah 9<br />

BARTH Isabelle 56<br />

BEETON Sue 26<br />

BROOKER Ed 31<br />

BROWN Anthony 248<br />

BROWN Graham 164<br />

CHAN Jennifer Kim Lian 9<br />

CHOI Hwan-Suk Chris 102<br />

CLEEVELY Olivia 248<br />

COLE Shu 37<br />

CORREIA Anabela Gomes 282<br />

DE GRANDPRÉ François 175<br />

DEERY Margaret 38<br />

DIMANCHE Frederic 40<br />

DIMANCHE Christine 40<br />

DO VALLE Patrícia 299<br />

FORMÁDI Katalin 270<br />

FUKUTOMI Akira 248<br />

GERRITSMA Roos 43, 280<br />

GICZI Johanna 203<br />

GUSTAVO Nuno Silva 45<br />

HALLEM Yousra 56<br />

HANAN Katharine 248<br />

HENDERSON Ian 66<br />

HJALAGER Anne-Mette 67<br />

HONGNAPHADOL Wanvipha 76<br />

HOWAT Gary 164<br />

HSIEH Mei-ting (Jessica) 85<br />

HUIJBENS Edward H. 92<br />

İÇÖZ Onur 261<br />

IRIMIÁS Anna 93<br />

JAGO Leo 38<br />

JOPPE Marion 31, 102<br />

JOUKES Veronika 109<br />

JUDIT Torday 376<br />

KIRÁĽOVÁ Alžbeta 121<br />

KOMPPULA Raija 144<br />

KONU Henna 154<br />

KONU Henna 67<br />

LAING Jennifer 164, 378<br />

(Quick search: Ctrl+F)<br />

LAUKKANEN Tommi 154<br />

LEBLANC Marc 175<br />

LUND-DURLACHER Dagmar 184<br />

MAGGI Rico 408<br />

MARCUSSEN Carl 194<br />

MAYER Peter 270<br />

MENDES Júlio 299<br />

MICHALKÓ Gábor 203<br />

MOLNAR Elisabeth 315<br />

MUNDRUCZÓ Margit 227<br />

NEMES Andrea 238<br />

PARMAR Rina 248<br />

PESONEN Juho 144<br />

PIRNAR İge 261<br />

PONOCNY Ivo 184<br />

PRISZINGER Krisztina 270<br />

PUERTAS Xavier 280<br />

QUINTELA Joana Alegria 282<br />

RÁTZ Tamara 189, 203<br />

RENDA Ana 299<br />

ROWLAND Eleanor 248<br />

RULLE Monika 309<br />

SEBASTIAN Filep 42<br />

SHEN Ching-Cheng 309, 358<br />

STANCIULESCU Gabriela Cecilia 324<br />

SZIVA Ivett 333<br />

TAMÁS Várhelyi 378<br />

TOOMAN Heli 348<br />

TREMBATH Richard 164<br />

TRIKI Abdelfattah 56<br />

TSENG Tzuhui A. 315, 348<br />

TUOHINO Anja 366<br />

UJMA Dorota 376<br />

VIIN Tiina 333<br />

VOIGT Cornelia 164,<br />

381<br />

WEILER Betty 164<br />

WENG Janet I-Jane 381<br />

YU Ping 397<br />

ZINS Andreas H. 408<br />

ZOLTAN Judit 424


<strong>Health</strong> <strong>and</strong> Spa <strong>Tourism</strong> Business: Tourists’ Profiles <strong>and</strong> Motivational<br />

Factors<br />

Inoormaziah Azman<br />

Postgraduate Centre<br />

inoora83@hotmail.com<br />

And<br />

Jennifer Kim Lian Chan<br />

School of Business <strong>and</strong> Economics,<br />

University Malaysia Sabah (UMS),<br />

88450, Kota Kinabalu,<br />

Sabah, Malaysia<br />

E-mail: jkimchan@yahoo.co.uk; jenniferchan@ums.edu.my<br />

Abstract<br />

<strong>Health</strong> <strong>and</strong> spa tourism has increasingly become an important economic <strong>and</strong> marketing<br />

strategy for hoteliers, resorts <strong>and</strong> tourist destinations to attract tourist visitations. Despite the<br />

fast expansion <strong>and</strong> popular dem<strong>and</strong> of health <strong>and</strong> spa services/activities by both local <strong>and</strong><br />

international <strong>tourists</strong>, there is little underst<strong>and</strong>ing of the spa <strong>and</strong> wellness consumers in the<br />

Malaysian context. It argues that a deep underst<strong>and</strong>ing of consumer profiles <strong>and</strong> their key<br />

motivations within this context is vital in order to sustain the growth of health <strong>and</strong> spa tourism<br />

<strong>business</strong>. The paper presents a preliminary pioneering exploratory qualitative study that seeks<br />

to underst<strong>and</strong> the spa <strong>and</strong> wellness <strong>tourists</strong>’ motivation that are grounded in their own words<br />

during their visits to spa <strong>and</strong> wellness service centers in Sabah, Malaysia. It reports the<br />

empirical findings of spa <strong>and</strong> wellness <strong>tourists</strong>’ motivation by extending the push-pull<br />

motivation theory that focuses on the individual’s psychological factors (motivation,<br />

perception <strong>and</strong> attitude towards spa <strong>and</strong> wellness) <strong>and</strong> the destination’s (Sabah’s) spa <strong>and</strong><br />

wellness attributes. Data collection was conducted using in-depth interviews with 15 foreign<br />

<strong>tourists</strong> in various health <strong>and</strong> spa service centres in Sabah, Malaysia. It reveals that the retired<br />

aged group is the main category of <strong>tourists</strong> who go for health <strong>and</strong> spa services followed by the<br />

professionals who are very health conscious <strong>and</strong> practice <strong>healthy</strong> lifestyle. The findings<br />

revealed that health <strong>and</strong> spa tourist motivation is largely attributed to personal needs <strong>and</strong><br />

lifestyles, the price <strong>and</strong> the functionality/performance of health <strong>and</strong> spa service providers in<br />

Sabah. The paper provides the broad underst<strong>and</strong>ing of health <strong>and</strong> spa <strong>tourists</strong>’ profiles in<br />

Sabah, Malaysia <strong>and</strong> the key motivation factors. The finding benefits the health <strong>and</strong> spa<br />

service providers in term of developing appropriate marketing strategies <strong>and</strong> enhanced tourist<br />

satisfaction. The nature of the exploratory study <strong>and</strong> the type of respondent (foreign <strong>tourists</strong>)<br />

limit the generalizability of the research findings.<br />

Key words: health <strong>and</strong> spa, tourist profiles, motivation factors, tourist lifestyle, marketing<br />

strategies for health <strong>and</strong> spa <strong>business</strong><br />

Introduction


Over the past centuries, health <strong>and</strong> wellness-oriented activities have been recognized around<br />

the world, with existing of different health practices of the people in different regions for<br />

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

can be resonated with the echoes of the great economic growth <strong>and</strong> major demographic shift,<br />

occurring in most countries across the globe. Consequently, the society is aligned between the<br />

consumer’s strong interest in health <strong>and</strong> the rising affluence, resulting in plethora of consumer<br />

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

<strong>and</strong> well-being (Yeoman, 2008). Additionally, people are practicing a <strong>healthy</strong> lifestyle to keep<br />

them fit <strong>and</strong> <strong>healthy</strong>. This lifestyle, Ryan <strong>and</strong> Travis (1981); in Kammermann et. al. (1983); in<br />

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

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

the individual able to control, such as how they exercise, eat, manage stress, <strong>and</strong> perceive the<br />

environment, <strong>and</strong> achieving a high-level wellness involves continual striving for a more<br />

healthful way of living.<br />

Benner, King <strong>and</strong> Milner (2004) suggested that health tourism is any pleasure-oriented<br />

tourism which involves an element of stress relief could be considered to be a form of health<br />

tourism. They highlighted the importance of distinguishing between health tourism <strong>and</strong> the<br />

wide phenomenon of tourism because product perceptions on the part of both suppliers <strong>and</strong><br />

consumers will influence the extent to which more specialized travel experiences such as<br />

medical treatment are promoted to mainstream market. Likewise, subsuming spa as a sub<br />

sector of the health <strong>and</strong> wellness tourism, the spa sector is concomitantly mushrooming in the<br />

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

increasingly become an important economic <strong>and</strong> marketing strategy for hoteliers, resort <strong>and</strong><br />

tourist destinations to attract tourist visitations. McNeil <strong>and</strong> Ragins (2004) suggested that spa<br />

participation is currently showing incredible growth, as more consumers turn to spa facilities<br />

as venues to improve their health <strong>and</strong> well-being. Although it is luxury, it is seen as much<br />

more necessity, <strong>and</strong> factors like, personal space, time out, escapism, retreats contribute to spa<br />

visitation. Additionally, Smith <strong>and</strong> Puczkó (2009) stated that, in historical terms, health <strong>and</strong><br />

wellness practices have been very much embedded in regional <strong>and</strong> local traditions <strong>and</strong><br />

cultures, with available natural resources also determining the forms of wellness that were<br />

developed. Therefore, it is arguable that there are extended key motivation factors of <strong>tourists</strong>’<br />

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

popular dem<strong>and</strong> of health <strong>and</strong> spa services/activities by both local <strong>and</strong> international <strong>tourists</strong>,<br />

there is a little underst<strong>and</strong>ing of the health <strong>and</strong> spa consumers in Malaysian context.<br />

Therefore, this exploratory qualitative study attempted to underst<strong>and</strong> the health <strong>and</strong> spa<br />

<strong>tourists</strong>’ motivation that are grounded in their own words during their visits to health <strong>and</strong> spa<br />

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

some insights of this popular <strong>business</strong>. The purpose of this paper is to provide a deep<br />

underst<strong>and</strong>ing of <strong>tourists</strong>’ profiles <strong>and</strong> their key motivations in health <strong>and</strong> spa tourism context<br />

which is vital in order to sustain the growth of this tourism <strong>business</strong>.<br />

Having brief on the issue, the research is aimed at providing a starting point for underst<strong>and</strong>ing<br />

Sabah’s health <strong>and</strong> spa tourism market, particularly from dem<strong>and</strong> perspective, by establishing<br />

a preliminary profile of the health <strong>and</strong> spa <strong>tourists</strong>, <strong>and</strong> identify the key motivators of these<br />

<strong>tourists</strong> in the health <strong>and</strong> spa tourism products <strong>and</strong> services in Sabah, Malaysia. The research<br />

objectives were undertaken in an effort to answer the following questions:<br />

• Who are the health <strong>and</strong> spa <strong>tourists</strong> in Sabah, Malaysia?<br />

• Why the <strong>tourists</strong> utilized any of health <strong>and</strong> spa products <strong>and</strong> services while they travel in<br />

Sabah, Malaysia?


Literature Review<br />

<strong>Health</strong> <strong>and</strong> Spa <strong>Tourism</strong><br />

In recent years, many researches have been undertaken in addressing the issues related to<br />

population health <strong>and</strong> health tourism. Smith <strong>and</strong> Puczko (2009) suggested that health tourism<br />

can be viewed from two different perspectives, which are medical <strong>and</strong> wellness. Spa is one of<br />

the sub sectors of health tourism which positioned in between medical <strong>and</strong> wellness,<br />

depending on the purposes <strong>and</strong> types of treatments received when visiting spas. There are<br />

many studies related to health tourism, especially in the field of medical tourism, but very<br />

limited on health, spa <strong>and</strong> wellness that can be found in tourism literature. Nonetheless, the<br />

studies focused on the development, marketing <strong>and</strong> positioning the spa establishments – the<br />

supply side, rather than the dem<strong>and</strong> side of health <strong>and</strong> spa goers/<strong>tourists</strong>.<br />

According to Mcneil <strong>and</strong> Ragins (2004), spa participation in the United Stated of America is<br />

showing an incredible growth in the early 1990s when the participation in gyms <strong>and</strong> health<br />

clubs for fitness slowed down. The researchers stated that many consumers turn to spa<br />

facilities as venues to improve their health <strong>and</strong> well-being, <strong>and</strong> the industry continues to grow<br />

at amazing rates <strong>and</strong> marketing opportunities abound. They highlighted the current issues <strong>and</strong><br />

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

consumers’ needs effectively as a shift in paradigm in spa concept – from indulgence to<br />

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

nowadays are not only cater to women, but also to men, <strong>and</strong> cater to all age-group of people,<br />

(iii) to provide a more comprehensive array of treatments, services, <strong>and</strong> activities combined in<br />

a highly conceptualized setting, <strong>and</strong> (iv) to stay up to date with technological advances in<br />

provision of spa information to prospective consumers. The researchers suggested the uses of<br />

strategies <strong>and</strong> techniques that respond to consumers’ dem<strong>and</strong>s, in the context of target<br />

markets <strong>and</strong> the four Ps – product, place, promotion <strong>and</strong> price. They concluded that the spa<br />

marketers must remain flexible <strong>and</strong> adapt to changes of spa users’ wants <strong>and</strong> needs, <strong>and</strong><br />

continue to improve communications about the spa experience <strong>and</strong> its benefits.<br />

In line with aforementioned, Chon <strong>and</strong> Singh (1995) provided a review of trends in marketing<br />

the resorts in USA. One of the product development trends they highlighted was the one that<br />

evolved health awareness – concerns about personal health <strong>and</strong> fitness which increased the<br />

dem<strong>and</strong> for health-related holidays. Consequently the resorts are adjusting their amenities <strong>and</strong><br />

services to accommodate the health dem<strong>and</strong>s on vacationer, such as fitness facilities <strong>and</strong><br />

health spas have been added to release stress <strong>and</strong> improve nutrition <strong>and</strong> physical conditioning.<br />

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

for drawing them. The trend is expected to continue as more <strong>and</strong> more people travel for health<br />

reasons to resorts <strong>and</strong> spas which provides fully monitored <strong>and</strong> individualized beauty<br />

treatments, <strong>and</strong> health programs.<br />

Tourist Motivation<br />

Motivation has long been a central subject of study in psychology from varieties of ways,<br />

including from the physiological, psychological or philosophical approaches (Petri <strong>and</strong><br />

Govern, 2004: 3-14). The study of motivation is widely being used in underst<strong>and</strong>ing human<br />

behaviour <strong>and</strong> can be found in the literature of many disciplines. Likewise in tourism, the<br />

concept of motivation has been used in underst<strong>and</strong>ing tourist behaviours <strong>and</strong> their travel<br />

decision-making which can be indicative to tourism providers as to attract <strong>tourists</strong> <strong>and</strong> fulfil<br />

their needs during their travel at a particular destination.


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

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

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

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

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

psychological concept refers to <strong>tourists</strong> <strong>and</strong> the reasons why they embark on a particular trip.<br />

It is too, directly linked to the dem<strong>and</strong> for tourism, which can affected by a range of factors,<br />

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

tourist experience as well as future decisions (Lomine <strong>and</strong> Edmunds, 2007: 125).<br />

Consequently, motivation models <strong>and</strong> studies are seen in a variety in underst<strong>and</strong>ing tourist<br />

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

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

(e.g. <strong>tourists</strong>’ souvenir purchase decision by Swanson <strong>and</strong> Horridge, 2006), <strong>and</strong> tourism<br />

<strong>business</strong> marketing <strong>and</strong> planning strategies (e.g. Oh et. al., 1995; Bansal <strong>and</strong> Eiselt, 2004).<br />

The results lead to a greater underst<strong>and</strong>ing of <strong>tourists</strong>’ behaviours <strong>and</strong> thus contributing to<br />

effective marketing strategy in targeting the right tourist market. One of the concepts that are<br />

considered in tourist’s motivation <strong>and</strong> purchasing process is in term of push-pull factors<br />

which has been widely adopted in researches mostly associated with <strong>tourists</strong>’ behaviours <strong>and</strong><br />

segmentation, from general holiday-takings to special interest tourism, but rather in different<br />

contexts <strong>and</strong> countries.<br />

Push-Pull Factors of Tourist Motivation<br />

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

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

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

destination pull in response to motivational push, which distinguishes between the motivation<br />

of the individual tourist in terms of the level of desire (push) <strong>and</strong> the pull of the destination or<br />

attraction. Similarly, Page <strong>and</strong> Connell (2006: 68) stated that push factors are those that<br />

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

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

psychological (push) motives: (i) escape from a perceived mundane environment, (ii)<br />

exploration <strong>and</strong> evaluation of self, (iii) relaxation, (iv) prestige, (v) regression, (vi)<br />

enhancement of kinship relationships, (vii) facilitation of social interaction, <strong>and</strong> two cultural<br />

(pull) motives: (viii) novelty <strong>and</strong> (xi) education. This concept has been extensively studied<br />

<strong>and</strong> widely accepted in tourism literature (e.g., Chan & Baum, 2007; Yoon & Uysal, 2005;<br />

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

It is suggested that push-pull motivation concept is a useful approach for examining the<br />

motivations underlying tourist <strong>and</strong> visitation behaviour. Gilbert (1991) acknowledged the<br />

push <strong>and</strong> pull factors influencing the tourism consumer decision-making process (as cited in<br />

Page <strong>and</strong> Connell, 2006: 68).<br />

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

two forces, which are push <strong>and</strong> pull factors (Bansal & Eiselt, 2004). The push factors are<br />

considered to be socio-psychological motivations that predispose the individual to travel,<br />

while the pull factors are those that attract the individual to a destination once the decision to<br />

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

encompasses the push motivation factors, which are related to the <strong>tourists</strong>’ desire, <strong>and</strong> pull<br />

motivation factors which are associated with the attributes of the destination choices (Yoon &<br />

Uysal, 2005; Oh, Uysal & Weaver, 1995; Kim <strong>and</strong> Lee, 2002; Kim, Lee <strong>and</strong> Klenosky, 2003;<br />

Jang <strong>and</strong> Wu, 2006).


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

aspects, while pull motivations are connected to external, situational, or cognitive aspects. On<br />

the other h<strong>and</strong>, the push factors are origin-related, intangible or intrinsic desires of the<br />

individual travellers, such as the desire for escape, rest <strong>and</strong> relaxation, health <strong>and</strong> fitness,<br />

adventure, prestige, <strong>and</strong> social interaction. Meanwhile, pull factors are those that emerge as a<br />

result of the attractiveness of a destination as it is perceived by the traveller. They include<br />

tangible resources such as beaches, recreation facilities <strong>and</strong> historic resources as well as<br />

travellers’ perception <strong>and</strong> expectation such as novelty, benefit expectation <strong>and</strong> marketing<br />

image of the destination.<br />

Chan <strong>and</strong> Baum (2007) investigated the motivation factors of eco<strong>tourists</strong> in ecolodge<br />

accommodation by adopting the push <strong>and</strong> pull motivation factors. The findings revealed that<br />

the eco-<strong>tourists</strong> are primarily attracted by the destination attributes (natural attractions,<br />

wildlife, local lifestyle <strong>and</strong> eco-activities), where ecolodges are located (pull factors), <strong>and</strong> they<br />

are also pushed by their social psychological desire to escape from their routine of normal life<br />

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

account of what attracts the eco<strong>tourists</strong> to stay at ecolodges <strong>and</strong> suggested that the marketing<br />

strategies for ecolodges should focus more on the destination attractions around the ecolodge<br />

accommodation by positioning the ecolodges based on the unique destination attributes.<br />

Nonetheless, conservation <strong>and</strong> protection the surrounding natural resources are important too<br />

as these are the main motivational factors for <strong>tourists</strong> to patronize ecolodges. In contrast, Kim,<br />

Lee <strong>and</strong> Klenosky (2003) examined the influence of push <strong>and</strong> pull factors on visitors to the<br />

national parks in Korea. The results of a factor analysis identified four push factor domains<br />

<strong>and</strong> three pull factor domains underlying respondents’ push <strong>and</strong> pull factor ratings. The push<br />

factor domains suggested that the visitors to national parks in Korea considered the park to be<br />

valuable recreational resources that provide important opportunity to appreciate natural<br />

resources or enhance health or building friendship (consistent with results of 1999 Report of<br />

Korean National Travel). Meanwhile the pull factor domains reflected the fact that the<br />

national parks in Korea are relatively accessible <strong>and</strong> located close to most residential <strong>and</strong><br />

work areas. The study also provided the additional analyses investigated differences in push<br />

<strong>and</strong> pull factor domains for different socio-demographic sub-groups <strong>and</strong> examined the<br />

interrelationships among the push <strong>and</strong> pull factor domains. The study provided valuable<br />

information in underst<strong>and</strong>ing Koreans’ motivation to visit national parks <strong>and</strong> the results hold<br />

useful implication for park managers <strong>and</strong> researchers in studying how push-pull factors<br />

impact <strong>tourists</strong> <strong>and</strong> visitors behaviour.<br />

In line with aforementioned, it argues that the push <strong>and</strong> pull theory of tourist motivation can<br />

be applied into health <strong>and</strong> spa tourism context. Similarly, there must be underlying factors<br />

that motivate <strong>tourists</strong> for health <strong>and</strong> spa services while travel to a holiday destination, <strong>and</strong><br />

there must be certain health <strong>and</strong> spa attributes that attract the <strong>tourists</strong> to health <strong>and</strong> spa<br />

facilities at the destination countries. Therefore, this research attempted to adopt push <strong>and</strong> pull<br />

theory motivation concept in identifying the health <strong>and</strong> spa <strong>tourists</strong>’ motivation factors <strong>and</strong><br />

profiling these <strong>tourists</strong>.<br />

The push-pull concept was utilized, with modifications being made to focus into health <strong>and</strong><br />

spa tourism, which is likely to be more central on the <strong>healthy</strong> lifestyles of the health <strong>and</strong> spa<br />

goers <strong>and</strong> the holiday destination’s health <strong>and</strong> spa attributes. Accordingly, the push factors are<br />

considered to be socio-psychological motivations that predispose the individual to travel (Oh<br />

et. al., 1995), which evolves tourist’s personal attributes, or a dem<strong>and</strong>-side approach which is<br />

to underst<strong>and</strong> tourist’s decision-making process, such as attitudes, perceptions, <strong>and</strong> learning


<strong>and</strong> motivation factors – the four major psychological factors of the individual’s purchase<br />

behaviour (Knowles, Diamantis <strong>and</strong> El-Mourhabi, 2004: 57). Meanwhile the pull factors are<br />

those that attract the individual to a specific destination once the decision to travel has been<br />

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

facilities <strong>and</strong> historic resources, as well as travellers’ perception <strong>and</strong> expectation such as<br />

novelty, benefit expectation <strong>and</strong> marketing image of the destination (Yoon <strong>and</strong> Uysal, 2005).<br />

Petri <strong>and</strong> Govern (2004: 20-21) suggested that some behaviour can be understood as<br />

motivated by internal states that activate the individual to respond in genetically determined<br />

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

light of acquired experiences. This approach of motivation provides a dimension at which<br />

motivation can be studied concerning the source of motivation, that is, the internal motives<br />

versus external motives. The researchers stated that needs are commonly viewed as internal<br />

sources of motivation that activate <strong>and</strong> direct behaviour to items in the environment that<br />

alleviate some state of deprivation. It implies of physiological terms, <strong>and</strong> may also include<br />

social <strong>and</strong> psychological needs. Meanwhile, the external sources of motivation are<br />

emphasized on the motivating effects of either various goal objects or social relationship.<br />

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

external environment.<br />

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

that individuals have unique personal needs that stimulate or arouse them to pursue tourism<br />

(the desires to satisfy individual or internal needs – self-improvement, self-realization, or<br />

achieve state of happiness, <strong>and</strong> ego-enhancement). In contrast, the extrinsic motivation<br />

approach examines the broader conditioning factors that shape individuals’ attitudes,<br />

preferences <strong>and</strong> perceptions, but are more externally determined (the society <strong>and</strong> the culture<br />

one lives in). Goeldner <strong>and</strong> Ritchie (2006: 254) suggested that the extrinsic <strong>and</strong> intrinsic<br />

motivation must be able to consider that travellers are variously motivated by intrinsic, selfsatisfying<br />

goals <strong>and</strong> at other times are motivated by extrinsic socially controlled rewards (e.g.<br />

other’s opinions). The framework in this research integrated the individual’s psychological<br />

factors <strong>and</strong> the destination’s health <strong>and</strong> spa attributes adopting push-pull factors motivation<br />

concept, in order to explain tourist’s motivations in utilizing health <strong>and</strong> spa services when<br />

they travel to Sabah, Malaysia <strong>and</strong> the key attractiveness of local health <strong>and</strong> spa to the <strong>tourists</strong><br />

on the other h<strong>and</strong>, by moderating the demographic variables with the push-pull dimension in<br />

explaining the tourist motivation on health <strong>and</strong> spa services. This contributes to a better<br />

underst<strong>and</strong>ing of health <strong>and</strong> spa <strong>tourists</strong> in Sabah, Malaysia <strong>and</strong> also to the development of<br />

the sector in the coming future, as it benefits the health <strong>and</strong> spa operators in term of<br />

developing appropriate marketing strategies <strong>and</strong> thus enhances tourist satisfaction.


Push factors<br />

Internal motives – physiological, social <strong>and</strong><br />

psychological needs<br />

(Needs that activate <strong>and</strong> direct behaviour)<br />

Petri <strong>and</strong> Govern (2004)<br />

Intrinsic Factors<br />

(Unique personal needs that stimulate or arouse<br />

them to pursue tourism)<br />

Page (2009)<br />

Push Factors – Psychological Factors<br />

(Oh et. al., 1995; Yoon <strong>and</strong> Uysal, 2005; Cooper<br />

et al. 1993: 36; Knowles, Diamantis <strong>and</strong> El-<br />

Mourhabi, 2004)<br />

<strong>Health</strong>-related attitudes<br />

<strong>Health</strong>, spa <strong>and</strong> wellness perceptions & learning<br />

<strong>Health</strong>-related motivations<br />

Pull factors<br />

External motives – the motivating effects of<br />

either various goal objects or social relationship<br />

(Motivation can be activated by changes in the<br />

external environment)<br />

Petri <strong>and</strong> Govern (2004)<br />

Extrinsic Factors<br />

(The broader conditioning factors that shape<br />

individuals’ attitudes, preferences <strong>and</strong><br />

perceptions, but are more externally determined)<br />

Page (2009)<br />

Pull Factors – Destination Attributes<br />

(Oh et. al., 1995; Yoon <strong>and</strong> Uysal, 2005)<br />

Spa as a tangible resource<br />

Unique spa treatments <strong>and</strong> experiences<br />

(marketing image)<br />

<strong>Health</strong> <strong>and</strong> Spa Tourists<br />

Motivation Factors<br />

Figure 1: The Framework for <strong>Health</strong> <strong>and</strong> Spa Tourist Motivation Factors<br />

<strong>Health</strong>-related Tourist Motivation<br />

Though health tourism has longevity in historical terms, health <strong>and</strong> spa tourism can be<br />

considered at its infant stage, at which health <strong>and</strong> spa <strong>tourists</strong>’ motivation remains a<br />

substantive interest for researches. There is generally lack of empirical studies on health <strong>and</strong><br />

spa tourism motivation in underst<strong>and</strong>ing the fundamental needs of the health <strong>and</strong> spa goers<br />

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

suggested that research investigating health, spa <strong>and</strong> wellness from dem<strong>and</strong> perspective is<br />

needed as many of the available literatures (as presented above) are basically focusing on the<br />

development, marketing <strong>and</strong> positioning studies of the health, spa <strong>and</strong> wellness<br />

services/facilities.


One of the available researches that directly linked to health <strong>and</strong> spa goers is of Mak <strong>and</strong><br />

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

search for spa experiences while travelling away from Hong Kong. The structured<br />

questionnaires were employed to conduct the survey <strong>and</strong> received a total of 302 responses.<br />

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

pampering, beautifying treatments, <strong>and</strong> enhancement of overall health. The motivation<br />

factors; ‘relaxation <strong>and</strong> relief’, ‘escape’, ‘self-reward <strong>and</strong> indulgence’, <strong>and</strong> ‘health <strong>and</strong> beauty’<br />

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

found to be an integration of European spa goers health perspective <strong>and</strong> American spa goers<br />

self rewarding perspective. The findings of their study provide researchers <strong>and</strong> practitioners in<br />

the spa industry with useful insights into underst<strong>and</strong>ing the present nature of the dem<strong>and</strong> of<br />

spa in the Asian market.<br />

On the contrary, there are studies integrating <strong>healthy</strong> lifestyle into consumer/<strong>tourists</strong><br />

behaviours by Gonzalez <strong>and</strong> Bello (2002) show that a strong dependency relationship<br />

between <strong>tourists</strong>’ behaviours <strong>and</strong> lifestyle, <strong>and</strong> the segmentation of the market that emerged<br />

makes a division into five clusters: home-loving, idealistic, independent, hedonistic <strong>and</strong><br />

conservative. The labels give a general idea of the lifestyle of each segment. Similarly, the<br />

study by Hallab (2004) on <strong>healthy</strong>-living oriented lifestyle in the field of travel <strong>and</strong> tourism<br />

show that the connection between <strong>healthy</strong>-living habits of US citizens <strong>and</strong> their travel<br />

characteristics with respect to travel push <strong>and</strong> pull motivational factors <strong>and</strong> sociodemographics.<br />

It revealed significant findings in regard to individuals who have a <strong>healthy</strong>living<br />

lifestyle <strong>and</strong> their travel behaviour <strong>and</strong> shed a light on their socio-demographic<br />

characteristic. The researcher also suggested future researches to use more variables in<br />

seeking to underst<strong>and</strong> further the mentioned segment’s travel behaviour.<br />

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

problem of simplifying complex psychological factors <strong>and</strong> behaviour into a universally<br />

acceptable theory that can be tested <strong>and</strong> proved in various tourism contexts. In this study, the<br />

concept of push <strong>and</strong> pull motivations is used to refer to the perceived importance of health<br />

<strong>and</strong> spa services for international <strong>tourists</strong> during their holiday in Sabah, Malaysia. This<br />

implies that certain reasons for health <strong>and</strong> spa services during travel may correspond to<br />

certain benefits to the <strong>tourists</strong> that are to be valued <strong>and</strong> obtained at the destination site.<br />

Therefore, the tourism providers, health <strong>and</strong> spa providers must underst<strong>and</strong> the <strong>tourists</strong> with<br />

regards to their health <strong>and</strong> spa perceptions, expectations <strong>and</strong> decisions; <strong>and</strong> so, matching the<br />

destination’s health <strong>and</strong> spa attributes to the <strong>tourists</strong>’ diverse needs.<br />

Research Methodology<br />

Research Method <strong>and</strong> Study Site<br />

The qualitative approach was used in this research to provide an insightful underst<strong>and</strong>ing of<br />

the underlying motivation factors <strong>and</strong> perceptions that encourage the utilization of health <strong>and</strong><br />

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

more subjective in nature <strong>and</strong> involved examining <strong>and</strong> reflecting on perceptions in order to<br />

gain an underst<strong>and</strong>ing of social <strong>and</strong> human activities, which this research dealt with – the<br />

<strong>tourists</strong>’ ideas, perceptions <strong>and</strong> involvement in health <strong>and</strong> spa during holiday. Moreover,<br />

Weaver <strong>and</strong> Lawton (2002: 388) stated that the qualitative research is suited for situations<br />

where little is known about the subject matter.


Respondents were the international <strong>tourists</strong> who stayed at four respective resorts in Kota<br />

Kinabalu, Sabah (Shangri-La Tanjung Aru, Shangri-La Rasa Ria, Sutera Harbour, <strong>and</strong> Nexus<br />

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

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

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

five-stars resort hotels, <strong>and</strong> (iii) they provide similar leisure <strong>and</strong> recreational activities <strong>and</strong><br />

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

not allowed the guests to be interviewed, the interviews were conducted at the Kota Kinabalu<br />

International Airport (KKIA) before they depart back to their home countries or to their next<br />

destinations. The semi-structured interview questions for in-depth interview with the <strong>tourists</strong>.<br />

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

accommodation selection; spa <strong>and</strong> wellness experiences in Sabah; the individual’s healthrelated<br />

perceptions <strong>and</strong> attitudes; <strong>and</strong> demographic questions. Besides that, the Englishspeaking<br />

international <strong>tourists</strong> were specifically chose to alleviate the interview conversation<br />

in order to maintain the genuineness of the data, <strong>and</strong> avoiding translation into other languages,<br />

since nuances may be lost in this process possibly resulting in bias <strong>and</strong> loss of meaning.<br />

Data Collection<br />

In-depth interviews were conducted with 21 health <strong>and</strong> spa <strong>tourists</strong> at the Kota Kinabalu<br />

International Airport (KKIA) from January to February 2010. Approximately 150<br />

international <strong>tourists</strong> were approached, about 80 were staying at the respective resorts, less<br />

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

in-depth interviews completed (notably <strong>tourists</strong> from America, Europe <strong>and</strong> Australasia<br />

regions) due to time constraint.<br />

In-depth interview were conducted using recordings <strong>and</strong> lasted an average of 40 minutes.<br />

They were conducted with the consent of the health <strong>and</strong> spa <strong>tourists</strong> on the day they were<br />

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

guide approach with a semi-structured format to enable the researcher to identify the topic <strong>and</strong><br />

issues in advance <strong>and</strong> therefore sequence <strong>and</strong> words the questions during the course of the<br />

interview. The interview started with an introductory note <strong>and</strong> followed up with demographics<br />

characteristics of the informants. The informants were first asked with questions pertaining to<br />

their destination <strong>and</strong> accommodation selection, the purposes for coming to Sabah <strong>and</strong> reasons<br />

to stay at the particular resort, as well as the key attracting factors of the destination <strong>and</strong><br />

accommodation selected. Then they were asked about their views on health-related activities<br />

during holiday, <strong>and</strong> also their spa experience in Sabah (particularly at the resort). The final<br />

section of the interview sought on their perceptions <strong>and</strong> attitude on health especially<br />

pertaining to spa services <strong>and</strong> treatments during holiday in Sabah. The informants were asked<br />

<strong>and</strong> probed for detail explanation wherever required throughout the interviews.<br />

Data Analysis<br />

The recorded interviews were transcribed into a written format for data analysis. The data was<br />

revised <strong>and</strong> analyzed in three stages to identify <strong>and</strong> develop appropriate themes. First, the<br />

sample will be profiled by socio-demographic characteristics. This is because the relative<br />

importance of the motivational forces has been found to vary as a function of <strong>tourists</strong>’ sociodemographic<br />

characteristics (Kim, Lee <strong>and</strong> Klenosky, 2003). Second, push <strong>and</strong> pull<br />

motivation items will be identified by drawing out the key themes <strong>and</strong> variables relating to the<br />

descriptive themes – push-pull motivation <strong>and</strong> push <strong>and</strong> pull forces (Oh et. al., 1995; Yoon<br />

<strong>and</strong> Uysal 2005). It was then linked to the tourist motivation factors from the previous studies<br />

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


analysis was based on health, spa <strong>and</strong> wellness concept suggested in the literature (Mak <strong>and</strong><br />

Wong, 2009; Smith <strong>and</strong> Puczkó, 2009), at which health <strong>and</strong> spas are seen as promoting the<br />

individuals’ health <strong>and</strong> well-being rather than cure (medically), <strong>and</strong> also the main motivations<br />

of having health-related <strong>and</strong> spa services during travel associated with the individuals’<br />

awareness of health <strong>and</strong> well-being. In addition, as push-pull concept was adopted in this<br />

research, therefore, the main health <strong>and</strong> spa’s attributes were recognized. This provides an<br />

interpretation of health <strong>and</strong> spa tourism in Sabah, Malaysia.<br />

Findings <strong>and</strong> Discussions<br />

Profiling <strong>Health</strong> <strong>and</strong> Spa Tourists<br />

Table 1 summarizes the demographic profile of the study informants, who are mainly from<br />

the America, Europe <strong>and</strong> Australasia regions. Majority of the informants were female (75%),<br />

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

(73%), <strong>and</strong> annual income more than 50,000 USD (67%).<br />

Table 1 Profiles of <strong>Health</strong> <strong>and</strong> Spa Tourists in Sabah<br />

No Demographic variables % No. Demographic Variables %<br />

1 Nationality (regionally) 4 Occupation<br />

America 20 Professional 80<br />

Europe 80 Non professional 7<br />

Australasia 80 Housewife 13<br />

2 Gender 5 Annual income<br />

Male 25 50000 – 70000 USD 20<br />

Female 75 Above than 70000 USD 47<br />

Not given answer 33<br />

3 Age<br />

Less than 30 20 6 Educational Level<br />

30 – 49 47 Self-taught 7<br />

More than 50 33 College/University 73<br />

Not given answer 20<br />

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

general demographic information of health <strong>and</strong> spa <strong>tourists</strong>, who are mostly female in<br />

professional <strong>and</strong> executive jobs; baby boomers dominate this market, which fall into the 30-<br />

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

findings indicate an encouraging interest in <strong>healthy</strong> lifestyle, health <strong>and</strong> spa tourism among<br />

the <strong>tourists</strong>. Therefore, it can be said that <strong>tourists</strong> would likely to go to spa during holiday.<br />

There is an absent of data from a few of informants regarding their annual incomes <strong>and</strong><br />

education levels including the housewives. But generally it reveals that the informants have<br />

an annual income of more than 50,000 USD <strong>and</strong> are university graduates.<br />

<strong>Health</strong> <strong>and</strong> Spa: Perceptions <strong>and</strong> Attitudes


Perceptions, learning <strong>and</strong> attitudes may be influential to ones’ motivation factors <strong>and</strong> thus<br />

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

important to participate in activities that contribute to ones’ health <strong>and</strong> well-being. They seek<br />

to find balance or moderation in their lifestyles which is believed to makes ones <strong>healthy</strong> or<br />

healthier thus ones may live longer <strong>and</strong> able to lead more enjoyable lives. The informants<br />

seem to be health conscious, most of them claimed to have being part of the health regimes,<br />

for examples, they do regular exercises, walking or running, Pilates <strong>and</strong> Yoga, practice<br />

<strong>healthy</strong> eating, involve in sport activities <strong>and</strong> occasionally go to spas, have massages,<br />

pedicure <strong>and</strong> manicure. Few informants confessed that they do not have much time to involve<br />

in any health activities due to the nature of their works (physical jobs, a dem<strong>and</strong>ing work): “I<br />

don’t do daily activities in Engl<strong>and</strong>. No time, because of my work. My work is long, so after<br />

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

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

indicates that the informants are health conscious but they do not have much time for health<br />

remedies.<br />

According to the findings, holiday seems as the best time <strong>and</strong> opportunity for the informants<br />

to do things that they do not normally do at home to improve their health <strong>and</strong> well-being –<br />

relaxation being part of their holiday as majority of the informants came to Sabah for holiday<br />

<strong>and</strong> relaxation. They travelled mainly to see the wildlife (Orang Utan, Proboscis monkey, <strong>and</strong><br />

turtles) <strong>and</strong> natural environment (rainforest, mountain, beaches <strong>and</strong> isl<strong>and</strong>s) in Sabah. Other<br />

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

(transit flights to home countries) <strong>and</strong> the range of activities like trekking up Mount Kinabalu,<br />

golfing <strong>and</strong> water activities (snorkelling <strong>and</strong> diving). Previous travel experiences, the travel<br />

agents’ <strong>and</strong> friends’ recommendations also influenced <strong>tourists</strong>’ decisions to come to Sabah,<br />

especially for the first-time <strong>tourists</strong>. The travel agents <strong>and</strong> the internet were the main sources<br />

of information for the <strong>tourists</strong> when selecting a travel destination.<br />

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

Sabah as a holiday destination. However, when selecting an accommodation, the informants<br />

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

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

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

of massage <strong>and</strong> varieties of treatments, regeneration, clean <strong>and</strong> calm, tranquillity, enjoyment,<br />

<strong>and</strong> expensive. Interestingly, there were informants associated spas with hot tubs or hot<br />

springs. This suggests that the spa is associated with water <strong>and</strong> hot springs are the common<br />

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

expensive… I think tranquil… hot tub… (Interview informant 13)” <strong>and</strong> “Different, because I<br />

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

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

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

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

Besides of being relaxed during holiday, the spa experience is regarded as part of the<br />

enjoyment of holiday experience. This is reflected in the response “It is part of the enjoyment<br />

of my holiday <strong>and</strong> it also adds to the relaxation of my holiday <strong>and</strong> the experience of my<br />

holiday” (Interview informant 7)<br />

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

activities during holiday. They suggested that ones need <strong>healthy</strong> activities all around <strong>and</strong> not<br />

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


not the most important, the most important is relaxation; as evidenced from the following<br />

quotes: “We try to incorporate relaxation, walking <strong>and</strong> tourism” (interview informant 12), “I<br />

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

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

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

<strong>and</strong> “Relaxation is the most important, not exercise” (interview informant 18). Interestingly,<br />

the lifestyle factor also motivates the health <strong>and</strong> spa <strong>tourists</strong> to visit spa during holiday. This is<br />

evidenced from the quote: “When you’re away from home, <strong>and</strong> even if you’re relaxing on<br />

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

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

experiences during holiday are very nice, enjoyable <strong>and</strong> relaxing as part of the holiday. To<br />

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

opportunity to relax <strong>and</strong> a nice excuse for pamper, <strong>and</strong> mainly because they have time to do it<br />

during holiday.<br />

<strong>Health</strong> <strong>and</strong> Spa Tourists Motivational Factors<br />

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

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

take a break), unwind <strong>and</strong> rejuvenate <strong>and</strong> regeneration (busy <strong>and</strong> stressful life, distant travel<br />

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

physical look – tangible resource (environment, atmosphere, decoration) <strong>and</strong> marketing image<br />

of the spa (affordability, availability <strong>and</strong> accessibility, range of treatments <strong>and</strong><br />

professionalism). The findings are presented in Table 2.<br />

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

are the main motivations for the informants to visit health-related <strong>and</strong> spa facilities during<br />

their holiday in Sabah, Malaysia. When asked why the informants used spa <strong>and</strong> health<br />

services at the resorts, majority of them answered for relaxation, pampering, distress, unwind,<br />

rejuvenate <strong>and</strong> enjoyment; all that related to ones’ health <strong>and</strong> well-being in a more goaldirected<br />

way (self-satisfying goals <strong>and</strong> self-fulfilment). Very less of mentioning the attributes<br />

that attracts them to the spas – accessibility, affordability <strong>and</strong> the physical look of the<br />

establishments. The informants simply answered their reasons for having spa experiences<br />

were to relax <strong>and</strong> pamper themselves during holiday; for example: “We wanted some time-out<br />

just to relax” (Interview informant 4), or “To relax <strong>and</strong> to get pampered” (Interview<br />

informant 5) <strong>and</strong> “I wanted to be pampered” (Interview informant 6), “Just to relax <strong>and</strong> have<br />

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


Table 2 Themes of Motivation Factors <strong>and</strong> Push/Pull Factors<br />

Themes / Push <strong>and</strong> Pull Factors<br />

Sub-themes<br />

Push factor :<br />

Self-satisfying goal Escape - relax <strong>and</strong> pamper<br />

Reward after working hard<br />

Self-fulfilment Distress / Time-out<br />

Relieve from work-stress<br />

Take a break<br />

Unwind / Rejuvenate / Regeneration<br />

Recovery from tension in busy life<br />

Distant travel / long flights<br />

Travel activities<br />

Pull factors :<br />

Spa attributes Physical looks – tangible resource<br />

Environment / Atmosphere<br />

Well-decorated<br />

Spa attributes Marketing image<br />

Affordability<br />

Availability <strong>and</strong> accessibility<br />

Range of treatments<br />

Professionalism<br />

In addition, the reasons of having spa treatments were also related to the tiredness of being<br />

involved in activities during holiday <strong>and</strong> the travelling itself (e.g. had long flight). This is<br />

evidenced from the following quotes: “To distress, to relax <strong>and</strong> after playing physical sports,<br />

it helps my muscles rejuvenate” (Interview informant 10) <strong>and</strong> “Because I come from the Sri<br />

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

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

commonly as one of the main motivators for holiday exists <strong>and</strong> related to motivation of<br />

having health <strong>and</strong> spa experiences at the holiday destination selected. This can be reflected<br />

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

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

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

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

home, I’ll feel refresh <strong>and</strong> back to routine <strong>and</strong> work” (Interview informant 15)<br />

Clearly, the motivating factors that emerged from the responses, as shown in Table 2,<br />

suggested that health <strong>and</strong> spa <strong>tourists</strong> were generally motivated from the individual’s<br />

psychological aspects including variety of reasons related to relaxation during holiday (needs<br />

<strong>and</strong> wants). From the themes <strong>and</strong> sub-themes of informants’ motivational factors, it also<br />

suggests that informants are mainly attracted by the spa attributes such as the tangibility of the<br />

spa itself <strong>and</strong> the marketing image it conveys which have considerate influences on the<br />

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


environment <strong>and</strong> decoration of the spa establishment, the affordability, availability <strong>and</strong><br />

accessibility of the spa, the varieties of treatments <strong>and</strong> the professionalism of the staffs.<br />

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

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

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

types of spa treatments – traditional/local types of massages.<br />

Push <strong>and</strong> Pull Factors<br />

It is discovered that the notion of underst<strong>and</strong>ing the consumer/<strong>tourists</strong> behaviours is to study<br />

their travel/holiday motivations. These motivations often related to <strong>tourists</strong>’ behaviours <strong>and</strong><br />

decisions during travel <strong>and</strong> holiday. It is interesting to note that there is an existence of pushpull<br />

motivational dimension; push factors – the real goal-satisfying <strong>and</strong> self-fulfilment in<br />

relation to informants’ needs <strong>and</strong> wants for relaxation <strong>and</strong> pamper, either as a reward for<br />

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

life <strong>and</strong> works; <strong>and</strong> pull factors – the spa attributes itself that play an important role in<br />

activating the needs <strong>and</strong> wants for spa treatments during holiday <strong>and</strong> resulting health <strong>and</strong> spa<br />

dem<strong>and</strong>s at the destination country. In many circumstances, the initial needs <strong>and</strong> wants are the<br />

unconscious motivators that are activated upon the actions (spa visitation) by the tangibility<br />

sources of the spa itself.<br />

Although the two different motivating factors emerged in motivating spa visitation among the<br />

<strong>tourists</strong>, it is the push factors that have a comparative greater effect in influencing the health<br />

<strong>and</strong> spa <strong>tourists</strong>’ behaviours to visit spas when they go on holiday. These <strong>tourists</strong> are the<br />

people who practice generally a <strong>healthy</strong> lifestyle – involve regular exercises, <strong>healthy</strong> eating<br />

<strong>and</strong> perhaps occasional visits to spas or health-related facilities. This indicates that the <strong>tourists</strong><br />

are health conscious <strong>and</strong> well-educated pertaining to their health <strong>and</strong> well-being, which<br />

increased the dem<strong>and</strong> for health-related holidays (Chon <strong>and</strong> Singh, 2005). Although some<br />

<strong>tourists</strong> might not be a regular spa goers at their home countries (generally due to time<br />

constraint <strong>and</strong> their nature of works), but most of the <strong>tourists</strong> would have spa treatments<br />

during holiday which commonly related to relaxation purposes, <strong>and</strong>/or other sociopsychological<br />

factors, which reflected the findings of Mak <strong>and</strong> Wong (2007); Smith <strong>and</strong><br />

Puczkó (2009). It signals the importance of viewing the <strong>tourists</strong>’ needs <strong>and</strong> wants in<br />

developing range of products <strong>and</strong> treatments that fulfilling these needs <strong>and</strong> wants.<br />

However, it is discovered that health <strong>and</strong> spa <strong>tourists</strong> may be conscious on their needs <strong>and</strong><br />

wants before their actual travel, but these sub-conscious needs <strong>and</strong> wants may be evolved or<br />

become significant within the actual travel period. Therefore, it suggests the primary focus<br />

<strong>and</strong> attention for health <strong>and</strong> spa providers should be on the aspects of fulfilling the <strong>tourists</strong>’<br />

health-related needs <strong>and</strong> wants – that push the individuals to go to spas during holiday. As<br />

concluded by Mc Neil <strong>and</strong> Ragins (2004), the spa marketers must remain flexible <strong>and</strong> adapt to<br />

changes of spa users’ wants <strong>and</strong> needs, <strong>and</strong> continue to improve communications about the<br />

spa experience <strong>and</strong> its benefits. Apart from that, the push factors of health <strong>and</strong> spa <strong>tourists</strong> in<br />

Sabah also reflected the wellness dimension of health tourism (Smith <strong>and</strong> Puczko, 2009).<br />

Nevertheless, in some circumstances, the spa attributes equally play a significant role in<br />

motivating spa visitations at the holiday destination, particularly in stimulating the “subconscious”<br />

needs <strong>and</strong> wants. Meanwhile, to occasional or regular spa goers, there certainly<br />

perceptions <strong>and</strong> expectation established prior to their visitation to spas at a particular holiday<br />

destination. As spa is perceived to be a place for relaxation, with parallel to health <strong>and</strong> spa<br />

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


elaxation as this is generally the main motivator for the <strong>tourists</strong> to visit spas. The spa<br />

attributes include the physical environment <strong>and</strong> decoration of the spa itself, the reasonable<br />

price <strong>and</strong> accessibility of the spa, the wide range of treatments or signature treatments that<br />

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

presentation, significantly the marketing image of the spa through media advertisement such<br />

as brochures <strong>and</strong> resort’s websites has attracted the <strong>tourists</strong> to decide for spa visitation during<br />

their holiday in Sabah, Malaysia. Within the framework of push <strong>and</strong> pull factors, it suggests<br />

that these are the important elements that promote the overall spa experiences from the very<br />

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

treatment, <strong>and</strong> also as part of the holiday relaxation.<br />

Conclusion <strong>and</strong> Implications<br />

<strong>Health</strong> <strong>and</strong> spa tourism in Sabah, Malaysia is still at an infant stage, <strong>and</strong> there is no<br />

established definition of this growing niche tourism <strong>business</strong> which indicates an importance to<br />

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

<strong>and</strong> attitudes which predispose a person to act in a specific touristic goal-directed way, it is<br />

discovered that the informants’ motivation to spas are associated with <strong>tourists</strong>’ motivation to<br />

travel for holiday – relaxation, which this paper has explored <strong>and</strong> presented the motivational<br />

factors of health <strong>and</strong> spa <strong>tourists</strong> in Sabah, Malaysia thus provides an insightful underst<strong>and</strong>ing<br />

of what motivates health <strong>and</strong> spa <strong>tourists</strong> to visit spas during holiday in Sabah. It is clear that<br />

both self-satisfying <strong>and</strong> self-fulfilment (push factors) <strong>and</strong> the spa attributes (pull factors) serve<br />

as the motivational factors to spa visitation.<br />

Moreover, the profiles of the <strong>tourists</strong> have reflected the findings of previous researches (e.g.<br />

Mak <strong>and</strong> Wong, 2007; Smith <strong>and</strong> Puczkó, 2009). The growth of health <strong>and</strong> spa tourism indeed<br />

affected by the major demographic shift of the world population. As previously stated,<br />

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

are emerging groups of younger spa goers, within less than 30 years old. The health <strong>and</strong> spa<br />

market also evolved among the professionals who perceive spas as a way to rest <strong>and</strong> relieve<br />

from their work stresses, besides having the affordability for holiday <strong>and</strong> spa treatments as<br />

indicated from their level of income. In addition, health <strong>and</strong> spa seemingly begin to be<br />

acceptable among the male spa goers. These have directly indicated the needs for products<br />

development to cater different groups of health <strong>and</strong> spa tourist market.<br />

Particularly, the findings presented in this paper may indeed be significant on an international<br />

scale, as it certainly possible that the <strong>tourists</strong> (notably from the America, Europe <strong>and</strong><br />

Australasia regions) to be indirectly attracted to spa attributes at the holiday destination (in<br />

this case, Sabah, Malaysia) because their main travel motivators are mostly associated with<br />

relaxation when holiday. This paper suggests that marketing strategies for health <strong>and</strong> spa<br />

should focus on the individual tourist health-related needs <strong>and</strong> wants. As relaxation <strong>and</strong><br />

pamper are the significant motivational factors for health <strong>and</strong> spa <strong>tourists</strong>, the health-spa<br />

providers should position their spas based on the relaxation attributes that may stimulate a<br />

relaxing mood throughout the spa experiences – the atmosphere, the layout <strong>and</strong> decoration,<br />

the staffs, <strong>and</strong> the spa treatments.<br />

A major limitation of this study is due to the nature of the exploratory study <strong>and</strong> the type of<br />

respondent (foreign <strong>tourists</strong>) which limit the generalizability of the research findings. It<br />

suggests a comparative work in a similar context in different locations <strong>and</strong> countries would<br />

prove beneficial for the possible validation of the findings. Additionally, the generalization of<br />

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 <strong>and</strong><br />

spa tourism – health <strong>and</strong> spa <strong>tourists</strong>’ satisfaction, spa treatment preferences, or perceptions<br />

<strong>and</strong> expectations.<br />

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Holidays as <strong>Health</strong>: The No Leave, No Life Campaign<br />

Sue Beeton<br />

La Trobe University, Australia<br />

s.beeton@latrobe.edu.au<br />

Abstract<br />

The current interest in health, wellness <strong>and</strong> tourism tends to focus on travel for medical reasons<br />

(Connell, 2006; Henderson, 2003; Herrick, 2007), travel for mental <strong>and</strong> physical rejuvenation<br />

(Mueller <strong>and</strong> Kaufmann, 2001; Smith <strong>and</strong> Puczkó, 2009) <strong>and</strong> travel connected to physical activities<br />

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

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

<strong>and</strong> recreation leave is considered in many nations as a necessary enabler of one making a<br />

productive <strong>and</strong> <strong>healthy</strong> contribution to society.<br />

Furthermore, the potential financial, social <strong>and</strong> community health costs of workers not taking their<br />

allocated annual recreation leave has been recognised for some time, with researchers <strong>and</strong> tourism<br />

professionals calling for programs to encourage holiday taking. For example, during 2002, just<br />

under a third of Australians did not take any holidays, <strong>and</strong> of those who did, only 30 percent took<br />

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

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

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

taking a break are held to ameliorate have become the reasons for not taking a break”.<br />

Tourist commissions <strong>and</strong> other government organisations have developed programs over the years<br />

to encourage people to take holidays, especially domestic short breaks. However, the problem of<br />

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

employees accrued in 2009, equating to AUD$33 billion in wages (<strong>Tourism</strong> Australia, 2009a).<br />

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

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

domestic tourism industry: that of community health <strong>and</strong> <strong>business</strong> viability.<br />

It is clear that workers need to be persuaded to take their recreation leave, <strong>and</strong> employers to<br />

encourage the development of a supportive corporate culture. In 2009, the Australian government,<br />

under the auspices of <strong>Tourism</strong> Australia, developed an innovative program to encourage workers to<br />

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

core strategies:<br />

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

organisations;<br />

2. To remind employees of the personal <strong>and</strong> professional benefits of taking annual leave (<strong>and</strong><br />

taking it in Australia). (<strong>Tourism</strong> Australia, 2009a: 2)<br />

This paper examines the process that <strong>Tourism</strong> Australia has adopted to achieve its desired<br />

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

elsewhere.<br />

Persuasive Communication<br />

In any case where a change in people’s behaviour is required, it is important to underst<strong>and</strong> the<br />

barriers to participating in the desired activity. Persuasive communication theory can assist in<br />

analysing the process <strong>and</strong> frames this particular Case Study.


According to Ajzen, “persuasive communication can produce a profound <strong>and</strong> lasting change, a goal<br />

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

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

towards the behaviour, normative beliefs that determine the subjective norms (perceived social<br />

pressures), <strong>and</strong> control beliefs that underpin perceptions of behavioural control, advancing<br />

advanced the Theory of Planned Behaviour, outlined in Figure 1.<br />

Figure 1. Ajzen’s Theory of Planned Behaviour<br />

Source: Ajzen (1988: 133)<br />

According to the theory, the intention to act precedes the actual behaviour, with intentions based on<br />

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

social pressures to undertake the behaviour (or subjective norm), <strong>and</strong> the perception of how much<br />

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

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

persuasive communication theory in affecting national park visitor beliefs, attitudes <strong>and</strong> intentions<br />

<strong>and</strong>,, ultimately their behaviour.<br />

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

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

namely internal <strong>and</strong> external (McCool <strong>and</strong> Braithwaite, 1992) - where a person believes that their<br />

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

a low level of perceived behavioural control in Ajzen’s model.<br />

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

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

there are times when there may be little or no influence from attitudes <strong>and</strong> subjective norms, so<br />

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

(Ajzen, 1988). Such differences are also reflected in the model, presenting a flexible <strong>and</strong> effective<br />

model that has been applied many times in relation to persuading others (for some tourism <strong>and</strong><br />

recreation examples, see Lackey et. al., 2002, Beeton et; al., 2005).<br />

The Case of No Leave, No Life<br />

As noted earlier, the Australian No Leave, No Life campaign commenced in 2009, with the longterm<br />

aim to reduce the amount of accrued recreation leave by Australians <strong>and</strong> to increase domestic


tourism. Previous attempts in the late 1980s <strong>and</strong> early 2000s to encourage local holidays by<br />

Australians was only partially successful, with accrued leave continuing to rise <strong>and</strong> domestic<br />

tourism growth remaining flat. In order to address this, <strong>Tourism</strong> Australia shifted from the<br />

traditional supply focus of a Destination Marketing Organisation (DMO) to attempting to influence<br />

dem<strong>and</strong> by enlisting the employers along with the tourism industry.<br />

<strong>Tourism</strong> Australia employed research consultants, Jones Donald Strategy Partners to undertake the<br />

research, using Focus Groups, In Depth Interviews <strong>and</strong> Online Surveys in 2005 <strong>and</strong> 2009, along<br />

with Single Source Surveys from 2006 to March 2009 in order to gather the required data (<strong>Tourism</strong><br />

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

using ‘workplace <strong>and</strong> personal barriers’ as the differentiators.<br />

The industry provides the domestic holiday options, while <strong>Tourism</strong> Australia developed tactical<br />

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

<strong>and</strong> other collateral. The target employees are full time staff deemed to have ‘stockpiled’ over 25<br />

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

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

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

older children <strong>and</strong> empty nesters (<strong>Tourism</strong> Australia, 2009b). The younger, single, child-free <strong>and</strong><br />

women workers did not feature, underlining the broadly accepted fact that the Australian workforce<br />

remains dominated by men at the higher levels of organisations, <strong>and</strong> as longer-serving employees<br />

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

DMO to focus on changing the domestic tourism dem<strong>and</strong> environment (or ‘push’ factors as<br />

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

<strong>Tourism</strong> Australia has taken a three-stepped approach to working with employers, with the first<br />

providing background data on leave stockpiling, the second suggesting some workplace strategies<br />

to address the issue, with the third focusing on enabling employers to change the culture <strong>and</strong><br />

attitudes towards taking leave within the organisation through engaging with the No Leave, No Life<br />

program. All of this material was made available via the internet as training modules <strong>and</strong> videos<br />

(see http://www.noleavenolife.com/employer/<strong>business</strong>Benefits.aspx).<br />

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

Ajzen claims informs our intentions, namely attitude (towards the behaviour), (perceived)<br />

behavioural control <strong>and</strong> subjective norms. This is outlined in Figure 2.<br />

Figure 2. Stated Reasons for not Taking Leave<br />

Attitude:<br />

Move up corporate ladder<br />

Prefer to work<br />

Saving (for emergencies)<br />

Saving (for big trip)<br />

Hard to find things to do<br />

Subjective Norms:<br />

Taking leave is a sign of weakness<br />

Cause work for others<br />

Internal work culture


Behavioural Control:<br />

Workload<br />

Lack of<br />

resources<br />

Support from<br />

management<br />

Job security<br />

Source: <strong>Tourism</strong> Australia, 2009b<br />

Will not meet targets<br />

Hard to fit around projects<br />

Unable to take when it suits<br />

Lack of money<br />

Partner’s availability<br />

Children’s availability<br />

Time taken planning<br />

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

control’ area, which responds directly with organisational culture. If these outweigh the<br />

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

taken. In order to shift this, <strong>Tourism</strong> Australia has adopted a strategy aimed at the dem<strong>and</strong><br />

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

awareness’ of employers <strong>and</strong> employees, but they are doing more than this – they are working<br />

to change the salient beliefs of those not taking holidays.<br />

However, <strong>Tourism</strong> Australia has not looked at those who DO take leave, which would<br />

provide a more holistic perspective <strong>and</strong> provide data that can be used in the Theory of<br />

Planned Behaviour. By getting both sides <strong>and</strong> then ascertaining the strength of these beliefs in<br />

the targe group (leave stockpilers) <strong>and</strong> range of consistent messages can be developed.<br />

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

influence’s one’s decision to act. By ascertaining what are the strongest drivers <strong>and</strong> inhibitors,<br />

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

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

Conclusion<br />

The following comment from Beeton <strong>and</strong> Pinge some years ago remains true: “We need to<br />

take holidays in order to refresh <strong>and</strong> recharge, otherwise our governments may well face<br />

expensive community health issues in the future” (Beeton <strong>and</strong> Pinge, 2003: 320).<br />

<strong>Tourism</strong> Australia’s strategy in relation to employers is to raise awareness of the issue, recruit<br />

employers to the project <strong>and</strong> then assist them to create a positive leave culture. In terms of<br />

employees, <strong>Tourism</strong> Australia aims to raise their awareness <strong>and</strong> communicate the benefits of<br />

taking leave while encouraging them to book a domestic holiday. By analysing <strong>Tourism</strong><br />

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

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

influence the persuasive communications generate. Data is yet to be analysed <strong>and</strong> published<br />

by <strong>Tourism</strong> Australia regarding this outcome.<br />

This case demonstrates an innovative, integrated <strong>and</strong> inclusive approach to the issue of<br />

accrued leave from the <strong>business</strong>, community <strong>and</strong> tourism perspectives that could be further<br />

enhanced using the Theory of Planned Behaviour.


References<br />

Ajzen, I. (1988) Attitudes, Personality <strong>and</strong> Behaviour, The Dorsey Press, Chicago<br />

Ajzen, I. (1992) Persuasive Communication Theory in Social Psychology: A Historical<br />

Perspective, in Michael M. Manfredo (editor), Influencing Human Behaviour: Theory<br />

<strong>and</strong> Applications in Recreation, <strong>Tourism</strong> <strong>and</strong> Natural Resources Management,<br />

Sagamore Publishing, Inc., Champaign IL, pp.1-28<br />

Beeton, S. & Pinge, I. (2003) ‘Casting the Holiday Dice: Demarketing Gambling to Encourage<br />

Local <strong>Tourism</strong>’. Current Issues in <strong>Tourism</strong>, 6(4): 309-322<br />

Beeton, S., Weiler, B. <strong>and</strong> Ham, S. (2005) Contextual Analysis for Applying persuasive<br />

Communication Theory to Managing Visitor Behaviour. A Scoping Study <strong>and</strong> Port<br />

Campbell National Park, CRC for Sustainable <strong>Tourism</strong>, Griffith<br />

Connell, John (2006) ‘Medical <strong>Tourism</strong>: Sea, sun, s<strong>and</strong> <strong>and</strong>... surgery’. <strong>Tourism</strong> Management,<br />

27(6): 1093-1100<br />

Dann, G.M.S. (1977) Anomie, Ego-Enhancement in <strong>Tourism</strong>. Annals of <strong>Tourism</strong> Research,<br />

4(4): 184-194<br />

Fishbein, M. <strong>and</strong> Manfredo, M.M. (1992) A Theory of Behaviour Change, in Michael M.<br />

Manfredo (editor), Influencing Human Behaviour: Theory <strong>and</strong> Applications in<br />

Recreation, <strong>Tourism</strong> <strong>and</strong> Natural Resources Management, Sagamore Publishing, Inc.,<br />

Champaign: 29-50<br />

Henderson, Joan, C. (2003) ‘<strong>Health</strong>care <strong>Tourism</strong> in Southeast Asia’. <strong>Tourism</strong> Review<br />

International, 7(3-4): 111-121<br />

Herrick, Devon, M. (2007) Medical <strong>Tourism</strong>: Global Competition in <strong>Health</strong>care. NCPA Policy<br />

Report, No. 34, National Centre for Policy Analysis, Dallas<br />

http://www.medorganiza.com/news/whitepaper/Medical%20<strong>Tourism</strong>-by-National-Centerfor-Policy-Analysis.pdf.<br />

[accessed 1 March, 2010]<br />

Jones Donald Strategy Partners (2009) Research Report for <strong>Tourism</strong> Australia, unpublished<br />

report, March 2009<br />

Lackey, B., Ham, S. <strong>and</strong> Hall, T. (2002) ‘Tests of perceived risk <strong>and</strong> attention paying to bear<br />

safety signs in Yosemite National Park’, Final Research Report to Yosemite National<br />

Park, Wildlife Conservation Society, New York<br />

McCool, S.F. <strong>and</strong> Braithwaite, A.M. (1992) Persuasive Messages <strong>and</strong> Safety Hazards in<br />

Dispersed <strong>and</strong> Natural Recreation Settings, in Michael M. Manfredo (editor),<br />

Influencing Human Behaviour: Theory <strong>and</strong> Applications in Recreation, <strong>Tourism</strong> <strong>and</strong><br />

Natural Resources Management, Sagamore Publishing, Inc., Champaign IL, pp.292-326<br />

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

health tourism segment <strong>and</strong> implications for the hotel industry’. Journal of Vacation<br />

Marketing, 7(1):<br />

Smith, Melanie K. <strong>and</strong> Puczkó, László (2009) <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>, Butterworth<br />

Heinemann, Oxford<br />

<strong>Tourism</strong> Australia (2009a) No Leave, No Life, Industry Prospectus, <strong>Tourism</strong> Australia, Sydney<br />

<strong>Tourism</strong> Australia (2009b) No Leave, No Life: Employer Module 1. Analysing the Issues for<br />

Employers, <strong>Tourism</strong> Australia, Sydney<br />

Woolcott Research (2002) Annual Leave Evaluation. Conducted for See Australia. Woolcott<br />

Research job no 5435-M. Sydney


A Case Study of Innovative <strong>Wellness</strong> <strong>Tourism</strong>: The Case of RP Vacations,<br />

Netherl<strong>and</strong>s<br />

Ed Brooker<br />

Griffith University, Australia<br />

ebniagara@gmail.com<br />

<strong>and</strong><br />

Marion Joppe<br />

University of Guelph, Canada<br />

Introduction<br />

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

by which they exploit change as an opportunity for a different <strong>business</strong> or a different service.<br />

Entrepreneurs need to purposely search for sources for innovative opportunities, <strong>and</strong> they<br />

need to apply the principles of successful innovation. Roompot Parks in the Netherl<strong>and</strong>s<br />

represents an example of classic entrepreneurship in that the owner sensed an opportunity to<br />

capitalize on the renewed interest in health <strong>and</strong> wellbeing, <strong>and</strong> over time, developed an<br />

innovative program which pulls <strong>tourists</strong> to Roompot Parks for the primary purpose of<br />

wellness facilities <strong>and</strong> programs.<br />

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

interview with the current manager of RP Care <strong>and</strong> RP <strong>Wellness</strong>, along with previous<br />

research undertaken by the lead author four years ago when the concepts were developing. In<br />

so doing, the study explores the relationship between health, wellness <strong>and</strong> tourism perspective<br />

through an entrepreneurial perspective.<br />

Background – Roompot Parks<br />

The Dutch are keen campers (Klemm & Rawel, 2001), <strong>and</strong> as a result, there are between 400<br />

<strong>and</strong> 450 recreational home parks in the Netherl<strong>and</strong>s. Roompot is the third largest holiday park<br />

operator in the Netherl<strong>and</strong>s <strong>and</strong> considered to be the market leader in ‘sea park’ holidays<br />

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

bungalow parks to traditional camping grounds.. The two larger companies include Pierre &<br />

Vacances <strong>and</strong> L<strong>and</strong>al Greenparks. Pierre & Vacances, a French company, is the largest actor<br />

in the Netherl<strong>and</strong>s holiday park market, offering br<strong>and</strong>s that include Center Parcs, Free Life<br />

<strong>and</strong> Sea Spirit. L<strong>and</strong>al Greenparks have a strong emphasis on nature <strong>and</strong> space. Competition<br />

is not limited to just the other holiday park operators. It also comes from external sources, as<br />

new long haul <strong>and</strong> exotic destinations, often in less developed countries, attract travelers who<br />

may be seeking alternatives (Buhalis, 2000). Roompot is keeping a close eye on the trend<br />

towards the growth in low-cost air travel to foreign markets, realizing that these vacations<br />

may be more affordable than a week spent at a Roompot Park. This scenario, i.e. competing<br />

with ‘more glamorous’ international travel is also a challenge for other holiday parks, as<br />

shown in ongoing research into innovation in Australian holiday parks.<br />

Roompot Parks began has grown over a 45 year period from an initial local family camping<br />

<strong>business</strong> to an enterprise that now operates 46 parks, 40 of which are in the Netherl<strong>and</strong>s, <strong>and</strong><br />

six in Germany. Combined, the parks offer a total of 3,450 holiday bungalows, 1,800 mobile<br />

homes, 5,950 campsites, <strong>and</strong> 400 marina slots. All the parks are positioned in the mid to<br />

higher end of the market, attracting families <strong>and</strong> mature couples seeking quality facilities <strong>and</strong><br />

services.


While the supply of accommodation had been the company’s core activity, the company had a<br />

change in direction in 2002, focusing on being a full-service provider of all-inclusive<br />

holidays. The strategy was designed to enable Roompot to capitalize <strong>and</strong> exp<strong>and</strong> on its<br />

existing customer base. Enlarging its product portfolio <strong>and</strong> service offering enabled Roompot<br />

to clearly distinguish itself from its competitors. In 2010, Roompot Parks sells vacation<br />

accommodations in over 100 resorts <strong>and</strong> campgrounds, across Europe, including 55 resorts in<br />

the Netherl<strong>and</strong>s, 50 resorts in France, 16 resorts in Germany, 5 resorts in Belgium, 3 resorts in<br />

Denmark, <strong>and</strong> 1 resort in Pol<strong>and</strong>. Locations in Italy <strong>and</strong> Spain are under current negotiation.<br />

Roompot’s second area of expertise lies with tour operating. Roompot has developed the<br />

capability of selling its holiday offerings through its own direct distribution channel called<br />

Roompot Vakanties. Perspective customers can book a vacation through three channels,<br />

including:<br />

1. Direct sales via Roompot’s booking centre – remains the most popular method<br />

2. Direct sales via the Internet – increasing in popularity<br />

3. Indirect sales channels through various intermediaries including international travel<br />

agencies (for resale).<br />

Innovation is not new to the company. It has been the first to develop a new product or service on<br />

many fronts including being the first in the Dutch industry to introduce on-line reservations for a<br />

holiday bungalow or campsite. The company is now in the unique position of being able to act as a<br />

consultant, offering its expertise to other operators in the industry.<br />

Introducing a new product or line of services will only benefit Roompot if it can propel the new<br />

offerings into economic <strong>and</strong> competitive advantages (Walder, 2006). The company however<br />

underst<strong>and</strong>s the lag time <strong>and</strong> effort required prior to seeing any results from its efforts. The firm<br />

has experience with diversification, growing from its initial campground to the point where it now<br />

offers a range of services including holiday reservations, real estate development, construction,<br />

retail <strong>and</strong> insurance. The net financial result has seen sales almost double from EUR 68.4 million<br />

in 2002 to EUR 118.4 million in 2004 (Bencis, 2005). Very few SMTEs can boost such growth<br />

within such a short period of time. In 2009, Roompot Parks turned over EUR 225 million. Its<br />

parks attracted 1.3 million guests, who stayed approximately 7 million nights.<br />

Methodology<br />

In order to gain insights, it was essential for Roompot personnel to speak to the concept of<br />

wellness tourism within their parks in their own words <strong>and</strong> from their individual perspectives.<br />

This study therefore employed qualitative methodology where the research tool comprised of<br />

a single case study based on semi-structured interviews with two individuals with specific<br />

connections to the program. The first interview was conducted in 2006 with the visionary<br />

staff person who was instrumental in developing the concept <strong>and</strong> a follow up interview in<br />

2010 with the current manager overseeing RP Care <strong>and</strong> RP <strong>Wellness</strong>.<br />

RP Care<br />

Johannsson (2004) suggests the best chance to innovate is found in the ‘intersection’ – a<br />

connection between two different fields. Roompot has clearly found the intersection, by merging<br />

health care <strong>and</strong> vacations, within its existing operation. The result is known as RP Care, yet<br />

another extension of the Roompot offering.


RP Care is an innovative modular extension of Roompot Vacations, providing guests (both<br />

domestic <strong>and</strong> European Union) to obtain a variety of quality health <strong>and</strong> wellness services while<br />

also enjoying a Dutch sea <strong>and</strong> s<strong>and</strong> vacation. RP Care has been established in part in response to<br />

the international focus of health care tourism, in particular, the number of Dutch, German <strong>and</strong><br />

English who travel abroad in response to long waiting lines <strong>and</strong>/or electing to undertake elective<br />

medical procedures while on vacation. Roompot felt that it could exp<strong>and</strong> on its initial entry into the<br />

health care, started five years ago with the offering of kidney dialysis at the Banjaard, a five-star<br />

holiday bungalow park, located 10 kms from the first established Roompot Park.<br />

The kidney dialysis service stemmed from the local hospital’s inability to service the needs of an<br />

exp<strong>and</strong>ed vacation market <strong>and</strong> local knowledge, as the founder of Roompot was a member of the<br />

local hospital board, was therefore aware of both the need for additional dialysis service <strong>and</strong> the<br />

hospital’s desire to establish an off-site clinic. Thus in true entrepreneurial spirit, a separate<br />

building was constructed within the park to house the dialysis service. Patients no longer had to<br />

travel to <strong>and</strong> remain in a hospital for the procedure. Rather they have the option of visiting the<br />

clinic three times a week, for 2 weeks, enjoying a non-sterile, relaxed but professional<br />

environment. Appointments can be made on line through the Roompot Vacations website, with the<br />

knowledge that the onsite medical staff are all associated with the local hospital.<br />

The dialysis service is a radical innovation amongst holiday parks that traditionally offer<br />

recreational opportunities to a variety of markets. However, previously, the mature market has<br />

been viewed simply as a market opportunity based on their numbers only, as no serious efforts<br />

have been made to alter the product mix in order to attract <strong>and</strong> retain a larger percentage of this<br />

market. Roompot/RP Care has.<br />

The success of the kidney dialysis service has led Roompot to extend its modular service offerings<br />

into care <strong>and</strong> cure, augmenting the existing recreation facilities. Thus RP Care was created.<br />

However, the creation of the service has not come without any difficulties. At first, it was a<br />

difficult sell getting medical professionals to partner with RP Care. But Roompot’s founder<br />

understood the value of networks, both in <strong>and</strong> outside of the <strong>business</strong> (Grulke, 2005). Based on his<br />

relationships with external organizations, including the local hospital board, he managed to create<br />

the necessary interest in the offering. In 2010, professional personnel from the local hospital staff<br />

the dialysis center, but a local doctor also spends a day now visiting the park booking appointments<br />

with park guests. Other doctors are inquiring about participating in the program.<br />

Table 1 outlines the modular services <strong>and</strong> amenities planned for various Roompot locations within<br />

Zeel<strong>and</strong> in partnership with local health providers. A clinic specializing in plastic surgery is<br />

intended to be located in Goes, centrally positioned close to other Roompot parks <strong>and</strong> the regional<br />

hospital. The location is of benefit to both doctors <strong>and</strong> patients, who will be able to convalesce in a<br />

quality holiday setting, with family <strong>and</strong>/or friends.<br />

The strategy to focus initially on the province of Zeel<strong>and</strong> is based in part on local knowledge of<br />

health care providers, networks <strong>and</strong> also represents the location of Roompot’s base of operations.<br />

The strategy can be exp<strong>and</strong>ed into other provinces within Holl<strong>and</strong> based on local success <strong>and</strong><br />

learning curve.


Recreation Care Cure<br />

• Fun stuff<br />

• Care facilities<br />

• Conference facilities<br />

• Pools<br />

• Sauna<br />

Table 1 - RP Care building blocks<br />

• Plastic surgery<br />

• Cosmetic<br />

• Orthopaedic<br />

• Eye<br />

• Pain reduction<br />

• Radiology<br />

• X-rays<br />

• Physiotherapy<br />

• Preventative<br />

• Therapy<br />

• Sauna<br />

• Nutrition<br />

• Acupuncture<br />

The strength of the concept is based on various factors. First, Roompot has essentially created a<br />

win win situation for a variety of players, including local hospitals, health insurance companies,<br />

individuals <strong>and</strong> for its own corporate opportunity. Local hospitals can now partner with a reputable<br />

private sector <strong>business</strong> to continue to offer its services but within a decentralized framework.<br />

<strong>Health</strong> insurance companies benefit from the preventative nature of the services, <strong>and</strong> the solid<br />

reputation of Roompot to deliver quality care. It eliminates the uncertainty attached with travel to<br />

Asia or other areas of Europe. The individual benefits from the opportunity to avoid lengthy<br />

waiting lists, select the necessary service from the extensive offering, <strong>and</strong> to recuperate in a<br />

comfortable location, where family <strong>and</strong> friends can visit, recreate, <strong>and</strong> remain in the Netherl<strong>and</strong>s.<br />

Roompot is the other winner in this situation, using a radical approach to capitalize on disruptive<br />

social trends. The development of RP Care capitalizes on the aging population in a manner far<br />

removed from what the competition has considered. This competitive advantage can also be<br />

sustained as Roompot has first mover advantages with government health care providers. In<br />

addition, the addition of RP Care addresses the issue of seasonality head on through the<br />

introduction of a new service line <strong>and</strong> market that may otherwise not frequent a Roompot Park.<br />

Facilities <strong>and</strong> amenities designed for use during the busy summer months now will be occupied<br />

<strong>and</strong> used during the spring <strong>and</strong> fall, raising occupancy rates, <strong>and</strong> creating new opportunities for<br />

programs <strong>and</strong> events. Current estimates suggest that two to three percent of Roompot patrons<br />

utilize RP Care services. That number is expected to grow to ten percent as a result of promotion<br />

efforts <strong>and</strong> the demographic changes noted earlier – older population will seek out care at Holiday<br />

Parks The addition of RP care sends a clear message to the loyal customers who have frequented a<br />

Roompot park over several summers – we’re not ab<strong>and</strong>oning you as you age. In fact, we want to<br />

keep you as a customer, so we’ve developed new programs designed with your needs in mind.<br />

The modularity of the three cornerstones – recreation, cure <strong>and</strong> care provide the flexibility for<br />

application to a diverse set of circumstances. <strong>Health</strong> services can be added to a vacation or<br />

conference. Convalescents can recover in a comfortable setting, knowing their needs are looked<br />

after, <strong>and</strong> the care is available locally.<br />

Roompot’s decision to capitalize on disruptive social trends, focusing on collaboration – aligning,<br />

exchanging, <strong>and</strong> leveraging opportunities (Dvir et al, 2004) builds on a modular <strong>business</strong> model.<br />

Such a modular approach gives the company the capability to couple <strong>and</strong> decouple service delivery<br />

on dem<strong>and</strong>, based particularly on three building blocks – recreation, cure, <strong>and</strong> care. On dem<strong>and</strong><br />

<strong>business</strong> enables a customer to connect in a flexible manner – for instance health services to a<br />

holiday or vice versa, contingent on his/her circumstances or personal preferences. It offers<br />

convalescents a sense of security that they can recover in a comfortable setting, in the knowledge<br />

that their needs are looked after in a professional manner.


The introduction of its modular <strong>business</strong> model enabled its subsidiary RP care to thrive in an<br />

intensely competitive tourism environment. It also demonstrates Roompot’s leadership in the trade<br />

<strong>and</strong> beyond, particularly that a radical innovation approach can bring rewards well worth the risk.<br />

In 2010, RP Care facilitates care, cure <strong>and</strong> wellness opportunities through partnerships with<br />

various health oriented organizations. For example, it provides facilities for disabled guests,<br />

kidney dialysis, accommodations for people with allergies, <strong>and</strong> automated external<br />

defibrillators at certain properties. It provides arrangements for home care, medical<br />

equipment, <strong>and</strong> health checks for those vacationing at a Roompot Park, thereby leveraging its<br />

strengths as a Holiday Park chain, with the wide range of health service partners.<br />

The number of requests to capitalize on these facilities <strong>and</strong> services is growing, as noted in the<br />

increased bookings from 2007 to 2009, illustrated in Table 2.<br />

Bookings<br />

accommodations<br />

for adjusted<br />

Bookings for home care <strong>and</strong> medical<br />

equipment<br />

Bookings from foundations <strong>and</strong><br />

organizations<br />

Table 2 – Increased RP Care Bookings<br />

2007 2008 2009<br />

3,500 4,800 6,000<br />

279 597 799<br />

833 1,081 1,387<br />

The results showcase a growth in patron response to capitalizing on the opportunities for care<br />

<strong>and</strong> wellness facilities <strong>and</strong> services, a trend which is expected to grow as awareness of the<br />

program is extended. The actual number of bookings may appear to be low, but the program<br />

itself is quite unique, given that care, cure <strong>and</strong> wellness are not automatically associated with<br />

a caravan or holiday park experience. The bookings provide opportunities for increased<br />

<strong>business</strong> for the parks during the shoulder periods, a time when “holiday” patronage has<br />

decreased substantially.<br />

As with many innovations, there is a test <strong>and</strong> measure component to the implementation of<br />

the program. Currently, five resorts within the Roompot Parks ‘chain’ have wellness centres,<br />

two which are directly managed. The other three are parks within the RP Parks vacation<br />

umbrella, i.e. vacation bookings. The overall success of the existing wellness programs will<br />

impact future extension of facilities, services <strong>and</strong> partnerships. Broadly speaking, however, it<br />

is anticipated that the program will continue to grow, given the needs of an aging population,<br />

the opportunities to provide an enhanced visitor experience, <strong>and</strong> additional <strong>business</strong><br />

opportunities for the parks themselves.<br />

Conclusion<br />

RP Care represents a classic example of radical innovation in the sense that the concepts are<br />

very unique – i.e. spending your vacation at holiday park for various care, cure <strong>and</strong> wellness<br />

programs. The vast majority of holiday park operations shy away from introducing radical<br />

innovation. They are aware of changes in demographics, economics, <strong>and</strong> environmental<br />

factors, but remain hesitant to initiate new ideas. The concepts generally require a substantial<br />

cash investment up front which, by itself, is a limiting factor for many. Initial returns are<br />

limited, as illustrated previously with the relatively small, although increasing, number of RP<br />

Care bookings. Radical innovation is a risky undertaking, given the longer term payback, <strong>and</strong><br />

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<br />

is very novel to the industry, <strong>and</strong> time is needed for the program to exp<strong>and</strong> to fulfill its<br />

potential. Risk has been mitigated to a degree through limiting the number of parks that offer<br />

the facilities, <strong>and</strong> through partnering with a variety of wellness associations.<br />

Nonetheless, the concept has attracted academic interest in the areas of innovation <strong>and</strong><br />

entrepreneurship (Go <strong>and</strong> Israels, 2010) <strong>and</strong> practioners. A group of Australian holiday park<br />

operators are scheduled to tour the wellness facilities in mid-September as part of their study<br />

tour of European parks who offer health <strong>and</strong> wellness activities. Thus in keeping with Rogers<br />

(1962) model of innovation diffusion, the concepts of RP Care may inspire strategic<br />

innovation to take hold in other geographic regions, where it may become a norm to have<br />

health <strong>and</strong> wellness facilities <strong>and</strong> activities in holiday parks in the future.<br />

References:<br />

Bencis. (2005). “Roompot Company Description”. Amsterdam.<br />

Buhalis, D. (2000). “Marketing the competitive destination of the future”. <strong>Tourism</strong><br />

Management, (21) pp.97-116.<br />

Drucker, P (1985). Innovation <strong>and</strong> Entrepreneurship. New York: Harper & Row, Publishers.<br />

Dvir, R., Lettice, F, <strong>and</strong> Thomond, P. (2004). Are you ready to Disrupt it? Israel: The<br />

Disrupt-IT Consortium.<br />

Go, F. & Israels, R. (2010). “Innovation of Care <strong>and</strong> Cure in the Netherl<strong>and</strong>s” in K.<br />

Weiermair, P. Keller, H. Pechlaner <strong>and</strong> F. Go (Eds.) Innovation <strong>and</strong> Entrepreneurship:<br />

Strategies <strong>and</strong> Processes for Success in <strong>Tourism</strong>, Berlin: Erich Schmidt Verlag.<br />

Grulke, W. (2005). People Management. 11(21) pg. 44.<br />

Johansson, F. (2004). “The Medici Effect”. Boston: Harvard Business School Press.<br />

Klemm, M. <strong>and</strong> J. Rawel (2001) ‘Extending the School Holiday Season: The Case of<br />

Eurocamp’ In Seasonality in <strong>Tourism</strong>, T. Baum <strong>and</strong> S. Lundtop, (Eds). Oxford : Elsevier.<br />

Rogers, E. M. (1962). Diffusion of innovations. New York: Free Press.<br />

Walder, B. (2006). “Sources <strong>and</strong> determinants of innovations – the role of market forces” in<br />

Innovation <strong>and</strong> Product Development in <strong>Tourism</strong>, B. Walder, K. Weiermair, A. Perez,<br />

(Eds.) Berlin: Erich Schmidt Verlag.


UNDERSTANDING THE IMPACT OF LEISURE TRAVEL ON THE QUALITY OF<br />

LIVES OF PEOPLE WITH MOBILITY IMPAIRMENS<br />

Shu Cole<br />

Indiana University<br />

colest@indiana.edu<br />

Abstract<br />

To date, most research on underst<strong>and</strong>ing travel of people with disabilities has been focused on<br />

accessibility issues. Much of this research was a response to policies <strong>and</strong> regulations set forth<br />

to protect the rights of people with disabilities, such as ADA in 1990. Recently, there is a call<br />

for research looking beyond accessibility when underst<strong>and</strong>ing the consumer market of people<br />

with disabilities (Yau, McKercher, & Packer , 2004; Baker, 2006). One of the reasons for this<br />

call is because 2000 Census data show that there are approximately 50 million people with<br />

disabilities in the U.S. Of these, about 36 million people are mobility-challenged (Ray, &<br />

Ryder, 2003). Limited literature on travel for people with disabilities demonstrates that they<br />

have the same desires for travel (Baker, 2005). In addition, some suggest that travel has<br />

special meanings to travelers with disabilities. For example, Yau et al. (2004) concluded that<br />

“being able to travel is a meaningful task through which a person with a disability can<br />

demonstrate to others that they have recovered or started to regain their control over destiny<br />

<strong>and</strong> to assert their future quality of life” (p.958). Findings from their study imply the potential<br />

impact of being able to travel on the quality of lives of people with disabilities. However, the<br />

impact of travel on the lives of people with disabilities has not been further examined <strong>and</strong><br />

determined in the literature. The purpose of this study was to explore the role of travel in the<br />

quality of lives of people with mobility impairments.<br />

Method<br />

Two focus group discussions were held among avid travelers with mobility impairments at the<br />

13 th Congress of Society for Accessible Travel <strong>and</strong> Hospitality (SATH) in 2009. A total of 12<br />

people participated in the focus groups. Two questions were asked: 1) What was the role of<br />

travel in your life before you became mobility impaired (or “What is the role of travel in your<br />

life?”, if the impairment is a congenital condition)? <strong>and</strong> 2)Based on your past travel<br />

experience, has travel in general impacted your quality of life? How?<br />

Results & Implications<br />

Focus group discussions revealed the essential role of travel in the lives of people with<br />

mobility impairments. Many considered travel as a basic need in life, such as food <strong>and</strong> air.<br />

Participants confirmed the positive impact of leisure travel on their quality of lives. They<br />

believed that leisure travel had helped them to 1) regain control of life; 2) overcome the fear<br />

of leaving their mundane environment; 3) complete the rehabilitation successfully; 4) enhance<br />

their relationship with family members; 5) continue learning <strong>and</strong> exploring of different<br />

culture; <strong>and</strong> 6) keep the adventurous spirit in their lives. Findings of this study suggested the<br />

psychological, mental, <strong>and</strong> health benefits for people with mobility impairments. Policy<br />

makers should protect the rights of this population to travel, <strong>and</strong> <strong>business</strong> owners/managers<br />

should make sure their facilities <strong>and</strong> services are accessible.


The Impact of <strong>Tourism</strong> on Community Wellbeing <strong>and</strong> Quality of Life: A<br />

Longitudinal Study<br />

Margaret Deery<br />

Centre for <strong>Tourism</strong> <strong>and</strong> Services Research Faculty of Business <strong>and</strong> Law, Victoria University<br />

<strong>and</strong> PO Box 14428, Melbourne City, Victoria, Australia 8001<br />

Tel: (613) 9919 4626<br />

Marg.deery@vu.edu.au<br />

Leo Jago<br />

Centre for <strong>Tourism</strong> <strong>and</strong> Services Research, Victoria University, Faculty of Business <strong>and</strong> Law<br />

PO Box 14428, Melbourne City, Victoria, Australia 8001<br />

Tel: (613) 9919 1541<br />

The Impact of <strong>Tourism</strong> on Community Wellbeing <strong>and</strong> Quality of Life: A Longitudinal<br />

Study Introduction<br />

Over the last few decades, substantial research has been undertaken examining the social<br />

impacts of tourism on communities (see for example Sharma, Dyer, Carter <strong>and</strong> Gursoy, 2008;<br />

Easterling, 2004) with the focus, often, on the level of support residents have for tourism<br />

development. While these studies are extremely useful for tourism planners <strong>and</strong> policy<br />

makers, they provide less information for those concerned about the wellbeing of the<br />

community <strong>and</strong> the individuals that comprise communities. Some studies have, in fact,<br />

examined the impact of tourism on the community <strong>and</strong> residents’ quality of life (QOL),<br />

beginning with the early work by Milman <strong>and</strong> Pizam (1988) <strong>and</strong> Perdue, Long <strong>and</strong> Allen<br />

(1990). More recent work by Tovar <strong>and</strong> Lockwood (2008), Andereck, Valentine, Knopf <strong>and</strong><br />

Vogt (2005) <strong>and</strong> Jago, Fredline <strong>and</strong> Deery (2006) have focussed on the specific tourism<br />

impacts that either enhance or detract from the quality of residents’ lives. Much of this<br />

research, however, is a ‘point in time’ examination of the social impacts with little or no<br />

underst<strong>and</strong>ing of how perceptions of these impacts change over time. Although studies such<br />

as that by Huh <strong>and</strong> Vogt (2007) <strong>and</strong> Getz’s (1994) study of residents’ perceptions in the Spey<br />

Valley of Scotl<strong>and</strong> have provided some insights into the changes that may occur over time,<br />

few other studies have added to this area. This current study aims to address the paucity of<br />

studies on the impacts of tourism on residents’ quality of life over time.<br />

Method<br />

This paper examines the impact of tourism on the QOL of residents <strong>and</strong> the community as a<br />

whole <strong>and</strong> it does so at two points in time, 2005 <strong>and</strong> 2008, using the same 3 questionnaire <strong>and</strong><br />

in the same location. Data were collected from host residents using a survey method based on<br />

the instrument developed by Fredline (2002) <strong>and</strong> Fredline, Deery <strong>and</strong> Jago (2005). The<br />

sample sizes were 420 in 2005 <strong>and</strong> 317 in 2008.<br />

Findings<br />

The findings show that, at the personal level, perceptions of the impacts of the benefits of<br />

tourism had deteriorated over time <strong>and</strong> it is through the examination of the specific impacts<br />

that a partial answer as to why this would occur can be found. Between 2005 <strong>and</strong> 2008,<br />

respondents were statistically less positive about having more interesting things to do, that<br />

tourism provided economic benefits <strong>and</strong> that tourism enhances pride in the town <strong>and</strong> an<br />

opportunity to showcase the region. When examining the comments from respondents, there<br />

were comments in 2008, not elicited in 2005, that tourism was spoiling the area <strong>and</strong> that it<br />

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<br />

sustainable tourism, that ‘<strong>Tourism</strong> growth should stop’. The study examines the ramifications<br />

of these findings on the community’s QoL <strong>and</strong> provides recommendations for enhancing <strong>and</strong><br />

managing the wellbeing of the community.<br />

References<br />

Andereck, K.L., Valentine, K.M., Knopf, R.C. & Vogt, C.A. (2005). Residents’ perceptions<br />

of community tourism impacts. Annals of <strong>Tourism</strong> Research, 32(4), 1056–1076.<br />

Easterling, D. (2004). The Residents’ Perspective in <strong>Tourism</strong> Research: A Review <strong>and</strong><br />

Synthesis. Journal of Travel & <strong>Tourism</strong> Marketing, 17(4), 45-62.<br />

Fredline L. (2002). Host Community Perceptions of the Impacts of <strong>Tourism</strong> on the Gold<br />

Coast. CRC for Sustainable <strong>Tourism</strong>: Gold Coast. 4<br />

Fredline, L. Deery, M. & Jago, L. (2005). Social Impacts of <strong>Tourism</strong> on Communities. CRC<br />

for Sustainable <strong>Tourism</strong>: Gold Coast<br />

Getz, D. (1994). “Residents’ Attitudes towards <strong>Tourism</strong>: A Longitudinal Study in Spey<br />

Valley, Scotl<strong>and</strong>.” <strong>Tourism</strong> Management, 15 (4): 247–58<br />

Huh, C. & Vogt, C.A. (2008). Changes in Residents' Attitudes toward <strong>Tourism</strong> over Time: A<br />

Cohort Analytical Approach. Journal of Travel Research, 46 (4), 446-455.<br />

Jago, L., Fredline, L. & Deery, M. (2006). <strong>Tourism</strong> in small communities: Risk <strong>and</strong> benefits.<br />

<strong>Tourism</strong> Review International, 10(1-2), 91-101.<br />

Milman, A. & Pizam, A. (1988). Social impacts of tourism on Central Florida. Annals of<br />

<strong>Tourism</strong> Research, 15, 191-204.<br />

Perdue, R.R., Long, P.T., & Allen, L. (1990). Resident Support for <strong>Tourism</strong> Development,<br />

Annals of <strong>Tourism</strong> Research, 17(4), 586-599.<br />

Sharma, B., Dyer, P., Carter , J. & Gursoy, D. (2008). Exploring residents' perceptions of the<br />

social impacts of tourism on the Sunshine Coast, Australia. International Journal of<br />

Hospitality <strong>and</strong> <strong>Tourism</strong> Administration, 9(3), 288-311<br />

Tovar, C. & Lockwood, M. (2008). Social Impacts of <strong>Tourism</strong>: An Australian Regional Case<br />

Study. International Journal of <strong>Tourism</strong> Research, 10, 365-378.


Air travel <strong>and</strong> your health: Is it safe up there?<br />

Frederic Dimanche <strong>and</strong> Christine Dimanche<br />

Center for <strong>Tourism</strong> Management at SKEMA Business School<br />

Nice<br />

France<br />

Frederic.DIMANCHE@cote-azur.cci.fr ; f.dimanche@skema.edu<br />

Abstract<br />

When considering the literature about <strong>tourists</strong>’ health, one finds three main threads: First, the<br />

tourism literature has been mostly concerned with the benefits of travel <strong>and</strong> tourism on<br />

visitors’ health <strong>and</strong> wellness. Discussions of medical tourism, spa tourism, wellness tourism<br />

have particularly focused on health tourism as a market <strong>and</strong> product (e.g., García-Altés, 2005;<br />

Henderson, 2003; Heung, Kucukusta, & Song, 2010). Second, there has been a line of<br />

publications dedicated to managing tourist health <strong>and</strong> safety (e.g., Keystone et al., 2008;<br />

Wilks & Page, 2003). Finally, a comparatively larger body of the literature considers<br />

perceptions <strong>and</strong> management of risks, but not necessarily as they relate exclusively to health<br />

(e.g., Lepp & Gibson, 2003, Sonmez & Graefe, 1998). To find specific research about the<br />

effects of travel on travelers’ health, one has to search the medical literature. Among favorite<br />

topics are the effects of traveling to tropical destinations, the risk of infectious diseases,<br />

travelers <strong>and</strong> sexually transmitted diseases, <strong>and</strong> digestive disorders. The medical literature<br />

also examines the effects of air travel on the human body.<br />

Of particular interest to us is the impact of travel on <strong>tourists</strong>’ health <strong>and</strong> well-being. Traveling<br />

<strong>and</strong> flying both lead to increased stress <strong>and</strong> increased risks for the traveler’s health. The<br />

medical literature documents, for example, that <strong>business</strong> travelers experience significant stress<br />

<strong>and</strong> file more health insurance claims than their non-traveling colleagues (DeFrank,<br />

Konopaske, & Ivancevich, 2000; Liese, Mundt, Dell, Nagy, & Demure, 1997). It has also<br />

been reported that there was a two- to three-fold increase in psychological claims for travelers<br />

over non-travelers. More specifically, this paper will focus on an aspect of traveling that is<br />

rarely considered in the literature: the impact of air travel <strong>and</strong> health <strong>and</strong> well being. Indeed,<br />

in their edited book on managing tourist health in the new millenium (Wilks & Page, 2003),<br />

no author examines the particular case of air travel <strong>and</strong> health, except to discuss the risk of<br />

transportation accidents. The purpose of this paper is (1) to document through a literature<br />

review the major risk factors <strong>and</strong> health issues, both psychological <strong>and</strong> physical, that travelers<br />

face when flying <strong>and</strong> traveling, <strong>and</strong> (2) to suggest recommendations to help manage risk <strong>and</strong><br />

reduce traveler stress. Indeed, previous research has shown that travel counselors, travel<br />

agents, or human resource departments in <strong>business</strong> firms do not properly inform <strong>and</strong> educate<br />

travelers about the risks of flying <strong>and</strong> traveling (e.g., Lawlor et al., 2000; Lawton & Page,<br />

1997; Welch, Welch, & Worm, 2007) <strong>and</strong> that experienced travelers had low knowledge of<br />

travel health-related issues (Hamer & Connor, 2004). Those recommendations should be<br />

taken into consideration by individual travelers, human resource management departments in<br />

firms with a traveling workforce, <strong>and</strong> by travel companies, travel agents, or tour operators.<br />

References<br />

DeFrank, R. S., Konopaske, R., & Ivancevich, J. M. (2000). Executive travel stress: Perils of<br />

the road warrior. The Academy of Management Executive, 14(2), 58-71.<br />

García-Altés, A. (2005). The development of health tourism services. Annals of <strong>Tourism</strong><br />

Research, 32(1), 262-266.


Hamer, D., & Connor, B. (2004).Travel health knowledge, attitudes <strong>and</strong> practices among<br />

United States travelers. Journal of Travel Medicine, 11, 23-26.<br />

Henderson, J. (2003). <strong>Health</strong> care tourism in Southeast Asia, <strong>Tourism</strong> Review International,<br />

7(3-4), 111-121.<br />

Heung, V., Kucukusta, D., & Song, H. (2010). A conceptual model of medical tourism:<br />

Implications for future research. Journal of Travel & <strong>Tourism</strong> Marketing, 27(3), 236-<br />

251.<br />

Keystone, J., Kozarsky, P., Freedman, D., Nothdurft, H., & Connor, B. (Eds.). (2008). Travel<br />

Medicine (2 nd ed.). New York: Mosby Elsevier.<br />

Lawlor, D., Burke, J., Bouskill, E., Conn, G., Edwards, P., & Gillespie, D. (2000). Do British<br />

travel agents provide adequate health advice for travellers? British Journal of General<br />

Practice, 50(456), 567-568<br />

Lawton, G., & Page, S. (1997). Evaluating travel agents' provision of health advice to<br />

travelers. <strong>Tourism</strong> Management, 18(2), 89-104.<br />

Lepp, A, & Gibson, H. (2003). Tourist roles, perceived risk <strong>and</strong> international tourism. Annals<br />

of <strong>Tourism</strong> Research, 30(3), 606-624.<br />

Liese, B., Mundt, K. A., Dell, L. D., Nagy, L. & Demure, B. (1997). Medical claims<br />

associated with international <strong>business</strong> travel. Occupational <strong>and</strong> Environmental<br />

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Sonmez, S. & Graefe, A. (1998). Influence of terrorism risk on foreign tourism decisions.<br />

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Striker, J., Luippold, R., Nagy, L., Liese, B., Bigelow, C., & Mundt, K. (1999). Risk factors<br />

for psychological stress among international <strong>business</strong> travelers. Occupational<br />

Environmental Medicine, 56, 245-252.<br />

Welch, D., Welch, L., & Worm, V. (2007).The international <strong>business</strong> traveller: A neglected<br />

but strategic human resource. The International Journal of Human Resource<br />

Management, 18(2), 173-183.<br />

Wilks, J., & Page, S. (2003). Managing tourist health <strong>and</strong> safety in the new millennium.<br />

Oxford: Elsevier.


“A Happy Tourist Experience”<br />

Filep Sebastian<br />

Victoria University<br />

sebastian.filep@vu.edu.au<br />

Abstract<br />

Happiness is a concept that has fascinated thinkers for centuries because it is central to<br />

underst<strong>and</strong>ing the meaning of human life. Research on happiness has flourished in recent<br />

years in many social sciences. The concept can be defined from multiple perspectives. In<br />

positive psychology (a research field that studies wellbeing in psychology), happiness is<br />

typically defined in terms of three main dimensions: engagement, meaning <strong>and</strong> positive<br />

emotions. A happy person would therefore be actively involved (engaged) in his or her daily<br />

activities, would lead a personally meaningful life (eg believe in God or contribute to a cause<br />

that he or she believes in) <strong>and</strong> would regularly experience positive emotions of interest, joy,<br />

contentment <strong>and</strong> love. Each of the three dimensions of happiness is measurable. Happiness is<br />

therefore a concept that is worthy of scientific research - it can be defined <strong>and</strong> scientifically<br />

assessed <strong>and</strong> it is a conscious state of mind.<br />

A qualitative doctoral thesis on tourist experience <strong>and</strong> happiness was recently finalised <strong>and</strong><br />

awarded. In this PhD project, a study of a tourist experience of a group of study abroad<br />

university students was conducted. The study assessed travel motivation <strong>and</strong> travel<br />

satisfaction of the group in three phases of the students’ travel experience (anticipatory, on<br />

site <strong>and</strong> reflective phases). Travel motivation themes were identified in the anticipatory phase;<br />

immediate <strong>and</strong> post hoc satisfaction themes were identified in the on site <strong>and</strong> reflective phases<br />

of the tourist experience. The students’ motivation <strong>and</strong> satisfaction themes were identified<br />

through qualitative positive psychology approaches. An exploratory picture of a happy tourist<br />

experience has emerged from this psychological investigation. In this picture, the three<br />

dimensions of happiness from positive psychology – meaning, engagement <strong>and</strong> positive<br />

emotions – are linked to the students’ travel motivation <strong>and</strong> satisfaction themes in their three<br />

travel phases.<br />

A series of future quantitative <strong>and</strong> qualitative studies of <strong>tourists</strong>’ positive emotions, meaning<br />

<strong>and</strong> engagement has emerged from this micro analysis of the students’ tourist experience. The<br />

suggested studies are important agendas for future research as the three happiness dimensions<br />

have been linked to a range of health benefits by other happiness researchers. An example of<br />

these health benefits is the improvement in cardiovascular health as a result of experiencing<br />

positive emotions. Investigations of happy tourist experiences from positive psychology <strong>and</strong><br />

other social science perspectives therefore need to continue in tourism studies.


URBAN ZEN – AND HOW TO EXPLORE THIS PHENOMENON?<br />

Roos Gerritsma<br />

University of InHoll<strong>and</strong>, Amsterdam/Diemen<br />

The Netherl<strong>and</strong>s<br />

roos.gerritsma@inholl<strong>and</strong>.nl<br />

Abstract<br />

The presentation will mainly focus on describing the concept of urban zen <strong>and</strong> what<br />

theoretical framework <strong>and</strong> methods of research will be applied during this PhD research.<br />

Urban Zen – the appearance of a new cultural l<strong>and</strong>scape<br />

“The complexity <strong>and</strong> speed of modern life urgently requires counterbalancing experiences for<br />

human beings to feel well. A health <strong>and</strong> wellness revolution is under way as individuals<br />

attempt to redesign their lives – sometimes in superficial <strong>and</strong> sometimes in profound ways –<br />

to achieve higher levels of physical, emotional, mental <strong>and</strong> spiritual wellness”, (Bushell <strong>and</strong><br />

Sheldon 2009) i .<br />

In some western cities we can see a reflection of this revolution when we look at the increase<br />

of a holistic ii <strong>and</strong> <strong>healthy</strong> offer, such as yoga/meditation centers, health food shops or vegan<br />

restaurants, urban spas or hammans. We can perceive a new urban cultural l<strong>and</strong>scape in which<br />

holistic leisure activities give an extra quality or dimension to public <strong>and</strong> semi-public space.<br />

In this research this phenomenon has been named: urban zen.<br />

The wellness industry is rapidly growing worldwide. The first results of research amongst<br />

wellness <strong>tourists</strong> have been documented, but not much, or hardly anything, is known about the<br />

wellness needs <strong>and</strong> expectations of city dwellers who would like to fulfill their aim of striving<br />

for a holistic lifestyle in their own urban environment. The following three questions are<br />

leading during this research: What lifestyle characteristics do these citizens share <strong>and</strong> what<br />

does this lifestyle contribute to the quality of their lives? What Western cities iii <strong>and</strong> specific<br />

areas within these cities are playing a key role in urban zen, both economically <strong>and</strong><br />

symbolically? And finally, to what extent are cities marketed as places where you can find<br />

such an cultural l<strong>and</strong>scape?<br />

Theories <strong>and</strong> methods<br />

Several theories <strong>and</strong> methods will be applied in order to gain a clearer picture of urban zen<br />

adepts <strong>and</strong> places. Next to structuring lifestyles characteristics, the results will be connected<br />

with the ideas Pine <strong>and</strong> Gilmore (1999) on the transformation economy. In their study on the<br />

experience economy, the next step after experiences is said to be the economy of<br />

transformations. Based upon earlier research <strong>and</strong> own observations, the idea of “selling”<br />

transformations to consumers seems to be an essential part in starting <strong>and</strong> maintaining an<br />

urban zen lifestyle. Practicing Yoga for example, does not stop after having experienced the<br />

weekly Wednesday evening class; it generally is just a minor marker of a long internal<br />

process of transforming one’s attitude in life <strong>and</strong> lifestyle manifestations. The choice of<br />

Western cities will be based upon making an inventory <strong>and</strong> a comparison of the extent of the<br />

urban zen offer. Apart from desk research <strong>and</strong> participatory observations, in-depth interviews<br />

with participants, practitioners, entrepreneurs <strong>and</strong> city marketeers will also be carried out.<br />

Key words: holistic <strong>and</strong> <strong>healthy</strong> 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<br />

where people can enjoy a moment of rest”.<br />

(Floris Wyers, owner of <strong>Wellness</strong>.nl)<br />

References:<br />

i Bushell <strong>and</strong> Sheldon, (2009). <strong>Wellness</strong> <strong>and</strong> <strong>Tourism</strong> - Body, Mind, Spirit <strong>and</strong> Place, New<br />

York, Cognizant. Communication Books<br />

ii There are many definitions about the term holistic. The following description seems to be the<br />

most appropriate for this research: “According to AHHA (2007) holistic health as an<br />

approach to creating wellness encourages you to: 1) Balance <strong>and</strong> integrate your physical,<br />

mental, emotional, <strong>and</strong> spiritual aspects. 2)Establish respectful, cooperative relationshops<br />

with others <strong>and</strong> the environment.3)Make wellness-oriented lifestyle choices. 4)Actively<br />

participate in your health decisions <strong>and</strong> healing process.” – Smith <strong>and</strong> Puczko (2009).<br />

<strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>, Butterworth-Heinemann<br />

iii Focus lies on cities in: Europe, the USA, Canada, Australia <strong>and</strong> New Zeal<strong>and</strong>.


<strong>Health</strong> <strong>Tourism</strong> – The SPA Goers in Portugal<br />

Nuno Silva Gustavo<br />

ESHTE<br />

Rua do Campo da Bola, Quinta da Raposeira, Mosqueiros<br />

2460-203 Alfeizerão, Portugal<br />

nuno.gustavo@eshte.pt<br />

Abstract<br />

This paper is part of a work-in-progress PhD dissertation entitled “<strong>Tourism</strong>, Leisure <strong>and</strong><br />

<strong>Health</strong> – discovering the new SPAs”, the first national study in this particular field.<br />

Having Portugal as a case study, a country in which <strong>Health</strong> <strong>Tourism</strong> was recently pointed out<br />

as one of the ten strategic segments for tourism development, this paper aims at presenting<br />

<strong>and</strong> discussing the new SPAs customers' profiles, as well as helping to underst<strong>and</strong> how<br />

relevant leisure <strong>and</strong> tourism moments are <strong>and</strong> how they are used in health management. The<br />

motivations of these new SPA customers, their concerns with spa consumption <strong>and</strong> health<br />

management in general, <strong>and</strong> the meanings of SPA consumption in global health management<br />

are other issues focused on in this paper.<br />

This investigation has a national spectrum <strong>and</strong> it includes about twenty-one cases studies,<br />

including SPAs in different locations (in metropolises, cities, countryside, in <strong>and</strong> out of the<br />

Portuguese tourism regions, day SPAs, thermal SPAs, <strong>and</strong> marine SPAs), different concepts<br />

(e.g.: holistic), services (hydrotherapies, balneoteraphies, massages, aesthetics <strong>and</strong> natural<br />

treatments) infrastructures, <strong>and</strong> main natural resources (tap water, sea water, spring hot water,<br />

wine, etc.).<br />

In the twenty-one case studies mentioned, <strong>and</strong> as the main investigation resource, a survey<br />

was developed. This survey focused on SPA customers' consumption <strong>and</strong> on their health<br />

management practices (the data was collected during three months with support from the SPA<br />

Staffs). The data collected (824 surveys) was analyzed with SPSS (Statistical Package for<br />

Social Sciences). It was map out the average profile of SPA Goers in Portugal. Different<br />

consumer clusters were outlined with a scalable cluster analysis algorithm - The SPSS Twostep<br />

– log-likelihood.<br />

Keywords: <strong>Health</strong> <strong>and</strong> Body management, Leisure, <strong>Health</strong> <strong>Tourism</strong>, SPAs<br />

Introduction<br />

With the pace of globalisation, urbanisation, state-of-the-art technologies <strong>and</strong> on-line<br />

consumerism in 21 st century western societies, people now live out the illusion of a new<br />

paradigm – the myth of eternal life. In the euphoria of longevity, the adoption of <strong>healthy</strong> life<br />

styles takes on a singular importance to postmodern daily life. Founded on biomedicalisation<br />

<strong>and</strong> promoted by neoliberal philosophies of government, health has been reinvented as a<br />

capital to be valued <strong>and</strong> optimized, taking on a unique centrality within the lifestyle concept<br />

(Clarke, 2003).<br />

In the light of a new social centrality of health, that is, the growing medicalisation of western<br />

habits, the universe of health services proliferates, a reality which manifests itself in a<br />

growing allocation of leisure <strong>and</strong> tourism time to body care. This reality is particularly<br />

reflected in the discovery of leisure <strong>and</strong> tourism periods as privileged opportunities for body<br />

care <strong>and</strong> management. In accordance with the new concepts <strong>and</strong> dimensions which


circumscribe the scope of health at the outset of the 21 st century, this niche market has<br />

witnessed a significant diversification in supply. Alongside the pathogenic view of health <strong>and</strong><br />

associated services, this market also currently incorporates a new range of services, now<br />

focused on a holistic approach to the body, congregating highly disparate <strong>and</strong> different<br />

motivations <strong>and</strong> services within the same market niches thereby expressing this new vision of<br />

the health concept (Yeoman, 2008).<br />

Founded on the wellness ideal (an integrated <strong>and</strong> holistic view of health), SPAs have imposed<br />

themselves as a leading players in this new health universe as a result of the appropriateness<br />

of their concepts <strong>and</strong> services to meeting the new challenges emerging from the globalised,<br />

agitated <strong>and</strong> eminently urban consumer of the 21 st century. “SPAs <strong>and</strong> wellness resorts may<br />

therefore be conceptualised in cultural/sociological terms as modern day temples where<br />

people can experience rituals, learn to deepen their personal wellness practices, raise their<br />

consciousness, become open to enhanced ways of being <strong>and</strong> deepen their experience of being<br />

alive” (Cohen, 2008: 8).<br />

The growing centrality of these spaces, expressed through the growth in supply <strong>and</strong> dem<strong>and</strong><br />

in postmodern western societies, is the departure point for this article in which we aim to<br />

contribute towards a greater underst<strong>and</strong>ing of the dem<strong>and</strong> profile using Portuguese SPAs as<br />

the case study following a nationwide data collection survey.<br />

Literature Survey<br />

The significance <strong>and</strong> me<strong>and</strong>erings of health in the 21 st century<br />

Today, the meaning <strong>and</strong> the universe of health find expression in a private, lucrative <strong>and</strong> wide<br />

ranging market of products <strong>and</strong> services where slogans <strong>and</strong> sound bites abound, such as<br />

eternal youth, the most beautiful, the strongest or the healthiest. This is a new notion of public<br />

health which goes beyond the paradigm of disease-free <strong>and</strong> establishes a holistic <strong>and</strong> positive<br />

vision of health supported by a specific, socio-political environment which permeates<br />

postmodern 21 st century societies (Minkler, 1989). In the face of growing levels of economic<br />

prosperity, in no way comparable to those prevailing in the post World War Two boom ("The<br />

Glorious Thirty Years”) inaugurating the model of Welfare States when the nationalisation of<br />

the services <strong>and</strong> the social responsibility of health was taken on by national health services.<br />

Subsequently, the development of new <strong>and</strong> contemporary, neoliberal governing principles <strong>and</strong><br />

policies, were complemented <strong>and</strong> articulated with the fostering of a vast private market of<br />

health services leading to a new alternative health management model in which the individual<br />

now plays an active <strong>and</strong> self-responsible role (Rose, 2001). In a society which is profoundly<br />

marked by globalisation, by information technology <strong>and</strong> communication as well as by the<br />

liberalization of markets, new “health brokers” are affirming themselves in health<br />

management in competition with the traditional “experts”. These offer new, more<br />

“autonomous” <strong>and</strong> more “accessible” health management products <strong>and</strong> solutions, which<br />

circulate freely in a new <strong>and</strong> vast private health market where the laws of marketing rule.<br />

This transfer of responsibility in the health care field, as presented in the new model, is from<br />

the outset a reflection of a scenario marked by the growing disappointment as to the limits of<br />

medicine <strong>and</strong> its capacity to overcome the new challenges, such as chronic illness or the<br />

unrelenting quest (the myth) for eternal life. “A 2005 report by the WHO (…) estimates that of<br />

all the 58 million deaths in the world in 2005, 35 million (60%) will be caused by chronic<br />

diseases such as heart disease, stroke, cancer, chronic respiratory disease <strong>and</strong> diabetes”<br />

(Cohen, 2008:10).


Whether we opt for more realistic scenarios, or those more visionary as regards the current<br />

issues (EFILWC, 2004), it is clear that health faces a set of new paradigms at the outset of the<br />

21 st century. These require ongoing analysis <strong>and</strong> reflection, conditioned by a unique scenario<br />

of uncertainty expressed in the paradoxical perception of loss of “power” over the body in no<br />

way consensual with human ambitions <strong>and</strong> within the scope of new self-management<br />

practices, a hybrid <strong>and</strong> universal approach to the body <strong>and</strong> its control have been presented as<br />

the solution.<br />

Simultaneously <strong>and</strong> in response, a new private health market has emerged rendering new<br />

services, many of which represent genuine technological revivalisms of health practices from<br />

a ‘golden’ pre-scientific era, expressing a new ideological promotion of health, sold under the<br />

holistic sign of wellness, in which the individual is morally responsible for dem<strong>and</strong>ing the<br />

best physical <strong>and</strong> psychological setup able to play a determinant role in day-to-day<br />

performance.<br />

From Natural Hot Spring Treatments to <strong>Health</strong> <strong>Tourism</strong><br />

In a postmodern society, increasingly organised around globalisation vectors, as shown by the<br />

profound political, economic <strong>and</strong> social changes which mark the beginning of this 21 st<br />

century, “<strong>Health</strong> <strong>Tourism</strong>” <strong>and</strong> the associated practices of health, leisure <strong>and</strong> tourism have<br />

reinvented themselves <strong>and</strong> are gaining ever greater popularity as a result of new imperatives<br />

<strong>and</strong> the greater significance attached to them. This reality is manifested in the reaffirmation of<br />

a new leisure <strong>and</strong> tourism market, which now emerges dominated by new dimensions,<br />

concepts, spaces <strong>and</strong> services. “In the 21 st century, wellness travel has become a global<br />

phenomenon. (...) In response to increasing dem<strong>and</strong>, traditional SPA towns around the world<br />

are upgrading or constructing modern SPA facilities. The growth in supply is expected to<br />

foster continuing market expansion, attract new types of customers <strong>and</strong> diversify product<br />

offerings.” (Messerli, H. <strong>and</strong> Oyama, Y, 2004: 6)<br />

Sustained by new holistic <strong>and</strong> wholesome offerings, the new leisure <strong>and</strong> tourism facilities <strong>and</strong><br />

products are today different from those of post-war Europe, then confined to the dominating<br />

logic of classical thermal hot springs, dependent on the existence of medicinal mineral water<br />

(a natural resource) <strong>and</strong> limited to an eminently hospitalcentric philosophy of service. Today,<br />

supply within the scope of <strong>Health</strong> <strong>Tourism</strong> has tended to define itself as wide-ranging <strong>and</strong><br />

heterogenic, structuring itself according to global, holistic <strong>and</strong> health promoting parameters,<br />

resorting to a panoply of knowledge, resources <strong>and</strong> techniques <strong>and</strong> not confining itself to mere<br />

usage of hot spring thermal water in evasive leisure facilities (Tabbachi, 2008).<br />

This is a distinct market, of facilities <strong>and</strong> products of a hybrid nature, where appeals are made<br />

to unique <strong>and</strong> sometimes paradoxical fusions <strong>and</strong> interchanges such as those of the natural<br />

<strong>and</strong> the technological, the scientific <strong>and</strong> the profane, the western <strong>and</strong> the eastern, the rural <strong>and</strong><br />

the urban. Despite leisure <strong>and</strong> water continuing to occupy a place of excellence in the<br />

imaginaries of health <strong>and</strong> leisure, today this is materialised in a variety of services which<br />

range from medical surgery in India (Medicinal <strong>Tourism</strong>) to recourse to therapeutic<br />

techniques in a thermal facility in Europe (Therapeutic <strong>Tourism</strong>) to the simple search for<br />

wellness by means of relaxation techniques (<strong>Wellness</strong> <strong>Tourism</strong>), thus concentrating such<br />

distinct motivations under the umbrella of the same aims.<br />

By associating these hydrotherapeutic techniques, irrespective of their properties or the nature<br />

of the water used – medicinal mineral, tap or sea water, the new technologies <strong>and</strong> a service<br />

guided by nature, the natural <strong>and</strong> ancestral (where technique, decoration <strong>and</strong> the surrounding


soundscape are examples of the essential variables of service <strong>and</strong> inherently meticulously<br />

controlled), the rejuvenated SPA label adapts <strong>and</strong> expresses itself through this new vision of<br />

health which is increasingly defined as <strong>healthy</strong>, vitalising, positivist, global, holistic <strong>and</strong><br />

symbolic. These are new ideals <strong>and</strong> imaginaries which have in the thermal facilities both their<br />

origin <strong>and</strong> their antithesis in that, with due exceptions, a new concept of pathogenic <strong>and</strong><br />

functional health prevails within them. “The modern SPA is a unique combination of both<br />

ancient traditions <strong>and</strong> up-to-date technology. The modern-day SPA is centred on holistic<br />

healing as well as wellness philosophies, just as in ancient times. SPAs now offer a myriad of<br />

techniques <strong>and</strong> services inspired by both Eastern <strong>and</strong> Western traditions, catering to a broad<br />

array of individuals, each possessing different expectations <strong>and</strong> needs” (Haden, L. 2007: 9).<br />

Faced with the expansion <strong>and</strong> privatisation of the healthcare scope, we witness the<br />

proliferation <strong>and</strong> diversification of services <strong>and</strong> facilities where leisure <strong>and</strong> health cross paths<br />

<strong>and</strong> which, in view of their growing relevance, have been entitled “<strong>Health</strong> <strong>Tourism</strong>” or<br />

“<strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>”. This new conceptual designation not only reflects the<br />

growing emphasis on the wellness perspective of health but also significant growth in this<br />

niche market <strong>and</strong> its consequent specialisation. “In fact, health tourism <strong>and</strong> wellness tourism<br />

are frequently used interchangeably. However, as this industry <strong>and</strong> its consumers become<br />

increasingly sophisticated, discriminate use of these terms is expected” (Messerli, H. <strong>and</strong><br />

Oyama, Y, 2004: 10).<br />

Today, “<strong>Health</strong> <strong>Tourism</strong>” has assumed the br<strong>and</strong> image of the original <strong>and</strong> classic<br />

“Thermalism”, englobing an endless variety of services, which have health <strong>and</strong> leisure in<br />

common, <strong>and</strong> where water, due to its natural relationship with the essence of the human<br />

being, remains one of the main elements, albeit used in different ways, with different<br />

objectives <strong>and</strong> alongside new techniques.<br />

The SPA service supply<br />

The new health concepts, increasingly wider in scope <strong>and</strong> resulting from the<br />

biomedicalization trends of modern western societies, have, among other aspects, definitively<br />

contributed to the growth of this market, as well as to its specialisation <strong>and</strong> resulting<br />

segmentation. According to the International SPA Association (ISPA) we can currently<br />

systematise the SPA offer into seven different types: Club SPA, Cruise Ship SPA, Day SPA,<br />

Destination SPA, Medical SPA, Mineral Springs SPA <strong>and</strong> Resort/Hotel SPA. Nevertheless the<br />

diversity of services in this area allows us to identify other essential variables in the<br />

conceptualisation of this service: the philosophy of service (Holistic SPAs, Zen SPAs,<br />

Spirituality SPAs, Romantic/Honeymoon SPAs, Luxury SPAs), or the type of therapy where in<br />

addition to hydrotherapies (medicinal mineral water for human consumption, sea water)<br />

therapies based on balneotherapy, vinotherapy, chocolate therapy, algotherapy, cromotherapy,<br />

aromatherapy, to name just a few, remain common, as well as the universe of associated<br />

services, (Mountain SPAs, Ski SPAs, Golf SPAs).<br />

From the outset, this service range has grown both qualitatively <strong>and</strong> quantitatively. Today, the<br />

sector tends to be dispersed worldwide, even though it continues to be closely associated with<br />

the US health market where it developed <strong>and</strong> consolidated its current conceptual state. On the<br />

international level, Europe also currently ranks as a preferred <strong>and</strong> growing destination for<br />

such services.<br />

When combining the underlying physical dimension with an integrated <strong>and</strong> holistic view,<br />

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 <strong>and</strong><br />

eastern views of health “The initial pioneers of the modern-day SPA concept concentrated<br />

upon the physical aspects of wellness by providing their guest with visible results to nagging<br />

physiological problems. (…) Over the years more <strong>and</strong> more players in the industry have<br />

adopted holistic philosophies, <strong>and</strong> integrated Eastern <strong>and</strong> Western wellness systems into their<br />

menus” (Haden, 2007: 1).<br />

In the image of 21 st consumer societies, these spaces have today adopted an eminently<br />

commercial philosophy dedicated to a clientele valuing health, the body, the environment,<br />

social justice, personal development <strong>and</strong> sustainability. In these facilities, health continues to<br />

be a <strong>business</strong> of an essentially liberal nature, predominantly out of medical reach <strong>and</strong> where<br />

br<strong>and</strong>ing laws are sovereign. In our days, SPAs emerge as places of greater affirmation of the<br />

ideals of self-health <strong>and</strong> of self-responsibility where individuals learn to control <strong>and</strong> monitor<br />

their bodies by resorting to a set of specified techniques which lead precisely into a dialogue<br />

<strong>and</strong> rediscovery of their own bodies.<br />

Method<br />

Sample<br />

It is currently impossible to quantify the universe of the SPA sector in Portugal given the<br />

absence of a legal framework regulating SPA activities: there is only a legal framework for<br />

hot spring thermalism, <strong>and</strong> within that, for Thermal SPAs. Thus, we must begin by<br />

establishing minimum selection criteria. Only those SPA infrastructures which significantly<br />

render the following services were selected: health care involving recourse to water,<br />

specifically as regards thermal bath treatments <strong>and</strong> hydrotherapy techniques <strong>and</strong> the provision<br />

of alternative therapies. Most of the aforementioned infrastructures are integrated into hotels.<br />

In partnership with an expert (invited) from the National <strong>Tourism</strong> Authority (Turismo de<br />

Portugal) so as to identify the establishments which could be classified as SPAs,<br />

approximately 60 infrastructures were identified. In addition to the aforementioned criteria,<br />

this selection additionally considered geographical location so as to guarantee full coverage<br />

both geographically <strong>and</strong> the actual SPA concept thus safeguarding the representation of as<br />

many different SPA types as possible.<br />

29 SPAs from the resulting universe agreed to participate in this study with 20 later being<br />

validated. Taking into consideration that a significant part of the questionnaire contemplated<br />

variables of a clinical nature, a minimum of 30 questionnaires was established as the base<br />

requirement for the autonomous validation of an entity. The participant Day Spas, Resort<br />

Hotel SPAs, Destinations SPAs, Medical SPAs ensured the completion of a total of 824<br />

questionnaires by their SPA Goers between May <strong>and</strong> August of 2009.<br />

Procedure <strong>and</strong> questionnaire design<br />

The questionnaire was produced within the scope of a PhD project which in its first phase<br />

carried out a review of the available literature on themes such as health, body, leisure <strong>and</strong><br />

tourism. The second part of this research, of an empirical nature, first contemplated analysis<br />

of articles <strong>and</strong> messages conveyed by the major woman’s <strong>and</strong> men’s magazines in circulation<br />

in Portugal <strong>and</strong> later, the application of the aforementioned questionnaire. The questionnaire<br />

was produced after analysis by experts in SPA management <strong>and</strong> involved a pre-test period of<br />

one month. The final version of the questionnaires consisted of four parts: a first section on<br />

SPA consumption (regularity, services used, motivations, satisfaction level <strong>and</strong> factors of<br />

choice), a second part focused on the representation <strong>and</strong> meaning of wellness <strong>and</strong> health, <strong>and</strong><br />

a third on health care (practices <strong>and</strong> routines) <strong>and</strong> finally a fourth aiming to define the social


<strong>and</strong> cultural <strong>and</strong> socio-economic profile of the respondent. The questionnaire was essentially<br />

composed of closed questions, except in the second part where open questions were preferred.<br />

The validation of the applied questionnaire was based on a panel of experts (SPA Managers)<br />

<strong>and</strong> on a pre-test carried out over one month in March 2009. The final version of the<br />

questionnaire was produced in five languages (Portuguese, English, Castilian Spanish, Italian<br />

<strong>and</strong> French). The questionnaires were applied in the form of a survey with the cooperation of<br />

the managers <strong>and</strong> receptionists of the SPAs. Clients would be invited to participate in the<br />

survey after their SPA session.<br />

The statistical processing of the information was carried out using the SPSS -Statistical<br />

Package for Social Sciences- software version 1.7. Based on a descriptive statistical analysis,<br />

the typical profile of the SPA consumer was obtained. So as to identify possible segments in<br />

this dem<strong>and</strong> universe, grouping analysis was later applied with recourse to a TwoStep<br />

algorithm – log-likelihood (considering the nature of the variables in question <strong>and</strong> the<br />

questionnaire structure).<br />

Survey Findings<br />

Based on the sample gathered through the aforementioned questionnaire, one can immediately<br />

present a social <strong>and</strong> cultural profile of the client who currently frequents Portuguese SPAs. As<br />

regards age, the average SPA client is 38.5, with individuals aged between 30 <strong>and</strong> 39<br />

representing the client age range with greatest weighting (38.7%). As for gender, women<br />

dominate, accounting for approximately 69.8%. In the case of family structures, those without<br />

dependents (49.5%) emerge as the main users, that is, couples (married or in common law<br />

relationships) (24.4%) <strong>and</strong> single people without dependents (25.1%). However, the<br />

married/common law relationship with children prevails as the single most important family<br />

structure category with 34.6%.<br />

The Portuguese SPA client is mostly permanently resident in Portugal (73%), despite some<br />

being of other nationalities. Clients permanently residing in other countries represent 27% of<br />

dem<strong>and</strong> with United Kingdom residents (30%) significant in this sample. The typical area of<br />

residence of the SPA client is also classified as being eminently urban (71.7%), be it in a city<br />

(49.5%) or in a metropolis (22.2%).<br />

In terms of educational levels, there is a clear domination of individuals with higher education<br />

(73.9%), particularly honours degrees (56.1%). In line with the social <strong>and</strong> cultural profile is<br />

also the socio-economic profile with particular emphasis on individuals engaged in<br />

employment (91.7%) <strong>and</strong> mainly of employee status (73.2%). These individuals mostly work<br />

in the tertiary sector (89.1%), essentially holding executive responsibilities, at corporate<br />

management level (28.0%) or in specialised intellectual <strong>and</strong> scientific professions (37.0%).<br />

The average monthly net salary of the family aggregate immediately reflects the sociocultural<br />

<strong>and</strong> socio-economic level of the current population, with the vast majority earning<br />

more than €2,000 monthly. It must also be mentioned that 48.9% of the households of<br />

individuals attending SPAs report average monthly earnings in excess of €3,000.<br />

The study shows that the range <strong>and</strong> frequency of SPA use is an emerging practice, despite<br />

already being an integral part of the monthly routines of 31.2% respondents. Despite it not<br />

being a regular practice for 40.7% of SPA service clients, it is nevertheless engaged in with a<br />

certain regularity. This scenario is reinforced by the fact that SPA service consumers apply<br />

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<br />

their own residential areas (28%) or an intentional journey to outside the regular area of<br />

residence to frequent a SPA (36.5%) reinforces the routine <strong>and</strong> preferential consumption of<br />

these types of services/facilities. In fact, 75% of the clients from our sample mentioned that<br />

when selecting their holiday accommodation they took into consideration whether or not there<br />

was a SPA, with 25% of clients declaring that this is a determinant factor in their final choice.<br />

The main motive of these individuals in visiting a SPA is connected to relieving stress <strong>and</strong>/or<br />

relaxation. Across the 824 questionnaire respondents, 74.3% mentioned this reason as very<br />

important in their visiting a SPA. It must also be noted that improving mental <strong>and</strong> physical<br />

health was the determinant reason given for visiting a SPA by over 50%.<br />

From the universe of the most relevant services available at SPAs, clients clearly mention<br />

massages (90.9%) <strong>and</strong> body treatments (including thermal water therapy – 70%) as the most<br />

sought after. As regards the most relevant services used at SPAs, it must also be noted that<br />

50% of the clients, did not use hydrotherapy services (vichy shower, simple immersion bath,<br />

hydro massage, etc.) during their last visit to a SPA.<br />

Overall <strong>and</strong> still in terms of services consumed, SPA clients classified their experiences as<br />

positive with 64.7% saying that the services met all their expectations <strong>and</strong> 31.1% declaring<br />

their expectations were exceeded. Only 4.2% of clients declare that their SPA experiences<br />

globally fell short of their expectations. When deciding which SPA to visit, clients from our<br />

sample identified the quality of treatment, service, hygiene <strong>and</strong> cleanliness, the service cost as<br />

well as the SPA location as the most relevant factors. 78.6% declared they personally paid for<br />

their last visit to a SPA. Worthy of note is the fact that 14.4% of SPA experiences were gifted,<br />

namely in the form of vouchers.<br />

In addition to the variables described thus far, the current questionnaire also focused on a set<br />

of behaviours <strong>and</strong> health care attitudes which the SPA clients adopt in their daily lives. When<br />

questioned globally on their lifestyles, 87.3% declared that on a merely personal assessment<br />

they had a <strong>healthy</strong> lifestyle. The majority of SPA clients questioned declared that a <strong>healthy</strong><br />

life depends essentially on their personal care (53.5%), while 45.4% declared that in addition<br />

to taking care of their health, there are also external factors which can condition that <strong>healthy</strong><br />

life. Only 1.1% of the sample declared that a having a <strong>healthy</strong> life does not depend on them<br />

but solely on external factors over which they have no control, such as work, stress imposed<br />

by the pace of daily routines, environmental quality, economic conditions or interpersonal<br />

relationships, specifically with family members <strong>and</strong> close friends.<br />

As for necessary personal care for a <strong>healthy</strong> life, the clients questioned transversely referred to<br />

“food <strong>and</strong> diet” (89.4%) <strong>and</strong> “physical exercise” (82.9%) as fundamental care. “Alternative<br />

medicine <strong>and</strong> techniques” were also mentioned as an important recourse in the universe of<br />

personal care” (for example: meditation <strong>and</strong> pilates, tai-chi, yoga, the SPA, etc.). Other<br />

aspects mentioned, while not as unanimous, were “relaxation” (for example: sleeping duration<br />

patterns, searching for calm environments) “deviating behaviours” (alcohol <strong>and</strong> tobacco<br />

consumption) “hygiene” <strong>and</strong> “recourse to monitoring by conventional medicine” (visiting the<br />

doctor) <strong>and</strong> “associated techniques” (regular check-ups). Only in passing was a direct<br />

reference made to (considered in the category of “others”) external factors (beyond the control<br />

of the individual) which have implications for a <strong>healthy</strong> life. Although not as consensual in<br />

comparison with the main personal health care factors already described, these are related to<br />

“work” (such as the number of working hours, the workplace <strong>and</strong> conditions, relations with<br />

colleagues, satisfactory payment conditions), with “everyday stress” (resulting from the


various timetables <strong>and</strong> obligations to comply with, traffic <strong>and</strong> the urban rhythm of life in<br />

general) – 36.9% of those questioned mentioned they had a very stressful daily life, the<br />

“environment” (pollution, area of residence) “interpersonal <strong>and</strong> economic constraints” (family<br />

wellness, resources/economic limitations) are major issues. Among the “other” factors<br />

referred, are “genetic/hereditary”, “epidemics” <strong>and</strong> “frequenting places which are also<br />

frequented by smokers”.<br />

When confronting those questioned with their wellness practices, on the one h<strong>and</strong> we see the<br />

prevalence of the aforementioned set of personal care initiatives with the objective of<br />

achieving a <strong>healthy</strong> life, such as “physical activity” (67.1%), “food <strong>and</strong> diet”, recourse to<br />

alternative medicine <strong>and</strong> techniques <strong>and</strong> visits to SPAs – 33.7% – here, this is a systematically<br />

mentioned <strong>and</strong> autonomous category in contrast with that initially observed, <strong>and</strong> on the other<br />

h<strong>and</strong>, a set of practices diverse in nature. This new universe encompasses sociability practices<br />

– 24.6% – (for example: dinner with friends, going on family outings, going out in the<br />

evening with friends) <strong>and</strong> hobbies – 21.0% – (for example: travelling, going to the cinema or<br />

theatre, listening to music, reading, painting, gardening, etc.). Recognition of the importance<br />

of physical exercise <strong>and</strong> an appropriate diet for a <strong>healthy</strong> life is reinforced by the general<br />

incorporation of these practices in lifestyles. Among those questioned 71.2% regularly<br />

exercise or include exercise in their lifestyle, with only 28.7% of individuals never having<br />

practised regular exercise or only now not involved in regular exercise.<br />

As regards, special care with food <strong>and</strong> diet (for example: purchasing diet or organic products<br />

etc.) <strong>and</strong> as mentioned, the scenario is very identical in that 70.2% of individuals regularly<br />

watch what they eat <strong>and</strong> actually consider it an integral part of their lifestyle. Additionally,<br />

70.1% of those questioned take or have taken food supplements, while 34.1% take or have<br />

taken weight control products (natural or synthetic) These two care initiatives are reflected<br />

namely in the body mass index (BMI) of those questioned (23.2 Kg/m 2 ). Overall, the sample<br />

shows that 69.5% of SPA goers present a normal or below average BMI.<br />

There is yet another set of practices <strong>and</strong> habits complimentary to those mentioned, for<br />

example, the non-consumption of alcoholic drinks <strong>and</strong>/or no smoking. Among those<br />

questioned, 51.3% do not drink alcoholic beverages outside mealtimes or do so very rarely<br />

while 41.9% of individuals limit consumption to the weekends <strong>and</strong> special occasions. In this<br />

sample, 69.4% of individuals are non-smokers <strong>and</strong> only 18.1% smoke. The remainder are<br />

occasional smokers (particularly at parties or commemorative events). This series of care<br />

initiatives is complemented by a set of monitoring practices such as simple weight watching.<br />

This habit is common to 59.5% of those questioned, with the vast majority routinely watching<br />

their weight at home. In addition to weight watching, 80.4% of the SPA goers who make up<br />

our sample regularly have medical check-ups <strong>and</strong> in this particular universe 56.7% do so on<br />

their own initiative with 43.3% acting based upon medical recommendation. This scenario<br />

inverts only in the case of illness, upon which 66.3% resort primarily to a doctor <strong>and</strong> 33.7%<br />

initially seek out the chemist (12.2%), self-medicate, (11.9%) or turn to alternative medicine<br />

(9.6%).<br />

The use of health management equipment in the home is another common practice. Overall,<br />

52.9% of those questioned have equipment at home, with 28.5% having medical equipment<br />

(such as blood pressure, glycaemia or cholesterol measurement devices etc.) <strong>and</strong> 38% have<br />

physical fitness equipment (for example: bicycle, exercise machines, etc.). These practices<br />

incorporate yet another formative/informative dimension on health, sustained by women <strong>and</strong><br />

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%) <strong>and</strong> the<br />

men’s magazine Men’s <strong>Health</strong> (7.8%). The internet complements this information source,<br />

with the specific objective of obtaining information necessary to health management by<br />

63.5% of questioned SPA goers, as well as regular reading of specialized magazines <strong>and</strong><br />

books on health (40.4%). Despite the overwhelming majority of those questioned being<br />

beneficiaries of their respective national health systems (84.2%), 65.7% have also taken out<br />

additional health insurance coverage.<br />

Finally, <strong>and</strong> as regards specific beauty care, 78.1% of the sample regularly consume typical<br />

beauty products <strong>and</strong> 21.0% use or have used the latest technologies to carry out plastic<br />

surgery treatments (for example: lifting, liposuction etc.), slimming or cellulite treatments,<br />

laser hair removal or skin rejuvenation.<br />

When applying the TwoStep agglomeration technique, with a view to identifying clusters<br />

within the universe of SPA consumers, we identify three clusters: Fans SPA Goers, First<br />

Experience SPA Goers, Men SPA Goers<br />

Figure 1 – SPA Goers by cluster in relation to the use of SPAs <strong>and</strong> other health care<br />

responsibility uses<br />

FIRST EXPERIENCE<br />

SPA GOERS<br />

- MEN SPA GOERS<br />

<strong>Health</strong> Management<br />

Responsability<br />

+<br />

-<br />

SPA FANS<br />

GOERS<br />

Source: Author<br />

SPA<br />

Services<br />

Consumptio<br />

The figure presented allows us to verify how the differences between the respective clusters<br />

can be systemized by the regularity in SPA practices <strong>and</strong> by the responsibility as to health,<br />

expressed in frequency <strong>and</strong> health practice categories. The Fans SPA Goers (19.8%)<br />

demonstrate a high level of SPA practice <strong>and</strong> regularity with the frequency of SPA use <strong>and</strong><br />

consumption being as significant as other habits <strong>and</strong> regularities as regards health care. This<br />

cluster has a positioning in terms of body <strong>and</strong> health management which is singular within<br />

+


this universe, which is in itself already particular. In the case of the First Experience SPA<br />

Goers (40.6%) <strong>and</strong> the Men SPA Goers (32.9%) there is a distinct positioning. In this case<br />

health habits <strong>and</strong> care are also greater than that of the general population, although just as in<br />

frequency of visits, lesser than that of Fans SPA Goers.<br />

Limitations<br />

The first limitation of this study is the fact that it focuses on the reality of one single country<br />

in matters which tend to be global in nature. It is important to stress that Portugal is integrated<br />

in Europe, a region where the SPA sector <strong>and</strong> social significance are not as expressive as in<br />

other parts of the world <strong>and</strong> so the phase of development of this market cannot be<br />

underestimated. The second limitation of this study pertains to its period of application, which<br />

for technical <strong>and</strong> financial reasons was limited to a few months when a full year of application<br />

would have been preferable.<br />

Conclusions<br />

The development of the SPA market <strong>and</strong> the consumers associated seem to a great extent to<br />

reflect a set of new ideals <strong>and</strong> a new vision associated to health <strong>and</strong> its management. Centred<br />

on a positivist acceptation of health, where well-being is the dominating theme, SPAs have<br />

reinvented themselves <strong>and</strong> have reinvented the whole ideal of health. In the SPA image,<br />

health has also tended to diversify <strong>and</strong> conquer new domains thus transforming the universe<br />

<strong>and</strong> the imaginary of health tourism, now sustained by a vaster range of services. This is an<br />

evident reality in the consumer universe of -Salut per Aqua-, which goes much further than<br />

the traditional concept associated to water in favour of new holistic techniques <strong>and</strong> services<br />

founded on principals of relaxation <strong>and</strong> massage. This is the affirmation of a new, responsible<br />

<strong>and</strong> proactive philosophy which is the antithesis of that which had previously prevailed.<br />

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(2003), “Biomedicalization: Techno - scientific Transformations of <strong>Health</strong>, Illness, <strong>and</strong><br />

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(Eds.). Underst<strong>and</strong>ing the global SPA industry, Butterworth-Heinemann, London, pp. 3-<br />

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Towards a Genealogy of Morals”, <strong>Health</strong>, Vol. 6, No. 2, pp. 107-137.<br />

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Underst<strong>and</strong>ing the global SPA industry, Butterworth-Heinemann, London, pp. 26-40.<br />

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Stream: Managing the Self: Identity, Consumption <strong>and</strong> Choice, 11-13 May, Manchester,<br />

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hanem.pdf (accessed 20 August 2009)<br />

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Fundação Calouste Gulbenkian, Lisbon, Vol. 1, pp.737-752.<br />

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Yeoman, I. (2008), Tomorrow’s Tourist, Butterworth-Heinemann, London


Customer perceived value of medical tourism: an exploratory study<br />

The case of cosmetic surgery in Tunisia<br />

Yousra Hallem<br />

Doctoral student<br />

Ecole de Management de Strasbourg/Institut Supérieur de Gestion de Tunis<br />

Yousra_hallem@yahoo.fr<br />

Isabelle Barth<br />

Professor<br />

Ecole de Management de Strasbourg<br />

Isabelle.barth@free.fr<br />

Abdelfattah Triki<br />

Professor<br />

Institut Supérieur de Gestion de Tunis<br />

Abdel.triki@yahoo.fr<br />

Abstract<br />

The present study is an attempt to investigate the dimensions of customer-perceived value in<br />

the context of a medical tourism experience. The value dimensions of the use of the Internet<br />

will also be explored owing to the role of the Internet in the worldwide growth of medical<br />

tourism. On the basis of the theory of consumption value developed by Sheth, Newman <strong>and</strong><br />

Gross (1991), the netnographic study shows that the functional dimension has a great<br />

influence on the value perception of the medical tourism experience. The use of the Internet<br />

essentially has functional, social <strong>and</strong> epistemic values.<br />

Keywords: medical tourism, perceived value, netnography, Internet<br />

Customer perceived value of medical tourism: an exploratory study<br />

The case of cosmetic surgery in Tunisia<br />

Medical tourism is not a modern trend. “<strong>Health</strong> tourism is a concept as ancient as prehistory<br />

<strong>and</strong> as up-to-date as tomorrow” (Ross, 2005). What is different in the 21 st century is that<br />

<strong>tourists</strong> are travelling farther away, to poorer countries, <strong>and</strong> for medical care that is invasive<br />

<strong>and</strong> high-tech. (Bookman <strong>and</strong> Bookman, 2007). In recent years, medical tourism has<br />

experienced an explosive growth; it thus seems obvious that patients moving from developed<br />

to developing countries for care perceive value.<br />

Researchers believe that the growth of medical tourism has been facilitated by the rise of the<br />

Internet (Connell, 2006). Bookman <strong>and</strong> Bookman (2007) think that the Internet has opened<br />

the doors to medical tourism in developing countries. The Internet is a huge source of<br />

information for medical <strong>tourists</strong>, enabling them to know more about destinations, facilities,<br />

service suppliers <strong>and</strong> procedures. It is also a primary medium for suppliers to promote their<br />

service offers <strong>and</strong> an increasing number of informative medical tourism websites can be<br />

observed.<br />

We can then suppose that medical tourism is a profitable activity for developing <strong>and</strong><br />

developed countries. On one h<strong>and</strong>, developed countries can resolve the problem of long<br />

waiting lists <strong>and</strong> patients can take advantage of attractive costs. On the other h<strong>and</strong>, medical


tourism is a lucrative activity for developing countries, <strong>and</strong> several of them are now tapping<br />

into this niche. Countries are thus searching for new ways to promote their infrastructures <strong>and</strong><br />

skills, attract medical <strong>tourists</strong>, increase their numbers <strong>and</strong>, most importantly, improve their<br />

satisfaction. Therefore, customer value is now a strategic weapon in attracting <strong>and</strong> retaining<br />

customers (Woodruff, 1997; Zeithaml, 1988). As perceived value is considered as a key<br />

component of consumers’ decision-making <strong>and</strong> behaviour (Zeithaml, 1988), countries<br />

receiving medical <strong>tourists</strong> <strong>and</strong> practitioners should underst<strong>and</strong> what is the value sought by the<br />

customers <strong>and</strong> where they should focus their attention to achieve the market positioning<br />

required <strong>and</strong> to best satisfy the customer. From a marketing perspective, it thus appears<br />

interesting to look at medical tourism experiences through the concept of customer-perceived<br />

value.<br />

Our research deals with medical tourism in Tunisia <strong>and</strong> more specifically with cosmetic<br />

surgery in Tunisia. Through a qualitative study, we will investigate some research questions:<br />

What are the dimensions of customer-perceived value in the context of medical tourism? Is<br />

customer-perceived value only limited to cost consideration? What are the dimensions of<br />

customer-perceived value related to the use of the Internet in the context of medical tourism?<br />

Conceptual background<br />

Medical tourism: a booming <strong>business</strong><br />

Medical tourism is a growing market catering to patients who travel to foreign countries to<br />

obtain medical care (Deloitte report, 2008). The <strong>Tourism</strong> Research <strong>and</strong> Marketing Report<br />

(2006) indicates that the market included approximately 19 million trips in 2005 with a<br />

<strong>business</strong> volume of around $ 20 billion. This report estimates that the number of trips will<br />

have reached 40 million by 2010, with a growth of 4% for the overall market volume.<br />

Other statistics report that, in 2005, countries like Singapore (www.udel.edu) <strong>and</strong> Thail<strong>and</strong><br />

respectively received between 250,000 <strong>and</strong> 1 million foreign patients. Similarly, the number<br />

of foreign patients who took a medical tourism journey in Tunisia has more than doubled<br />

between 2003 <strong>and</strong> 2007. Their number reached 102,000 (<strong>Tourism</strong>ag, 2008) in 2007, as<br />

opposed to 42,000 in 2003 (Lautier, 2005).<br />

Connel (2006) states that “the biggest hurdle that medical tourism has had to face <strong>and</strong><br />

continues to face, is the challenge of convincing distant potential visitors that medical care in<br />

relatively poor countries is comparable to what is available at home in terms of results <strong>and</strong><br />

safety”. Despite this, we can observe that a growing number of patients from developed<br />

countries are travelling for medical treatment to regions once characterized as ‘third world’<br />

(Herrick, 2007).<br />

Therefore, with the increasing number of medical travellers, we can suppose that elements of<br />

value other than financial ones may motivate their decision.<br />

The concept of customer-perceived value<br />

Day (1990) stated that the perceived customer value represents the difference between<br />

“customers’ perceived benefits” <strong>and</strong> “customers’ perceived costs”. The first<br />

conceptualizations of customer-perceived value begin with the works of Zeithaml (1988),<br />

who defined customer-perceived value as “the consumer’s overall assessment of the utility of<br />

a product based on the perception of what is received <strong>and</strong> what is given”.<br />

The pioneering ideas about perceived value were based on economic theory <strong>and</strong> the concept<br />

of utility. Despite the relevance of this one-dimensional conceptualization of customerperceived<br />

value, it remains too simplistic <strong>and</strong> does not make it possible to grasp all of the<br />

explanatory attributes of a purchase. In a marketing context, it has been acknowledged that


value is not restricted to aspects related to price <strong>and</strong> quality but that it also combines other<br />

functional, emotional <strong>and</strong> social aspects (Sweeney <strong>and</strong> Soutar, 2001). Sheth, Newmann <strong>and</strong><br />

Gross (1991) identified five consumption values that influence consumer choices, which are<br />

functional, social, emotional, epistemic <strong>and</strong> conditional values. Sweeney <strong>and</strong> Soutar (2001)<br />

developed a multiple-item scale for measuring consumer-perceived value (PERVAL). Four<br />

dimensions of perceived value emerged, which are emotional, social, quality/performance <strong>and</strong><br />

price/value for money.<br />

The perceived value of the Internet<br />

The use of IT <strong>and</strong> especially the Internet in healthcare has the potential to change the<br />

healthcare industry worldwide in terms of infrastructure, costs <strong>and</strong> quality of services<br />

(Wickramasinghe <strong>and</strong> Goldberg, 2004; Wickramasinghe <strong>and</strong> Mirsa, 2004). The Internet has<br />

especially become an important medium for marketers <strong>and</strong> healthcare providers to provide<br />

information <strong>and</strong> market a wide variety of health care services <strong>and</strong> products (Bodkin <strong>and</strong><br />

Miaoulis, 2007). It has been confirmed that perceived value has a big impact on the use of the<br />

Internet as a medium for the search <strong>and</strong> procurement of goods. In general, people seeking<br />

information related to health care may act on several motives (Williams et al. 2003). They<br />

may be searching for information as a health care professional, as a consumer looking for a<br />

self-diagnosis or other diagnosis, as a patient to complement information from a doctor, as a<br />

consumer to exchange information with peers or for general interest browsing. Consumers<br />

access online health information in three primary ways: searching directly for health<br />

information, consulting with health professionals <strong>and</strong> participating in online support groups<br />

(Clines <strong>and</strong> Haynes, 2001)<br />

Method<br />

Through a qualitative study, we explore the concept of customer-perceived value in a medical<br />

tourism context. We choose netnography as a research methodology because it has been<br />

acknowledged that consumers making product <strong>and</strong> br<strong>and</strong> choices are increasingly turning to<br />

computer-mediated communication for information on which to base their purchasing<br />

decisions (Kozinets, 2002). Medical <strong>tourists</strong> are using forums, chat rooms <strong>and</strong> blogs to<br />

exchange large amounts of information, share ideas, look for advice, <strong>and</strong> make contact with<br />

other patients who have experienced a medical tourism adventure. Netnography is a research<br />

method that taps into this huge amount of information by analyzing the exchanges of<br />

members of online virtual communities. On the basis of the criteria developed by Kozinets<br />

(2002), such as the high traffic of posts <strong>and</strong> the relevance <strong>and</strong> richness of the data exchanged<br />

among members, we decided to work on the virtual community of Doctissimo. We used nonparticipant<br />

observation, only reading the posts of members with no intervention, <strong>and</strong><br />

participant observation by participating in conversations <strong>and</strong> inducing new discussions.<br />

Findings<br />

A thematic analysis was conducted. The choice of categories to be studied was made<br />

according to the method developed by Miles <strong>and</strong> Huberman (1991). Based on the<br />

consumption value theory of Sheth, Newman <strong>and</strong> Gross (1991), a thematic analysis of posts 1<br />

has allowed us to highlight different dimensions of perceived value related, on one h<strong>and</strong>, to<br />

the medical tourism service <strong>and</strong>, on the other h<strong>and</strong>, to the use of the Internet in the same<br />

context.<br />

1 We decided to keep the spelling <strong>and</strong> grammar mistakes to give more credence to the talk of participants.


Functional value<br />

Functional value is defined as the perceived utility based on the functional, utilitarian, <strong>and</strong><br />

physical performance of a product (Sheth, Newmann <strong>and</strong> Gross, 1991). A study has shown<br />

that the main functional value attributes, in the context of the purchase of a tourism product,<br />

are the quality of the travel agency’s installations, the staff’s professionalism at the travel<br />

agency, the quality of the tourism package purchased <strong>and</strong> the price. (Sanchez et al. 2006).<br />

Concerning the medical tourism service, several attributes have emerged, such as the cost<br />

differential, the skills of the surgeon <strong>and</strong> nursing staff, the quality of the equipment, the<br />

quality of care <strong>and</strong> the importance of the recovery period.<br />

It may seem obvious that cost is a major incentive in the medical tourism industry. In fact,<br />

some figures show that operations in India cost 80% less than in the United States (Walker,<br />

2006). We can observe the same relation between France <strong>and</strong> Tunisia. “This difference of<br />

price between Tunisia <strong>and</strong> France is hallucinating, until now I could hardly believe it!!!!”<br />

“Who said it was cheap-rate surgery?? Life over there is cheaper than here <strong>and</strong> that’s why<br />

prices are lower than here!!”<br />

Before deciding to get an operation, future patients spend a lot of time searching for<br />

information about the skills of surgeons.<br />

“Someone who listens, is attentive, calm, thoughtful <strong>and</strong> is most importantly licensed, belongs<br />

to a medical association <strong>and</strong> is very competent!” “My motivations were a competence similar<br />

to what is available in France for a price sharply lower than in France, following the<br />

principle of value for money! Because if surgeons were not worth the trip, I wouldn’t go<br />

there, even if it’s cheaper!”<br />

Concerning the modernity of foreign hospitals, it appears that in many developing countries,<br />

public <strong>and</strong> particularly private hospitals are well-equipped <strong>and</strong> meet international st<strong>and</strong>ards.<br />

“I leave for the operating room, it’s large, I recognize the respirator… it’s the same br<strong>and</strong> we<br />

have at home, everything is exactly the same, which goes to show that some received ideas<br />

are wrong.”<br />

Regarding the care, many patients appreciate the reactivity <strong>and</strong> efficiency of the medical staff.<br />

« …I wasn’t feeling very good…, immediately the anaesthetist took care of me,<br />

electrocardiogram, drip, regular blood tests, I felt reassured in this health care<br />

environment.” “As someone who has gone through several operations, I can EASILY SAY<br />

that I had never got or even seen such care at this price.”<br />

The travelling patient aims to purchase a particular service <strong>and</strong> to achieve a defined health<br />

goal (Bookman <strong>and</strong> Bookman, 2007). Despite the importance of the medical aspect, it appears<br />

that non-medical services are not insignificant to the medical tourism experience. Medical<br />

<strong>tourists</strong> especially appreciate the recovery period.<br />

«In my opinion, the advantage of being operated in Tunisia is the rest afterward, they keep<br />

you in the clinic for as long as it takes, after that you end your stay in a hotel, where there are<br />

no concerns such as going shopping or doing housework or what’s for dinner tonight, or the<br />

postman ringing <strong>and</strong> so on!!”<br />

Bookman <strong>and</strong> Bookman (2007) asked the question of why a medical tourist picks one<br />

destination over another. They believe that factors such as cultural similarities, distance from<br />

home, medical specialties <strong>and</strong> reputation influence an individual to favour one country.<br />

Travelling patients think that Tunisia is well reputed in the field of cosmetic surgery. Tunisia


also has strong cultural similarities with France <strong>and</strong> it is a country where the people speak<br />

fluent French. Finally the geographical proximity between France <strong>and</strong> Tunisia seems to play<br />

an important role in the choice of medical <strong>tourists</strong>.<br />

“My first criterion was the fact that the first country to have done surgery for <strong>tourists</strong> was<br />

Tunisia, so they are more experienced than the others, the second criterion was the proximity:<br />

a two-hour flight is very manageable, <strong>and</strong> finally the third criterion, the language. In Tunisia,<br />

unlike in Eastern Europe, Thail<strong>and</strong> or Brazil, all the doctors speak French! It’s important to<br />

be able to easily discuss operating techniques, etc., without asking myself whether I was<br />

properly understood…????”<br />

As regards the use of the Internet, the functional value of the tool lies in its ability to ensure<br />

remote contact between medical <strong>tourists</strong> <strong>and</strong> service providers (surgeon <strong>and</strong>/or tour operator).<br />

Novak <strong>and</strong> al (2000) considered the ease of contact as a component of a “compelling online<br />

experience”. Through an empirical study, Heinonen (2008) highlighted how well companies<br />

respond to customers’ inquiries using technology such as e-mails. E-mails have the potential<br />

to improve patients’ perception of the accessibility of their managed care organization <strong>and</strong><br />

healthcare providers (Moyer, 1999). Therefore, several medical <strong>tourists</strong> think that the Internet<br />

<strong>and</strong> particularly e-mails are an efficient tool to communicate with their surgeon or tour<br />

operator.<br />

“Doubts, questions, I immediately send an e-mail to my surgeon who replies to me within the<br />

day, he reassures me, tells me not to hesitate to ask any questions that pop into my head <strong>and</strong><br />

that it's normal to be anxious. I appreciate this permanent contact.”<br />

Several studies have also shown the usefulness of electronic mail as a medium for patientphysician<br />

communication, as they make it possible to gain time, <strong>and</strong> improve convenience<br />

<strong>and</strong> access to medical care for purposes such as renewing prescriptions, communicating<br />

laboratory results <strong>and</strong> making appointments (Sciamanna et al. 2007).<br />

In our case, it was found that administrative issues inherent to the medical tourism package<br />

are easily <strong>and</strong> well h<strong>and</strong>led by electronic communication.<br />

“Did you send him the pictures directly by e-mail or through the website? The surgeon has to<br />

see your pictures to make a diagnosis <strong>and</strong> assess the cost!<br />

Then his assistant will send an e-mail or call you, anyway, the written estimate will surely be<br />

sent by e-mail <strong>and</strong> then to show you agree, you will need to send him the confirmation of your<br />

plane ticket reservation!”<br />

Other studies have found that follow-up care is among the main reasons why patients use emails<br />

(Nelson <strong>and</strong> Stewart, 1993, Houston <strong>and</strong> al, 2004).<br />

The same finding is observed in a medical tourism context, where the follow-up is performed<br />

remotely. The patient sends photos of the evolution following the operation to the doctor, who<br />

examines them <strong>and</strong> then gives advice <strong>and</strong>/or renews prescriptions to the patient.<br />

“He remained available after I got back, by e-mail <strong>and</strong> by phone <strong>and</strong> even on live chat…!<br />

Regarding the e-mails, it’s useful to send him photos showing the progress of healing for<br />

example!” “I just had my surgeon on the phone a moment ago, <strong>and</strong> after observing the<br />

photos, he thinks all the same that I have a stitch that went off under the nipple…”<br />

In the context of our study, the Internet is not only a means used to ensure remote contact, it’s<br />

also the main source of information for medical <strong>tourists</strong>. The Internet is a wide source of<br />

information that allows customers to access more customized information with minimal effort<br />

<strong>and</strong> cost (Alba et al. 1997). Through forums, travelling patients can easily get information<br />

with minimal effort.


“Before my operation, I did extensive research on the Internet…” “So I started, I began my<br />

search! I typed “facelift in Tunisia” on my friend Google. It gave me the names of clinics <strong>and</strong><br />

forums. The breaking point, but yes, the forums, what an idiot not to have thought about it<br />

before, these things are full of information, lol…. So I signed up on 2 forums, <strong>and</strong> I visit both<br />

of them daily, I don’t post but I read.”<br />

Social value<br />

Social value is defined as the perceived utility based on the association of a product with one<br />

or more specific social groups (Sheth, Newmann <strong>and</strong> Gross, 1991).<br />

As regards social value, the attributes most often mentioned in literature are obtaining social<br />

approval (Cengiz <strong>and</strong> Kirkbir, 2007), improving self-image, feeling accepted <strong>and</strong> making a<br />

good impression (Sweeney <strong>and</strong> Soutar, 2001), <strong>and</strong> finally turning to a service provider known<br />

by many other customers (Sanchez et al. 2006). The aspects which st<strong>and</strong> out the most from<br />

the discussions of medical <strong>tourists</strong> are related to improving self-image <strong>and</strong> to turning to a<br />

well-known service provider.<br />

We were able to observe that a large majority of medical <strong>tourists</strong> turn to cosmetic surgery in<br />

order to improve their self-image <strong>and</strong> physical appearance in the aim of improving their selfesteem.<br />

“That’s it, I’ve made my decision, after having 6 children, being “obese”, having lost 50 kilos<br />

<strong>and</strong> reached my forties, I am going to have an abdominoplasty in Tunisia!”<br />

Moreover, medical <strong>tourists</strong> are looking for the most famous <strong>and</strong> particularly the most skilled<br />

service provider (surgeon <strong>and</strong>/or tour operator). We can also observe the formation of groups<br />

supporting for example a surgeon who became famous on the forum.<br />

“It’s true that our surgeon is very attentive to details <strong>and</strong> very thoughtful. He knows how to<br />

reassure us…” “Our surgeon will soon need a new set of arms to operate all of us!” “What a<br />

successful man he is!”<br />

As regards the Internet tool, the two aspects which st<strong>and</strong> out the most are related to the<br />

sharing of experience <strong>and</strong> the formation of groups <strong>and</strong> social connections.<br />

In addition to seeking health information, individuals can also use the Internet to<br />

communicate with one other in support groups (Houston <strong>and</strong> al, 2004). In fact, the advent of<br />

the Internet has given rise to many forms of online socialization.<br />

“Thank you for your testimony on your surgical experience in Tunisia: this will be a great<br />

contribution for forum users… so being able to have information on your experience will<br />

provide valuable elements to forum users…” “This forum is an important tool when one<br />

embarks on the adventure of “cosmetic surgery” <strong>and</strong> I’ve met many people on the forum<br />

ready to help the others.”<br />

Forums dedicated to medical tourism foster the creation of social connections among<br />

members sharing the same opinions <strong>and</strong> interests. In the forum under study, we can observe<br />

the formation of groups of medical <strong>tourists</strong>, such as the group of the “lolol<strong>and</strong>aises” <strong>and</strong> the<br />

“Tunis girls”. The “Tunis girls” group is formed by women who have been operated in Tunis.<br />

The “lolol<strong>and</strong>aises” group is formed by women who have undergone breast surgery.<br />

“Congratulations! You will become a Tunisgirl!!!” “THANK YOU all for your<br />

encouragement!!! And for the lolol<strong>and</strong>aises-to-be: GO THERE stress-free, it’s wonderful to<br />

feel so feminine!!”


Emotional value<br />

Emotional value is defined as the perceived utility based on the ability of a product to arouse<br />

feelings or affective states (Sheth, Newmann <strong>and</strong> Gross, 1991). Emotional value is related to<br />

the development of positive emotions, such as happiness, interest, <strong>and</strong> pleasant surprise, <strong>and</strong><br />

negative emotions, such as sadness, fear, anger, disgust, <strong>and</strong> unpleasant surprise (Borod et al.<br />

1998).<br />

Previous studies focused on a range of positive <strong>and</strong> negative feelings arising from a tourism<br />

experience (William <strong>and</strong> Soutar, 2000; Sanchez et al. 2006; Petrick, 2002) <strong>and</strong> from a medical<br />

experience (Cengiz <strong>and</strong> Kirkbir, 2007), such as fear, excitement, pleasure <strong>and</strong> happiness. In<br />

our case, members made for example comments about being “afraid” <strong>and</strong> “excited”.<br />

“I keep jumping around because I can’t wait! In 8 days, I’ll be on the plane at this hour!” “A<br />

small tablet before I went to bed to feel relaxed even though I was pretty wired. Not stressed<br />

but excited at the thought of fulfilling my dream.”<br />

“I am supposed to go there on March 2 nd for a breast operation, <strong>and</strong> now I am really afraid<br />

because there is no way of checking the surgeon’s skills…, I am just afraid of failure.”<br />

Epistemic value<br />

Epistemic value is defined as the perceived utility based on the ability of a product to arouse<br />

curiosity, provide novelty, <strong>and</strong>/or satisfy a desire for knowledge (Sheth, Newmann <strong>and</strong> Gross,<br />

1991). Goetzinger et al. (2007) stated that the Internet has revolutionized the way consumers<br />

search for information <strong>and</strong> has completely changed consumers’ decision-making process,<br />

particularly in the health care industry. In the same vein, it has been acknowledged that the<br />

Internet provides some level of epistemic value to those who use it as a resource for health<br />

care information (Wilkins, 1999). Medical <strong>tourists</strong> conduct several searches on:<br />

The service providers (surgeon <strong>and</strong>/or tour operators):<br />

“Before my operation, I had done extensive research on the Internet <strong>and</strong> I had consulted<br />

several surgeons to be sure to have a good surgeon.”<br />

The cost of stays:<br />

"Are rates really more interesting than in France????”<br />

And the postoperative care:<br />

“Otherwise, as regards post-operation care, I clean the scar using Bétadine, by tapping<br />

gently, without rubbing, then you put a good coat of IALUSET healing cream, all over, <strong>and</strong><br />

use IALUSET PLUS where it weeps, because it is a healing <strong>and</strong> disinfecting cream at the<br />

same time!”<br />

Conditional value<br />

Conditional value is defined as the perceived utility based on the specific context or set of<br />

circumstances faced by the patient. An alternative acquires conditional value in the presence<br />

of previous physical or social contingencies that enhance its functional or social value (Sheth,<br />

Newman <strong>and</strong> Gross, 1991).<br />

The conditional value of the medical tourism experience finds its essence in the presence of<br />

several contingencies which tend to improve its functional value. These contingencies are<br />

related to the high prices applied in France, the long waiting lists at teaching hospitals <strong>and</strong> the<br />

absence of coverage for cosmetic surgery.<br />

“It is true that in France, it can be twice as expensive as in Tunisia! Otherwise, there are<br />

some teaching hospitals where prices are around 2,300 euros, but for some, the waiting<br />

periods are too long”<br />

“Concerning coverage, it’s not the lost weight that matters, it is whether or not you have a<br />

"deck", <strong>and</strong> I have no deck <strong>and</strong> therefore no coverage…so I’m not interested in being<br />

operated in France”


The table below recapitulates the main findings.<br />

Value Medical tourism service Internet<br />

Functional -cost differential<br />

-abilities of surgeon <strong>and</strong> nursing<br />

staff<br />

-equipment quality<br />

-quality of care<br />

-importance of the recovery period<br />

-assets of the Tunisian offer<br />

(cultural similarity, geographical<br />

proximity, reputation)<br />

Social -turning to a well-known service<br />

provider<br />

-enhancing self-image<br />

-Maintaining remote communication<br />

through e-mails (making the steps<br />

prior to the service contract easier,<br />

<strong>and</strong> facilitating post-operative<br />

follow-up)<br />

-easy <strong>and</strong> quick information<br />

gathering<br />

-sharing experiences<br />

-formation of groups <strong>and</strong> social<br />

connections<br />

Emotional -positive <strong>and</strong>/or negative feelings<br />

resulting from the experience<br />

Epistemic -information search tool regarding<br />

service providers, costs, treatment<br />

(before <strong>and</strong> after the operation)<br />

Conditional -high costs in France<br />

-long waiting lists in teaching<br />

hospitals<br />

-no coverage for cosmetic surgery<br />

Summary of the dimensions of perceived value in the context of medical tourism<br />

Conclusion<br />

This research shows that the medical tourism experience <strong>and</strong> the use of the Internet in this<br />

context include a set of value dimensions. Knowing the contribution of each value dimension<br />

to consumers’ choice, <strong>and</strong> in our case to the choice of medical <strong>tourists</strong>, gives valuable<br />

information to managers (Williams <strong>and</strong> Soutar, 2000), enabling them to better underst<strong>and</strong> the<br />

concerns <strong>and</strong> expectations of medical <strong>tourists</strong>. Like in other studies, it thus seems obvious that<br />

the contribution of functional value is highly significant in the perceived value (Cengiz <strong>and</strong><br />

Kirkbir, 2007), especially as regards costs. It is also interesting to note that despite the<br />

importance of costs, medical <strong>tourists</strong> would not be able to overcome their apprehension if<br />

services were of poor quality; which explains the importance of other aspects of functional<br />

value, such as the surgeon’s skills, the quality of care <strong>and</strong> the modernity of the equipment. It<br />

is therefore essential that health establishments undergo certification <strong>and</strong> accreditation to<br />

enhance their reputation.<br />

The functional value of the Internet tool lies in its ability to guarantee a permanent contact. It<br />

is thus essential to optimize the potentialities of the tool. However, <strong>and</strong> in conjunction with<br />

other studies (Williams <strong>and</strong> Soutar, 2000, Sanchez et al. 2006), the importance of the<br />

functional dimension in the perception of value should not make us forget the contribution of<br />

other aspects.<br />

Medical <strong>tourists</strong> see in the Internet tool, <strong>and</strong> particularly in forums, an effective means of<br />

sharing experience, finding positive stimulation, <strong>and</strong> especially of finding information on the


different aspects of the Tunisian medical tourism offer. The components listed are<br />

respectively related to social, emotional <strong>and</strong> epistemic values.<br />

<strong>Health</strong> care professionals can get more out of these value dimensions, for example by creating<br />

their own blogs or forums, around which they will be able to rally real virtual communities,<br />

thus improving access to information <strong>and</strong> creating positive word-of-mouth.<br />

The conditional value of the Tunisian medical tourism offer is based on certain aspects of<br />

Western health care systems, such as long waiting lists <strong>and</strong> the lack of coverage for certain<br />

operations. It would be interesting to communicate more about these issues.<br />

From a managerial viewpoint, the results obtained are a first attempt to enlighten managers on<br />

the major dimensions of the value perceived by medical <strong>tourists</strong> <strong>and</strong> on the relative<br />

contribution of each dimension to the perception of value. The goal is to better underst<strong>and</strong> the<br />

needs of medical <strong>tourists</strong> <strong>and</strong> thus to better guide their choices <strong>and</strong> marketing decisions.<br />

From a theoretical viewpoint, these results are a first step in developing a synthetic theoretical<br />

model incorporating the dimensions of both the perceived value in the context of a medical<br />

tourism experience <strong>and</strong> the usefulness of the Internet in the same context. It is also a first step<br />

towards underst<strong>and</strong>ing the key dimensions of perceived value <strong>and</strong> their impact on behavioural<br />

consequences in a medical tourism context. The ultimate goal is to operationalize the<br />

dimensions of perceived value <strong>and</strong> test their impact on satisfaction <strong>and</strong> behavioural<br />

consequences.<br />

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www.udel.edu/PR/UDaily/2005/mar/tourism072505.html


Cruise <strong>Tourism</strong> - Changing Products – Improving <strong>Wellness</strong>?<br />

Ian Henderson<br />

TTC International<br />

Belfast, UK<br />

henderson@ttcinternational.com<br />

Abstract<br />

“This presentation examines the rapidly changing cruise tourism industry across the world but<br />

notably in Europe where growth has exceeded all expectations. (NB It will not cover river<br />

cruising). Not only is the market receiving br<strong>and</strong> new cruise ships but it is seeing a much<br />

greater spread of products on board. One theme being promoted is that of life, health <strong>and</strong><br />

wellness – which may seem to conflict with the image of constant eating <strong>and</strong> drinking on<br />

board such ships!<br />

The image presented <strong>and</strong> the products offered may not appear to be consistent in ensuring a<br />

total ‘wellness’ regime.<br />

Additionally the rapid growth in cruise tourism <strong>and</strong> the need to fill ever larger ships may drive<br />

new customers on board whose desired ‘experience’ may not always be compatible with that<br />

of their fellow cruisers. Mixing market segments creates tensions between groups of<br />

passengers where those who are lured by price may have a totally different lifestyle <strong>and</strong> set of<br />

ambitions <strong>and</strong> values to those who are focusing on a more ethereal experience.<br />

The presentation will consider the proposition that ‘wellness’ takes on many meanings to<br />

cruise passengers <strong>and</strong> that visiting the spa <strong>and</strong> gymnasium may not be an essential part of the<br />

experience”.<br />

Thankfully my own cruise experience 5 cruises on 3 different cruise lines has not faced that<br />

problem because we fly to USA <strong>and</strong> avoid Southampton (where I did the highly successful<br />

cruise tourism strategy in 2004/5).<br />

We prefer Celebrity which is said to be four star <strong>and</strong> promotes wellness <strong>and</strong> ‘life enrichment’<br />

<strong>and</strong> does to some extent. Good gyms <strong>and</strong> exorbitantly prices spas – plus new products that<br />

suggest healthier eating <strong>and</strong> living on board.<br />

Cruise <strong>Tourism</strong> Work undertaken:<br />

Port of Southampton Cruise <strong>Tourism</strong> Strategy<br />

Scottish Cruise <strong>Tourism</strong> Review<br />

Economic Impact of Cruise <strong>Tourism</strong> Dover<br />

Antigua <strong>Tourism</strong> Masterplan<br />

St Maarten <strong>Tourism</strong> Masterplan<br />

Limassol Cruise Terminal Feasibility<br />

Mombassa Cruise tourism Feasibility<br />

Dublin Cruise <strong>Tourism</strong> Feasibility


Cosmeceuticals in wellness tourism – Cases of co-br<strong>and</strong>ing <strong>and</strong> co-creation<br />

Anne-Mette Hjalager<br />

Associate professor, University of Southern Denmark, Centre for <strong>Tourism</strong>, Innovation <strong>and</strong><br />

Culture<br />

Niels Bohrsvej 9, DK 6700 Esbjerg<br />

Hjalager@advance1.dk<br />

Henna Konu<br />

Researcher, University of Eastern Finl<strong>and</strong>. Centre for <strong>Tourism</strong> Studies<br />

Puistokatu 5,, FI-57101 Savonlinna<br />

Henna.konu@uef.fi<br />

Abstract<br />

“Cosmeceuticals” is a combination of the terms “cosmetics” <strong>and</strong> “pharmaceuticals”.<br />

Cosmeceuticals are supplied to the wellness facilities, <strong>and</strong> they materialize for the <strong>tourists</strong><br />

during treatments. <strong>Tourism</strong> research has not to any significant degree addressed the role of<br />

cosmeceuticals in the wellness industry.<br />

The paper provides examples of strategic alliances from the Nordic countries of co-br<strong>and</strong>ing.<br />

Additionally, the producers/distributors of cosmeceuticals may become crucial partners in the<br />

creation of the experience offered in the wellness facilities. With examples from the Nordic<br />

countries, it is demonstrated that alliances can lead to innovation <strong>and</strong> development in<br />

cosmeceutical enterprises, <strong>and</strong> that the collaboration can also assist the wellness industry in its<br />

attempts to obtain inimitability. Based on innovation literature, the paper discusses models for<br />

co-creation <strong>and</strong> factors that facilitate or hamper collaborative processes. Co-creation <strong>and</strong> cobr<strong>and</strong>ing<br />

constitute strategic alleys for the wellness industry. The Nordic evidence suggests<br />

that the opportunities are not fully exploited.<br />

Keywords: Spa <strong>and</strong> wellness tourism; cosmeceuticals; innovation; co-br<strong>and</strong>ing; co-creation;<br />

the Nordic countries.<br />

Introduction<br />

“Cosmetics” <strong>and</strong> “pharmaceuticals” together form the term cosmeceuticals, which embrace<br />

anti-aging creams, moisturizers, bathing salts, lip balms <strong>and</strong> many other products. When<br />

extending the use of cosmeceuticals <strong>and</strong> applying the rhetoric of health improvements, the spa<br />

<strong>and</strong> wellness industry is increasingly marching into domains formerly exclusively occupied<br />

by “serious” medical professionals. Similar movements <strong>and</strong> invasions can be observed in for<br />

example electronics where GPS-technologies have moved from restricted military use to<br />

become an instrument for play <strong>and</strong> enjoyment, <strong>and</strong> in the clothing sector waterproof clothes<br />

previously used mainly for military purposes or as working clothes have also disseminated<br />

into outdoor activities for recreation <strong>and</strong> tourism (Logue 2005, Smedstad 1995).<br />

<strong>Wellness</strong> tourism integrates body, mind <strong>and</strong> spirit. A satisfactory tourism experience depends<br />

on the intentions, mood <strong>and</strong> adaptability of the tourist, but also on the competencies <strong>and</strong><br />

professionalism of the wellness staff to interpret <strong>and</strong> meet the needs of the visitor. Relations<br />

between human beings are found to be crucial in wellness tourism (Kelly & Smith 2009).<br />

However, wellness experiences are not only a matter of intangible procedures <strong>and</strong> services.<br />

The delivery process is assisted by a large number of auxiliary remedies. Thus,


cosmeceuticals are supplied to the wellness facilities, <strong>and</strong> they materialize for the <strong>tourists</strong><br />

during treatments. As it will be further developed <strong>and</strong> explained in this article, the image <strong>and</strong><br />

the commercial success of cosmeceutical products depend on the interaction between the staff<br />

<strong>and</strong> the customers in the wellness facilities. Accordingly, it assumed that there is a mutuality<br />

of the two industries, which may or may not be fully envisaged <strong>and</strong> exploited. It is part of a<br />

collaborative picture that cosmeceuticals are also merch<strong>and</strong>ised on the premises <strong>and</strong> often part<br />

of the décor. Thus, the role of the cosmeceuticals is, potentially, even more far-reaching in<br />

terms of development <strong>and</strong> br<strong>and</strong>ing.<br />

Although wellness tourism is a topic that attracts many tourism researchers, the role of<br />

cosmeceuticals in the wellness industry has not been addressed too any significant degree.<br />

Generally, it is remarkable how few research reports are generated from the “engine room” of<br />

the wellness industry.<br />

The geographical framework for this study is the Nordic countries, where spa tourism has<br />

existed for a long period of time (Aho 2007, Hemmi & Vuoristo 2004, Kangas & Tuohino<br />

2008, Konu et al. forthcoming 2010, Smith & Puczkó 2009, Suontausta & Tyni 2005). There<br />

are many strategically sound ways for spa <strong>and</strong> wellness tourism enterprises to move in<br />

developing their competitiveness <strong>and</strong> br<strong>and</strong>s, <strong>and</strong> developing their cosmeceutical alliances<br />

might be one of them. One assumption here is that the producers/distributors of<br />

cosmeceuticals are crucial partners in the creation of the experience offered in the wellness<br />

facilities. Cosmeceutical producers play a role both in terms of innovation of new products<br />

<strong>and</strong> services <strong>and</strong> in the marketing <strong>and</strong> br<strong>and</strong>ing process. The terms co-creation <strong>and</strong> cobr<strong>and</strong>ing<br />

are applied in the investigation of the nature of such collaborative structures.<br />

Literature review<br />

<strong>Wellness</strong> tourism has its roots in the long history of spa resorts, <strong>and</strong> in that sense is not a new<br />

phenomenon. During more recent decades it has modernized <strong>and</strong> diversified into a large<br />

variety of categories. As demonstrated by Smith <strong>and</strong> Puczkó (2009) wellness tourism includes<br />

a high focus in facilities for medical treatments, as well as pure leisure <strong>and</strong> relaxation sites.<br />

There are also great variations in profiles when it comes to expectations of the <strong>tourists</strong>’<br />

involvement <strong>and</strong> activity, either mentally or physically. The rapidly upcoming research<br />

interest covers many issues, but there seems to be an overwhelming interest, for instance in<br />

users’ profiles <strong>and</strong> in motivations, behaviours <strong>and</strong> experience. Generally, the rationale is that<br />

there are significant growth prospects due to ageing <strong>and</strong> changed lifestyles (Bushell &<br />

Sheldon 2009). In parallel, destination studies contribute to the wider perspectives with<br />

evidence about local resources, sustainability fit <strong>and</strong> economic viability (Pechlaner & Fischer<br />

2006).<br />

In the pharmaceutical literature, the development of cosmeceuticals is given quite noteworthy<br />

attention. There is a science based focus on the ingredients that influence the skin's biological<br />

function <strong>and</strong> the discovery of new active agents (Draelos 2008, Tsai & Hantash 2008).<br />

Spa <strong>and</strong> wellness facilities provide a long range of treatments. Not all of them imply the use<br />

of cosmeceuticals. There is an ongoing development in the treatments, such as cooling <strong>and</strong><br />

hot stones, <strong>and</strong> vitaminized massages, as well as treatments of the extended body, <strong>and</strong><br />

combined mental <strong>and</strong> physical treatments. Simultaneously, there is a t<strong>and</strong>em process of<br />

ongoing development with cosmeceuticals that can be applied in those treatments.<br />

Manufacturers are enthusiastic to explore the uses of traditional <strong>and</strong> new raw materials in<br />

their products. Trends for the near future are claimed to be that natural products <strong>and</strong> extracts


will replace chemical materials; additionally, plants <strong>and</strong> fermentation will replace animals as<br />

ingredient sources.<br />

The use of cosmeceuticals in wellness tourism is only fragmentarily covered in the research<br />

literature, <strong>and</strong> then only in conjunction with the descriptions of the treatments provided. Smith<br />

<strong>and</strong> Puczkó (2009) reviewed the many categories of wellness tourism, from medical to<br />

recreational, relaxationally passive to sportily active, physical to spiritual, <strong>and</strong> focused to<br />

holistic. Treatments where cosmeceuticals are prevalent occur in some of the categories <strong>and</strong><br />

not in others. The experiential cosmeceuticals do receive some anecdotal attention in the<br />

literature, for example massages <strong>and</strong> body wraps based on chocolate. The general trend seems<br />

to be that the inclusion of spa elements in for example hotels <strong>and</strong> sports centres increases the<br />

profits, <strong>and</strong> that the growth rate of goods <strong>and</strong> merch<strong>and</strong>ise is particularly impressive<br />

(M<strong>and</strong>elbaum & Lerner, 2008). In terms of treatments, Behrens (2007) points to the strong<br />

diversification <strong>and</strong> internationalization trends, where large corporations with huge marketing<br />

budgets tend to be the main driving forces. Those players in the wellness <strong>and</strong> spa market may<br />

have alliances with suppliers of cosmeceuticals in the same league.<br />

On a more general level co-br<strong>and</strong>ing with the tourism <strong>business</strong> <strong>and</strong> their suppliers is an upcoming,<br />

but still novel research theme (Pechlaner et al. 2006). Co-br<strong>and</strong>ing is when two<br />

companies form an alliance to work together, creating marketing synergy. In this situation, a<br />

tourism enterprise will enhance its image by using respected <strong>and</strong>, preferably, already wellbr<strong>and</strong>ed<br />

products, while the suppliers can achieve an extra marketing platform for its<br />

products. Any wellness provider will apply scrubs, lotions, muds etc. during the treatments<br />

<strong>and</strong> the br<strong>and</strong>s of these can be made very visible <strong>and</strong> their merits included in verbal<br />

appraisals. The spa-goers are expected to take the first step towards a loyalty to the particular<br />

product. They can also find the same products in the shop to bring back for home treatments<br />

<strong>and</strong> gifts. Additionally co-br<strong>and</strong>ing can include club memberships offers. The co-br<strong>and</strong>ing<br />

can also take place on the websites of the enterprises, sometimes even including e-shopping<br />

opportunities (Lee et al. 2006). The research literature is fairly tacit about strategic cobr<strong>and</strong>ing<br />

alliances between the wellness industry <strong>and</strong> its suppliers in this field (Gibson, 2008;<br />

Weiermair & Steinhauser, 2003). Smith <strong>and</strong> Puczkó (2009) talk about “signature products”, a<br />

term that embraces the development of new spa products <strong>and</strong> treatments special to the place<br />

<strong>and</strong> destination. Signature products might involve an active <strong>and</strong> mutually beneficial a cobr<strong>and</strong>ing<br />

of the spa-facilities with the producer <strong>and</strong> the local community, from where an<br />

element of the signature derives.<br />

Co-creativity moves the issue further. In this case a wellness operator will collaborate<br />

intensively with suppliers of cosmeceuticals in order to develop new products. The open<br />

processes lead to cross-fertilization of knowledge. During the process of co-creation the<br />

purpose for the supplier is also to gain new ideas <strong>and</strong> insights, which may eventually lead to<br />

product introductions to a wider market (Möller & Törrönen, 2003). Accordingly, tourism<br />

service providers <strong>and</strong> their suppliers are partners in an innovation process, <strong>and</strong> leading<br />

tourism enterprises are responsive test benches for new supplies with a higher quality <strong>and</strong><br />

better market potential. Such innovation processes are not well illuminated in tourism<br />

innovation literature (Hjalager, 2010).<br />

Methodology<br />

This study combines literature reviews with brief <strong>and</strong> targeted case studies. As the research is<br />

part of a larger project on “Nordic Wellbeing” the geographical focus is the Nordic countries,<br />

in particular Denmark <strong>and</strong> Finl<strong>and</strong>. Persons selected for interviews are managers of spa <strong>and</strong>


wellness facilities <strong>and</strong> cosmeceutical manufacturers <strong>and</strong> distributors. As tourism research is<br />

only marginally addressing issues about co-br<strong>and</strong>ing <strong>and</strong> co-creation, the Internet <strong>and</strong> the<br />

trade press has been an important supplementary source of knowledge on specific practices in<br />

the global spa <strong>and</strong> wellness industry.<br />

Spa Industries <strong>and</strong> their Suppliers – Cases from Denmark <strong>and</strong> Finl<strong>and</strong><br />

The inclination to place additional weight on the spa products <strong>and</strong> the relations with the<br />

producers <strong>and</strong> distributors of them can be demonstrated by the cases from Denmark <strong>and</strong><br />

Finl<strong>and</strong>. The cases illustrating the strategies are far from uniform.<br />

Table 1. Cases of co-operation <strong>and</strong> co-br<strong>and</strong>ing between cosmeceuticals <strong>and</strong> wellness firms.<br />

Strategies of spa firms <strong>and</strong> cosmeceutical firms<br />

Comwell Hotel<br />

Chain<br />

Development of a series of skin care products together with Matas, a retail<br />

materialist chain. Intensive co-br<strong>and</strong>ing in shops <strong>and</strong> in the wellness facilities<br />

in the hotels. Joint marketing campaigns. The “Spalosphy” series has been<br />

very successful in the spas <strong>and</strong> as a retail product.<br />

Vejlefjord Spa Development of private label cosmeceuticals to the spa. The products are<br />

available in the spa <strong>and</strong> in the webshop. The suppliers of ingredients are<br />

anonymous. The staff prepares the products in the “back office” on a regular<br />

base, <strong>and</strong> there is a great concern about the freshness <strong>and</strong> the full <strong>and</strong> open<br />

Queen Dorothea’s<br />

Bath<br />

declaration of the ingredients.<br />

The theme of the bath is medieval, <strong>and</strong> historical line has also been chosen for<br />

the spa product series, developed in collaboration with a local supplier of<br />

cosmeceuticals. The concept will be developed in order to create a wider level<br />

experience for the spa-users.<br />

SeaWest Spa SeaWest imports an Isl<strong>and</strong>ic spa product series, chosen for its image of being<br />

“clean”, <strong>and</strong> with ingredients from the Nordic natural environment. The<br />

Anttolanhovi <strong>and</strong><br />

LUMENE<br />

products are also available in the spa shop <strong>and</strong> on the web.<br />

A distinct concept is the ‘wellness bar’ (following the idea of minibar), which<br />

are found in Art&Design villas. The bars are filled with Finnish wellness<br />

products from Lumene <strong>and</strong> Cutrin (both labels owned by LUMENE Oy). The<br />

intention is to give customers a possibility to pamper themselves with<br />

products with arctic ingredients.<br />

Hotel Kalevala Hotel Kalelava uses Frantsila’s supplies, which concentrates on organically<br />

grown <strong>and</strong> produced herbs <strong>and</strong> plants. Raw materials of the cosmeceuticals<br />

are mainly cultivated for the purpose, but in addition some of the ingredients<br />

are gathered from nature. All herbs <strong>and</strong> plants that are used are well known in<br />

folk medicine, <strong>and</strong> as such used to enhance health <strong>and</strong> wellbeing <strong>and</strong> cure<br />

illnesses.<br />

Designermudder The firm is a cosmeceuticals producer diversifying into experiences <strong>and</strong><br />

events. The strategy to offer good <strong>and</strong> interesting skin care products, for<br />

example coloured muds. However, additional services that enhance the<br />

experience of the spa-user are also offered, <strong>and</strong> the specialists from the firm<br />

are responsible for fun-events such as producing your own soap. The strategy<br />

is also about building mutual relations with the spa facilities employees.<br />

Guest Comfort Guest Comfort is a cosmetic supplier who acts as a creative intermediary<br />

between cosmeceuticals <strong>and</strong> <strong>business</strong>es in the tourism sector. It is also a<br />

knowledge intermediary between spa facilities <strong>and</strong> the producers of<br />

cosmeceuticals, <strong>and</strong> sees itself as a motivator for continual creativity in the<br />

field.


Issues in Co-br<strong>and</strong>ing <strong>and</strong> Co-creation<br />

The br<strong>and</strong>ing literature elaborates on the many dimensions of effective co-br<strong>and</strong>ing. Aaker<br />

(1996) demonstrates that the companies in collaboration must have a deep underst<strong>and</strong>ing of<br />

their customers’ motivations in order to create <strong>and</strong> enhance the loyalty for more products in a<br />

co-br<strong>and</strong>ing group. Furthermore, the quality levels must be comparable, <strong>and</strong> the product<br />

character stable <strong>and</strong> unshakeable, as compromising will harm the collaborating partners. In<br />

the cases of successful co-br<strong>and</strong>ing, a mutual respect <strong>and</strong> trust has been built up over time.<br />

Suppliers are likely to be more willing to launch into risky partnerships if they have the<br />

prospects of lasting contracts that guarantee a return from their innovation <strong>and</strong> other<br />

investments (Crotts et al. 1998).<br />

According to Lee <strong>and</strong> Decker (2008) there are three distinguishable effects of co-br<strong>and</strong>ing:<br />

• Mutual effects which occur if there is a high degree of product fit, where the two<br />

products are interlinked. That is the case in cosmeceuticals, as the products are directly<br />

applied during the treatments <strong>and</strong> exposed to the customers, while the treatments take<br />

place. If the customer gets a sense of wellbeing after the treatment, he/she will build<br />

up a favourable attitude towards both the spa <strong>and</strong> the particular cosmeceutical.<br />

• Extension effects happen later as a responsive consumption behaviour. By<br />

remembering the spa-experience, the customer will also be likely to bring back gifts<br />

from the spa gift shop <strong>and</strong> to choose the spa product during daily shopping.<br />

• Reciprocity effects are the long term effects where the customer on a more permanent<br />

base perceives the quality of a product in a certain manner. At this time the<br />

collaboration between the supplier of cosmeceuticals <strong>and</strong> the spa facility can exp<strong>and</strong><br />

their collaboration <strong>and</strong> utilize the established br<strong>and</strong> equity, for example by introducing<br />

more cosmeceutical products or by appealing to new market segments.<br />

In the private label case of Vejlefjord, there is of course no co-br<strong>and</strong>ing, <strong>and</strong> none of the<br />

effects are materializing. It demonstrates a careful strategic choice, which coincides with for<br />

example the strategies in professional staffing.<br />

Other cases in this collection are examples of the harvesting of the effects of mutuality. Thus,<br />

the Hotel Kalevala <strong>and</strong> the Seawest work with producers with a distinct image, which<br />

supports the br<strong>and</strong> of the place as “Nordic”, “clean”, <strong>and</strong> “responsible”.<br />

In the co-operation model of Anttolanhovi <strong>and</strong> Lumene, Lumene’s products are introduced to<br />

different customer segments <strong>and</strong> possibly also to people that have not tested Lumene products<br />

before. This can encourage customers to buy Lumene products also from other places, e.g.<br />

during daily shopping. Comwell/Matas likewise exp<strong>and</strong> the likelihood of extra <strong>business</strong> for<br />

both partners, not least because the Matas shops are found in nearly all towns in Denmark.<br />

Designermudder is an example of a supplier that has the reciprocity in mind to have products<br />

that appeal to categories of spa goers that most spas are not yet geared to serve. The<br />

intermediating of Guest Comfort also helps spa providers <strong>and</strong> cosmeceutical products that are<br />

not experienced in, or capable of, exploiting the potentials of co-br<strong>and</strong>ing.<br />

Generally speaking, there are several driving forces for innovation in tourism, for example the<br />

technological developments, suppliers’ provision, market dem<strong>and</strong>/customer requirements, <strong>and</strong><br />

governmental regulation (Hjalager, 2002). Innovative suppliers can be decisive for tourism,<br />

due to the fact that much innovation is already embedded in technology <strong>and</strong> raw materials.<br />

Suppliers’ innovations are “released” when integrated in the service delivery in the next step<br />

in the value chain. Barras (1986) declare this a typical “reverse” road to innovation in<br />

services. Cosmeceutical producers can be analysed in this logic. Eventually, the most


innovative producers of cosmeceuticals may theoretically be able revolutionize the product<br />

that the spa facilities are offering to their customers. Seen from that perspective, spa <strong>and</strong><br />

wellness enterprises are in a situation where they have to consider existing <strong>and</strong> emerging<br />

cosmeceutials not exclusively as enhancers of products, features <strong>and</strong> functions, but also as<br />

facilitators of experiences. The case study of Designermudder exemplifies that more colourful<br />

spa muds <strong>and</strong> scrubs can be a stepping stone for the spa experiences for new target groups,<br />

<strong>and</strong> thereby a re-orientation or a diversification for the spa <strong>and</strong> wellness facility. Likewise,<br />

Guest Comfort has a “push effect” on its customers in the spa <strong>business</strong>.<br />

The literature on service design (Pine & Gillmore, 1998; Voss & Zomeijk, 2007) widely<br />

advocates to use metaphors from the theatre in order to enhance the experience <strong>and</strong> make the<br />

products innovative as far as the user is concerned. Producers of cosmeceuticals possess<br />

distinct chances to contribute to the development in the spa <strong>business</strong> in a proactive way.<br />

Systematic approaches as suggested by Edensor (2001) <strong>and</strong> Mossberg (2007) reveal that there<br />

might be a plea for enhanced underst<strong>and</strong>ing of the theatrical focus in spa innovations, <strong>and</strong> the<br />

cases in this study illustrate that co-creation with cosmeceuticals can be seen as a construction<br />

of dramatic progressions.<br />

• Scripting is about creating the story <strong>and</strong> the rituals. Scripting is a multifaceted process<br />

that integrates issues about the socio-economic <strong>and</strong> educational background of the<br />

customers <strong>and</strong> the type of <strong>business</strong>. The scripting process can reflect a range of<br />

matters: What is the place of origin of the ingredients? What scientific evidence is<br />

available? What auxiliary remedies? Spa ceremonies are often very rigidly scripted,<br />

<strong>and</strong> the customers more or less know what to expect. However, spa providers are<br />

attempting to make variations in order to create surprises. A uniqueness of the<br />

cosmeceuticals <strong>and</strong> the producers’ contributions to the script are methods of enhancing<br />

the period of time - before some other <strong>business</strong> is copying elements from the concepts.<br />

The renaissance case of Queen Dorethea’s Bath is good illustration of the potentials of<br />

a thematic script with monks <strong>and</strong> their medical herbs.<br />

• Sceneography <strong>and</strong> stage-design. There is an ongoing architectural <strong>and</strong> ethnic<br />

proliferation <strong>and</strong> thematic remodeling of the spa interiors. The importance of the décor<br />

seems to increase, as the colours, shapes, sounds, surfaces etc. tend to create the<br />

signature of the place <strong>and</strong> contribute to the overall feeling of wellbeing. The cases in<br />

this study vary from very classical, to modern Finnish design <strong>and</strong> to the medieval<br />

Queen Dorothea’s Bath. However, these specific wellness facilities exhibit limited<br />

attempts to bind together <strong>and</strong> co-create the cosmecuticals <strong>and</strong> the sceneography, for<br />

example underlining the views to pine trees outside <strong>and</strong> a Nordic ambiance with pinebased<br />

scents.<br />

• Casting <strong>and</strong> instructing deal with the recruiting <strong>and</strong> managing the staff who are<br />

capable of enacting the story that is laid out in the script <strong>and</strong> embraced in the<br />

sceneography. From the point of view of the suppliers of cosmeceuticals, it is hardly<br />

enough that the staff are professional therapists or cosmetologists <strong>and</strong> able to apply the<br />

products in exactly the required way. Innovating goes beyond that <strong>and</strong> includes for<br />

example the use of costumes that are harmonized with the setting <strong>and</strong> potentially also<br />

the image of the cosmeceuticals. Instruction also contains preferred behavior <strong>and</strong><br />

procedures that reinforce the image with some scope for improvisation. Innovativeness<br />

in the field of casting <strong>and</strong> instructing is about creating norms <strong>and</strong> cultures of a place,<br />

which contributes to uniqueness, <strong>and</strong> which creates a learning environment for the


producers of the cosmecuticals to achieve relevant <strong>and</strong> reliable feedback for their<br />

innovation processes. Enhanced sales methods for merch<strong>and</strong>ise <strong>and</strong> after sales services<br />

are also a part of this picture <strong>and</strong> crucially relevant in terms of cosmeceuticals. The<br />

proprietors’ interviews emphasis the need for training as part of the co-creation <strong>and</strong><br />

co-br<strong>and</strong>ing process.<br />

• Directing the <strong>tourists</strong>’ performance. Tourists in spa <strong>and</strong> wellness establishments are<br />

not only spectators, they are also co-producers of their own <strong>and</strong> other people’s<br />

experience <strong>and</strong> therefore partly responsible for the success of the theatric play. There<br />

is normally a good deal of guiding of the visitors through treatment programmes <strong>and</strong><br />

offers, <strong>and</strong> most customers are accepting the implicit conformism. Self-pampering<br />

requires particular advice <strong>and</strong> encouragement, as seen in Anttolanhovi <strong>and</strong> Comwell<br />

cases. When appealing to broader audiences, there might be a need to introduce other<br />

ways of play directing into the spa product. Designermudder sees the opportunities in<br />

organizing events for children where they produce their own soaps or lotions. Such<br />

events – however in line with the objectives of both spas <strong>and</strong> cosmeceutical producers<br />

– may require new modes of interacting with the customers.<br />

Discussion <strong>and</strong> Implications<br />

This study approaches a tourism niche from the point of view of the suppliers, <strong>and</strong> this is a<br />

method that is not conventional in tourism research. By accumulating an underst<strong>and</strong>ing for<br />

the <strong>business</strong> models <strong>and</strong> marketing strategies from the suppliers’ side, it is possible to broaden<br />

the perspective in terms of innovation <strong>and</strong> knowledge transfer. Accordingly, the study unveils<br />

that the co-br<strong>and</strong>ing <strong>and</strong> co-creation is taking place under quite different underst<strong>and</strong>ings of<br />

boundaries of the enterprises. It is a conclusion from the cases that there are both existing <strong>and</strong><br />

emerging overlaps in the roles of the cosmeceutical producers <strong>and</strong> the spa wellness<br />

enterprises. Collaboration tends to soften the boundaries <strong>and</strong> opens up inspiration <strong>and</strong><br />

communication, enlarging the knowledge base can contribute to the competitiveness of a firm<br />

(Howell et al. 2003) <strong>and</strong> influence innovativeness (Tether 2005, Walsh 1996).<br />

The cases suggest that co-br<strong>and</strong>ing is an emerging issue in the spa industry, <strong>and</strong> that that the<br />

cosmeceutical industry seems to be responsive. However, in the Nordic cases there is only<br />

marginal emphasis on creating destination/nation specific wellness cosmeceuticals.<br />

Accordingly, the destination signature expressed through products with names of specific<br />

locations or geographical features is generally weak. Rather, both the spa industry <strong>and</strong> the<br />

producers tend to rely on the international practice in the <strong>business</strong>, where oils, fragrances are<br />

acquired from all parts of the world <strong>and</strong> assimilated into the spa product. There are many very<br />

persistent traditions in the ingredients sector, but the choice of ingredients also has an<br />

economic background. When it come to the collection <strong>and</strong> processing of ingredients from the<br />

natural environment where supply is distributed over large spaces in remote areas, the<br />

obtaining of an economics of scale in countries with high labour costs becomes very difficult.<br />

As it is illustrated by Finnish Frantsila <strong>and</strong> Lumene it is possible to create some economies of<br />

scale in this field. It is important to envisage that particularly Lumene has experienced growth<br />

<strong>and</strong> now the firm represents a major actor in its home market.<br />

For those enterprises <strong>and</strong> governments who intent to proceed along the road of creating<br />

stronger alliances or backward integration with the value chain there are a number of focus<br />

points to be aware of <strong>and</strong> to address:<br />

• Is there a resource base for a cosmeceuticals in the Nordic countries?


• Are “lived Nordic values” (Nordisk Råd <strong>and</strong> Nordisk Ministerråd, 2009) contributing<br />

leads for wellness <strong>and</strong> wellbeing tourism?<br />

• Are there supportive <strong>business</strong> structures <strong>and</strong> a collaborative network? Are the spa <strong>and</strong><br />

wellness industry <strong>and</strong> the cosmeceutical producers prepared to enter into collaborative<br />

agreements <strong>and</strong> trustful interaction?<br />

• Do the regulatory regimes challenge <strong>and</strong> support the endeavours to create Nordic<br />

value chains?<br />

When it comes to meanings <strong>and</strong> values the Nordic elements in spa <strong>and</strong> wellness are intrinsic,<br />

<strong>and</strong> there is still substantial research to be undertaken when it comes to a better grasp of cobr<strong>and</strong><br />

management in this context (Pechlaner et al. 2006). None of the actors in this study<br />

have yet to achieve a consistent <strong>and</strong> full-bodied co-br<strong>and</strong>ing <strong>and</strong> co-creation profile, <strong>and</strong> that<br />

is not a surprise. We are talking about a discipline in tourism that is still emerging in terms of<br />

academic research <strong>and</strong> in terms of practical implementation. Destinations still have to be<br />

invited in to do a job.<br />

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An exploratory study of consumer choice <strong>and</strong> motivation of medical<br />

tourism in Thail<strong>and</strong>: A case study of healthcare consumers visiting a<br />

private hospital in Pattaya<br />

Miss Wanvipha Hongnaphadol<br />

The University of York, UK<br />

wh541@york.ac.uk<br />

Introduction<br />

According to Gee (1997), travellers are now travelling with different expectations; rather than<br />

going for sightseeing in different places those <strong>tourists</strong> seek more meaningful experiences.<br />

Therefore, any country’s economy depending on the tourism sector needs to create uniqueness<br />

in their tourism products or come up with a special interest tourism product such as cultural<br />

tourism, adventure tourism <strong>and</strong> health tourism. <strong>Health</strong> tourism, the concept of travelling for<br />

healthcare, has been developed for centuries since the Greek <strong>and</strong> Roman periods or, according<br />

to Burkett (2007) <strong>and</strong> Swarbrooke <strong>and</strong> Horner (2007), since the sixteenth <strong>and</strong> seventeenth<br />

centuries. <strong>Health</strong> tourism, in the first place, was just the utilisation of natural resources, e.g.<br />

mineral springs, sea water, including social activity. <strong>Health</strong>care has been combined with<br />

leisure facilities <strong>and</strong> entertainment since then. Later in the seventeenth <strong>and</strong> eighteen centuries,<br />

many wealthy Europeans visited places like France for medical expertise. Yet, this can be seen<br />

as a regional health travel. Global health travel occurred afterwards, as Swarbrooke <strong>and</strong><br />

Horner (2007) point out the most sophisticated recent form of health tourism is where people<br />

travel abroad for medical treatment.<br />

Context of the Research<br />

<strong>Tourism</strong> in Thail<strong>and</strong><br />

International tourism in Thail<strong>and</strong> started its journey in the seventeenth century when<br />

Europeans travellers began visiting the country both for commercial <strong>and</strong> sightseeing purposes<br />

(Oppermann <strong>and</strong> Chon, 1997). More recently, tourism has played a significant role in the<br />

growth <strong>and</strong> development of the country’s economy as the country shifted from an agricultural<br />

base to a more industrialised <strong>and</strong> service based economy. The first five-year <strong>Tourism</strong><br />

Development Plan (1977-1981) was undertaken in 1976. The industrialisation of the Thai<br />

economy resulted in the increased export value of tourism as well as textile products, rice <strong>and</strong><br />

rubber during the 1980s (Higham, 2000). By 1995 the foreign exchange income from<br />

international tourism exceeded the country’s top ranking exports (TDRI, 1998). The ‘Visit<br />

Thail<strong>and</strong> Year’ campaign in 1987 succeeded in gaining a dramatic increase in the number of<br />

foreign <strong>tourists</strong> <strong>and</strong> the ‘Golden Decade of Thai <strong>Tourism</strong>’ followed between 1987 <strong>and</strong> 1996.<br />

The rise of Thai tourism continued into the mid-1990s <strong>and</strong> rapidly dropped in 1997 due to the<br />

economic recession. Overall, the number of international arrivals in Thail<strong>and</strong> has increased<br />

from 1.2 million in 1975 to about 7 million arrivals in 1995 <strong>and</strong> risen to 14 million in 2007<br />

(TAT, 2008).<br />

<strong>Health</strong>care services in Thail<strong>and</strong><br />

Thail<strong>and</strong> has a market-oriented healthcare system as people have free choice in selecting a<br />

healthcare facility (Janjaroen <strong>and</strong> Supakankunti, 2002). Although public providers play a<br />

major role in delivering healthcare services, the private sector is significantly growing.<br />

Regarding the health insurance system in Thail<strong>and</strong> particularly the universal coverage (UC) 2<br />

2 The Thai government has implemented national health insurance consisting of the Civil Servant Medical<br />

Benefit Scheme (CSMBS) – covering government officials, their parents, spouses <strong>and</strong> children, the Social


scheme, although this theoretically increases individuals’ access to healthcare <strong>and</strong> provides the<br />

same quality health services as offered by other health schemes, it can lead to healthcare<br />

service <strong>and</strong> provision not being equally accessible to many local people with the same quality<br />

st<strong>and</strong>ards (Sreshthaputra <strong>and</strong> Indaratna, 2001). Unlike the developed countries, their public<br />

healthcare can not only reach everyone for free, but also with good quality <strong>and</strong> st<strong>and</strong>ard of<br />

care. Pachanee <strong>and</strong> Wibulpolprasert (2006) argue that the UC scheme, the incoherent health<br />

policy implemented by the Thai government, hinders the promotion of international trade in<br />

health services. The UC scheme has large impact on healthcare system in Thail<strong>and</strong> including<br />

financing system, quality of care, manpower, etc. Although the UC scheme increases people’s<br />

health security <strong>and</strong> decreases people’s healthcare expenditure (Ngosurachet <strong>and</strong><br />

Sornlertlamvanich, 2004), some middle- <strong>and</strong> upper-classes eligible for it decide not to use the<br />

service because of long queues, <strong>and</strong> non-confidence in the quality <strong>and</strong> st<strong>and</strong>ard of care<br />

(Sreshthaputra <strong>and</strong> Indaratna, 2001; NaRanong, 2005). Therefore, they rather visit private<br />

hospitals. As any individual claiming for this health insurance benefit can mainly receive the<br />

service at public hospitals, the promotion of healthcare services to medical <strong>tourists</strong> in public<br />

medical providers is unlikely due to the existing high dem<strong>and</strong> of the local people, <strong>and</strong> the<br />

contribution of major affordable resources to firstly serve most local people. Consequently,<br />

medical tourism <strong>business</strong> in Thail<strong>and</strong> is focused on private hospitals 3 which provide good<br />

images of hotel-like atmosphere in medical settings <strong>and</strong> create positive attitudes towards Thai<br />

healthcare services <strong>and</strong> medical expertise for medical <strong>tourists</strong>.<br />

Medical tourism<br />

Medical tourism is an emergence of a new <strong>and</strong> distinct niche market in terms of the deliberate<br />

articulation of the healthcare <strong>and</strong> tourism industry where patients travelling overseas for<br />

medical care – involving specific medical intervention – treatments <strong>and</strong> operations in hospital<br />

context combined with a vacation (Cornell, 2006a; 2006b). However, medical tourism is not<br />

considered as a new concept in terms of travelling for healthcare as evidenced since the Greek<br />

<strong>and</strong> Roman periods. While Caballero-Danell <strong>and</strong> Mugomba (2007) agree with Connell by<br />

shedding light on tourism experience gained from leisure activities after medical treatment,<br />

others emphasise the cost effective medical care provision (Awadzi <strong>and</strong> P<strong>and</strong>a, 2006).<br />

In this research, the term ‘medical tourism’ will be used to denote foreign patients travelling to<br />

seek medical treatments <strong>and</strong> operations from the healthcare services in Thail<strong>and</strong>. However, the<br />

participation in tourism either before or after treatment <strong>and</strong> the degree of participation is not<br />

yet defined in the term as this can be highly diverse <strong>and</strong> really depends on the types of<br />

treatments medical <strong>tourists</strong> have. This is yet to be investigated in the research if medical<br />

tourism in Thail<strong>and</strong> is about tourism. Although medical tourism covers a wide range of<br />

products <strong>and</strong> services (elective <strong>and</strong> non-elective treatments), cosmetic surgery, such as<br />

Security Scheme (SSS) – covering employees in private companies, <strong>and</strong> the universal coverage scheme (UC or<br />

30 baht scheme) – covering the rest who is not eligible for the first two schemes, since October 2001<br />

(Ngosurachet <strong>and</strong> Sornlertlamvanich, 2004). Each scheme has different types of payment: fee for service on<br />

CSMBS; capitation on both SSS <strong>and</strong> UC. With the UC scheme, the beneficiaries have to register to particular<br />

health facilities <strong>and</strong> pay only 30 baht per hospital visit for most of diseases in public hospitals which are the<br />

main providers. Therefore this leads to a huge workload but low pay to doctors in public providers, <strong>and</strong> to an<br />

increasing internal brain drain of doctors to private hospitals which provide better incentives. 30 baht is about<br />

£0.58 (51.52 baht equivalent to £1, rated on 2 August 2010).<br />

3 Private hospitals, accredited by Thail<strong>and</strong>’s Ministry of Public <strong>Health</strong> (MoPH), deliver not only expertise in<br />

healthcare but also excellent service. Private hospitals sometimes cooperate <strong>and</strong> liaise with ‘medical travel<br />

agencies’, which work just like traditional travel agencies except that they specialise in medical travel services<br />

<strong>and</strong> can help consumers make medical appointments, make arrangements for travel-related needs (e.g., flight <strong>and</strong><br />

accommodation bookings), <strong>and</strong> also include leisure <strong>and</strong> sightseeing activities in customer itinerary.


enhancement <strong>and</strong> beauty, will be more in focus as considering significant figures of foreign<br />

patients travelling to Thail<strong>and</strong> for this particular purpose.<br />

The development of medical tourism in Thail<strong>and</strong><br />

According to Connell (2006b), Thail<strong>and</strong> became a medical tourism destination in the 1970s<br />

with its expertise in sex change operations <strong>and</strong> cosmetic surgery. The medical tourism industry<br />

played an important role again due to the currency collapse <strong>and</strong> rapid devaluation of the Thai<br />

baht 4 in the Asian Economic Crisis in 1997. Many Asian governments, including Thail<strong>and</strong>, all<br />

promoted economic diversification, with the notion of turning round health service earnings<br />

through attracting foreigners. They considered medical tourism as a potential growth factor of<br />

the economy <strong>and</strong> promoted it because they foresaw its <strong>business</strong> opportunities <strong>and</strong> as a catalyst<br />

to their economies. Thus, a big budget for improving healthcare services in these countries<br />

was established to develop the best international st<strong>and</strong>ards. In support of what Teh (2007)<br />

points out, merging medical expertise <strong>and</strong> tourism has become a government policy in many<br />

Asian countries. The <strong>Tourism</strong> Authority of Thail<strong>and</strong> (TAT) launched a campaign to promote<br />

Thai traditional healthcare including massage, herbs <strong>and</strong> authentic Thai food to attract more<br />

foreign <strong>tourists</strong>. The TAT started a promotional programme for health tourism with the first<br />

‘Thail<strong>and</strong> <strong>Health</strong> Travel Mart’ in 1999, repeated in 2000. The purpose of medical tourism at<br />

the beginning was to generate another way of earning foreign income <strong>and</strong> to help the<br />

hospitality <strong>business</strong> such as private hospitals <strong>and</strong> hotels during the recession. Medical tourism<br />

thus became the new trend of Thail<strong>and</strong>’s tourism industry.<br />

Previous studies of medical tourism research<br />

In research on people travelling for health reasons or so-called ‘health tourism’, Goodrich <strong>and</strong><br />

Goodrich (1987) started by conducting an exploratory study of health-care tourism 5 with<br />

travellers visiting hotels or resorts for healthcare treatments. In studies discussing motivating<br />

factors of travellers seeking wellness <strong>and</strong> spa experiences, Chen, Prebensen <strong>and</strong> Huan (2008)<br />

<strong>and</strong> Mak, Wong <strong>and</strong> Yang (2008) focused more on the motivation of wellness travellers by<br />

addressing how visitors are motivated. While the former study revealed that cost <strong>and</strong> variety<br />

of attractions rather than healthcare facilities at the destination were the main reasons to select<br />

<strong>and</strong> visit the destination, the latter found that relaxation, health consciousness, <strong>and</strong><br />

attractiveness are among the most salient motivations attracting customers to wellness resorts<br />

which corresponds well with the marketing schemes emphasising tranquility, enjoyment <strong>and</strong><br />

body pampering, in other words relaxation. Psychological benefits accordingly appear to be<br />

the most important driving force pulling customers to wellness resorts. Although these studies<br />

emerge from people travelling for health reasons, the settings are in a more relaxing context<br />

i.e. hotels, resorts. Unlike the proposed study, it aims at exploring motivations for people<br />

seeking healthcare in medical settings i.e. hospitals. However, it can be contributed to this<br />

study as an initial guidance in exploring tourist motivations in search of healthcare as there is<br />

little investigation of tourist motivation in relation to health seeking behaviours.<br />

Caballero-Danell <strong>and</strong> Mugomba (2007) emphasise that little academic research has been done<br />

on the medical tourism market due to the fact that it is a relatively new niche market.<br />

Rittichainuwat, Qu <strong>and</strong> Mongkhonvanit (2008) additionally agree that there is little empirical<br />

4<br />

The devaluation of the Thai baht, on the other h<strong>and</strong>, provided the opportunity for hospital to attract overseas<br />

patients due to the relatively lower charges.<br />

5<br />

“[T]he attempt on the part of a tourist facility (e.g. hotel) or destination (e.g. Baden, Switzerl<strong>and</strong>) to attract<br />

<strong>tourists</strong> by deliberately promoting its health-care services <strong>and</strong> facilities, in addition to its regular tourist<br />

amenities” (Goodrich <strong>and</strong> Goodrich, 1987: 217).


study identifying the motivation of travellers to Thail<strong>and</strong> generally, <strong>and</strong> far less on medical<br />

tourist motivation.<br />

Conceptual framework<br />

Theory of consumer motivation<br />

The study of motivation in tourism is obviously important due to its role as a trigger to travel.<br />

<strong>Tourism</strong> literature emphasises the significance of both push <strong>and</strong> pull factors in shaping tourist<br />

motivation 6 (Crompton, 1979). Many scholars have worked on the definition of tourist<br />

motivation partially by identifying the underlying reasons for travel. Each individual tourist<br />

motivation framework may not fully explain the circumstance. According to Fodness (1994),<br />

the most common empirical studies on tourist motivation are from the works of Dann (1977),<br />

Crompton (1979), <strong>and</strong> Pearce <strong>and</strong> Caltabiano (1983), all of which explored push <strong>and</strong> pull<br />

motives. Pull factors are the destination’s extrinsic forces, such as attractiveness <strong>and</strong> specific<br />

features of the destination, perceived by potential <strong>tourists</strong> <strong>and</strong> pull people to choose that<br />

particular destination whereas push factors are consumer’s intrinsic forces establishing the<br />

desire to travel <strong>and</strong> push people to travel in the first place. In other words, according to Bolles<br />

(1975), human behaviour is pulled through the perception of valuable characteristics in the<br />

environment <strong>and</strong> pushed through the action of motivating drives. Klenosky (2002) further<br />

suggested that a single pull factor of a particular destination can be driven by multiple push<br />

motivational forces. People may have multiple <strong>and</strong> possibly very different push motivational<br />

reasons for evaluating positively the same pull factor. Likewise, <strong>tourists</strong> with different<br />

demographic profiles may have different push <strong>and</strong> pull travel motivations in visiting a<br />

particular place.<br />

Interestingly, according to Chen et al. (2008), no academic literature has shed light on the<br />

types of motivation of consumers visiting medical tourism settings, therefore investigating<br />

those different motivations will help identify the possible leading attributes influencing the<br />

dem<strong>and</strong> since <strong>tourists</strong> often possess more than one motive (Pearce, 1993, as cited in Chen et<br />

al., 2008). Additionally, as Sangpikul (2008) points out, there is limited research on the pull<br />

motivational factors or destination-based attributes segmentation in a Thai context. According<br />

to Kozak (2002), the destination attributes of a particular destination or pull factors, could be<br />

various <strong>and</strong> different from one destination to another depending on the perception of travellers<br />

towards a particular destination. According to Lubbe (1998, as cited in Sangpikul, 2008),<br />

travellers’ motivations to visit any particular destination begin when they become aware of<br />

certain needs <strong>and</strong> perceive that certain destinations may be able to satisfy those needs. Thus,<br />

the investigation of pull factors in Thail<strong>and</strong>’s medical tourism context is important in<br />

developing a successful marketing program.<br />

Consumer behaviour <strong>and</strong> decision making<br />

Following Bourdieu’s (1990, as cited in Dressler, 2007) idea of medical anthropology, which<br />

draws on the disciplines of medicine, anthropology <strong>and</strong> history (Comelles, 2002), to<br />

underst<strong>and</strong> human behaviour, requires the analysis of the intersection of social structure <strong>and</strong><br />

cultural construction. Underst<strong>and</strong>ing human behaviour in general, <strong>and</strong> human health seeking<br />

behaviour - the intrinsically motivated behaviour (Deci, 1975, as cited in Deci, 1978) - in<br />

6 <strong>Tourism</strong> motivation has been defined by several tourism scholars as “a meaningful state of mind which<br />

adequately disposes an actor or group of actors to travel, <strong>and</strong> which is subsequently interpretable by others as a<br />

valid explanation for such a decision” (Dann, 1981: 211); “a dynamic process of internal psychological factors<br />

(needs <strong>and</strong> wants) that generate a state of tension or disequilibrium within individuals” (Crompton <strong>and</strong> McKay,<br />

1997: 427). Crompton <strong>and</strong> McKay’s definition reflects Murray’s (1938) psychological needs as deep-seated<br />

driving factors of motivation.


particular, thus requires the exploration of how shared cultural constructs, known as cultural<br />

consonance in behaviour, meet social structure. As Comelles (2002) contends, it is impossible<br />

to study health seeking behaviours without taking account of the long development of<br />

healthcare providers which have delivered care services from the late Middle Ages to the end<br />

of the 20 th century <strong>and</strong> cultural context.<br />

Due to the different pattern of previous <strong>and</strong> new healthcare consumers, a consumer influence<br />

has reflected into different levels (Hjertqvist, 2002). Previously, the healthcare provider was<br />

not designed to serve a real consumer influence. Similarly later, in the welfare state, the<br />

patients’ specific dem<strong>and</strong>s could not be fully responded as need, not dem<strong>and</strong> consideration,<br />

was the key to the healthcare provision. Western healthcare consumers today, however, seek<br />

to influence the organisation of the healthcare system <strong>and</strong> the services provided. Apart from<br />

being used to making complex decisions, Western healthcare consumers are also provided<br />

with greater access to various means of information sources which they require to create<br />

satisfying information in order to compare the providers’ quality <strong>and</strong> choices among those<br />

offered (Borgenhammar, 1997, as cited in Hjertqvist, 2002). Freedom of choice <strong>and</strong> the use of<br />

healthcare facilities in many countries are predominant in the current healthcare consumer’s<br />

framework when they can benefit from shorter waiting times <strong>and</strong> better quality services.<br />

Hence, this kind of framework promotes the development of healthcare provision both<br />

regionally <strong>and</strong> globally. As commented by Hjertqvist (2002), the more consumers supported<br />

by public or insurance funding cross borders, the more pressure that is exerted on providers to<br />

offer competitive price information. Herzlinger (1997, as cited in Belien, 2000) agrees that, in<br />

order to achieve patient empowerment or consumer-oriented healthcare, competition in<br />

healthcare services as well as an unrestricted supply of these services, both of which create an<br />

expansion <strong>and</strong> differentiation of services <strong>and</strong> make prices decrease, are required (Herzlinger,<br />

1997, as cited in Belien, 2000).<br />

Consumer/Patient Choice<br />

Identity: patient, consumer, citizen<br />

Patients, according to Hogg (1999: 6), are ‘people with particular health problems who may be<br />

taking medicines or receiving treatment’. As Edwards <strong>and</strong> Elwyn (2001) point out, the term<br />

‘patient’ tends to describe associated images of stereotypical patient with passive role seeking<br />

<strong>and</strong> following physician advice. ‘Consumer’, on the other h<strong>and</strong>, depicts those who seek<br />

healthcare in active role <strong>and</strong> perhaps making their own decisions <strong>and</strong> having the ability of<br />

exercise choice. Contemporary thinking in the healthcare arena leads health professionals to<br />

view patients as consumers.<br />

As the role of market raises the significant issue of identity, in terms of healthcare market, the<br />

identity of health service users is considered whether they are patients receiving services<br />

passively, consumers shaping <strong>and</strong> controlling the receipt of services, or citizens utilising their<br />

rights to free healthcare (Milewa, 2009). Therefore, it is essential to explore how health<br />

service users have engaged with these identities, i.e. patient, consumer, citizen as these words<br />

can be differently conceptualised due to different healthcare systems <strong>and</strong> the role of those<br />

receiving healthcare, <strong>and</strong> how they are considered in terms of individual consumer (individual<br />

identity) <strong>and</strong> independent collective mobilisations (collective identity).<br />

Generally, the consumer’s decision to purchase a particular service involves many more risk<br />

considerations than purchasing a product. This is because heathcare service provision is<br />

different from other areas of economic activity, products or services due to the prevalence of<br />

irregular, uncertain <strong>and</strong> unpredictable dem<strong>and</strong> <strong>and</strong> supply in healthcare (Arrow, 1963). As


highlighted by Foll<strong>and</strong> et al (2001), consumers are uncertain of their health status <strong>and</strong> need for<br />

healthcare in any particular time. There is additionally a product uncertainty associated with<br />

the health context as consumers may not know the expected outcomes of treatments without<br />

their physicians’ advice. This is supported by what Arrow (1963: 302) suggests, ‘the patient is<br />

forced to trust his physician, lacking the latter’s knowledge <strong>and</strong> experience; the customer<br />

cannot test the product before using it; recovery from disease is as unpredictable as its<br />

incidence; <strong>and</strong> entry into the field of healthcare is limited by professional <strong>and</strong> licensing<br />

restrictions’. Consequently, these characteristics make the healthcare market difficult to<br />

achieve when compared to other types of market.<br />

In conclusion, healthcare is no longer defined by people receiving services when they are ill –<br />

the stereotypical patient. Instead, the term ‘healthcare consumers’ engaging with healthcare<br />

professionals as a formal equal have been used more widespread in the development in<br />

healthcare phenomenon when mentioning people acquiring healthcare where traditionally<br />

people sought <strong>and</strong> received healthcare in their own locality, <strong>and</strong> certainly within their own<br />

country. However, healthcare consumers have recently challenged the healthcare seeking<br />

patterns by travelling across country.<br />

Consumerism in healthcare<br />

Consumerist approaches can be categorised under the form of marketisation reforms. The idea<br />

of consumerism was introduced in the 1980s by the British <strong>and</strong> American governments due to<br />

its significance to people’s lives (Miles, 1998). In Britain, the ideology of consumerism<br />

providing consumers with the rights <strong>and</strong> political citizenship is defined through charters (e.g.,<br />

The Patient’s Charter, The Citizen’s Charter) rather than in terms of active domestic<br />

participation. The marketisation of the welfare state represents a response to the growth of<br />

individualism <strong>and</strong> rising consumer expectations about service delivery, which have led to calls<br />

for more user involvement <strong>and</strong> greater consumer choice (Glendinning <strong>and</strong> Kemp, 2006). A<br />

consumerist approach, according to Needham (2007), is possible to damage citizenship<br />

gradually by making public services as commodities in the marketplace <strong>and</strong> putting people in<br />

the situation of caveat emptor. Some commentators have argued that consumer-style<br />

approaches to choice undermine the collective provision of welfare (Needham, 2003).<br />

However, for others increasing choice is a way of ensuring that the welfare state can survive,<br />

by making it more responsive to the needs <strong>and</strong> aspirations of those who use it (Glendinning<br />

<strong>and</strong> Kemp, 2006). According to Cullum, Deputy Chief Executive of the National Consumer<br />

Council (2004), it can be argued that a consumer-centred approach is important to the<br />

development of public services as it does not concern turning the public sector into the private<br />

sector or so-called privatization, or introducing market values onto public services. Instead, it<br />

is the means to ensure that everybody has access to necessary services with as high st<strong>and</strong>ard as<br />

possible.<br />

Patient choice<br />

According to Shackley <strong>and</strong> Ryan (1994), the main barrier to consumer sovereignty in<br />

healthcare is the asymmetry of information between buyers <strong>and</strong> sellers. The nature of<br />

healthcare is that providers of healthcare have a large informational advantage over<br />

consumers. The existence of informational asymmetry between buyers <strong>and</strong> sellers is common<br />

in other markets as well. In general, sellers know more about a product than buyers, e.g.<br />

sellers will be better informed than consumers regarding the characteristics of a product <strong>and</strong><br />

the technology that was used to produce it. Yet this does not prevent consumers from freely<br />

exercising their own preferences in making their consumption choices regarding the product.<br />

The essential difference between healthcare <strong>and</strong> other commodities is that for other


commodities the consumer is more aware than the seller of what these products’<br />

characteristics mean to him/her. They know their own needs.<br />

The situation in healthcare, on the other h<strong>and</strong>, is quite different. The acquisition of information<br />

is costly in terms of time <strong>and</strong> resources. There is little opportunity for consumers to learn by<br />

experience as they will be infrequent users of the market. Doctors, on the other h<strong>and</strong>, use the<br />

market regularly. In many instances consumers will be unaware that they actually need<br />

healthcare, e.g. women in the early stages of breast cancer, therefore the consumer may no<br />

longer be deemed to be the best judge of his/her own interests. Because of the complex<br />

relationship between healthcare (which consumers do not value per se, i.e. individuals derive<br />

no direct utility from consuming healthcare, rather healthcare is consumed in the expectation<br />

that health status will be improved as a result) <strong>and</strong> health status, the consumer becomes very<br />

reliant upon the much better informed provider to make the link between the consumption of<br />

healthcare <strong>and</strong> the resultant effects on health status. Hence, there is a special relevance of the<br />

agency (doctor-patient) relationship in healthcare.<br />

Patients want to be treated as consumers of healthcare in the sense that they want better<br />

information about treatment options <strong>and</strong> to be more involved in making the decision as to<br />

which option to follow. How far patients behave as consumers depends on the severity of their<br />

illness, the nature of the procedure involved <strong>and</strong> their individual circumstances. Most severely<br />

ill patients face complex treatment options <strong>and</strong> many prefer decisions to be made on their<br />

behalf by a well-informed <strong>and</strong> trusted health professional. On the other h<strong>and</strong>, they may not<br />

want to be treated as consumers as the nature of healthcare product <strong>and</strong> service, which is<br />

unpredictable, does not support the role of being a consumer.<br />

However, as suggested by Appleby, Harrison <strong>and</strong> Devlin (2003), choice is not always<br />

advantageous as it should be counterbalanced by the costs of creating it. Choice for some may<br />

limit <strong>and</strong> impact on the choice of others. Tritter et al (2010) agree with this as greater choice<br />

may, in fact, even add to a further health inquality burden. In summing up, choice seems<br />

structurally associated with enhanced marketisation of healthcare provision <strong>and</strong> the arena of<br />

the consumer tends to be based on the economic rationality of maximising personal benefits<br />

within market-based systems. However, evidence about what is driving patients’ choices in<br />

reality is currently limited.<br />

In conclusion, the conceptual frameworks of push-pull, consumer behaviour, consumer choice<br />

<strong>and</strong> consumerism in healthcare are proposed due to several important factors. According to<br />

Snepenger et al. (2006), the push-pull theory has prevailed over other paradigms in examining<br />

motivations underlying tourist <strong>and</strong> visitation behaviour (Dann, 1977, 1981; Crompton, 1979),<br />

attracting most attention from several scholars (e.g. Dann, 1977, 1981; Crompton, 1979;<br />

Klenosky, 2002; Kim et al., 2003; Kao, Patterson, Scott <strong>and</strong> Li, 2008). Due to its theory<br />

having been used much in travel motivation research, this provides a better opportunity to<br />

compare <strong>and</strong> contrast findings with previous studies. Consumer behaviour literature identifies<br />

the interrelationship between needs <strong>and</strong> motivations (Goodall, 1988; Witt <strong>and</strong> Wright, 1992)<br />

as the presence of the former constructs the latter. In other words, people’s needs for<br />

healthcare create their motivations in searching for it. The examination of differences of<br />

motivations between sample populations representing different cultures is important in<br />

underst<strong>and</strong>ing <strong>tourists</strong>’ behaviour (Kim, 1999, as cited in Kozak, 2002). Different cultural<br />

conditionings <strong>and</strong> different healthcare <strong>and</strong> insurance system of healthcare consumers will<br />

influence their expectations <strong>and</strong> perception. As a result, the investigation of health seeking<br />

behaviours <strong>and</strong> motivations of medical <strong>tourists</strong> having different cultural <strong>and</strong> social


ackgrounds is expected to accomplish in this study as they are likely to have different<br />

motivations <strong>and</strong> perceptions in seeking healthcare services<br />

Aims of the Study<br />

The present research project aims to explore the reasons why consumers from major Western<br />

countries where English is the main language travel to Thail<strong>and</strong> for their medical treatment.<br />

The research will investigate the motivations of potential medical <strong>tourists</strong>, differences in these<br />

motivations among different groups both from the same <strong>and</strong> different countries,<br />

interrelationships among these motivations, consumer choices in selecting a particular<br />

treatment in Thail<strong>and</strong> over other medical tourism destinations, <strong>and</strong> the degree of tourism<br />

participation of those medical <strong>tourists</strong>.<br />

Research Questions<br />

What are the significant motives that influence the decision of medical <strong>tourists</strong> from the US<br />

<strong>and</strong> the UK to travel to Thail<strong>and</strong>, <strong>and</strong> to Bangkok Pattaya Hospital in particular?<br />

How are these motives different with respect to age, nationality <strong>and</strong> gender?<br />

How does Bangkok Pattaya Hospital perceive the consumer motivation from these countries?<br />

To what extent does Bangkok Pattaya Hospital applied perceived consumer motivation to<br />

service provision for medical <strong>tourists</strong>? How is a healthcare provider’s service provision<br />

related to what motivates medical <strong>tourists</strong> to visit the hospital?<br />

What are the major keys influencing consumer choices about provider <strong>and</strong> destination? Why<br />

does a medical tourist choose one destination over another?<br />

To what extent do medical <strong>tourists</strong> take tourism component as a part in their decision making<br />

process?<br />

Is medical tourism in Thail<strong>and</strong> about tourism? Is medical tourism likely to<br />

utilise the tourism component?<br />

What is it about the tourist part of medical tourism?<br />

To what extent do medical <strong>tourists</strong> participate in tourism?<br />

Research Rationale <strong>and</strong> Methodology<br />

This research will consist of three stages of data collection: exploratory study (observations<br />

<strong>and</strong> small interviews with patients in a first visit to hospital), designing the questionnaire, <strong>and</strong><br />

the main study (a second visit to hospital).<br />

Rationale for selection of hospital<br />

Bangkok Pattaya Hospital (BPH) was chosen as the study site for two principal reasons.<br />

Firstly, it met the following parameters: segmenting foreigners as a major target market;<br />

providing internationally st<strong>and</strong>ardised quality of hospital, medical treatment, facilities <strong>and</strong><br />

infrastructure, <strong>and</strong> management personnel to the foreign patients. Secondly, BPH’s major<br />

target market is not expatriates only but also medical <strong>tourists</strong> both in contact with the hospital<br />

directly <strong>and</strong> via the agents in their home countries. The major target market is medical <strong>tourists</strong><br />

from major Western countries such as Western Europe (e.g. UK) <strong>and</strong> US; Arabic countries<br />

such as UAE <strong>and</strong> Oman; <strong>and</strong> Australia <strong>and</strong> New Zeal<strong>and</strong>. It was thus felt that with the<br />

resources available to the researcher, a study uncovering consumer motivation <strong>and</strong> a<br />

healthcare provider response could adequately be tackled at this hospital.<br />

Participant selection<br />

Due to the researcher’s limitation of time <strong>and</strong> funding, only the medical tourist participants<br />

from major Western countries where English is the main language, i.e. the UK <strong>and</strong> the US are


chosen as the research target. Although expatriates 7 represent a high proportion in the foreign<br />

patient market share in private hospitals generally, they are not selected here simply because<br />

they do not travel to Thail<strong>and</strong> for medical care <strong>and</strong> are not representative sample of actual<br />

medical <strong>tourists</strong>. The countries mentioned are selected since they represent a significant group<br />

of total medical <strong>tourists</strong>. Approximately 150 patients, or about 75 patients from each country<br />

will be sought for the questionnaire study to generate a representative sample as equally as<br />

possible in terms of nationality <strong>and</strong> gender. These countries additionally provide a<br />

comparative study of two different continents in terms of cross-cultural study with similar<br />

Western background in order to compare their motivations for visiting a Thai private hospital.<br />

Questionnaire survey<br />

Interviews with medical <strong>tourists</strong><br />

Piloting the questions for interview<br />

The piloting of all the questions for actual interview with medical <strong>tourists</strong> will be first carried<br />

out by semi-structured interviews, elaborating in-depth response, in the UK with<br />

approximately 5 British people who have visited Thail<strong>and</strong> for some kind of medical treatment.<br />

As supported by what Gillham (2007) mention, a proper pilot study is a reproduction of the<br />

main study involving fewer participants who possess the same characteristics as the final<br />

target group.<br />

Exploratory interviews<br />

After the piloting, the first visit to BPH will take place with about 20 patients- 10 from the UK<br />

<strong>and</strong> 10 from the US - who will be interviewed in a semi-structured format with open-ended<br />

questions, such as ‘what motivated you to travel to Thail<strong>and</strong> for medical care?’ As suggested<br />

by Gillham (2007), careful semi-structured interviewing before the questionnaire being<br />

constructed can help identify the most of the likely answers. The most frequent keywords of<br />

travel motivations from the medical <strong>tourists</strong>’ answers will be incorporated into the<br />

questionnaire.<br />

Main questionnaire study<br />

The researcher will inform the hospital during the first study visit of the requirement to survey<br />

150 medical <strong>tourists</strong> using the quota sampling from two different countries visiting BPH. This<br />

sampling is proposed here because it is aimed as far as possible to include an equal proportion<br />

of participants from two different countries <strong>and</strong> from both genders (nationality <strong>and</strong> gender<br />

distribution) in order to address a representative sample. Medical <strong>tourists</strong> from each<br />

nationality will be approached until quotas are filled, in other words until there are at least 75<br />

medical <strong>tourists</strong> from each individual nationality.<br />

7 Foreigners resident in Thail<strong>and</strong>


Underst<strong>and</strong>ing mature traveller’s dem<strong>and</strong> <strong>and</strong> choice in spring destination<br />

Mei-ting (Jessica) Hsieh<br />

Lecturer, Taiwan Hospitality <strong>and</strong> <strong>Tourism</strong> College<br />

PhD c<strong>and</strong>idate, University of Lincoln, U.K.<br />

jessicah62@hotmail.com<br />

Abstract<br />

The ageing population in Taiwan is entering 11% who were 65 years old <strong>and</strong> above by 2009.<br />

This percentage is likely to reach 20% by 2025 <strong>and</strong> 39% in 2051. Not surprisingly, after 2010<br />

the emerging age cohort categories of 55 starting to reach retirement, <strong>and</strong> will continue to<br />

increase in Taiwan. Mature people undoubted have much free time from working careers <strong>and</strong><br />

start to concern the long-term health status. This study examines how the Taiwanese mature<br />

spring/spa travellers’ needs affect the travel motivation to choose spring destination <strong>and</strong> what<br />

extent dem<strong>and</strong> for the particular groups in springs. 200 valid responses to the questionnaire<br />

carried out in spring destinations of Taiwan. The factor analysis of motivation factors<br />

revealed three underlying spring/spa destination attributes <strong>and</strong> four socio-psychological<br />

underlying dimensions. The main spring/spa travel motivations of Taiwanese were ‘Personal<br />

health & building relationship’<strong>and</strong> ‘commercial Internal’; which appeared to be the most<br />

important push <strong>and</strong> pull motivations, respectively. The study also suggests that there is a<br />

significant relationship between travel motivation <strong>and</strong> age groups effect on destination choice.<br />

Based on the results, the findings will point out spring/spa marketing implications in<br />

conjunction with the theoretical framework, <strong>and</strong> add to other relevant organisation.<br />

Key words: Mature traveller, Destination choice, Spring/spa tourism, Taiwan<br />

Introduction<br />

With rapid growth in an ageing population, baby boomers comprise a large proportion of the<br />

world travel market. The emerging age cohort categories of 55 starting to reach retirement,<br />

<strong>and</strong> will continue to increase in Taiwan. Mature people undoubted approach an advanced life<br />

cycle stage (e.g. the retirement stage) <strong>and</strong> are free from working careers. Nowadays, they are<br />

likely to have sufficient savings, ample time, more motivation to enjoy, spend more freely on<br />

activities <strong>and</strong> concentrated on personal health. Particularly in the health tourism industry, the<br />

marketer have started to focus differentiate segmentation on the mature groups (Silvers, 1997;<br />

Mochis, 1997). The growth of hot spring tourism since 1900s is well-known in Taiwan<br />

society. Spring tourism in travel market of Taiwan has been acknowledged for century as<br />

different type of natural springs has its own specific medicinal cures for improving people’s<br />

health. In 1999, due to the Taiwanese government’s promotional spring/spa activities, visitors<br />

are increasingly seeking a healthier lifestyle to maintain their wellness. The spring <strong>and</strong> spa<br />

tourism would seem that become one of the pioneer “value sectors” during the modernisation<br />

process in Taiwan. A number of re-birth spring/spa destinations increased extremely, this<br />

potential attraction draw people to visit spring/spa destination through diverse products.<br />

Moreover, it also tapped the potential of a rapidly exp<strong>and</strong>ing market, which includes sectors<br />

such as healthcare services <strong>and</strong> the medical wellness industry.<br />

People travelling for health in spring/spa resorts <strong>and</strong> destinations become an attraction<br />

phenomenon for prevention on people’s health. The broad reasons for participating in<br />

spring/spa travel nowadays are not only on socialise, improve well-being, <strong>and</strong> physical<br />

therapy. New senses people went to the spring/spa in a quest of spiritual events <strong>and</strong> develop a


<strong>healthy</strong> lifestyle. Hence, to develop tailor facilities product <strong>and</strong> service to meet particular<br />

groups’ needs, <strong>and</strong> upgrading the quality of spa destination are as an important for market<br />

segmentation. Research has paid limited attention to the mature travellers studied, or the<br />

mode of spring/spa destination choice. It is vital to be aware that mature traveller needs are<br />

more diverse <strong>and</strong> multifaceted than ever, <strong>and</strong> this highlights the need for innovation to meet<br />

the dem<strong>and</strong> for a variety of recreational activities.<br />

Characteristics of mature spring traveller<br />

According to the Taiwan <strong>Tourism</strong> Bureau (2004), the Central Geological (2002) survey that<br />

Taiwan has over 128 nature spring destinations located in different geological areas including<br />

plains, mountains, valleys, <strong>and</strong> oceans. It has been identified different type of springs (i.e. s<br />

hot springs, cold springs, mud springs, <strong>and</strong> seabed springs) with different destination<br />

attributes based on the water temperature, geology, chemistry, <strong>and</strong> mechanism.<br />

As spring have multi functions for curative effects <strong>and</strong> medical benefits of soaking. It has<br />

gained popularity for people to ‘taking the water’ in the natural spring/spa destination,<br />

particularly for aged people <strong>and</strong> patients. Travelling for mineral spring therefore has become<br />

one of most representative recreational activity in Taiwan. (Hsieh et al., 2007). This vogue<br />

beneficial effects relevant industry growing well not only for health tourism industry but also<br />

for medical treatments, social insurance system, <strong>and</strong> national economy. The majority of<br />

health spa tourism in Taiwan is domestic tourism, the total number of visitors increased from<br />

approximately 4 million in the 2002s to 15 million people (23%) to visit hot springs for<br />

experience their therapeutic techniques <strong>and</strong> leisure activities purposes, compare with inbound<br />

dem<strong>and</strong> only 17% for hot spring tourism (Taiwan <strong>Tourism</strong> Bureau, 2004). Nowadays, people<br />

traveling for health in spa resorts <strong>and</strong> destinations as an attraction phenomenon. Particularly<br />

the new health spring/spa revive health tourism market, the features <strong>and</strong> potential attraction<br />

draws people to visit particular destination.<br />

The emerging health <strong>and</strong> spa tourism is blooming in Taiwan since the government carried out<br />

the ‘Taiwan hot spring tourism year’ by 1999. Following the Taiwan <strong>Tourism</strong> Bureau was<br />

allied springs festival to revive the health spring/spa industry, it is not surprising to see or hear<br />

that the reason travel for desirable health spring/spa destination in the mass medium. It<br />

indicates the health spring/spa tourism is not only as an important curative activity for<br />

domestic <strong>tourists</strong> but interests overseas <strong>tourists</strong>. With this potential growth health spring/spa<br />

market, the further developments of health tourism are crucial to the Taiwan tourism industry.<br />

With the society transformations, a number of sociologists recognised the phenomenon of<br />

leisure activities may create a new lifestyle to good <strong>and</strong> reenergised for mature travellers. As<br />

different value orientation on new aged have different needs in terms of attitudes <strong>and</strong> quality<br />

of leisure. Thus, it is possibly different approaches on the ways to travel <strong>and</strong> time to spend.<br />

Norman et al. (2001) refers to mature market as a complex phenomenon in which of<br />

interaction on the biological, psychological, historical <strong>and</strong> social factors. It is means that<br />

characteristics of mature traveller are response to various activities in particular the new-age<br />

of baby boomers entry mature travel market. As people in the modern time have more<br />

opportunities to arrange their working hours <strong>and</strong> leisure time, in addition, life expectancy<br />

continue to rise, it impel many people doing more physical health activities during their lives.<br />

<strong>Health</strong> spring/spa tourism products are dependent on natural resources such as mineral water<br />

<strong>and</strong> seaside location. Although, the broad reasons for participating in spring/spa travel are to<br />

socialise, improve well-being, <strong>and</strong> physical therapy, the new sense in a quest of health is<br />

spiritual events <strong>and</strong> 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<br />

aware that mature traveller needs are more diverse <strong>and</strong> multifaceted than ever, <strong>and</strong> this<br />

highlights the need for innovation to meet the dem<strong>and</strong> for a variety of recreational activities.<br />

Methodology<br />

Study Design<br />

The aim of research methodology was undertaken survey of mature spring/spa travellers<br />

visiting natural springs of Taiwan. Besides, the study designed to extend the theoretical<br />

framework for Taiwanese mature spring/spa traveller. This design was chosen because it<br />

provides a highly accurate picture of the phenomenon under study. Questionnaire was<br />

developed based on relevant literature review, conversations with mature spa/springtravellers,<br />

<strong>and</strong> amendatory pilot survey. The questionnaire considered what information<br />

would be essential related to the respondents’ needs of destination attributes in spring/spa.<br />

Structured questions were used to gather information on natural spring/spa attributes <strong>and</strong><br />

socio-demographic. The sample was r<strong>and</strong>omly selected from spring/spa travelers, who had an<br />

interest in staying <strong>and</strong> visiting spring/spa destinations for particular purposes such as health,<br />

activities, or being in a nature-based environment. The empirical evidence for the relationship<br />

between motivation <strong>and</strong> destination choice is investigated in order to see what those factors<br />

may mean for particular spring/spa groups, government policy reform, <strong>and</strong> market<br />

management.<br />

Sample<br />

Data for this research were collected from 33 spring/spa destinations with 15 different<br />

geology natural springs <strong>and</strong> on cold spring region in Taiwan. The data collection phase was<br />

conducted over a period of seven months beginning in October of 2007 <strong>and</strong> finishing in April<br />

2008. The questions on the destination attributes are based on using internal <strong>and</strong> external<br />

forces to represent intrinsic <strong>and</strong> extrinsic factors. It contains the real reason for visit,<br />

companions, <strong>and</strong> geographical characteristics in the health spring/spa destination. 285 mature<br />

spring/spa travellers were invited to fill in the questionnaire at destinations after they had<br />

visited or stayed in the spring/spa. Analysis of numerical data was followed by data entry of<br />

200 valid responses.<br />

Accordingly, the statistical method of analysis was summaries of the broad category of<br />

descriptive statistics to describe mature spring/spa traveller’s characteristics related to<br />

motivation, <strong>and</strong> how destination feature in spring/spa tourism experiences. Following the<br />

study used exploratory factor approach as an analysis technique to explain traveller<br />

motivations <strong>and</strong> to explore if there are differences between demographics <strong>and</strong> destination<br />

choice. A principal component factor analysis was used to examine the importance of push<br />

<strong>and</strong> pull motivation factors within the spring/spa travel groups; <strong>and</strong> if there were differences<br />

in terms of destination attributes. Subsequently, the analysis proceeded to investigate if there<br />

is a significant difference in socio-psychological characteristics <strong>and</strong> demographic variables<br />

that influence mature spring/spa travellers’ to a certain destination. Variables consist of<br />

demographic traits, trip purpose, characteristics of trip, <strong>and</strong> socio-psychological factors.<br />

Factor analysis of motivation factors revealed three underlying spring/spa destination<br />

attributes: commercial internal, commercial external, <strong>and</strong> natural & friendly service.<br />

ANOVA analysis revealed that the main effects of age groups effect on destination choice are<br />

significant.<br />

The study proceeds to find whether variations in these factors have an effect on the choice of<br />

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<br />

of the practical spring/spa market <strong>and</strong> will highlight methodological concerns in further<br />

research<br />

Data analysis <strong>and</strong> discussion<br />

A principal component factor analysis was used to investigate the importance push-<strong>and</strong>-pull<br />

factors within the Taiwanese mature travel groups, the underlying motivations of travellers,<br />

<strong>and</strong> the differences in terms of destination attributes. Independent samples T-test was used to<br />

compare the difference between the means of two groups, such as the mean push factors of<br />

male <strong>and</strong> female travellers in spring destination or if there are any significant differences<br />

between two means according to the demographic characteristics.<br />

Demographic Profile<br />

A summary of the demographic characteristics examined is show below in Table 1. The<br />

sample was composed of the 200 mature traveller respondents from health spring/spa<br />

destinations. It shows that 61.5% of respondents were males 38.5% were females. The<br />

majority of the mature travellers to spring/spa were male, compared with younger group in<br />

which over half of younger respondents were female. 42.5% of respondents were aged<br />

between 50 <strong>and</strong> 54, only 27.5% were over 60 years old with a mean of 57.1. The majority of<br />

population in Taiwan was young age group (15-45), while 73.3% mature group (45-65) <strong>and</strong> a<br />

minority (nearly 11%) aged 65 <strong>and</strong> above.<br />

Overall the sample of Taiwanese spring/spa mature travellers was less highly educated with<br />

college or university degree. 34.5% of respondents present that they are retired <strong>and</strong> others<br />

state their occupation as <strong>business</strong> owner. The similarity to white-collar worker (31.5%) was<br />

the most common occupation from respondents.<br />

When considering aspects of individual health status, most Taiwanese mature travellers<br />

generally replied that they perceived their own health to be good (50%) or excellent (15.5%).<br />

Only 3% of mature travellers feel they have some health problems, <strong>and</strong> 6.5% of them feel that<br />

they have poor health (either in physical or mental health in their daily living, including<br />

disease, impairment, disability, <strong>and</strong> h<strong>and</strong>icap).


Table 1 Travellers’ demographic profile (N = 200)<br />

Mature travellers<br />

(N=200)<br />

Frequency (%)<br />

Gender<br />

Female 77 (38.5)<br />

Male 123(61.5)<br />

Education<br />

Under college 130 (65)<br />

College above 68 (34)<br />

Income<br />

Under NT$10,000 28 (14)<br />

NT$10,001-NT$20,000 26 (13)<br />

NT$20,001-NT$30,000 38 (19)<br />

NT$30,001-NT$40,000 42 (21)<br />

NT$40,001-NT$50,000 28 (14)<br />

NT$50,001 <strong>and</strong> over 37 (18.5)<br />

<strong>Health</strong><br />

Bad 6 (3)<br />

Poor 13 (6.5)<br />

Fair 50 (25)<br />

Good 100 (50)<br />

Excellent 31 (15.5)<br />

Occupation<br />

Blue-collar worker 47 (23.5)<br />

White-collar worker 63 (31.5)<br />

Professional 21 (10.5)<br />

Retired <strong>and</strong> Others 69 (34.5)<br />

Travel Behaviour<br />

The result in travel behaviour shows nearly 77% of respondents indicate that they tend to a<br />

visit spring/spa destination more than once each year, whereas the remainders visit spring/spa<br />

destinations only annually. The vast majority of respondents (about 77%) have visited<br />

spring/spa destinations more than once before, whereas the rest have visited spring/spa<br />

destinations for the first time. This result indicates that Taiwanese mature travellers have<br />

experience in purchasing spring/spa products.<br />

The majority of respondents indicated that they usually make visit to spring/spa destinations<br />

or stay only one night in these destinations. This suggests that mature travellers in Taiwan<br />

generally stay for a very short time at spring/spa destinations. Nearly half of respondents<br />

reported that they have visited natural spring/spa destinations for curative purposes.<br />

In visiting group, more than half of the respondents (60%) were travelling with family as the<br />

primary party, <strong>and</strong> about 30% visited spring/spa with friends <strong>and</strong> colleagues. The social<br />

change in Taiwan increased opportunities for target marketing based on different family life<br />

cycle stages, for example, increased economic status <strong>and</strong> leisure time combined with shorter<br />

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<br />

present more than 50% of respondents that they spend less than NT$10,000 (less than £200)<br />

on spring <strong>and</strong> spa products each year whereas the remaining 39% of mature <strong>and</strong> 17% of<br />

younger travellers spend NT$10,000-$40,000 on spring <strong>and</strong> spa products each year.<br />

Travel motivations<br />

Factor analysis was performed to identify the underlying dimension of travel motivations in<br />

this study. These include 24 push <strong>and</strong> 19 pull motivation variables were initially chosen to be<br />

factor analysed. Using the PCFA orthogonal varimax rotation was performed to reduce the<br />

push items <strong>and</strong> pull items of Taiwanese mature spring/spa travellers’ motivations into specific<br />

underlying constructs. In addition, by using the statistical technique is to determine the linear<br />

combinations of motivation variables <strong>and</strong> investigate the interrelationships between. Items<br />

were dropped from further analysis while low correlations with the overall score of the<br />

questionnaire.<br />

The first step of PCFA was examining if the inter-correlation among the variables meet the<br />

similarity variables. Followed, the latent root criterion factors were extracted only eigenvalue<br />

greater than one. As the rules of principal components with higher variance than the<br />

st<strong>and</strong>ardised original variables should be extracted. The extracted factor communality loading<br />

greater than 0.50 was valid to include items in a factor. Regarding the reliability <strong>and</strong> validity<br />

of factors was measured by Chronbach’s Alpha, it was calculated for each of identified<br />

dimensions to test the internal consistencies <strong>and</strong> reliability of each specific dimension.<br />

The PCFA technique came up with three underlying spring/spa destination attributes:<br />

commercial Internal, commercial external, <strong>and</strong> nature & friendly services. Four underlying<br />

push motivation factors were ‘personal health & building relationship’, ‘education &<br />

learning’, ‘feeling good’, ‘arranged treatment’. The main distinguishing of motivation<br />

dimensions were the ‘personal health & building relationship’ <strong>and</strong> ‘commercial external’,<br />

which appeared has a significant differences regard to the age groups.<br />

The results of this study suggest that at least four main motivation dimensions benefit<br />

spring/spa tourism exist in Taiwan. In addition, it appears that mature travellers are looking<br />

for different products <strong>and</strong> services of benefits in order to meet their needs. These imply that<br />

the marketing segmentation should be clearly identified. Those information can be use to<br />

guide decisions related to marketing strategies development, quality of spring/spa<br />

environment, or social responsibility expansion.<br />

Conclusions <strong>and</strong> implications<br />

The mineral springs tourism is much different <strong>and</strong> beginning to change in Taiwan society.<br />

People visit spring or spa destination can be relaxation or for curative with alternative<br />

therapies purposes. In the new emerging spring <strong>and</strong> spa marketer start conscious that the<br />

opportunities of the market segments; <strong>and</strong> promote different packages <strong>and</strong> services in order to<br />

attract health travellers. One of the most important for marketing strategies is the need for a<br />

clear of the wellness concept from the therapeutic. The findings will point out health<br />

spring/spa marketing implications in conjunction with the theoretical framework, will add to<br />

knowledge of the practical mature travel group, will help make improvements to government<br />

policy, <strong>and</strong> will work towards the methodological concerns in the further research. To have a<br />

leading edge in the competitive health tourism, spring/spa marketers need to keep in mind that<br />

the changeable motivaions <strong>and</strong> trends for underst<strong>and</strong> different spring or spa travellers’ needs.<br />

The further recommendations are aimed in the spring/spa tourism market:


• To distinguish spring <strong>and</strong> spa travellers from spiritual <strong>and</strong> rehabilitation<br />

• Manage the high level of qualifed staff with further training in treatment skills<br />

• Establish good relationship <strong>and</strong> cooperate with policy makers<br />

• Explore suitable wellness programmes to meet different group needs<br />

References<br />

Gee, C., Makens, J. C., & Choy, D. J. L. (1989). The Travel Industry. New York: Van<br />

Nostr<strong>and</strong> Reinhold.<br />

Goodrich, J. N. G. a. G. E. (1987). <strong>Health</strong>-care tourism - an exploratory study. <strong>Tourism</strong><br />

Management, 8(3), 217-222.<br />

Hall, C. M. (1992). Adventure, sport <strong>and</strong> health tourism. In B. W. a. C. M. Hall (Ed.), Special<br />

Interest <strong>Tourism</strong> (pp. 141-158). London: Belhaven Press.<br />

Holloway, J. C. (2004). Marketing for <strong>Tourism</strong> (fourth ed.). Essex: Prentice Hall.<br />

Hsieh, L. F., Lin, L. H., & Lin, Y. Y. (2007). A service quality measurement architecture for<br />

hot spring hotels in Taiwan. <strong>Tourism</strong> Management, May.<br />

Norman, W. C., Daniels, M. J., McGuire, F., & Norman, C. A. (2001). Whither the mature<br />

market: An Empirical Examination of the travel motivations of Neo-Mature <strong>and</strong> Veteran-<br />

Mature Markets. Journal of Hospitality & Leisure Marketing, 8(3/4), 113-130.


Natural wellness - <strong>Health</strong> <strong>and</strong> wellness as nature-based tourism product<br />

Edward H. Huijbens<br />

Director,Icel<strong>and</strong>ic <strong>Tourism</strong> Research Centre<br />

edward@unak.is<br />

Abstract<br />

This paper is set in the context of a two year research project funded by the Nordic Innovation<br />

Centre (NICe), dealing with Nordic wellness <strong>and</strong> wellbeing. The researchers of the project<br />

collaborate with budding health <strong>and</strong> wellness destinations, one in each of the Nordic countries<br />

in order to establish a Nordic wellness concept <strong>and</strong> develop user-drive product improvements.<br />

This paper deals specifically with the Icel<strong>and</strong>ic case being studied under the terms of the<br />

project <strong>and</strong> will combine nature-based tourism with that of health <strong>and</strong> wellness. Nature-based<br />

tourism is by far the most prominent form of tourism in Icel<strong>and</strong>. Albeit vaguely defined it<br />

entails tourism in natural settings, tourism focusing on elements of the natural environment<br />

<strong>and</strong> tourism developed to conserve or protect natural environments. This paper looks at a<br />

development of a geo-thermal spa, much like the Blue Lagoon, but in the NE corner of<br />

Icel<strong>and</strong> near Lake Mývatn, a famed nature-based tourism destination in Icel<strong>and</strong>. The current<br />

spa facility was erected in 2004. It builds on a long history of locals using the thermal waters<br />

<strong>and</strong> steam coming from the ground for wellbeing, <strong>and</strong> is gaining steadily in visitor number per<br />

annum. Emerging from research amongst stakeholders involved in the building up of the<br />

Mývatn Nature Baths in NE Icel<strong>and</strong> was the role nature plays in health <strong>and</strong> wellness. Both as<br />

a fundamental concept of being in nature <strong>and</strong>/or at one with nature, <strong>and</strong> more specifically<br />

through health <strong>and</strong> wellness related activities in a natural setting. The paper will explore some<br />

of the tentative product manifestations <strong>and</strong> ideas of these emerging themes <strong>and</strong> their<br />

implications for product development in health <strong>and</strong> wellness tourism for NE Icel<strong>and</strong>.


Budapest’s thermal spas on screen<br />

Anna Irimiás<br />

Associate Professor, Kodolányi János University of Applied Sciences, <strong>Tourism</strong> Department.<br />

irimias@uranos.kodolanyi.hu<br />

Abstract<br />

The phenomenon of film-induced tourism has been well-documented in a number of locations<br />

world-wide. Feature films have become one of the most powerful tourism marketing tools<br />

offering an alternative selling method for destinations. Budapest’s famous thermal spas<br />

several times hosted international film productions, such as Red Heat (1988) with Arnold<br />

Schwarzenegger <strong>and</strong> I, Spy (2002) with Eddie Murphy <strong>and</strong> Owen Wilson. The Hungarian<br />

capital, well-known for its health tourism, but not for film-tourism, is clearly identified in<br />

these movies as a city of spas. The types of attracting qualities are as diverse as the films in<br />

which they reside. Usually viewers attach an icon to the location they have seen in a film,<br />

therefore locations which carry an emotional charge can easily be identified. Swimming pools<br />

used by the Hungarian national water polo team are strongly linked to national identity. The<br />

primary sites for the CCCP-Hungary, so called ‘blood in the water match’ in The Children of<br />

Glory (2006) were swimming pools used by the Hungarian athletes (BVSC on Szőnyi street<br />

<strong>and</strong> Alfréd Hajós).<br />

In film-induced tourism literature much emphasis has been given to the significance of films<br />

<strong>and</strong> locations in terms of its economic generation <strong>and</strong> on the motivations of visitors<br />

(Provenzano 2008; Beeton 2005; Riley-Baker-Van Doren 1998; Toke-Baker 1996), or<br />

recently a growing interest exists in the study of the impact of successful television<br />

programmes on local enterprises (Connell-Meyer 2009; Irimiás 2008; Messina-Bocchioli<br />

2008; Connell 2005). There, however, appears to be very little research on the films’ impact<br />

on a different tourism product, like health <strong>and</strong> wellness tourism, <strong>and</strong> the role of a successful<br />

movie production in reinforcing the image of the spa <strong>and</strong> the location.<br />

The aim of this paper is to analyse the relationship between film-induced tourism <strong>and</strong> health<br />

tourism <strong>and</strong> to elaborate a model of a possible collaboration. The research is based on a<br />

questionnaire survey carried out in 2009 among foreign <strong>tourists</strong> staying in Budapest (the<br />

collected data was analysed with SPSS), <strong>and</strong> on semi-structural interviews with Hungarian<br />

film-commissioners.<br />

Keywords: film-induced tourism, destination image, Budapest, spas.<br />

Introduction<br />

Films provide the objects <strong>and</strong> subjects for the gaze of many people, <strong>and</strong> movies may induce<br />

them to travel to the location where the film was set (Riley-Baker-Van Doren 1998). Image is<br />

central to marketing, even more so in tourism destination marketing, which promotes an<br />

intangible product. Destination imaging is multi-dimensional, comprising both symbolic <strong>and</strong><br />

tangible features (Beeton 2005). Image influences tourism related attitudes <strong>and</strong> it affects the<br />

individual’s perception <strong>and</strong> consequent behaviour (Gallarza-Saura-Calderòn Garcìa 2001).<br />

Moreover, image has long been considered as a primary decision-making factor in holiday<br />

travel. The importance of tourism destination image has been widely studied <strong>and</strong> the image<br />

has emerged as a crucial marketing concept in the tourism industry (Hall 1999).


Visual culture may influence many aspects of everyday life <strong>and</strong> the effect of film on human<br />

behaviour has long been debated mainly in psychological <strong>and</strong> sociological studies. In some<br />

feature films the development of a country’s identity, image <strong>and</strong> cultural representations can<br />

be traced through popular film <strong>and</strong> television series. The Lord of the Rings saga <strong>and</strong> its impact<br />

on New Zeal<strong>and</strong>’s tourism is one of the best examples of film-induced tourism (Buchmann-<br />

Moore-Fisher 2010; Corl-Kindon-Smith 2007).<br />

<strong>Tourism</strong> images are developed from the stories of returning travellers as well as the media of<br />

the day. In a wider sense, news coverage <strong>and</strong> popular culture (as in films, television programs,<br />

<strong>and</strong> literature) can provide substantial information about a place in a short period of time.<br />

Additionally, while watching a film, people usually are more open to all the information<br />

because they do not feel to be targeted for selling promotion compared to traditional<br />

advertising. Further, news <strong>and</strong> popular culture products are so deeply embedded in every day<br />

life that they are likely to have high market penetration. Thus, portrayals of places in news<br />

<strong>and</strong> popular culture can alter an area’s image significantly, even in a short period of time.<br />

Motion pictures are an important element of popular culture. They may impact on many<br />

people <strong>and</strong> few would deny that movie-going <strong>and</strong> television watching are the major leisure<br />

activities in the Western world. Usually popular films dominate the movies for a relatively<br />

short period, however, the impact of popular films on individual <strong>and</strong> societal beliefs <strong>and</strong><br />

behaviours will continue to increase as cable television, DVD use, <strong>and</strong> internet downloads<br />

diffuse rapidly. A film may create <strong>and</strong> prolong interest in a destination. According to Butler<br />

(1990) what is shown in movies, videos, <strong>and</strong> television will become even more important than<br />

print media in shaping images of, <strong>and</strong> visitation to, places, due to exp<strong>and</strong>ing accessibility <strong>and</strong><br />

high credibility of these information sources. It can be affirmed that contemporary <strong>tourists</strong>’<br />

organic images of places are shaped through the consumption of film <strong>and</strong> television series<br />

without the perceived bias of promotional material. Recognising that movies can enhance<br />

awareness of places <strong>and</strong> affect decision-making processes, marketers are increasingly working<br />

with film producers to promote their destinations as possible film locations (Beeton 2005;<br />

Seaton <strong>and</strong> Hay 1998).<br />

<strong>Tourism</strong> holds an important position in the substantial political, economic <strong>and</strong> social<br />

restructuring processes which have taken place in Central <strong>and</strong> Eastern Europe (CEE) in the<br />

past two decades. The ‘re’-imaging of the region faces different challenges <strong>and</strong> niche tourism<br />

products need to be developed <strong>and</strong> marketed in response to the changing nature of tourism<br />

dem<strong>and</strong>. Similarly, CEE cities like Budapest in order to enhance their role as tourism<br />

destinations are trying to create new <strong>and</strong> unique experiences for visitors (Rátz-Smith-<br />

Michalkó 2008). Br<strong>and</strong> identities are based on culturally distinctive features <strong>and</strong> new tourism<br />

trends like film-induced tourism may have a key role.<br />

This paper is concerned with the process of image formation related to film tourism. In the<br />

focus of the research the analysis of Budapest’s identity on feature films can be placed, with<br />

special attention on spas <strong>and</strong> baths. The featuring of spa locations in the Hungarian <strong>and</strong><br />

international film productions may offer different aspects of health <strong>and</strong> wellness tourism<br />

image formation <strong>and</strong> a co-operation between film commissions <strong>and</strong> the Hungarian tourism<br />

authorities would be auspicious.


Budapest as film location<br />

The power of film to motivate travellers, create new images, alter negative images, strengthen<br />

weak images, <strong>and</strong> create <strong>and</strong> place icons is recognised by many as a major factor in tourism<br />

promotion (Beeton 2005).<br />

Films familiarise audiences with places <strong>and</strong> attractions featured in them. Riley <strong>and</strong> Van Doren<br />

stated that ‘Extended exposure to attractions through the medium of film allows potential<br />

<strong>tourists</strong> to gather information <strong>and</strong> vicarious knowledge, therefore lowering the anxiety levels<br />

caused by anticipated risk’ (1992:269). Thus, it is proposed that observing a movie can<br />

increase the degree of familiarity with the places it portrays.<br />

That is, the popular view of a place offered by media may prompt that place to recreate its<br />

own identity in this image. This recreation of place identity implicates different levels of<br />

culture, <strong>and</strong> language, including the visual language of television, films, <strong>and</strong> other mass<br />

media. This implication provides representations that produce meanings which may reinforce<br />

place identity. These meanings regulate social practices, influence people’s behaviour, <strong>and</strong><br />

consequently might have real practical effects. In particular, movies, as visual language, have<br />

been one of the major vehicles to construct <strong>and</strong> transmit meaning, often of places with which<br />

people do not have first h<strong>and</strong> experience.<br />

The Hungarian capital has recently became ‘film friendly’ with a number of film commissions<br />

<strong>and</strong> film offices working on the promotion of the city as an ideal film location. Korda Studios<br />

established in the nearby of Budapest offers a wide range of film locations that might be<br />

attractive to film producers. Macionis (2004) discovered the international exposure a film can<br />

provide a destination; a film is an advertisement potentially viewed by millions of people who<br />

may be tempted to become film induced <strong>tourists</strong>.<br />

Films are often not shot at the locations they purport to be, however benefits of film-induced<br />

tourism can be traced only if the viewers can clearly identify the film location with the<br />

destination they are interested to visit. Moreover, considering the issues of cultural identity of<br />

a place <strong>and</strong> its role on films it seems to be clear that a film can reinforce the country’s identity<br />

if they are interrelated.<br />

Natural l<strong>and</strong>scape or atmosphere can be featured as backgrounds in a film, however the<br />

storyline <strong>and</strong> the characters add some emotional charge to places. This interrelationship of<br />

cognitive <strong>and</strong> affective image components eventually determines the predisposition for<br />

visiting a destination.<br />

Research hypothesis <strong>and</strong> study methods<br />

Based on the conceptual framework described in this study, two hypotheses were considered:<br />

Ha 1: The perceived destination image of Budapest will be reinforced through the films set<br />

there<br />

Ha 2: Budapest identity as a city of spas will be reconfirmed through the films<br />

The study was conducted using bilingual (English <strong>and</strong> Italian) questionnaires among foreign<br />

<strong>tourists</strong> staying in Budapest. The research was carried out in March-April 2009 <strong>and</strong> 600<br />

<strong>tourists</strong> were asked to fill in the questionnaire. Due to incomplete questionnaires a total of 67<br />

were dropped out of the sample. Consequently, 533 usable responses were available at the end<br />

of the research, meeting the criteria for statistical estimation for data analysis.


The questionnaire comprised 17 questions <strong>and</strong> classified the respondents by age, gender,<br />

origin, first visit to Budapest, length of stay, whether they travelled independently or as part<br />

of a package.<br />

To measure the cognitive component of participants’ image of Budapest, 11 image attributes,<br />

which were measured by five-point Likert type-scale, were included in the questionnaire.<br />

These 11 items refer to historical attractions, atmosphere of the destination, <strong>and</strong> lifestyle of<br />

local people. In order to measure the impact of films on Budapest tourism destination image, a<br />

popular motion picture was defined as a film produced for the entertainment of the general<br />

public employing plot <strong>and</strong> characters. A total of 38 film titles were selected to be included in<br />

the questionnaire. The selection of the films was based on the film location, all the 38 was set<br />

in Budapest, <strong>and</strong> the productions are Hungarian (17 films) <strong>and</strong> international (21 films) as<br />

well.<br />

Tourists who were familiar with some of the film titles were asked to underline those films<br />

which according to them, were set in the Hungarian capital city. They were also asked to<br />

nominate those films that give a positive image of the city, as well as those that give a<br />

negative image of the city in the film productions.<br />

Findings<br />

Budapest identity <strong>and</strong> its role in film tourism<br />

Tourists’ perception of Budapest was measured by the 11 image attributes given in the<br />

questionnaire. In a five-point Likert-type scale these image attributes were measured, <strong>and</strong> the<br />

mean value 4.05 (n=533) clearly shows that those <strong>tourists</strong> who participated in the research<br />

identify Budapest as a city of spas (Figure 1.). Budapest’s imposing baths such as Gellért Spa<br />

Baths <strong>and</strong> Hotel on the Buda side, <strong>and</strong> Széchenyi Baths in the Pest side of the city are<br />

considered to be the l<strong>and</strong>marks of the capital, as well as to be the leisure places preferred by<br />

Hungarians.<br />

Figure 1 Perception of <strong>tourists</strong> on Budapest<br />

Modern city<br />

Religious city<br />

City where is good to live<br />

Multicultural city<br />

Art city<br />

Shopping city<br />

City where is good to have holiday<br />

Party city<br />

Cultural city<br />

Historical city<br />

The city of spas<br />

3,37<br />

3,38<br />

3,44<br />

3,5<br />

3,6<br />

3,79<br />

3,83<br />

3,88<br />

4,02<br />

4,04<br />

4,05<br />

0 1 2 3 4 5<br />

Source: data collected by the author (2009)


Usually viewers attach an icon to the location they have seen in a film, therefore locations<br />

which carry an emotional charge can easily be identified. Swimming pools used by the<br />

Hungarian national water polo team are strongly linked to national identity (Table 1.). The<br />

Children of Glory (2006) Hungarian film production is a commemorative film about the<br />

national revolution of 1956 against the Soviet ‘Empire’. The days of heroic fight <strong>and</strong> struggle<br />

against the Soviet army on Budapest’s streets <strong>and</strong> in the major cities of Hungary coincide with<br />

the world-famous water polo match played in the finals of the Melbourne Olympic Games. In<br />

the film, the primary sites for the CCCP-Hungary, so called ‘blood in the water match’ were<br />

located in swimming pools in Budapest used by the Hungarian athletes (BVSC on Szőnyi<br />

Street <strong>and</strong> Alfréd Hajós). In certain types of place-oriented movies, viewers are offered the<br />

opportunity to learn about the place by imaginatively participating in the place-related<br />

experiences of the characters (Kim-Richardson 2003). These swimming pools, however not<br />

considered as tourism attractions, may be identified as the spaces of national proud of<br />

Hungarians <strong>and</strong> the icon attributed to the film (national proud) could be indentified as a<br />

thematic icon. In The Children of Glory film the above mentioned water polo match against<br />

the Soviet national team takes place in Melbourne, <strong>and</strong> the name of the athletes swimming<br />

pools are not cited at all. The identification of the film location using the film icon related to<br />

the place may induce film tourism only if the film viewers are aware of original place where<br />

the film was actually set. In this case, it could be stated that The Children of Glory may not<br />

generate any film tourism phenomenon in Budapest, however it reinforces the image of<br />

Hungarians as heroic <strong>and</strong> proud people through a significant water polo match <strong>and</strong> film<br />

viewers may have the opportunity to learn about the city from a different angle of view.<br />

In the case of these two movies, Hypothesis 1 (The perceived destination image of Budapest<br />

will be reinforced through the films set there) seems to be confirmed <strong>and</strong> film images could<br />

be used to reinforce Budapest’s tourism destination image.<br />

Table 1. Film icons in spa-located movie productions<br />

Title of Film Spa-locations in<br />

Budapest<br />

Icon<br />

The Children of Glory 2006 BVSC Budapest National<br />

polo team<br />

proud, water-<br />

Made in Hungária 2009 Csillaghegyi<br />

Pools<br />

Swimming Fun, youth<br />

I, Spy 2002<br />

In bed with the opposition 1997<br />

Csontváry 1980<br />

The Children of Glory 2006<br />

Mrs Ratcliffe’s Revolution 2008<br />

Gellért Spa Baths Aristocratic beauty, built<br />

heritage<br />

Hajós Alfréd Swimming National proud<br />

The Double Life of Mrs. Mici 1962<br />

Pool Complex<br />

Lukács Thermal Baths Third-age love affair<br />

Red Heat 1988 Rudas Thermal Baths Mystery<br />

Just sex <strong>and</strong> nothing else 2005 Szécheny Spa Budapest Built heritage, human<br />

Io e mia sorella 1987<br />

Csontváry 1980<br />

relationships<br />

Source: data collection by the author 2009. Table structure based on Riley&Baker&Van<br />

Doren (1998: 924)


Some icons, like built heritage <strong>and</strong> aristocratic beauty of the traditional spas in Budapest, can<br />

be recurrent or continuing images within a film, highlighted by the strong marketing<br />

communication based on these places as well. Other icons which may attract visitors can be<br />

single exciting events (the water polo match) which viewers can identify with the space they<br />

are interested to visit.<br />

Film icons may not all be visual as they may be storyline themes or atmospheric background<br />

for the plot that may become associated with locations. Example of visual icons is the<br />

American production I, Spy starring Eddie Murphy where Gellért Spa Baths, along with the<br />

Buda Castle district <strong>and</strong> the Chain Bridge over the Danube offer a powerful overview of the<br />

riverside <strong>and</strong> an outst<strong>and</strong>ing panorama of Budapest. Gellért Spa Baths is not featured as the<br />

main spa <strong>and</strong> baths centre of Budapest, instead the location was used to host scenes in an<br />

elegant <strong>and</strong> sophisticated environment. In this film, the name Budapest <strong>and</strong> the Gellért Spa<br />

Baths are mentioned several times <strong>and</strong> film viewers may easily identify the locations.<br />

Hungarian film productions, even if translated, have limited distribution within Europe <strong>and</strong><br />

even less overseas, on the contrary the I, Spy film has been broadcasted in the United States of<br />

America <strong>and</strong> in numerous European countries as well. Major films may have more than one<br />

icon that film tourist associate with locations. The physical icon has been illustrated above,<br />

however a detailed research on the effects of the I, Spy film on Budapest, <strong>and</strong> even more<br />

precise on Gellért Spa Baths still has to be done.<br />

The above mentioned film productions are clearly linked to Hungarian culture, to Budapest<br />

<strong>and</strong> to the spa traditions. However, in several feature films Budapest plays the role of another<br />

European capital, <strong>and</strong> the identification process is accessible only to those who are keen to<br />

search for the real location of the film or already has some knowledge of Budapest’s iconic<br />

spas <strong>and</strong> baths. In the case of the Red Heat (1988) film starring Arnold Schwarzenegger,<br />

Rudas Thermal Baths is featured in the opening scene of the film. Schwarzenegger plays the<br />

role of a Soviet soldier searching for a cruel criminal within the spa. In a mysterious <strong>and</strong><br />

vaporized atmosphere created by suffused lights the film viewer is guided through different<br />

parts of Rudas Spa, however the city plays the role of Moscow, the Russian capital.<br />

The other case of Budapest missed identity is the example of Mrs Ratcliffe’s Revolution<br />

(2008) in a recent film production, twenty years after the Red Heat. This comedy is about a<br />

British family eager to move to East Germany during the years of the Cold War because they<br />

believe in the ideal life on the Eastern side of the iron curtain. In Mrs Ratcliffe’s Revolution<br />

Budapest plays the role of East Berlin, <strong>and</strong> mainly derelict areas of the city were used as a<br />

film location. The Hajós Alfréd Swimming Pool is featured in the scene when Mrs Ratcliffe<br />

tries to organise her family’s escape from ‘East Berlin’ <strong>and</strong> the only neutral place to discuss<br />

such a crime is the swimming pool.<br />

Budapest missing identity in several films when the Hungarian capital plays the role for<br />

example of Buenos Aires (Evita), München (München), Moscow (Red Heat) or Berlin (Mrs<br />

Ratcliffe’s Revolution) is evidenced also by the questionnaire research carried out among<br />

tourist staying in Budapest. From the 38 film located in Budapest, only a few films were<br />

linked to the Hungarian capital as the film’s location. The respondents could indentify<br />

Budapest as the film location only in those films that can be clearly related to Hungarian<br />

culture or history (like Sunshine, The Children of Glory, Fateless). This means that the other<br />

films, even if successful movie productions, miss to contribute to Budapest promotion<br />

through films because the featured sites, however being of national pride <strong>and</strong> the key tourist<br />

attractions, for the general movie-goers can hardly be recognized <strong>and</strong> linked to Budapest.


In the second part of the questionnaire, respondents were asked to value on a scale from 1 to 4<br />

six different statements, all related to film tourism in Budapest. In the questionnaire the<br />

statements follow the 38 film set in Budapest in order to help association of Budapest as a<br />

film location, <strong>and</strong> to make the participants remember the films they might have seen. The<br />

mean value of the answers shows that those who participated in the research think the<br />

Budapest’s thermal spas are well represented on films (2.15) <strong>and</strong> that it is interesting to know<br />

which films were shot in Budapest (2.21). However, according to the mean value of the<br />

answers it cannot be stated that films strongly influence tourism towards Budapest.<br />

Table 2. The perception of Budapest as influenced by films<br />

Item Scale Mean<br />

(n=53<br />

3)<br />

The films set in Budapest contribute to the positive image of<br />

the city.<br />

1-4 2.25<br />

I can know Budapest better through the films set there. 1-4 2.51<br />

It is interesting to know which films were shot in Budapest. 1-4 2.21<br />

A film can influence my choice of a travel destination. 1-4 2.42<br />

If a movie map was available in my hotel, I would use it <strong>and</strong><br />

would visit the film locations.<br />

1-4 2.42<br />

I think that Budapest’s thermal spas are well represented on<br />

films, <strong>and</strong> give a good impression about the city.<br />

Scale: 1= Strongly Agree <strong>and</strong> 4 = Strongly Disagree.<br />

1-4 2.15<br />

According to the mean value of the answers given for the statements, it can be stated the<br />

Hypothesis 2 (Budapest identity as a city of spas will be reconfirmed through the films)<br />

cannot be reconfirmed, nevertheless several key attraction spas feature in different movies<br />

located in Budapest. In the research it has been evidenced that Budapest’s missing identity,<br />

her acting as other European cities, might cause some confusion in place identification.<br />

Conclusions<br />

Films have been, without a doubt a tourist inducing ingredient, turning destinations of little or<br />

no importance into much visited tourist attractions. Even if not all films have such an effect,<br />

nonetheless it cannot be disputed that films in general do affect the image of destination. For<br />

that reason, it is important that a well-planned image management plan to be produced for<br />

destinations. A tourist visiting a destination after seeing the location in a film or television<br />

series is an emerging phenomenon <strong>and</strong> due to the momentous impacts, many films have had<br />

their locations research into the issues relating to film induced tourism.<br />

Film-induced tourism in Budapest is a new phenomenon <strong>and</strong> what has emerged from the<br />

research is that tourist even if they are familiar with some films set in the Hungarian capital,<br />

would not acknowledge a strong motivational influence on their decisional process when<br />

selecting their holiday destination.<br />

By underst<strong>and</strong>ing the film tourist phenomenon, tourism <strong>and</strong> film stakeholders can better meet<br />

experiences, thus exp<strong>and</strong>ing on the positive impacts of such destinations. <strong>Tourism</strong> destination<br />

marketing ideally requires cooperation <strong>and</strong> input from all the sectors of community –<br />

<strong>business</strong>es, interest groups <strong>and</strong> local inhabitants. During the planning of tourism development,


conscious destination strategies that aim to create positive images of the destinations <strong>and</strong><br />

imprint them in potential visitors’ imaginations are developed.<br />

In Hungary health- <strong>and</strong> wellness tourism have become key tourism products <strong>and</strong> a strong<br />

marketing strategy has been based on them, promoting the medical <strong>and</strong> treatment services,<br />

leisure time in spas <strong>and</strong> baths. However, in the marketing strategy the powerful images shot in<br />

different spa locations of Budapest are unfortunately missed out. As stated above, several<br />

feature films, Hungarian <strong>and</strong> international productions as well, used Budapest’s flagship<br />

attractions like Gellért Spa Baths, Széchenyi Spas or Rudas Spas as key film locations.<br />

On screen Budapest’s spas carry a well-defined identity <strong>and</strong> emotional links to the location<br />

may be recognised in some feature films. The meaning of a place reinforced in some movie<br />

productions <strong>and</strong> the film-viewers familiarity with the place starring on screen could offer<br />

unparalleled possibilities to enhance the marketing strategy based on different tourism<br />

products. Film commissions in Budapest are already promoting <strong>and</strong> selling the unique places<br />

of the Hungarian capital city to host films, but until now this promotion has not been linked to<br />

tourism marketing. A possible collaboration between the film industry <strong>and</strong> the tourism<br />

industry could reinforce Budapest’s cultural identity.<br />

References<br />

Beeton S. (2005) Film-Induced <strong>Tourism</strong>. Channel View Publications, Clevedon.<br />

Buchmann A. & Moore K. & Fisher D. (2010) Experiencing Film <strong>Tourism</strong>. Authenticity <strong>and</strong><br />

Fellowship. In: Annals of <strong>Tourism</strong> Research 37 (1), 229-248.<br />

Butler R. (1990) The Influence of the Media in Shaping International Tourist Patterns. In:<br />

<strong>Tourism</strong> Recreation Research 15, 46-53.<br />

Connell J. & Meyer D. (2009) Balamory revisited: An evaluation of the screen tourism<br />

destination-tourist nexus. In: <strong>Tourism</strong> Management 30, 194-207.<br />

Connell J. (2005) ‘What’s the story in Balamory?’ The impacts of a children’s TV<br />

Programme on Small <strong>Tourism</strong> Enterprises on the Isle of Mull, Scotl<strong>and</strong>. In: Journal of<br />

Sustainable <strong>Tourism</strong> 13(3), 228-255.<br />

Corl D. & Kindon S. & Smith K. (2007) Tourist’s Experiences of Film Locations: New<br />

Zeal<strong>and</strong> as ‘Middle Earth’. In: <strong>Tourism</strong> Geographies 9 (1).<br />

Gallarza M. & Saura I. & Calderòn Garcìa H. (2001) Destination Image. Towards a<br />

Conceptual Framework. In: Annals of <strong>Tourism</strong> Research 29 (1), 56-78.<br />

Hall D. (1999) Destination br<strong>and</strong>ing, niche marketing <strong>and</strong> national image projection on<br />

Central <strong>and</strong> Eastern Europe. In: Journal of Vacation Marketing 5 (3), 227-237.<br />

Irimiás A. (2008) Világítás! Kamera! Turizmus indul! A filmek szerepe a kulturális<br />

turizmusban In: IV. Magyar Földrajzi Konferencia kötet. Debrecen. pp. 498-502.<br />

Kim H. & Richardson S. (2003) Motion Pictures Impact on Destination Images. In: Annals of<br />

<strong>Tourism</strong> Research 30 (1), 216-237.<br />

Macionis N. (2004) Film induced tourism: the tourist in the film place. Placing the Moving<br />

Image Symposium, Griffith University: Brisbane, 1–14.<br />

Messina E. & Bocchioli L. (2008) Cineturismo e identità territoriali In: Provenzano, R. (edit.):<br />

Al cinema con la valigia. FrancoAngeli, Milano, pp. 231-329.<br />

O’Connor N. & Flanagan Sh. & Gilbert G. (2010) The use of film in re-imaging a tourism<br />

destination: a case study of Yorkshire, UK. In: Journal of Vacation Marketing 16 (1) 61-<br />

74.<br />

Provenzano R. (edit.): Al cinema con la valigia. FrancoAngeli, Milano<br />

Rátz T. & Smith M. & Michalkó G. (2008) New Places in Old Spaces: Mapping <strong>Tourism</strong> <strong>and</strong><br />

Regeneration in Budapest. In: <strong>Tourism</strong> Geographies 10 (4), 429-451.


Riley R. & Van Doren C. (1992) Movies as <strong>Tourism</strong> Promotion: A “Pull” Factor in a “Push”<br />

Location. In: <strong>Tourism</strong> Management 13, 27-274.<br />

Riley R. & Baker D. & Van Doren C. (1998) Movie Induced <strong>Tourism</strong>. In: Annals of <strong>Tourism</strong><br />

Research 25 (4), 919-935.<br />

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Screened Locations. In: <strong>Tourism</strong> Management 17 (2), 87-94.<br />

Seaton A. & Hall B. (1998) The Marketing of Scotl<strong>and</strong> as a Tourist Destination, 1985–96. In:<br />

<strong>Tourism</strong> in Scotl<strong>and</strong>, R. MacLellan & R. Smith, eds., pp. 209–240. London: International<br />

Thompson Business Press.


THE EVOLUTION OF ATTITUDES TOWARDS SPA HOLIDAYS IN CANADA<br />

Marion Joppe, PhD,<br />

School of Hospitality <strong>and</strong> <strong>Tourism</strong> Management<br />

University of Guelph, Guelph, Ontario<br />

CANADA<br />

mjoppe@uoguelph.ca<br />

<strong>and</strong><br />

Hwan-Suk Chris Choi, PhD, Associate Professor<br />

School of Hospitality <strong>and</strong> <strong>Tourism</strong> Management, Macdonald Stewart Hall, University of<br />

Guelph, Guelph, Ontario, CANADA, N1G 2W1<br />

Introduction<br />

Canada is a fairly recent newcomer to the world of spa tourism. According to a<br />

PricewaterhouseCoopers study on the spa industry, undertaken on behalf of the International<br />

Spa Association, between 1990 <strong>and</strong> 2001, the number of spa establishments in North America<br />

went from 1400 to 10,900, of which 1300 were in Canada, <strong>and</strong> occupancy went from 40% to<br />

an average between 70 <strong>and</strong> 80%. Instead of slowing things down, the events of September 11,<br />

2001 actually spurred growth in this sector. By 2003, the International Spa Association<br />

(ISPA) estimated the number of establishments to have reached 12,100 spas throughout the<br />

U.S <strong>and</strong> 2,100 in Canada, a 26% growth in the States but 65% growth in Canada!<br />

In North America, health has become a major societal preoccupation, since all media bombard<br />

citizens with warnings about too sedentary a life, the health dangers of too much weight,<br />

cholesterol <strong>and</strong> stress, too little sleep, <strong>and</strong> high tension. Foods are considered too fatty, too<br />

sugar <strong>and</strong> salt-laden; both the air <strong>and</strong> the water is making people sick. If all that were not<br />

enough, North Americans have been made anxious, if not downright paranoid, about<br />

everything from possible terrorist attacks to catching SARS (Severe Acute Respiratory<br />

Syndrome), the avian flu or H1N1. At the same time, the strong baby boom cohort is<br />

becoming obsessed with aging, refusing to give in to wrinkles <strong>and</strong> sagging bodies. So it is not<br />

surprising that North Americans are desperate to find an oasis, a place where it is possible to<br />

be at peace, breathe deeply, regain one’s internal balance, re-establish the harmony between<br />

body, mind <strong>and</strong> soul so that they can confront this fast-paced, complex <strong>and</strong> increasingly scary<br />

world another day. Yet that older cohort is no longer prepared to make big efforts <strong>and</strong> huge<br />

sacrifices to look <strong>and</strong> feel better, as they did just a decade previously. The time has come to<br />

be kind to ourselves: to strive for balance, harmony but also pleasure. Spas are seen as a<br />

means of escaping the pressures <strong>and</strong> getting re-energized” (Association Resource Centre Inc.<br />

2006: 5).<br />

<strong>Health</strong> is no longer considered just an absence of illness, but rather an optimum state of<br />

physical, mental <strong>and</strong> social well-being that requires a more holistic approach <strong>and</strong> proactive<br />

participation by the individual (Nahrstedt 2004). The World <strong>Health</strong> Organization 8 defines<br />

8 World <strong>Health</strong> Organization (1946). Preamble to the Constitution of the World <strong>Health</strong> Organization as adopted<br />

by the International <strong>Health</strong> Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the<br />

representa-tives of 61 States (Official Records of the World <strong>Health</strong> Organization, no. 2, p. 100) <strong>and</strong> entered into<br />

force on 7 April 1948.


health as “a state of complete physical, mental <strong>and</strong> social well-being”, which reflects a<br />

preventive way of living that reduces, <strong>and</strong> even eliminates, the need for remedies. Thus,<br />

health tourism refers to someone who has one or more medical conditions that would make<br />

him travel to experience therapies that help to make him well - or to improve his health. On<br />

the other h<strong>and</strong>, the concept of wellness emphasizes personal responsibility for making lifestyle<br />

choices <strong>and</strong> self care decisions that will improve our quality of life. People who engage<br />

in wellness tourism are generally <strong>healthy</strong>, but seek therapies to maintain this state of wellbeing.<br />

While Europeans <strong>and</strong> Asians have recognized the benefits of “taking the waters” for<br />

centuries, <strong>and</strong> the concept of “wellness” has been recognized as a major force in the United<br />

States for more almost 20 years, it has really been part of the Canadian consciousness for only<br />

about 10 years. In that time, however, a significant change in attitudes has taken place.<br />

Methods<br />

One of the first comprehensive assessments of travel behaviour <strong>and</strong> motivators, including<br />

interest in vacations at health spas, was the Travel Activities & Motivation Survey (TAMS),<br />

completed in 1999, <strong>and</strong> repeated in 2006. For both studies, Statistics Canada undertook the<br />

survey of Canadians, using r<strong>and</strong>om digit dialing to obtain samples stratified by census<br />

metropolitan area (CMA). The samples were restricted to all persons aged 18 years of age <strong>and</strong><br />

older in the ten Canadian provinces <strong>and</strong> full-time residents of institutions were excluded.<br />

Travellers who took an out-of-town trip of one or more nights in the past two years were<br />

identified via the screening telephone interview.<br />

In 1999, the telephone survey was completed by 18,385 individuals. Respondents were<br />

selected r<strong>and</strong>omly within the household. 24,635 qualified for the mailback questionnaire. Of<br />

these 5,490 (35.2 %) returned the questionnaire. Using gender, age, education level <strong>and</strong><br />

income, responses were weighted to project the results to the national level. 2.4% (470,853<br />

when weighted to the population) of Canadians (as compared to 4% of Americans) had stayed<br />

at a health spa during the past two years. This survey also asked about travel intentions in the<br />

next two years, <strong>and</strong> identified 6.7% (1,314,463 of the population) of respondents as<br />

expressing an interest in visiting a health spa.<br />

In 2006, the telephone survey was completed by 53,150 individuals <strong>and</strong> a total of 24,692<br />

(53.5%) travelers completed the mail-back survey questionnaires. This survey contained two<br />

activity variables of interest: “Day visit to a health spa <strong>and</strong> wellness spa while on a trip of one<br />

or more nights" <strong>and</strong> “staying at a health spa”. For each variable, it was possible to choose<br />

either “On out-of-town trips of one or more nights in past 2 years” or “Main reason for taking<br />

any of these trips”. Among 24,692 Canadian overnight travellers, 2,538 made a day visit <strong>and</strong><br />

1,426 stayed at a health spa. When weighted to the Canadian population (Statistics Canada,<br />

2006), it was determined that 11.0% or over 2.23 million of Canadian overnight travelers<br />

visited a health <strong>and</strong> wellness spa <strong>and</strong>/or stayed at a spa resort while on an out-of-town,<br />

overnight trip of one or more nights.<br />

In addition to analysis of the weighted data using frequency, chi-square <strong>and</strong> analysis of<br />

variances techniques, the odds ratio was used as a measure of association. Due to the large<br />

sample size, all results were significant at the 0.001 level or better.


Results<br />

Demographic characteristics of spa-goers<br />

While only 2.4% had visited a spa during the previous two years while on an overnight trip in<br />

1999, this percentage had increased to 11% seven years later. In addition, 34% (almost<br />

800,000 respondents) reported that this activity was the main reason for taking at least one<br />

trip. While only Saskatchewan showed a high participation rate in 2000 (8% of overnight<br />

pleasure travelers), by 2006, Saskatchewan (13.6%), British Columbia (9.3%) <strong>and</strong> Quebec<br />

(8.3%) were all above average. In 1999, women were 47% more likely to have visited a health<br />

spa, but there was relatively little variation by age in the incidence of health spa visits, <strong>and</strong> the<br />

levels of formal education <strong>and</strong> household income were only weakly associated with health spa<br />

visits. By 2006, the picture had changed quite dramatically: women were 70% more likely to<br />

have visited a health spa, <strong>and</strong> spa visitors were over-represented among those 25 to 54 years<br />

of age <strong>and</strong> especially among Mature Couples. In addition, they were the third most likely to<br />

have a university degree <strong>and</strong> had the highest household income of any of the culture <strong>and</strong><br />

entertainment activity types.<br />

Indeed, there was a significant shift between 1999 <strong>and</strong> 2006 in the income groups that are<br />

both staying at health spas <strong>and</strong> participating in health <strong>and</strong> wellness spa activities. Whereas in<br />

1999 the majority of health spa goers earned $60,000 <strong>and</strong> more, by 2006 the majority earned<br />

$80,000 <strong>and</strong> more. This middle-aged group is, however, increasingly introducing both their<br />

parents (mainly mothers) <strong>and</strong> children (mainly daughters) to the spa experience, contributing<br />

to the extraordinary growth in dem<strong>and</strong> for facilities as well as treatments.<br />

Segmenting the spa segment<br />

Spa-goers made an estimated 14.1 million visits to Canadian spas. Half of these visits were<br />

taken to spas in Ontario <strong>and</strong> four out of five spa visits in Canada were made to day spas (11.3<br />

million). Over 40% of the Canadian adult population visits day spas while at home (Table 1):<br />

Table 1 Frequency of Spa Visitation<br />

During the past 12 months, how<br />

often did you visit a day spa?<br />

Frequency Percentage<br />

Frequently 398,952 5.4<br />

Occasionally 2,603,110 35.1<br />

Rarely 4,404,814 59.5<br />

Total 7,406,876 100.0<br />

Source: Lang Research Inc. (2007).<br />

It is clear that the spa segment is not a homogeneous one. In a 2006 study by The Hartman<br />

Group, three types of spa-goers were identified, based on the frequency with which they seek<br />

out these experiences <strong>and</strong> their attitude towards them: core spa-goers are knowledgeable<br />

about treatments <strong>and</strong> feel that learning about <strong>and</strong> going to spas is important to their lifestyle,<br />

while periphery spa-goers (at the other extreme) enjoy going to spas but otherwise show little<br />

interest in them. Between these two segments is a mid-level spa-goer segment that is<br />

interested in learning about spas but lacks the commitment <strong>and</strong> passion of the core spa-goers.<br />

If we take a closer look at that 40-50% of spa-goers that will travel for the purpose of spa <strong>and</strong><br />

wellness tourism, it is probably not surprising that these tend to be more core spa-goers, who<br />

are not only experienced, but have already tried a range of products <strong>and</strong> services <strong>and</strong> are thus<br />

the most critical. The majority considered themselves to be in good or excellent health <strong>and</strong> of<br />

average weight. In spite of this, they worry about their health, including what they eat <strong>and</strong>


how much exercise they get. Two-thirds of them take vitamins; <strong>and</strong> 61% limit the amount of<br />

fat they eat. So, while relaxation is their primary motivation for choosing a spa during their<br />

holidays (rated 2.74 on a 3-point benefit scale in terms of importance), with pampering <strong>and</strong><br />

stress reduction as secondary motives, a majority reported <strong>healthy</strong> meal choices to be<br />

important in the selection of accommodations. This does not mean that spa-goers forsake<br />

pampering: indeed, they are 2.5 to 2.7 times more likely to seek this as a somewhat to highly<br />

important benefit compared to other pleasure travellers. But only 37% said workout facilities<br />

were important which corresponds to their general attitude towards active involvement in<br />

regular fitness programs (rated 2.8 on a 5-point Likert scale). Nonetheless, odds are 50%<br />

higher than for other pleasure travelers that being physically challenged/energized is a highly<br />

important benefit sought of their spa vacation <strong>and</strong> .<br />

This, then, is the dramatic shift in perception we have seen from spas as “indulgence”,<br />

providing the ultimate in luxury <strong>and</strong> pampering: today, luxury is a given at any spa, but the<br />

“spa experience” that incorporates a tranquil, airy setting <strong>and</strong> information about health,<br />

wellness <strong>and</strong> self- or at-home care, in order to maintain a balanced lifestyle, is seen as a<br />

component of long- term, <strong>healthy</strong> living.<br />

The need for quality assurance<br />

Considering the demographic profile of spa-goers, it is somewhat surprising that no<br />

government has felt the need so far to impose any quality st<strong>and</strong>ards or regulate against<br />

possible fraudulent claims coming out of the many different treatments proposed, vitamins,<br />

supplements <strong>and</strong> lotions used, <strong>and</strong> statements made as to the psychological <strong>and</strong> physical<br />

improvements to be expected. Even ISPA has recognized that “as the spa industry continues<br />

to grow <strong>and</strong> exp<strong>and</strong> to mainstream consumers <strong>and</strong> their health <strong>and</strong> wellness regimes,<br />

therapists’ credentials as well as the overall effectiveness of the spa experience (menus,<br />

pricing, environment, “extras,” etc.) will come under greater scrutiny by all segments of<br />

consumers.” (The Hartman Group, 2006: 3).<br />

Indeed, one of the more recent research studies clearly indicates the quality of the treatment<br />

<strong>and</strong> services as well as the hygiene of staff <strong>and</strong> cleanliness of the spa facilities are the top<br />

concerns of spa goers (The Hartman Group, 2006).<br />

Table 2 Spa Traveller Concerns with Spa Treatments<br />

Canada USA<br />

Quality of treatment/services 35% 47%<br />

Cost of services 36% 41%<br />

Hygiene of staff <strong>and</strong> cleanliness of spa facilities 41% 39%<br />

Benefits of treatments 29% 27%<br />

Certification/Training of personnel performing treatments<br />

Source: The Hartman Group (2006).<br />

25% 18%<br />

Premier Spas of Ontario as well as its Quebec counterpart, Relais Santé, are the only industry<br />

associations in Canada that have recognized the need to provide consumers with a guarantee<br />

concerning both the facilities <strong>and</strong> treatments they will find at a spa, <strong>and</strong> the professionalism<br />

<strong>and</strong> credentials of the staff. Acquiring the Premier Spa accreditation by Spas Ontario Inc. is a<br />

comprehensive process involving application, inspection, report submission, <strong>and</strong> acceptance<br />

by the Board of Directors. The “Insight” lays out the stringent criteria for membership which


give consumers comfort <strong>and</strong> reassurance about the professionalism <strong>and</strong> credentials of the<br />

person or persons into whose care they are putting their body, their mind <strong>and</strong> their soul.<br />

Relais Santé follows a similar approach. Thus, these two organizations have laid a solid<br />

foundation to take advantage of the growth in what can be considered a ‘super-trend’ <strong>and</strong><br />

squarely address one of the major consumer concerns: quality assurance <strong>and</strong> consistency with<br />

respect to the facilities, spa products, services <strong>and</strong> treatments provided. For instance, massage<br />

therapy training in Ontario is more extensive than that found elsewhere <strong>and</strong> this province’s<br />

therapists are controlled by a government regulated college – both go a long way to reassuring<br />

consumers.<br />

Reaching the spa tourist<br />

As profound as the changes in the demographic characteristics of spa-goers have been since<br />

1999, so have the changes in information sources to which they resort. By far the most<br />

common source of information in 2006 was websites: over 80% of people who participated in<br />

health <strong>and</strong> wellness spa activities used them. This compares to less than 37% using the<br />

internet in 1999. Perhaps not surprising given their profile, the most visited types of websites<br />

involved travel (68%), entertainment (55%) <strong>and</strong> health (53%).<br />

The only other sources of any significance that were more popular in 2006 than in 1999<br />

included recommendations from friends <strong>and</strong> relatives (63% compared to 55%) <strong>and</strong> the<br />

respondent’s own past experience (59% compared to 57%). Even though all other forms of<br />

information sources have seen more or less steep declines over the years (e.g., the use of<br />

travel agents has dropped from 61% to 51% over the seven year period), the odds are quite<br />

high that spa-goers use them For example, spa-goers are twice as likely as non spa-goers to<br />

use a travel agent as an information source.<br />

Spa visitors are also very inclined to use the Internet to plan travel (89%), <strong>and</strong> rely heavily on<br />

accommodation (67%), airline (57%), travel planning/booking (e.g., Expedia, Travelocity –<br />

54%), <strong>and</strong> DMO websites (54%). They are also among the heaviest users of travel media, <strong>and</strong><br />

are particularly avid readers of health <strong>and</strong> wellness magazines <strong>and</strong> websites, city lifestyle,<br />

fashion <strong>and</strong> beauty magazines, <strong>and</strong> watch ‘better living’ programming (Lang Research Inc.,<br />

2007). Finally, spa-goers have always been more likely to book travel over the internet as<br />

well: already in 1999, 29% of those who had visited a health <strong>and</strong> wellness spa booked their<br />

trips this way, compared to 23% of those who were merely interested <strong>and</strong> 18% of those who<br />

were not interested in visiting them. (Lang Research Inc., 2000). By 2006, fully 68% of spagoers<br />

booked their stay over the internet, while 77.3% booked their accommodation <strong>and</strong> 76.9<br />

% booked their airline ticket, behavior that is significantly higher than pleasure travelers in<br />

general.<br />

Since spa-goers are particularly interested in “luxury resort vacations that are relaxing <strong>and</strong><br />

pampering, <strong>and</strong> that offer novelty, intellectual stimulation <strong>and</strong> physical challenge” (Lang<br />

Research Inc., 2007: 1), it is important that any promotion focus on these benefits. Spa-goers<br />

are one of the most likely segments to book their vacation experience over the internet (68%),<br />

largely through accommodation websites (77%).<br />

Generally speaking, “spa visitors are extremely active in both outdoor activities <strong>and</strong> in culture<br />

<strong>and</strong> entertainment activities while on trips. They frequently exercise <strong>and</strong> jog, <strong>and</strong> are much<br />

more likely than the average Canadian pleasure traveller to participate in strenuous winter<br />

activities (e.g., cross-country skiing <strong>and</strong> snowshoeing, downhill skiing) <strong>and</strong> summer sports<br />

(e.g., golf, tennis). They also frequently attend live art performances (e.g., live theatre, high


arts, comedy clubs <strong>and</strong> festivals) while traveling <strong>and</strong> exhibit particular interest in fine cruise<br />

(e.g., wine, beer & food tastings, inn or resort with gourmet dining)” (Lang Research Inc.,<br />

2007: 1). Indeed, there are a number of activities where the odds range from close to three to<br />

four times as likely that they will participate compared to non-spa goers. These include: ice<br />

climbing, dog sledding, hang-gliding, hot air ballooning, bungee jumping, horseback riding,<br />

windsurfing, cross- or back-country skiing, playing squash <strong>and</strong> tennis, working out, attending<br />

jazz concerts, recreational dancing, dining in restaurants with an international reputation,<br />

shopping/browsing in gourmet food retail stores <strong>and</strong> for clothing, shoes <strong>and</strong> jewellery. They<br />

are also three times more likely than non-spa goers to stay in a resort, whether it is located on<br />

a lakeside/riverside, in the mountains/ski or the seaside. And they are 5.5 times as likely to<br />

have stayed in a cooking school; indeed, over 40% of those who participated in health <strong>and</strong><br />

wellness spa activities also stayed in one of these schools!<br />

Implications<br />

The explosion in spa products for sale in almost any store that carries personal care <strong>and</strong><br />

beauty products is both a result of, <strong>and</strong> a contributor to, the growth in spa visits. This<br />

“personal introduction” is likely also the reason why even first-timers seem to have very high<br />

expectations regarding their visit. Men, who are introduced to the spa experience, often by<br />

their spouses, will usually start with a massage as they tend to be driven by notions of “work",<br />

i.e., improving some aspect of their body, their emotional state or their long-term spiritual <strong>and</strong><br />

personal dispositions (The Hartman Group, 2004). Increasingly, however, they are warming<br />

up to manicures <strong>and</strong> facials, largely as part of the broader societal trend that has seen a return<br />

of the acceptability of male grooming, along with greater acceptance of the gay culture <strong>and</strong><br />

the rise of the “metrosexual” who has many of the characteristics of his gay counterparts, but<br />

is heterosexual.<br />

As the spa consumer becomes more knowledgeable <strong>and</strong> educated about available treatments<br />

<strong>and</strong> their expected outcomes, he or she will increasingly look to the spa industry to provide<br />

ever more information about every aspect of a wellness program, <strong>and</strong> spas will be judged on<br />

their ability to make informed decisions <strong>and</strong> provide guidance in every aspect from menu<br />

design <strong>and</strong> implementation, to which training <strong>and</strong> treatment programs to engage in <strong>and</strong> why.<br />

But messages must go beyond addressing the core segment in terms of communications,<br />

menu designs <strong>and</strong> available spa treatments: even though they are the most committed, they<br />

represent the smallest percentage of the overall spa population, <strong>and</strong> thus, to convert the midlevel<br />

<strong>and</strong> periphery spa-goers, the messages must also address their lower level of knowledge.<br />

It is also important to realize that visits to day spas are an activity largely undertaken by<br />

women, but spa travel is not: 42% of the Canadian health spa resort clientele is men. Staying<br />

at such a resort is no guarantee, however, that they will actually participate in spa-related<br />

activities as only 37% indicated that they did so, based on 2006 TAMS study. Still, facilities<br />

at resorts <strong>and</strong> hotels must be adapted to a very discerning, mixed clientele, by also offering<br />

male-focused activities like golf, outdoor adventure, male cosmetic programs, <strong>and</strong> highoctane<br />

fitness programs.<br />

It is clear that this industry will have to place much greater emphasis on learning, by bringing<br />

in knowledgeable speakers from both the conventional <strong>and</strong> complementary or alternative<br />

medical fields to educate consumers who want to make informed decisions about their own<br />

health. Especially the core spa-goers are craving this type of knowledge, <strong>and</strong> avidly pursue<br />

their own underst<strong>and</strong>ing. Nutrition is already playing a much greater role as people become<br />

more aware of health effects procured by different food items, <strong>and</strong> weigh different dietary<br />

approaches to combat everything from obesity to medical problems. People’s anxiety over


genetically modified foods, additives <strong>and</strong> preservatives will lead them to sustain the growth in<br />

organic foods <strong>and</strong> the popularity of farmers’ markets, regional cuisines, <strong>and</strong> traditional foods,<br />

all of which are perceived to be more “natural” <strong>and</strong> therefore healthier.<br />

References<br />

Association Resource Centre Inc. (2006). 2006 Canadian Spa Sector Profile. Vancouver,<br />

B.C.: Canadian <strong>Tourism</strong> Commission<br />

Lang Research Inc. (2007). TAMS 2006: Canadian Travel Market - Visiting Spas While On<br />

Trips<br />

Of One or More Nights: A Profile Report. Toronto, ON: Ontario Ministry of <strong>Tourism</strong> <strong>and</strong><br />

partners.<br />

Lang Research Inc. (2001). Interest in <strong>Health</strong> Spas (Profile Report), Travel Activities &<br />

Motivation Survey (TAMS). Ottawa: Canadian <strong>Tourism</strong> Commission.<br />

Nahrstedt, W. (2004). “<strong>Wellness</strong>: A New Perspective for Leisure Centers, <strong>Health</strong> <strong>Tourism</strong>,<br />

<strong>and</strong> Spas in Europe on the Global <strong>Health</strong> Market” in Weiermair, K. & Mathies, C. (eds.).<br />

The <strong>Tourism</strong> And Leisure Industry: Shaping The Future. New York: Haworth Hospitality<br />

Press.<br />

PricewaterhouseCoopers (2004). The ISPA 2004 Spa Industry Study. Lexington, Ky:<br />

International SPA Association<br />

PricewaterhouseCoopers (2002). The ISPA 2002 Spa Industry Study. Lexington, Ky:<br />

International SPA Association<br />

The Hartman Group (2006). Identifying the Spa Traveler: A Look at US <strong>and</strong> Canadian<br />

Consumer Attitudes <strong>and</strong> Motivators for Spa Vacations. Canadian <strong>Tourism</strong> Commission<br />

<strong>and</strong> International SPA Association.


The use of the internet in wellness promotion by Portuguese spas<br />

Veronika Joukes<br />

Professor Auxiliar, DESG, CETRAD (ECHS),<br />

Universidade de Trás-os-Montes e Alto Douro (UTAD),<br />

Avenida Almeida Lucena 1, 5000-660 Vila Real, Portugal.<br />

veronika@utad.pt.<br />

Abstract<br />

Until 2004, Portuguese spas were traditionally thought of as establishments in which noninvasive<br />

therapies based on naturally-occurring sources of mineral water are provided under<br />

professional supervision. With the publication of the Decree-Law Nº 142/2004, Portuguese<br />

legislation regulating spas changed quite drastically: from that moment on, spa-owners,<br />

numbering some 40 establishments countrywide, were allowed to open up what had hitherto<br />

been a strictly health-orientated sector. Since then much has changed in the Portuguese<br />

mineral springs spa market: one of the main innovations has been the introduction of a large<br />

variety of services that may be termed “wellness treatments”, i.e. therapies not strictly related<br />

to pre-existing health conditions. These are now being offered as a product range in its own<br />

right along with traditional medical treatments, thus diversifying the services provided, all<br />

based on the same highly therapeutic naturally-occurring mineral water. Thus spa services are<br />

no longer just a health product, but have also become a tourist attraction, thereby legally<br />

formalising something that, to a limited extent, had always been the case. With the change in<br />

the services offered, the typical customer profile has also changed significantly: users of<br />

today’s spa facilities are younger (between 25 <strong>and</strong> 45 years of age) than in the past, from the<br />

middle to middle-upper socio-economic stratum, live in a large urban centre, have a<br />

reasonably high level of education, <strong>and</strong> could be either male or female. Such clients prefer<br />

making various short trips over the year to test out different destinations, <strong>and</strong> choose<br />

registered hotels with 3 or more stars for their stays. The changing client profile has meant<br />

changes in the means employed by firms to establish a growing <strong>and</strong> loyal client base. Indeed,<br />

over the past five years, a large majority of Portuguese spa service providers have<br />

significantly upgraded not only their services <strong>and</strong> infrastructures, but also their use of internet<br />

sites. With these changes in mind, the study reported on here 9 aimed to analyse the way such<br />

firms currently communicate with prospective clients using the web. The existing sites were<br />

therefore systematically screened during the Spring of 2009 (30 sites) <strong>and</strong> 2010 (34 sites),<br />

with a view to finding answers to the following questions: (i) how do they position their<br />

medical/wellness products? (ii) to what kind of public do they address their internet-based<br />

marketing efforts (iii) do they only mention their own services or do they also provide<br />

prospective clients with links that give information on other service providers, such as travel<br />

experts, sports organizations or nature guides? (iv) do the online marketing tools used by<br />

these spas stimulate user-communities? The results of this study may offer not only<br />

Portuguese but also spas in other locations the opportunity to further improve their dialogue<br />

with current <strong>and</strong> potential spa-goers.<br />

Introduction<br />

In Portugal, the supply side of health <strong>and</strong> wellness tourism consists of traditional spas based<br />

on natural mineral water springs (that have existed since Roman times at least), some<br />

9 This preliminary study was undertaken on our own initiative but the intention is to convert it into an<br />

international comparative project furnishing results that may be applicable to the sector under consideration.


thalassotherapeutic establishments (registered from 1990, <strong>and</strong> using therapies exclusively<br />

based on sea water), as well as a fast growing number of non-mineral water spas (established<br />

since the beginning of the 21st century, based on water from the public supply network). In<br />

numerical terms this situation translates into the following structure of suppliers: 38 mineral<br />

springs spas that, in 2008 10 , were open to the public (Turismo de Portugal, 2009b); fewer than<br />

10 sea-water units functioning in 2010 (Fern<strong>and</strong>es, 2006; Turismo de Portugal, 2009a); <strong>and</strong><br />

approximately 130 hotels with spa facilities reported by the Portuguese Hotel Association<br />

(AHP) for the same year, which corresponds to an increase of more than 1500% over the last<br />

8 years in the number of functioning “spa hotels” (Turismo de Portugal, 2010a). Meditative<br />

<strong>and</strong> holistic retreats (on the one h<strong>and</strong>) <strong>and</strong> medical tourism focusing particularly on<br />

aesthetic/cosmetic, dental <strong>and</strong> surgical treatments (on the other h<strong>and</strong>) are still in the<br />

introductory stage of their life cycle <strong>and</strong> consequently it is impossible to quantify their current<br />

share of the market – either because they are not yet the object of intensive promotion efforts<br />

<strong>and</strong>/or because these subsectors' activities still remain largely unstructured.<br />

This paper focuses on the spas that are based on mineral springs, commonly referred to in<br />

Portuguese as termas (the local adaptation of the Latin thermae, meaning hot springs/baths).<br />

In order to avoid misunderst<strong>and</strong>ings <strong>and</strong> to emphasize the unique Portuguese context, it<br />

should be underlined that for the Portuguese consumer the concept of “going to the termas”<br />

has long meant undergoing therapy based on mineral water springs, i.e. only those who were<br />

ill would “take the waters” <strong>and</strong>, consequently, mineral springs spa facilities were sought only<br />

by the un<strong>healthy</strong> <strong>and</strong> elderly. However, the number of spas nowadays greatly exceeded the<br />

number of termas <strong>and</strong> recent massive marketing <strong>and</strong> awareness campaigns have facilitated the<br />

introduction of the spa concept in Portugal, where the latter is now understood as a place (in<br />

an urban/rural environment, in a hotel/fitness complex, in a beauty centre or even in the<br />

traditional termas) where one can be pampered, but not necessarily with (mineral) water<br />

treatments. We have to stress another difference, important for the development of tourist<br />

products, between spa hotels <strong>and</strong> termas: the latter normally do not offer accommodation. On<br />

the other h<strong>and</strong>, the traditional termas are no longer seen as mere therapeutic infrastructures<br />

but also, <strong>and</strong> increasingly so, as places of leisure, recreation <strong>and</strong> relaxation. While, in<br />

principal, the two dimensions – therapy <strong>and</strong> recreation – are two facets of nowadays spas that<br />

can coexist in perfect harmony, the services provided by the emerging wellness tourism<br />

market in Portugal are still thought of as being quite separate from those offered by the<br />

turismo termal market (spa-based medical tourism), since Portugal has a much longer<br />

tradition in the latter field (Lapa, 2009).<br />

The main reason for finding these spas of analytical interest is the fact that they (i) are owned<br />

by relatively small public or private investor’s groups, (ii) are typically autonomous rather<br />

than part of a major grouping or conglomerate <strong>and</strong> (iii) are experiencing a phase of significant<br />

adaptation that obliges them to market their services more directly <strong>and</strong> aggressively.<br />

Based on a previously-conducted literature review, the empirical research analysed half of the<br />

existing spa websites in order to find out (i) how the termas position <strong>and</strong> promote both their<br />

traditional <strong>and</strong> new products, (ii) what kind of public they appeal to, (iii) whether they only<br />

mention their own services or also provide information on complementary service suppliers,<br />

such as travel experts, sports organizations or nature guides, to which potential clients are<br />

redirected, <strong>and</strong> (iv) whether they use interactive techniques. However, before presenting the<br />

results of this survey, the general context in which these mineral springs spas have evolved<br />

will be described.<br />

10 The most recent official statistics referring to the sector date from 2008.


The main characteristics of Portuguese mineral springs potential<br />

In Portugal 408 springs with mineral water are reported to have therapeutic properties, <strong>and</strong><br />

three quarters of them (300) are recognised by the local population as having curative<br />

properties (Sousa, 2006). In the spring of 2010 already 44 such spas were officially being<br />

exploited. However, only 39 were open to the public, two more than in the previous year. The<br />

Central region of Portugal has 20 spas (or 45% of the total), the North has 18 (41%), while<br />

only 14% of the total number of termas are located in the remaining four regions – three in<br />

the Alentejo <strong>and</strong> one each in Lisbon, the Algarve <strong>and</strong> the Azores (ATP, 2010; Turismo de<br />

Portugal, 2009b).<br />

It is not compulsory for spas to be registered members of the Associação das Termas de<br />

Portugal, the organisation that defends the interests of the country’s subscribing mineral<br />

springs spas. However, most spas are in fact members, with only the northern termas of<br />

Moledo, Eirogo <strong>and</strong> Carlão never having joined the ATP. These 3 independent spas (indicated<br />

in blue) <strong>and</strong> the limits of the NUTS II sub-regions (in green) are also indicated on the map<br />

below. Figure 1 shows the geographical spread of ATP-member spas across the country.<br />

In the Central region, as a matter of fact in São Pedro do Sul, the largest Portuguese termas<br />

are to be found with 17.017 medical spa goers in 2008. The second largest facility with regard<br />

to this kind of public, Termas de Chaves, another municipal company, however, h<strong>and</strong>led<br />

6.374 medical attendants over the same period, only a little more than one third of the number<br />

TERMALISTUR reached. This considerable discrepancy explains why the North only served<br />

25.814 mineral springs spa goers in 2008 <strong>and</strong> the Centre more than double (58.870) (Turismo<br />

de Portugal, 2009b).<br />

It is also important to note that of the 44 units under consideration (41 ATP members <strong>and</strong> 3<br />

independent ones), 21 (48%) already renovated their premises since 2000 <strong>and</strong> that another 5<br />

(11%) will reopen within a short span of time. This year the brochure Saúde & bemestar, in<br />

which 20 innovative <strong>and</strong> differentiating qualification projects sponsored by Turismo de<br />

Portugal over the last decade are listed in an appealing way, included mineral springs spa<br />

(along with spa hotel) renovation projects with a total investment value between 470.000€ <strong>and</strong><br />

20.900.000€ (Turismo de Portugal, 2010b).


Figure 1. Geographical spread of Portuguese mineral springs spas in 2010<br />

Termas (Nº indicates District Region Figure<br />

location on map)<br />

(NUTS<br />

II)<br />

04 Caldas de Chaves Vila<br />

05 Termas do Vidago<br />

06 Águas Santas de<br />

Carvalhelhos<br />

09 Termas de Pedras<br />

Salgadas<br />

001 Caldas de Moledo<br />

003 Caldas do Carlão<br />

14 Caldas de Aregos<br />

Real<br />

01 Termas de Viana<br />

Melgaço<br />

do<br />

02 Caldas de Monção Castelo North<br />

03 Termas do Gerês Braga<br />

002 Termas de Eirogo<br />

Centre<br />

07 Termas<br />

Caldelas<br />

de<br />

08 Caldas das Taipas<br />

11 Termas de Vizela<br />

12 Termas<br />

Vicente<br />

de S.<br />

10 Caldas da Saúde<br />

13 Termas de Entreos-Rios<br />

Porto<br />

Lisbon<br />

16 Caldas de S. Jorge<br />

21 Termas do Vale da<br />

Mó<br />

25 Termas da Curia<br />

26 Termas do Luso<br />

Aveiro<br />

Aveiro<br />

Alentejo<br />

17 Termas<br />

Carvalhal<br />

do Viseu<br />

Algarve<br />

20 Termas de S.<br />

Pedro do Sul<br />

22 Caldas<br />

Sangemil<br />

de<br />

23 Termas<br />

Felgueira<br />

da<br />

24 Termas<br />

Alcafache<br />

de<br />

Centre<br />

15 Termas<br />

Longroiva<br />

de Guarda<br />

18 Caldas da Cavaca<br />

19 Termas<br />

Almeida<br />

de<br />

27 Caldas<br />

Manteigas<br />

28 Caldas do Cró<br />

de<br />

North


29 Termas de Unhais<br />

da Serra<br />

30 Termas de<br />

Monfortinho<br />

31 Termas de Ladeira<br />

de Envendos<br />

32 Termas de Monte<br />

Real<br />

33 Termas das<br />

Salgadas<br />

34 Caldas da Rainha<br />

35 Termas do<br />

Vimeiro<br />

Castelo<br />

Branco<br />

Santaré<br />

m<br />

Leiria<br />

Lisbon<br />

39 Termas do Estoril Lisbon Lisbon<br />

36 Termas de<br />

Fadagosa de Nisa<br />

37 Termas de Monte<br />

da Pedra<br />

38 Termas de Cabeço<br />

de Vide<br />

40 Caldas de<br />

Monchique<br />

Portale<br />

gre<br />

Alentej<br />

o<br />

Faro Algarve<br />

41 Termas das Furnas Azores Azores<br />

Source: Mapped by the author (based on ATP, 2010; INETI, 2004; Turismo de Portugal,<br />

2009b).<br />

The data presented in Table 1 show that exactly half of the units are publicly-owned <strong>and</strong> the<br />

other half are in private h<strong>and</strong>s. Contrary to what we might expect, 62% of the 21 renovation<br />

projects so far executed were initiated by publicly-owned companies. Of the 5 that still have<br />

to reach their final stage, however, 80% are private. Of the 18 establishments where nothing<br />

has been undertaken yet, in turn, 44% are publicly-owned.<br />

Table 1. Renovation of publicly- <strong>and</strong> private-owned termas in 2010<br />

Publicly-owned termas Private termas Total<br />

Renovation projects (concluded) 13 8 21<br />

Renovation projects (in progress) 1 4 5<br />

Without renovation projects 8 10 18<br />

Total 22 22 44<br />

Source: Elaborated by the author based on the termas websites (see list <strong>and</strong> respective<br />

addresses in Table 2 below) <strong>and</strong> on the following publications: (ATP, 2010; Medeiros &<br />

Cavaco, 2008; Turismo de Portugal, 2009b).<br />

We also noted that the smaller the unit is, the less probable it is that it will be quickly<br />

renovated. Of the 15 termas that had less than 1.000 medical clients in 2008, 7 remain in<br />

exactly the same physical state as in 2000, 2 are under reconstruction <strong>and</strong> 6 have already<br />

concluded their renovation work. In contrast, the 10 termas with the best sales figures all had<br />

concluded such projects by 2010.<br />

Further calculations indicated that ownership of spa hotels tends to be private (78%): of 18<br />

such hotel units, 2 are owned by INATEL (a public body) <strong>and</strong> only those at Carvalhal <strong>and</strong>


Monção are run by the local municipality. Of the balneários (spas without residential<br />

facilities), one-third have private owners <strong>and</strong> two-thirds are in public h<strong>and</strong>s.<br />

Today’s typical spa goer<br />

In this section, in order to concentrate on “new” spa goers, “traditional” spa-goers (by which<br />

is meant elderly persons with medical conditions that require curative treatments, with very<br />

limited purchasing power, <strong>and</strong> with low expectations as to the quality of spa <strong>and</strong> lodging<br />

facilities that function only during the warmer months of the year) have been disregarded<br />

(Medeiros & Cavaco, 2008). Nowadays not only the mineral springs spas, but all the other<br />

types of spas want to widen their clientele <strong>and</strong> for this reason increasingly use websites as a<br />

means of attracting new clients to this niche market. Gustavo (Gustavo, 2009), drawing on his<br />

ongoing doctoral research, argues that spas occupy a privileged market position not only<br />

because they are associated with the principles of both health <strong>and</strong> well being, but also – <strong>and</strong><br />

probably mainly – because they are able to reinvent themselves in line with a global <strong>and</strong><br />

hybrid philosophy that mirrors the world in which we currently live.<br />

In order to discover clients’ motivations, the kind of services they prefer during a spa<br />

visit/stay <strong>and</strong> their daily health care practices at home, Gustavo collected responses from 824<br />

clients during May to August 2009 in 21 “classic” <strong>and</strong> “new” hydrotherapeutic leisure spaces.<br />

His results led him to conclude that the typical spa-goer today is predominantly female (70%),<br />

in their thirties (average age 39, with 40% of the sample between 30 <strong>and</strong> 39), has a degree<br />

(74%), with those in a stable conjugal relation being equal in number to single persons (24%<br />

<strong>and</strong> 25% respectively), many without children, living in an urban area (72%), in Portugal<br />

(73%); the vast majority (92%) are in employment, predominantly in high level managerial or<br />

technical capacities, 89% of the employed having jobs in the service sector. In almost half of<br />

the cases, the family net income exceeds 3.000€ per month i.e. more than six times the 2009<br />

Portuguese guaranteed minimum income of 450€/month. These clients are most likely to visit<br />

a spa facility during the week (45%) or to integrate it into a (short) holiday break (41%).<br />

Those interviewed by Gustavo regularly visit spas (31% of them once a month) in order to<br />

relieve stress or to relax (74%) <strong>and</strong>/or to upgrade mental <strong>and</strong> physical health (50%). Massage<br />

<strong>and</strong> body treatments are the spa services with most dem<strong>and</strong>. Notwithst<strong>and</strong>ing the dominant<br />

historical <strong>and</strong> cultural influence of the classical termas, nearly 50% of the clients said they<br />

had not undergone hydrotherapeutic treatments during their last spa visit.<br />

The same survey also revealed that future clients consider the quality of treatment, the quality<br />

of customer service, hygiene <strong>and</strong> cleanliness, the cost of services <strong>and</strong> the location of the spa<br />

as the most relevant factors influencing their decisions to visit or revisit particular sites.<br />

Another important conclusion to draw is that spa clients are essentially <strong>healthy</strong> people: 87%<br />

of those surveyed consider their routines as <strong>healthy</strong>, stressing the importance of food (89%)<br />

<strong>and</strong> physical exercise (83%) <strong>and</strong> their personal attitude in favour of a <strong>healthy</strong> lifestyle tout<br />

court (54%). 42% only consume alcohol at the weekends or on special occasions, while 69%<br />

are non smokers. They undergo annual medical check-ups every year on their own initiative.<br />

70% of the sample has a normal or below average Body Mass Index. For marketing purposes,<br />

finally, it is relevant to bear in mind that 14% of those answering the questionnaire were in<br />

the spa at the time as a result of having received a gift voucher.<br />

Portuguese spa managers may also find the annual SpaFinder forecasts a source of inspiration<br />

in defining their marketing strategies: these reports are compiled by “a team of experts who<br />

visit thous<strong>and</strong>s of spas”, interview top industry analysts <strong>and</strong> research organizations, <strong>and</strong> do


ongoing consumer <strong>and</strong> industry research in the spa, travel, wellness, <strong>and</strong> beauty sectors. In<br />

December 2009, the Top 10 Global Spa Trends to Watch in 2010 was launched, identifying<br />

global spa trends that will influence spa experiences for both consumers <strong>and</strong> the industry in<br />

2010 <strong>and</strong> for years to come. They argue, for example, that prevention is the new “P”-word<br />

(substituting its predecessor – “pampering”) <strong>and</strong> claim that belonging to a spa, rather than just<br />

visiting it, increases one's emotional health. They defend that, while the spa industry’s virtual<br />

presence will continue to grow, room has to be made for “wellness tourism”; <strong>and</strong> they also<br />

foresee an era of integrated spa, fitness, health, spiritual, wellness <strong>and</strong> beauty facilities<br />

(SpaFinder’s Seventh Annual “Top 10 Global Spa Trends to Watch in 2010” (Press Release),<br />

2010).<br />

Since prior knowledge of the customer is so important, greater adherence on the part of spa<br />

managers to the SPA & Thalasso Monitor, launched by the Portuguese Hotel Association<br />

(AHP) in May 2009, would seem appropriate. All participating hotel units in the sector are<br />

provided with free access to this benchmarking system that produces operational management<br />

information relevant for this market. The Monitor is supported by software that allows, at any<br />

time, all member <strong>business</strong>es to review their (historical) data <strong>and</strong> weigh the position of their<br />

own unit relative to others in the same or in different regions of Portugal. It fills a serious<br />

lacuna in technical information available on this segment, making accessible monthly-updated<br />

operational indicators as well as data on market activity, providing a <strong>business</strong> management<br />

tool, <strong>and</strong> guarantees that public tourism officials (local, regional <strong>and</strong> national) can access<br />

whenever necessary, reliable information relative to their geographical area (AHP, 2009;<br />

Mourão, 2010).<br />

Principal results of the analysis of 15 mineral springs spa websites<br />

It is not only those who want to decide how they are going to pamper themselves who take<br />

advantage of the internet, but also those active on the supply side. The internet constitutes the<br />

only medium capable of furnishing round-the-clock, “instant” <strong>and</strong> up-to-date information on<br />

new techniques, products <strong>and</strong> services. This makes it easy for service providers to innovate,<br />

reinvent <strong>and</strong> promote service packages <strong>and</strong> incentivise termas to continuously develop their<br />

communicative capacities <strong>and</strong> to explore the marketing techniques to the limit in the context<br />

of a market niche of substantial commercial interest (Gustavo, 2009).<br />

So far no research has been undertaken in Portugal into the internet marketing strategies of<br />

spas, neither have their websites been analyzed in any systematic way. The study reported on<br />

here concentrated on the years 2009 <strong>and</strong> 2010: one year ago, 37 termas were open to the<br />

public <strong>and</strong> 30 of them had a website, while in 2010 two more termas (39) were functioning, of<br />

which 34 promoted their services through the internet. In the two years under consideration,<br />

the arguments firms advanced for not employing a website were: (i) that the firm was in a<br />

remodelling phase <strong>and</strong> therefore there would be few if any returns deriving from an internet<br />

site; or (ii) that the firm’s main clients were principally local elderly customers, the spa<br />

facilities were limited, <strong>and</strong> only open during a short period of the year <strong>and</strong> therefore there was<br />

little hope of attracting new segments of spa goers. Only Moledo <strong>and</strong> Eirogo, two of the three<br />

independent spa units, are examples of the latter situation, while the other cases fit into the<br />

first group. As a matter of fact, in three (Almeida, Monte Real <strong>and</strong> Nisa) of the four cases of<br />

new websites created in 2010, the website launched coincided with the reopening of the<br />

premises after renovation, while the creation of the Taipas website has to be interpreted as<br />

part of the 2010-2013 plan of its newly elected board that, amongst other objectives, intends<br />

to redefine its public <strong>and</strong> modernize the spa (Taipas Turitermas, 2010).


In the same period, 9 termas merely offered basic information posted on the website of an<br />

umbrella institution (the Carvalhelhos spa on the website of the bottled water firm of the same<br />

name; those of Entre-os-Rios <strong>and</strong> Manteigas are to be found on INATEL’s website; Almeida,<br />

Vale da Mó, Sangemil, Cró <strong>and</strong> Cabeço de Vide on the website of the municipality that owns<br />

them; <strong>and</strong> Caldas da Rainha on the Ministry of <strong>Health</strong>’s website). With the exception of<br />

Cabeço da Vide, the termas with over 2.000 medical spa goers per year (corresponding to 1/3<br />

of the termas with a website link) have their own appealing websites, whereas of the 15<br />

smaller spas (receiving less than 1.000 visitors in 2008), 4 have no website at all <strong>and</strong> 4 only<br />

furnish the most basic details through an umbrella website. The internet presence of termas<br />

open to the public <strong>and</strong> with accommodation is 100% <strong>and</strong> 85% of those without integrated<br />

accommodation.<br />

In order to find out how the termas use the internet to sell their services, it was decided to<br />

focus on those that had created their own web page (excluding those with information inserted<br />

on an umbrella site) <strong>and</strong> that had been functioning in 2009 <strong>and</strong> 2010. This universe of spa<br />

units (i) was representative of the regional distribution of spas, (ii) included both private <strong>and</strong><br />

public initiatives, (iii) took in both well-visited <strong>and</strong> less-visited <strong>business</strong>es <strong>and</strong> (iv)<br />

incorporated both spas functioning without accommodation (balneários) <strong>and</strong> mineral springs<br />

spa hotels. As there were only 2 eligible sites in the South of Portugal, the sample taken from<br />

this universe was adjusted so as to include 7 sites in the Centre of the country <strong>and</strong> 6 in the<br />

North, respecting the 14% - 45% - 41% spatial distribution ratio referred to above, as can be<br />

verified in Table 2 below.


Name<br />

Table 2. Spa websites analysed<br />

São Pedro<br />

do Sul<br />

NUTS<br />

II<br />

Rankin<br />

g Nº of<br />

medical<br />

spagoers<br />

Nº of<br />

medical<br />

spagoers<br />

(2008)<br />

Centre 1 17.017<br />

Chaves North 2 6.374<br />

Felgueira Centre 4 4.511<br />

Renovate<br />

d during<br />

last<br />

decade?<br />

2005<br />

(Sept) -<br />

2007<br />

(June)<br />

2005<br />

(May)<br />

none<br />

(1997)<br />

São Jorge North 6 3.655 2003<br />

Concessio<br />

n holder<br />

in 2010<br />

Municipali<br />

ty<br />

Municipali<br />

ty<br />

Accomm<br />

-odation<br />

provided<br />

?<br />

balneári<br />

o<br />

balneári<br />

o<br />

Website address<br />

www.termas-spsul.com<br />

www.termasdechaves.com<br />

Private hotel www.termasdafelgueira.pt<br />

Municipali<br />

ty<br />

Gerês North 8 3.443 2007 (Jan) Private<br />

Monfortin<br />

ho<br />

Centre 10 2.358<br />

Saúde North 15 1.326<br />

São.<br />

Vicente<br />

North 16 1.258<br />

2000<br />

(Aug)<br />

none<br />

(1994)<br />

2008<br />

(June)<br />

balneári<br />

o<br />

balneári<br />

o<br />

www.termas-sjorge.com<br />

www.aguasdogeres.pt<br />

Private hotel www.monfortur.pt<br />

Private<br />

balneári<br />

o<br />

www.caldas-da-saude.pt<br />

Private hotel www.termas-svicente.pt<br />

Luso Centre 18 1.176 2010 Private hotel www.termasdoluso.com<br />

Longroiva Centre 21 1.004 2009 (Oct) Municipali<br />

ty<br />

balneári<br />

o<br />

www.termasdelongroiva.c<br />

om.pt<br />

Vimeiro Centre 22 637 none Private hotel www.termasvimeiro.com<br />

Monchiqu<br />

e<br />

Algarv<br />

e<br />

23 621<br />

2002<br />

(May)<br />

Aregos North 24 604 2009<br />

Cavaca Centre 28 421<br />

2008<br />

(July)<br />

Private hotel<br />

Municipali balneári<br />

ty o<br />

Municipali balneári<br />

ty o<br />

www.monchiquetermas.co<br />

m<br />

www.termascaldasdearegos.com<br />

www.caldasdacavaca.pt<br />

Furnas Azores no data no data 2008 (Oct) Private hotel www.furnasspahotel.com<br />

Source: compiled by author, based on the websites listed, INETI, 2004 <strong>and</strong> Turismo de<br />

Portugal, 2009b.<br />

As mentioned above, modernisation efforts on the part of the owners of mineral springs spas<br />

did not stop at infrastructural renovation projects: many also established internet sites, on<br />

which they placed <strong>and</strong> managed different types of information. Some of the more interesting<br />

aspects of the internet sites encountered in the survey are presented below.<br />

Almost all sites (Aregos <strong>and</strong> Longroiva being the only ones that offer only classic treatments)<br />

use different subpages to recommend both medical <strong>and</strong> wellness products. However, the<br />

degree of detail in the information provided is variable, with the Furnas site being the least<br />

impressive example, referring to nothing more than the installations where the treatments take<br />

place. In the majority of cases, sites not only summarise the treatments available, but also<br />

explain them: Three do so with photos <strong>and</strong> the São Jorge site supplies a glossary of almost 30<br />

terms. Only a small group bring together frequently asked questions in a dedicated “FAQ”<br />

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<br />

termas differentiate their prices following one or more of the following criteria: (i) the longer<br />

the stay <strong>and</strong>/or the more treatments acquired, the cheaper the unit price; (ii) prices vary<br />

according to whether the visit is made in the low, middle or high season; (iii) returning<br />

customers receive discounts; (iv) group bookings pay less; (v) in spa hotels, prices change<br />

according to whether the treatment is bought with or without accommodation.<br />

None of the termas created a subpage with general tips on <strong>healthy</strong> lifestyle, although some do<br />

mention that they have a staff nutritionist <strong>and</strong> it is in this context that certain advice is given.<br />

None of the termas elaborated a code of ethics, but São Jorge does mention a small list of<br />

commitments regarding the quality of the services offered. None of the termas explicitly<br />

mentions its concern for the principles of sustainability <strong>and</strong> local development. Implicitly,<br />

some display pro-nature values, describing the spa’s <strong>healthy</strong> surroundings in their<br />

introductory texts or including “green” pictures on the opening page of the site or in the site’s<br />

photo gallery. Only on the São Pedro do Sul site is there a subpage entitled “quality <strong>and</strong><br />

environment” that includes a manual of environmental good practices («Boas práticas<br />

ambientais»).<br />

The way the termas address their public is still very general. However, there are exceptions to<br />

the rule. The São Jorge, São Pedro do Sul, Felgueira <strong>and</strong> Monchique units let us know in a<br />

more or less obvious way that they welcome children: Felgueira provides them with a junior<br />

passport <strong>and</strong> has created the mascot Felgui, following the example of the São Pedro do Sul<br />

termas that uses the frog Afonsinho <strong>and</strong> the squirrel Amelinha. Monchique has a Kids’ Club.<br />

Monfortinho to some degree focuses on clients in the area for the hunting, while Monchique<br />

does something similar to attract the sailing community <strong>and</strong> Vimeiro targets horse riders <strong>and</strong><br />

golf players. Águas do Gerês hopes to conquer nature <strong>tourists</strong>, mentioning its unique<br />

localization in the Peneda-Gerês National Park.<br />

Only the Caldas de Aregos site had the Web Access Symbol for people with disabilities (a<br />

blue globe, marked with a grid, tilted at an angle with a yellow keyhole in the middle) at the<br />

bottom of its main page. There is no guarantee that a site using this symbol will be 100%<br />

accessible, or was even designed according to the guidelines: it is the responsibility of website<br />

users to “let the webmasters know when a site is or is not accessible to the disabled, <strong>and</strong> to<br />

offer suggestions for greater accessibility. Those who use the symbol should do so at their<br />

own discretion, underst<strong>and</strong>ing the goals of the growing group of people dedicated to making<br />

the Web useful for all” (Web Access Symbol, [S.d.]).<br />

Two-thirds of the websites consulted try to retain the loyalty of their clients by offering them<br />

the possibility of subscribing to their newsletter. It should be noted that, in most cases,<br />

prospective clients will not receive a real newsletter, but be notified of all the promotion<br />

actions of the enterprise. Eight websites used the main page of their website as an alternative<br />

way of announcing these kinds of special promotional campaigns.<br />

São Pedro do Sul is the only termas that can afford the luxury of investing in a year round<br />

programme of events <strong>and</strong> activities for its guests. The monthly programme can be<br />

downloaded from the internet. Smaller units like Chaves, São Jorge <strong>and</strong> Monchique only<br />

produce this kind of programme in the high season. In most cases though, future clients are<br />

not informed or are only informed in a very brief <strong>and</strong> vague way about complementary tourist<br />

activities in the surrounding area. São Pedro do Sul <strong>and</strong> Chaves, owned by the municipality,<br />

limit themselves to inserting links to other organisations patronised by the municipality. No


more than a h<strong>and</strong>ful of links were oriented towards “independent” companies offering<br />

specialised tourist activities: Aregos links to “Douro à Vela” a company specialising in river<br />

trips, São Jorge has a link to the Lourosa Zoo <strong>and</strong> to the “Visionarium” Science Museum <strong>and</strong><br />

the Monfortinho unit has a link to the “Naturtejo” Geopark. Monfortinho is also an exception<br />

inasmuch as it mentions direct competitors, be it Vimeiro (which belongs to the same group)<br />

<strong>and</strong> the Portuguese Spa Association (which can also be accessed via the website of São Pedro<br />

do Sul). All the spas that are integrated into hotels refer to their own lodging facilities, while 6<br />

balneários mention the addresses of local lodgings, <strong>and</strong> Longroiva <strong>and</strong> Cavaca also list local<br />

restaurants.<br />

All the termas bet on being reachable by internet, offering the possibility to open an emailbox<br />

by clicking on their e-mail address. 1/3 offers the possibility to fill out an online<br />

“message” form. More than half offer online reservation possibilities, although in 3 cases this<br />

is limited to a hotel reservation. São Jorge <strong>and</strong> Felgueira give their clients on top the<br />

possibility to telephone them for free.<br />

With regard to other aspects of online interactivity, scores are still very low: no unit has set up<br />

a discussion forum; only São Jorge has a website poll question, with questions such as: “Are<br />

you aware that a spa cure can benefit from refunds from the national health service?” Five<br />

spas give customers’ opinions, albeit in a partly “censored” form; São Jorge is connected to<br />

Twitter, São Pedro do Sul <strong>and</strong> Felgueira to Facebook, <strong>and</strong> Felgueira created a blog in January<br />

2010. São Pedro do Sul <strong>and</strong> Felgueira offer merch<strong>and</strong>ised products. In the former case they<br />

can be individually ordered online <strong>and</strong> paid for in the traditional way (by cheque, ATM or<br />

bank transfer); in the latter case an online shopping option (with a cart) is to be established,<br />

but was not working at the time of the survey. Of the three units that offer vouchers, São<br />

Jorge’s facilities are the most elaborate.<br />

Conclusions<br />

Having noted that the large majority of the mineral springs spa service providers have been<br />

significantly upgrading not only their services <strong>and</strong> infrastructures, but also their websites over<br />

the past five years, the survey analysed the way they currently communicate with their<br />

(prospective) clients through the internet. We conclude that the Decree-Law Nº 142/2004 has<br />

brought about real changes: the majority of Portuguese mineral spring spas now offer medical<br />

along with wellness services <strong>and</strong> inform prospective clients correctly <strong>and</strong> honestly about what<br />

to expect. Nevertheless, here are still numerous opportunities for spas to improve their<br />

internet presence in many directions: by putting more (<strong>and</strong> more accurate) information on<br />

their sites, they will be able to target special groups <strong>and</strong> market segments, redirecting<br />

prospective clients to complementary tourist activities <strong>and</strong> expressing their concern over<br />

environmental, sustainability <strong>and</strong> local development issues. Termas would be well advised to<br />

develop their interactivity by creating discussion forums, making their sites more accessible,<br />

offering more online shopping possibilities, taking more advantage of social networks or<br />

creating more transparent subpages in which clients’ opinions can be expressed. Our sample,<br />

moreover, provides evidence that the more content <strong>and</strong> links are put on the internet, the better<br />

informed clients will become <strong>and</strong> the more likely it will be that (potential) clients will be<br />

attracted by the product under consideration. We are also convinced that even “extremely<br />

small” spa units can benefit from developing focused <strong>and</strong> functional websites.<br />

In our opinion the results of this study offer not only Portuguese mineral springs spas but spas<br />

in general the chance to further improve their internet dialogue with current <strong>and</strong> potential spagoers.


In conclusion, researchers in this field are encouraged to develop a more comprehensive<br />

international comparative study of spa websites in order to work out guidelines for common<br />

best practices.<br />

I would like to thank Barrie Abbott, Louis Joukes <strong>and</strong>, most of all, Chris Gerry for their<br />

contributions to the final form of this text <strong>and</strong> also the first year students of UTAD's <strong>Tourism</strong><br />

degree (Ana Carina Lima, Ângela Silva, Carla Machado, Cátia Rodrigues, Marta Mota,<br />

Natércia Lourenço, Rita Teixeira, Sara Rebelo, Sara Teixeira, Sónia Ala, Telma Castilho,<br />

Telma Guerra, Teresa Gonçalves <strong>and</strong> Tiago Araújo) who assisted in the collection, during<br />

February of 2009, of some of the data necessary for this paper.<br />

References<br />

AHP (2009). Como aderir ao SPA & Thalasso Monitor. Retrieved 03-02-2010, from<br />

http://www.hoteis-portugal.pt/?data=read.obj&mod=news&aid=1500.<br />

ATP (2010). Turismo de saúde e bem-estar. <strong>Health</strong> <strong>and</strong> wellness tourism. Lisboa: ATP.<br />

Decreto-lei n.º 142/2004, de 11 de Junho. (2004). Diário da República, pp. 3632-3641.<br />

Fern<strong>and</strong>es, J. V. (2006). Thalassa, Thermae, SPA – Salute per Aqua. Lisboa: Plátano<br />

Editora.<br />

Gustavo, N. (2009). Turismo de saúde. Uma abordagem à luz dos desígnios do século XXI. In<br />

J. M. Simões & C. C. Ferreira (Eds.), Turismos de nicho. Motivações, produtos,<br />

territórios, pp. 191-204. Lisboa: CEG.<br />

INETI (2004). Termalbase. Retrieved 21-02-2010, from http://e-geo.ineti.pt/bds/termalbase/.<br />

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minerais naturais do concelho de Chaves pela Câmara Municipal (1892-1948).<br />

Unpublished PhD-Thesis, UTAD, Vila Real.<br />

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termais e talassoterapia. Lisboa: CEPCEP da Universidade Católica Portuguesa.<br />

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conference which opened BTL on 13-01-2010]. Lisboa: Turismo de Portugal.<br />

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http://www.aguaonline.co.pt/arquivo/noticias/termalismo.htm.<br />

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(2010). Retrieved 10-02-2010, from<br />

http://www.spafinder.com/about/press_release.jsp?relId=185.<br />

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01-2010, from http://www.taipasturitermas.pt/planodeactividades20102013.pdf.<br />

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EE912C729B26,frameless.htm.<br />

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http://ncam.wgbh.org/webaccess/symbolwinner.html.


<strong>Health</strong> Spa <strong>and</strong> <strong>Wellness</strong> – Competition or Supplement?<br />

The Czech Republic Case<br />

Alžbeta Kiráľová<br />

Vysoká škola obchodní v Praze/ University of Business in Prague, Prague, Czech Republic<br />

alzbeta.kiralova@vso-praha.eu<br />

Abstract<br />

This paper examines the relations between health spa <strong>and</strong> wellness in the Czech Republic.<br />

While the importance of health spa to the Czech economy is generally acknowledged wellness<br />

is often seen as a second-rate activity with no or very low effect on health because of the<br />

average length of stay <strong>and</strong> lack of treatments complexity.<br />

The Czech Republic combines a number of important attributes as a destination for health spa<br />

tourism, with a long lasting tradition of health spa culture. It offers climatic spas, healing hot<br />

<strong>and</strong> cold springs, healing torf <strong>and</strong> mud - all for treatment <strong>and</strong> recuperation <strong>and</strong> a high st<strong>and</strong>ard<br />

of services for medical <strong>and</strong> wellness tourism at cost–effective rates. The paper starts with a<br />

short introduction of tourism in the Czech Republic followed by health state <strong>and</strong> aging<br />

characteristic of the Czech Republic <strong>and</strong> implications for tourism. Together with the<br />

introduction of the Czech health spa industry the place of wellness in the Czech Republic<br />

tourism industry is explored <strong>and</strong> complements this with simple statistics.<br />

It reports about an exploratory case study that looked at the relation between health spa <strong>and</strong><br />

wellness in the Czech Republic from the point of view of <strong>tourists</strong>. The aim of the study was to<br />

explore the relation of both <strong>and</strong> to consider the expectations of <strong>tourists</strong> in this field.<br />

Accordingly, the management of facilities has been contacted individually; <strong>tourists</strong> were<br />

investigated through a survey. The concluding sections discuss options in attracting <strong>tourists</strong> to<br />

motivate them to frequent health spas <strong>and</strong> wellness visits.<br />

Keywords: <strong>Tourism</strong>, <strong>Health</strong> Spa, <strong>Wellness</strong>, Czech Republic<br />

Introduction<br />

The Czech Republic is a l<strong>and</strong>locked country, situated in Central Europe with the total area of<br />

78.866 sq km. Its total boundaries are 1.881 km (border countries: Austria 362 km, Germany<br />

646 km, Pol<strong>and</strong> 658 km, Slovakia 215 km). Climate is temperate, affected by the interaction<br />

of oceanic <strong>and</strong> continental effects.


Map of the Czech Republic Picture 1<br />

Source: Downloaded from: https://www.cia.gov/library/publications/the-worldfactbook/geos/ez.html<br />

(last accessed 7 March 2010)<br />

The number of population of the Czech Republic is 10.230.000. The Capital of the Czech<br />

Republic is Prague. The Czech Republic joined NATO in 1999 <strong>and</strong> the European Union (EU)<br />

in 2004.<br />

The Czech Republic is one of the most stable <strong>and</strong> prosperous of the post-Communist states of<br />

Central <strong>and</strong> Eastern Europe. 11 The per capita GDP reached 25.100 USD (2009 est.), the<br />

inflation rate is 1.1% (2009 est.), the unemployment rate is 9.3% (2009 est.), <strong>and</strong> 56.2 % of<br />

labor is employed in services. 12<br />

The conditions for tourism development are excellent – there are twelve historical monuments<br />

on the UNESCO Heritage list, 13 over 2.000 castles, chateaux <strong>and</strong> monuments, <strong>and</strong> more than<br />

40 protected historical towns <strong>and</strong> cities in the Czech Republic.<br />

Four national parks 14 were established to protect the country´s most rare <strong>and</strong> valuable nature,<br />

8 mountain ranges, <strong>and</strong> over 1.200 protected l<strong>and</strong>scape areas <strong>and</strong> natural spots are covering<br />

more than 10 % of territory of the Czech Republic offering 38.500 km walking trails, 19.024<br />

km cycling routes, 1.240 km skiing tours to visitors. The country is dotted with over 20.000<br />

lakes <strong>and</strong> ponds <strong>and</strong> more then 40 water basins.<br />

11 CIA. The World Fact Book – Czech Republic. Downloaded from:<br />

https://www.cia.gov/library/publications/the-world-factbook/geos/ez.html (last accessed 7 March 2010)<br />

12 CIA. The World Fact Book – Czech Republic. Downloaded from:<br />

https://www.cia.gov/library/publications/the-world-factbook/geos/ez.html (last accessed 7 March 2010)<br />

13 The historic centre of Prague, Český Krumlov, Telč, <strong>and</strong> Kutná Hora, the pilgrimage church of St. John of<br />

Nepomuk on Zelená Hora at Žďár nad Sázavou, South Moravia´s Lednice-Valtice Chateau <strong>and</strong> l<strong>and</strong>scape area,<br />

the Archbishop Chateau in Kroměříž with Květná <strong>and</strong> Podzámecká gardens, South Boheniam village of<br />

Holašovice, Litomyšl Castle, the Baroque Holly Trinity Column in Olomouc, Villa Tugendhat in Brno, <strong>and</strong> the<br />

Jewish Quarter <strong>and</strong> cemetery <strong>and</strong> the St. Prokop Basilica in Třebíč. Downloaded from:<br />

http://whc.unesco.org/en/statesparties/cz (last accessed 7 March 2010)<br />

14 Krkonoše, Šumava, Dyje, České Švýcarsko. Downloaded from: http://www.hory12.cz/narodni-parky-cr (last<br />

accessed 7 March 2010)


The Czech Republic is rich in spas (over 30), some of them with abundant tradition e. g.<br />

Karlovy Vary, Mariánske Lázně, Luhačovice, Teplice. 15<br />

Spas in the Czech Republic Picture 2<br />

Source: Downloaded from: http://www.czechtourism.com/cze/cz/docs/practicalinfo/map.html<br />

(last accessed 7 March 2010)<br />

Wide range of accommodation facilities, e. g. 41 five-star <strong>and</strong> 360 four-star hotels, 4.082<br />

other hotels <strong>and</strong> boarding houses, 509 tourist campsites, 941 holiday chalets <strong>and</strong> 1.772 other<br />

accommodation facilities are at disposal of the visitors. 16<br />

<strong>Tourism</strong> has grown to be an activity of high importance <strong>and</strong> significance in the Czech<br />

Republic. Above all after 1989 it becomes an important social <strong>and</strong> economic force in different<br />

regions of the country.<br />

The development of direct share of tourism on GDP as showed in Table 1 had a positive<br />

tendency up to 1996 when reached its maximum (7.1%) followed by decrease to 3.5 % in<br />

2008.<br />

The share of tourism receipts on export reached its maximum in 1997 <strong>and</strong> 1998 respectively<br />

as showed in Table 1. From 1999 decreasing tendency can be observed as a result of<br />

increasing export incomes.<br />

The share of foreign exchange receipts from tourism on the foreign exchange receipts from<br />

services reached its maximum in 1997 <strong>and</strong> 1998 respectively as can be observed in Table 1.<br />

Decrease can be seen from 1999 (44.8%), followed by drop to 41.7% in 2002. A light<br />

increase to 45.8% is evident in 2003 followed by drop to 34.7% in 2008.<br />

15 Spa & <strong>Wellness</strong> Catalogue. Downloaded from: http://www.czechtourism.cz/files/lazenstvi/lazne_2008_aj.pdf<br />

(last accessed 7 March 2010)<br />

16 <strong>Tourism</strong> in the Czech Republic. Facts <strong>and</strong> Figures 2008. Downloaded from:<br />

http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7 March<br />

2010)


Share of <strong>Tourism</strong> on National Economy Table 1<br />

Indicator<br />

Share of tourism<br />

receipts on GDP (in<br />

%)<br />

Share of tourism<br />

receipts on exports<br />

(in %)<br />

1993 5.0 11.0 33,0<br />

1994 5.5 14.0 43,2<br />

1995 5.6 13.4 42,8<br />

1996 7.1 18.6 49,8<br />

1997 6.9 16.3 50.9<br />

1998 6.8 15.0 50,6<br />

1999 5.8 12.0 44,8<br />

2000 5.9 10.3 43,5<br />

2001 5.5 9.3 43,8<br />

2002 4.2 7.7 41,7<br />

2003 4.2 7.3 45,8<br />

2004 3.8 6.2 43.4<br />

2005 3.7 6.8 39.7<br />

2006 3.9 5.8 39.7<br />

2007 3.8 5.4 38.7<br />

2008 3.5 5.5 34.7<br />

Source: Downloaded from: http//:www.cnb.cz (last accessed 7 March 2010)<br />

Share of tourism<br />

receipts on service<br />

receipts (in %)<br />

<strong>Tourism</strong> as one of the largest international industries has also a noticeable impact on the<br />

balance of payments of the Czech Republic. The development of the foreign exchange<br />

receipts <strong>and</strong> expenditure could be divided into two main stages – in the first stage, the<br />

receipts increased <strong>and</strong> reached its pick in 1996 with 4,1 bn USD, decrease of receipts is<br />

typical to the second stage, especially 1999, followed by 2000. Table 2 shows a light increase<br />

in 2001 but the situation after September 2001 <strong>and</strong> the floods in 2002 resonated in decrease of<br />

tourism receipts in 2002. The following years – 2003 - 2008 show increase in receipts again.


Foreign Exchange Receipts <strong>and</strong> Expenditure Table 2<br />

Indicator<br />

USD)<br />

(bn<br />

Receipts Expenditure Balance<br />

1992 1.1 0,5 0.6<br />

1993 1.6 0.5 1.1<br />

1994 2.2 1.6 0.6<br />

1995 2.9 1.6 1.3<br />

1996 4.1 3.0 1.1<br />

1997 3.6 2.4 1.2<br />

1998 3.9 1.9 2.0<br />

1999 3.2 1.5 1.7<br />

2000 3.0 1.3 1.7<br />

2001 3.1 1.4 1.7<br />

2002 2.9 1.6 1.4<br />

2003 3.6 1.9 1.6<br />

2004 4.2 2.3 1.9<br />

2005 4.7 2.4 2.3<br />

2006 5.5 2.8 2.8<br />

2007 6.6 3.6 3.0<br />

2008 7.7 4.6 3.1<br />

Source: Downloaded from: http//:www.cnb.cz (last accessed 7 March 2010)<br />

The survey “Incoming <strong>Tourism</strong> – Number of Visitors <strong>and</strong> Their Expenditure in the Czech<br />

Republic” was carried out in January 2008 – December 2008. 17 The main objective was to<br />

find out the number of foreign visitors coming to the Czech Republic <strong>and</strong> their consumer<br />

behavior. Data were collected at selected border crossings, the Ruzyně airport in Prague <strong>and</strong> 2<br />

railway stations in Prague. 18<br />

According to the survey the main reason for visiting the Czech Republic for foreign <strong>tourists</strong><br />

was recreation <strong>and</strong> entertainment (52.4%), visiting friends <strong>and</strong> relatives (22.1%), <strong>business</strong> trip<br />

(20.7%), <strong>and</strong> others (2.9%).<br />

17<br />

<strong>Tourism</strong> the Czech Republic - Facts & Figures 2008. Research by STEM/MARK for Ministry for Regional<br />

Development. Downloaded<br />

from:http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7<br />

March 2010)<br />

18<br />

<strong>Tourism</strong> the Czech Republic - Facts & Figures 2008. Downloaded from:<br />

http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7 March<br />

2010)


The main purpose of the one-day visitors coming to the Czech Republic was shopping<br />

(73.7%), <strong>business</strong> trip (11.5%), recreation <strong>and</strong> entertainment (6.6%) <strong>and</strong> visiting friends <strong>and</strong><br />

relatives (6.4%).<br />

<strong>Health</strong> State <strong>and</strong> Aging - Implication for <strong>Tourism</strong><br />

The World <strong>Health</strong> Organization (WHO) defines health as ‘a state of complete physical,<br />

mental, <strong>and</strong> social well-being <strong>and</strong> not merely the absence of disease, or infirmity’. This broad<br />

definition can be applied equally to developed <strong>and</strong> developing countries <strong>and</strong> to both genders.<br />

<strong>Health</strong> is a cumulative state, to be promoted throughout life in order to ensure that the full<br />

benefits are enjoyed in later years. Good health is vital to maintain an acceptable quality of<br />

life in older individuals <strong>and</strong> to ensure the continued contributions of older persons to<br />

society. 19<br />

<strong>Health</strong> state is an important part of the st<strong>and</strong>ard of living <strong>and</strong> quality of life of inhabitants of<br />

each country <strong>and</strong> is perceived as country´s development criteria. <strong>Health</strong>y life expectancy<br />

(HALE), defined by WHO as „Average number of years that a person can expect to live in<br />

"full health" by taking into account years lived in less than full health due to disease <strong>and</strong>/or<br />

injury“ 20 is a indicator which is monitored also in the Czech Republic.<br />

One of the common characteristic features of most European countries is demographic<br />

ageing: it occurs mainly as a result of decreasing or low <strong>and</strong> stagnant natality, along with<br />

decreasing mortality <strong>and</strong> related increasing life expectancy. 21 The share of children in the<br />

population diminishes while the share of persons at ages 65 years or more grows. The age<br />

preference index used for comparison of population age structures exceeds the value 100 (i.e.,<br />

the number of persons over 64 years exceeds the numbers of children) 22 in increasing<br />

numbers of countries including the Czech Republic (102.4 in 2007 <strong>and</strong> 105.1 in 2008). Due to<br />

a marked decrease of natality in the early 1990s it has low proportion of children up to 15<br />

years old (14.2 % in 2008), but it still belongs to countries with relatively low proportion of<br />

persons in the age group of 65 or more years (14.7 % in 2008). The latter proportion will<br />

further increase as the age limit 65 is crossed by the strong generation born after World War<br />

II.<br />

Another common characteristic of all European countries is the decreasing natality that<br />

dropped also in countries where it was traditionally high. In several countries including the<br />

Czech Republic a slow increase can be observed as the number of live born children steadily<br />

grows since 2002, in 2006 the number of live born children per 1 000 inhabitants exceeded<br />

again the value 10 <strong>and</strong> the value 11 in 2007. 23<br />

The indicator of total fertility, i.e., the average number of children live born to one woman<br />

during her reproductive period, does not reach the limit of simple replacement, i.e., the value<br />

2.1 children per one woman, in any European country including the Czech Republic where<br />

19 Ageing – exploding the myths. Ageing <strong>and</strong> <strong>Health</strong> Program (AHE). Geneva WHO, 1999, p. 1–21<br />

20 WHO Statistical Information System (WHOSIS). <strong>Health</strong>y life expectancy (HALE) at birth (years).<br />

Downloaded from: http://www.who.int/whosis/indicators/2007HALE0/en/ (last accessed 7 March 2010)<br />

21 European <strong>Health</strong> for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March<br />

2010)<br />

22 The index is defined as the number of persons aged 65 years or more per 100 children aged 0–14 years.<br />

23 European <strong>Health</strong> for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March<br />

2010)


the total fertility exceeded the value 1.3 in 2006, for the first time since 1994, <strong>and</strong> in 2007 <strong>and</strong><br />

2008 it reached the values 1.44 <strong>and</strong> 1.50. 24<br />

The increasing ages of first marriage <strong>and</strong> childbirth are also common trends in all Europe.<br />

Nevertheless, differences between countries of central <strong>and</strong> Eastern Europe <strong>and</strong> those of<br />

western, northern <strong>and</strong> southern Europe still persist. Women in Central <strong>and</strong> Eastern Europe<br />

begin their reproduction earlier, the trend of postponed childbirth started only in the 1990s. 25<br />

Decreasing mortality connected with growing life expectancy are additional common features<br />

of most European countries. However, marked differences still persist between mortality<br />

levels in Western Europe <strong>and</strong> in countries of Eastern <strong>and</strong> Central Europe. Mortality began to<br />

improve gradually in most post-communist countries in the 1990s, along with increasing life<br />

expectancy. The average value of st<strong>and</strong>ardized death rate (SDR) shows a long-term<br />

decreasing trend in European Union while the Czech Republic still has higher SDR values<br />

both for men <strong>and</strong> women than the averages of the whole EU. The most frequent groups of<br />

causes of death are circulatory system diseases. 26<br />

The position of the Czech Republic in Europe remains unchanged, in spite of the fast growth<br />

of life expectancy in the 1990s. Behind countries with the highest life expectancy at birth,<br />

Czech men lag by about 6 years <strong>and</strong> women by 4 years. The Czech Republic with 3.1 <strong>and</strong> 2.8<br />

per mille in 2007 <strong>and</strong> 2008 attains a foremost position in Europe <strong>and</strong> in the world. 27<br />

Common features of most European countries are decreasing natality <strong>and</strong> improving situation<br />

of mortality connected with growing life expectancy. This trend results in demographic<br />

ageing of the population. Europe became the oldest-age continent.<br />

The most dominant factors impacting upon the growth of the health spa <strong>and</strong> wellness industry<br />

are:<br />

• Increasing number of aging “Baby Boomers”– their interest <strong>and</strong> desire for travel<br />

opportunities that also meet their health needs is becoming a market force that greatly<br />

influences the development of health spa <strong>and</strong> wellness market. These “new seniors” no<br />

longer conform to the stereotype of an elderly stay-at–home. They are well educated,<br />

independent, able to enjoy life on their own terms, eager to make choices, excited to<br />

learn, living a fast-paced lifestyle, experiencing a sort of personal awakening. 28<br />

• Fascination with fitness <strong>and</strong> alternative therapies <strong>and</strong> their use for promoting <strong>and</strong><br />

enhancing health <strong>and</strong> healing; 29 for <strong>healthy</strong> lifestyle education; for nutrition<br />

counseling; for preventative medicine; for solving personal problems like stress or<br />

depression; for holistic, naturopathic, alternative or eastern medicinal<br />

practices/therapies. 30<br />

24 Ibid.<br />

25 European <strong>Health</strong> for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March<br />

2010)<br />

26 Ibid.<br />

27 Ibid.<br />

28 Péloquin, C.: Are Senior Travelers Really so Different? Downloaded from:<br />

http://tourismintelligence.ca/2005/05/22/are-senior-travellers-really-so-different/?tagged= (last accessed 7 March<br />

2010)<br />

29 Ross, K.: <strong>Health</strong> <strong>Tourism</strong>: An overview. In: HSMAI Marketing Review December 2001. Downloaded from:<br />

www.hospatality/net.org<br />

30 Verschuren, F.: Spa, <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>: A New Product Portfolio at the Canadian <strong>Tourism</strong><br />

Commission. CTC 2004, p. 5.


• Seeking something new <strong>and</strong> different in a holiday experience. Customers often want<br />

something educational or experiential, <strong>and</strong> many aspects of health <strong>and</strong> wellness<br />

tourism also fulfills those requirements.<br />

The Czech <strong>Health</strong> Spa Industry<br />

There are just a few other activities that can better characterize the economic, cultural <strong>and</strong><br />

social development of the Czech Republic in the last decades as health spa industry. Service<br />

development boomed in the last 20 years in the Czech Republic, <strong>and</strong> health spa industry as an<br />

integrated part of wide service industry boomed as well. The biggest changes can be seen in<br />

privatization <strong>and</strong> inflow of foreign investment. The role of state toward health spas has<br />

changed indeed although it keeps still its important legislative role.<br />

The Czech health spa industry is an integral part of the European health spa industry history<br />

of which starts in ancient Rome <strong>and</strong> Greece. It is a matter of fact that in south Moravia the<br />

Romans operated the first spa in the city of Carnuntum in the 3rd century A. D.<br />

The history of Czech health spas development can be sectionalized as follows: 31<br />

• Before 1800 – small number of spas, guests from high society only, little influence of<br />

scientific progress, high social prestige of spa visits.<br />

• 1800 – 1918 – dynamic development, which reached its peak before the World War<br />

1 st , fast growth of number of visits, improvement of transport infrastructure especially<br />

railways, positive impact of science especially medicine, physics, chemistry, changes<br />

in structure of guest with focus on high society, spas are mostly under German<br />

influence.<br />

• 1918 – 1945 – health insurance companies as a new element in spa development, spas<br />

are opening themselves to underprivileged. The further development has been<br />

influenced by economic <strong>and</strong> political situation, post-war restoration, the economic<br />

crises, the 2 nd World War), some of the spas get under, <strong>and</strong> new substitutes to spa are<br />

discovered.<br />

• 1945 – 1989 – spas are nationalized (in 1945), more spas get under, changes in<br />

financing system (state <strong>and</strong> labor union´s influence), most of the spa guests utilize spa<br />

treatments as a part of complex spa care, changes in incoming spa guests´ structure<br />

(most of them came from the socialist countries), high level of spa treatments,<br />

problems in service quality, obsolete spa infrastructure, the average length of stay is<br />

about 25 days, the remedial function of spas are preferred prior to other.<br />

• After 1989 – privatization, direct influence of state failed, but continued in legislation,<br />

quality <strong>and</strong> variety of services are improved, number of commercial <strong>and</strong> foreign<br />

guests increased.<br />

The International Spa Association (ISPA) defines spas as places devoted to overall well-being<br />

through a variety of professional services that encourage the renewal of mind, body <strong>and</strong><br />

spirit.“ 32<br />

ISPA presumes combined utilization of ten following healing elements: 33<br />

31 Attl. P., Nejdl, K.: Turizmus I. VSH, Praha 2005, ISBN 80-86578-37-2, p. 75


1. Waters - the internal <strong>and</strong> external use of water in its many forms.<br />

2. Nourishment - food, herbals, supplements <strong>and</strong> medicines.<br />

3. Movement - vitality <strong>and</strong> energy through movement, exercise, stretching <strong>and</strong> fitness.<br />

4. Touch - connectivity <strong>and</strong> communication embraced through touch, massage <strong>and</strong><br />

bodywork.<br />

5. Integration - the personal <strong>and</strong> social relationship between mind, body, spirit <strong>and</strong><br />

environment.<br />

6. Aesthetics - concept of beauty <strong>and</strong> how botanical agents relate to the biochemical<br />

components of the body.<br />

7. Environment - location, placement, weather patterns, water constitution, natural agents<br />

<strong>and</strong> social responsibility.<br />

8. Cultural Expression - the spiritual belief systems, the value of art <strong>and</strong> the scientific <strong>and</strong><br />

political view of the time.<br />

9. Social Contribution - commerce, volunteer efforts, <strong>and</strong> intention as they relate to wellbeing.<br />

10. Time, Space, Rhythms - the perception of space <strong>and</strong> time <strong>and</strong> its relationship to natural<br />

cycles <strong>and</strong> rhythms.<br />

Because of the different perception <strong>and</strong> different historic experience, spas are h<strong>and</strong>ed out by<br />

ISPA into seven categories: 34<br />

1. Club Spa - a facility whose primary purpose is fitness <strong>and</strong> which offers a variety of<br />

professionally administered spa services on a day-use basis.<br />

2. Cruise Ship Spa - a spa within a cruise ship providing professionally administered spa<br />

services, fitness <strong>and</strong> wellness components, <strong>and</strong> spa cuisine menu choices.<br />

3. Day Spa - a spa offering professionally administered spa services to clients on a day<br />

use basis.<br />

4. Destination Spa - a spa whose sole purpose is to provide guests with lifestyle choices<br />

improvement, <strong>and</strong> health enhancement through professionally administered spa<br />

services, physical fitness <strong>and</strong> exercise, educational programming, such as nutrition <strong>and</strong><br />

stress management <strong>and</strong> a sense of community through such features as on-site<br />

accommodations. Spa cuisine is frequently exclusively served.<br />

5. Medical Spa - a spa whose primary purpose is to provide comprehensive medical <strong>and</strong><br />

wellness care in an environment which integrates spa services, as well as conventional<br />

<strong>and</strong> complementary therapies <strong>and</strong> treatments.<br />

6. Mineral Springs Spa – a spa offering on-site natural mineral, thermal, or seawater<br />

baths, which are used in professionally administered hydrotherapy treatments.<br />

7. Resort/Hotel Spa - a spa within a resort/hotel that provides professionally administered<br />

spa services, fitness <strong>and</strong> wellness components <strong>and</strong> spa cuisine menu choices.<br />

The European Spa Association (ESPA) divides spas according naturally occurring local<br />

remedies, which are the basis for differentiation between several types of spas <strong>and</strong> health<br />

resorts such as:<br />

32<br />

International SPA Association's Global Best Practices for the Spa Industry. Downloaded from:<br />

http://www.experienceispa.com/education-resources/global-best-practices/ (last accessed 7 March 2010)<br />

33<br />

Ten Spa Domains. Downloaded from: http://www.experienceispa.com/education-resources/facts-<strong>and</strong>figures/10-spa-domains/(last<br />

accessed 7 March 2010)<br />

34<br />

ISPA Bylaws. Downloaded from: http://www.experienceispa.com/about-ispa/bylaws/; Verschuren, F.: Spa,<br />

<strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>: A New Product Portfolio at the Canadian <strong>Tourism</strong> Commission. Canadian<br />

<strong>Tourism</strong> Commission, Vancouver 2004 (last accessed 7 March 2010)


• Mineral spas;<br />

• Brine spas;<br />

• Thermal spas;<br />

• Peloid spas;<br />

• Spas at the seaside <strong>and</strong> in a <strong>healthy</strong> climate;<br />

• Kneipp spas.<br />

According to ESPA „despite common EU law there are still considerable differences in the<br />

use of these remedies depending on the country - definitions, parameters or legal basic<br />

conditions have been developing from different traditions. 35<br />

This overview shows that the ISPA´s perception of spas is wider than the European classical<br />

one – the closest approach to European approach is a destination spa, medical spa <strong>and</strong> mineral<br />

spring spa. The other categories represent more or less combinations of wellness <strong>and</strong> fitness<br />

with catering services, or ambulatory services only.<br />

Based on specification above <strong>and</strong> with focus on European specifics, the Czech health spa<br />

industry can be defined as one which is based on:<br />

• Utilization of natural resources, which are locally bounded, specific <strong>and</strong> unique;<br />

• Medical character of services <strong>and</strong> high expertise of the staff, including medical doctors<br />

<strong>and</strong> medical staff;<br />

• Complex effect of the elements of environment, as a result of mutual action of natural,<br />

cultural, social, architectonic <strong>and</strong> esthetic elements;<br />

• Traveling to <strong>and</strong> staying in places outside usual environment what is necessary for<br />

enrichment of the medical treatment;<br />

• Remedy, after-treatment, precaution (especially remedy makes a difference between<br />

health spa <strong>and</strong> wellness);<br />

• Long lasting beneficial effect of all the above mentioned elements on the guest.<br />

<strong>Health</strong> spas are classified according to indications - treated diseases in the Czech Republic.<br />

The list of indications is prepared by the Ministry of <strong>Health</strong>: 36<br />

• A - oncologic diseases;<br />

• B - circulatory diseases;<br />

• C - digestive diseases;<br />

• D - metabolic diseases;<br />

• E - respiratory diseases;<br />

• F - neurological diseases;<br />

• G - musculoskeletal diseases;<br />

• H - urinary diseases;<br />

• I - mental diseases;<br />

• J - dermatological diseases;<br />

• K - gynecological diseases;<br />

• L - Functionally infertile;<br />

• M - Obesity <strong>and</strong> overweight;<br />

35 Credo of the European Spas Association. Spas <strong>and</strong> <strong>Health</strong> Resorts in Europe. Downloaded from:<br />

http://www.espa-ehv.com/content/view/176/267/lang,en/ (last accessed 7 March 2010)<br />

36 Downloaded from: http://www.czechtourism.cz/files/lazenstvi/lazne_2008_aj.pdf (last accessed 7 March<br />

2010)


• N - Postoperative <strong>and</strong> posttraumatic conditions <strong>and</strong> convalescence.<br />

Spa care has been traditionally perceived as a part of health <strong>and</strong> social care system <strong>and</strong> one of<br />

the 3 pillars of medical treatment in the Czech Republic (besides hospital care <strong>and</strong> ambulatory<br />

care). The Czech health spa care system consists of:<br />

• Sequential professional spa care;<br />

• Professional spa care for chronic patients;<br />

• Professional ambulatory spa care;<br />

• Professional preventive spa care.<br />

From the point of view of tourism, one of the most important characteristics of health spa care<br />

system is reimbursement of costs. There are four different approaches applied in the Czech<br />

Republic:<br />

• Complex spa care - fully covered by health insurance companies (excluded travel<br />

costs);<br />

• Allowance spa care - medical treatments costs are partly covered by health insurance<br />

companies, catering <strong>and</strong> accommodation is covered by guests;<br />

• Commercial spa care – all costs are fully covered by guests;<br />

• Ambulatory spa care – guests are staying at their homes <strong>and</strong> are regularly visiting spa<br />

treatments without utilizing catering <strong>and</strong> accommodation services. 37<br />

The fundamental economic unit of output in health spa is a nursing day with following<br />

components:<br />

• Investigation <strong>and</strong> treatment<br />

• Accommodation<br />

• Catering<br />

• Cultural, sport <strong>and</strong> supplemental activity. 38<br />

The health spa industry is perceived as an important branch of economic activities with long<br />

history. It is a part of the traditional <strong>and</strong> successful economic activities with positive social,<br />

health, economic, ecological <strong>and</strong> regional effects.<br />

UNWTO stated spa care as one of the basic motivators in tourism, as it is defined as „the<br />

activities of persons traveling to <strong>and</strong> staying in places outsider their usual environment for not<br />

more than one consecutive year for lemure, <strong>business</strong> <strong>and</strong> other purposes” 39 , but there is still a<br />

discussion among a number of medical doctors <strong>and</strong> tourism stakeholders in the Czech<br />

Republic on relation <strong>and</strong>/or interconnection of tourism <strong>and</strong> health spa.<br />

37 In 2008, as in the preceding years, the predominant part of health expenditure was financed by the system of<br />

public health insurance that covered 76.4 % of the expenditure in the Czech Republic. The State <strong>and</strong> territorial<br />

budgets covered 7.0 % of the total <strong>and</strong> private expenditure covered 16.6 %. The relative proportions of these<br />

components remained roughly the same in recent years faster increase is only registered in private expenditure<br />

consisting mainly of expenses of households. Total expenditure on health increased from 2007 by 20 710<br />

mill.CZK <strong>and</strong> in 2008 their absolute value was 262.645 mill. CZK (i.e. 25.182 CZK per inhabitant). This total<br />

expenditure on health represents 7.12 % of the GDP in 2008. Public expenditure, i.e., that of the public budgets<br />

<strong>and</strong> of the public heath insurance system, was 219.119 mill. CZK, by 12.554 mill. CZK more than in the<br />

preceding year. The average expenditure of the public health insurance system per 1 client was 19.353 CZK. In:<br />

Czech <strong>Health</strong> Statistics. ÚZIS ČR 2009. ISSN 1210-9991, ISBN 978-80-7280-845-8<br />

38 This indicator can be used only when the health spa guest employ all above mentioned services.<br />

39 WTO Ottawa Conference on Travel <strong>and</strong> <strong>Tourism</strong> Statistsics, 1991. In: Collection of <strong>Tourism</strong> Expenditure<br />

Statistics. Technical Manual No. 2. WTO, 1995 p. 1, ISBN 978-92-844-0106-2


There is a “rigid medical” approach, a very conservative <strong>and</strong> protective one which does not<br />

tolerate the coexistence of different forms of health tourism <strong>and</strong> does not consider health spas<br />

as a part of tourism.<br />

The second, more open approach considers health spa as one of dynamically developing<br />

forms of tourism.<br />

Globalization creates a big pressure to health spa industry as well as the international<br />

competition <strong>and</strong> the substitutes - there are about 850 spa companies in more than 500 biggest<br />

spa places in Europe.<br />

Czech health spas are visited by 600.000 guests every year. The rate of foreign guest to<br />

residents in spa accommodation facilities was close to one to one in 2008 with a moderate<br />

change for the benefit of residents in 2009 as can be seen from Table 3. About 50% of<br />

international guests come from Germany the second biggest market is Russia, followed by<br />

Austria, Slovakia, the USA, Pol<strong>and</strong> <strong>and</strong> Israel (Table 3). 40 Guests coming from Germany,<br />

Slovakia <strong>and</strong> some other countries are often taking advantage from Czech allowance spa care<br />

as the health care system in their home countries allows them to travel for health spa care<br />

abroad <strong>and</strong> it covers their medical treatments costs.<br />

40 Lázeňský cestovní ruch – komparace zemí střední a východní Evropy. Downloaded from:<br />

http://www.czechtourism.cz/files/statistiky/lazne.pdf (last accessed 7 March 2010)


Foreign guests at accommodation facilities (spa): by country<br />

Table 3<br />

Number of guests Index % % Average Number<br />

2009/200 share share length of of nights<br />

2 008 2 009 8 2008 2009 stay<br />

Guests Total 674 313 647 568 96% 11.5 6 689 216<br />

Residents 337 392 341 520 101% 50.03<br />

%<br />

52.74% 12.8 4 031 776<br />

Foreign Guests 336 921 306 048 91% 49.97 47.26% 10.1 2 657 440<br />

Total<br />

%<br />

1 Germany 193 799 176 560 91% 57.52<br />

%<br />

57.69% 9.3 1 471 844<br />

2 Russia 68 237 54 102 79% 20.25<br />

%<br />

17.68% 13.7 685 800<br />

3 Other Asian 21 699 22 535 104% 6.44% 7.36% 7.2 139 052<br />

4<br />

Countries<br />

Ukraine 7 893 6 456 82% 2.34% 2.11% 13.3 79 433<br />

5 Austria 5 396 5 515 102% 1.60% 1.80% 6.9 32 294<br />

6 Israel 4 339 4 466 103% 1.29% 1.46% 13.8 57 215<br />

7 Other<br />

European<br />

Countries<br />

4 822 4 365 91% 1.43% 1.43% 9.9 38 676<br />

8 Slovakia 3 594 4 345 121% 1.07% 1.42% 5.1 17 999<br />

9 U.S.A. 3 315 3 304 100% 0.98% 1.08% 9.8 29 183<br />

1<br />

0<br />

Pol<strong>and</strong> 3 301 3 012 91% 0.98% 0.98% 4.6 10 981<br />

1<br />

1<br />

France 1 847 1 907 103% 0.55% 0.62% 4.5 6 666<br />

1<br />

2<br />

Italy 1 474 1 802 122% 0.44% 0.59% 5.3 7 806<br />

1<br />

3<br />

UK 1 692 1 592 94% 0.50% 0.52% 4.6 5 708<br />

1 The<br />

1 531 1 421 93% 0.45% 0.46% 6.8 8 225<br />

4 Netherl<strong>and</strong>s<br />

1<br />

5<br />

Switzerl<strong>and</strong> 1 246 1 252 100% 0.37% 0.41% 5.3 5 347<br />

1<br />

6<br />

Belgium 741 1 124 152% 0.22% 0.37% 5.1 4 602<br />

1<br />

7<br />

Sweden 878 1 081 123% 0.26% 0.35% 5.1 4 478<br />

1<br />

8<br />

Hungary 1 252 1 081 86% 0.37% 0.35% 3.8 3 048<br />

1<br />

9<br />

China 1 014 1 044 103% 0.30% 0.34% 2.2 1 223<br />

Source: Czech <strong>Health</strong> Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8<br />

Table 4 shows a systematic increase in number of guests <strong>and</strong> number of nights from 1997, but<br />

decrease in average length of stay although it is still quite high – 10.1. This average length of<br />

stay is motivated by focus on health spa care as a remedy <strong>and</strong> by cost reimbursement of spa<br />

care by health insurance companies.


Foreign Guests at <strong>Health</strong> Spa Accommodation Facilities Table 4<br />

Year Number of Guests<br />

Average Length of<br />

Stay<br />

Number of Nights<br />

1997 98 054 10.9 968 576<br />

1998 119 772 11.6 1 269 054<br />

1999 117 635 11.3 1 207 287<br />

2000 114 975 11.8 1 238 579<br />

2001 128 244 12.1 1 425 347<br />

2002 125 936 12.8 1 485 997<br />

2003 123 242 12.9 1 465 567<br />

2004 131 476 12.2 1 473 570<br />

2005 228 110 10.9 2 265 149<br />

2006 295 911 10.3 2 831 269<br />

2007 317 023 10.2 2 904 923<br />

2008 336 921 10.1 3 059 764<br />

Source: Czech <strong>Health</strong> Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8<br />

Table 5 shows that the occupancy of health spa accommodation capacities is increasing<br />

systematically from 2000 for the benefit of residents. The similar development can be seen in<br />

the number of overnight stays.<br />

Occupancy in <strong>Health</strong> Spa Accommodation Facilities in the Czech Republic Table 5<br />

Czech Republic Total<br />

Year Number of<br />

Guests<br />

Nonresidents<br />

Residents<br />

Number of<br />

Overnight<br />

Stays<br />

Nonresidents<br />

Residents<br />

1=2+3 2 3 4=5+6 5 6<br />

2000 437 308 176 387 260 921 5 709 748 1 658 234 4 051 514<br />

2001 435 200 203 166 232 034 5 983 085 2 028 945 3 954 140<br />

2002 451 505 201 028 250 477 6 431 035 2 139 202 4 291 833<br />

2003 450 346 202 126 248 220 6 509 168 2 198 472 4 310 696<br />

2004 481 120 217 134 263 986 6 538 058 2 215 747 4 322 311<br />

2005 497 248 234 141 263 107 6 557 320 2 336 223 4 221 097<br />

2006 571 101 295 911 275 190 6 743 893 2 831 269 3 912 624<br />

2007 650 667 317 016 333 651 7 163 718 2 904 912 4 258 806<br />

2008 674 313 336 921 337 392 7 045 620 3 059 764 3 985 856<br />

Source: Czech <strong>Health</strong> 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<br />

visible that the number of complex spa care guests as well as the allowance spa care guest is<br />

decreasing for the benefit of commercial spa care guests in both groups – residents <strong>and</strong> nonresidents<br />

as well.<br />

Number of Guests in <strong>Health</strong> Spas According to Costs Reimbursement Table 6<br />

Number<br />

Guests<br />

of<br />

2004 2005 2006 2007 2008<br />

Complex Spa<br />

Care<br />

112.670 105.324 94.429 92.605 91.488<br />

Allowance<br />

Spa Care<br />

Commercial<br />

19.147 18.253 18.572 15.708 15.149<br />

Spa Care 45.282 55.853 66.688 91.896 112.987<br />

(Residents)<br />

Commercial<br />

Spa<br />

(Non-<br />

Care<br />

117.003 119.929 134.518 133.761 153.704<br />

residents)<br />

Total 294.102 299.359 314.207 333.970 373.328<br />

Source: Czech <strong>Health</strong> Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8<br />

While the minimum length of stay for complex <strong>and</strong> allowance spa care was traditionally 21<br />

days, the average length of stay decreased to 18.4 days in 2004 followed by additional<br />

decrease to 14.8 days in 2008 in the Czech Republic.<br />

There is no official statistics on age structure of health spa visitors in the Czech Republic. The<br />

only research in this field was conducted by the agency Psyma in 2002. As it can be seen from<br />

Table 7 the most important group is a group of 60 years old guests (53.06%), the second<br />

important group is the one of 30 – 44 years old guests (10.88), followed by the group of 45 –<br />

59 years old guest (3.25%). It is assumed that the number of guests in the group of 45 – 59<br />

years old increased in the last decade.


Age Structure of <strong>Health</strong> Spa Visitors in the Czech Republic Table<br />

7<br />

Country of<br />

Origin<br />

Age Structure in %<br />

0 -14 15-29 30-44 45-59<br />

60 <strong>and</strong><br />

over<br />

Unlisted Total<br />

Germany 0.22 1.29 6.58 21.25 68.72 1.94 100.00<br />

Russia 1.25 0.83 18.67 50.62 17.01 11.62 100.00<br />

Israel 0.00 5.63 8.45 39.44 46.48 0.00 100.00<br />

Arabic<br />

Countries<br />

0.00 0.00 19.05 31.75 47.62 1.58 100.00<br />

Netherl<strong>and</strong> 0.00 0.00 12.50 18.75 68.75 0.00 100.00<br />

Switzerl<strong>and</strong> 0.00 0.00 14.29 42.86 38.09 4.76 100.00<br />

USA<br />

Other<br />

0.00 3.03 18.18 60.61 18.18 0.00 100.00<br />

European<br />

Countries<br />

0.00 0.76 21.21 63.64 14.39 0.00 100.00<br />

Other<br />

Countries<br />

0.00 9.37 9.37 15.63 62.50 3.13 100.00<br />

Total 0.31 1.44 10.88 3.25 53.08 3.06 100.00<br />

Source: Psyma, Prague 2002<br />

The Czech<strong>Tourism</strong> agency conducted a visitor monitoring in Western Spa Region in summer<br />

<strong>and</strong> winter seasons 2005. 41 According to this monitoring 65% of all summer visitors are<br />

residents, 58% of foreign visitors come from Germany, 6% from Russia. Two third of visitors<br />

reached the destination by car, 28% of them arrived from places more than 100 km remote<br />

from the destination. The average length of stay of 1/5 of visitors is 7 days, 2/3 of them stay<br />

longer than 1 day <strong>and</strong> 2/3 are frequent visitors. 45% of visitors prefer to stay in hotels <strong>and</strong><br />

43% prefer to eat in restaurants. Among the main motives visitors indicated was learning<br />

about new places (30%), relax (15%), <strong>and</strong> health (15%). 95 % of all respondents were looking<br />

for information in tourism guides <strong>and</strong> <strong>Tourism</strong> Information Centers.<br />

Sixty eight per cent of all winter visitors are residents, 67% of foreign visitors come from<br />

Germany. Two thirds of visitors reached the destination by car, 48% of them arrived from<br />

places more than 100 km remote from the destination. More than 55% of all visitors stay in<br />

the destination longer than 1 day, the average length of stay of 18% of visitors is 7 days. 45%<br />

of them prefer to stay in hotels <strong>and</strong> 36% prefer to eat in restaurants. Among the main motives<br />

winter visitors indicated was learning about new places (21%), visiting family (15%), <strong>and</strong><br />

health (11%). 89 % of all respondents were looking for information in tourism guides <strong>and</strong><br />

<strong>Tourism</strong> Information Centers, 55% used Internet as information tool.<br />

The Place of <strong>Wellness</strong> in the Czech Republic <strong>Tourism</strong> Industry<br />

The term “wellness” was originally used by Halbert L. Dunn in the book “High Level<br />

<strong>Wellness</strong>” released in 1961 42 when he connected the word well-being with the word fitness.<br />

41 Monitoring of Visitors in Czech Republic Regions – Profiles of <strong>Tourism</strong> Regions. Downloaded from:<br />

http://www.czechtourism.cz/files/regiony/07_01_08_monitoring_navstevniku_fakta_inspirace.pdf (last accessed<br />

7 March 2010)<br />

42 Ardell, D.: What is <strong>Wellness</strong>. 2000. Downloaded from: www.seekwellness.com (last accessed 7 March 2010)


M. Zuckerman defines wellness as programs devoted to an individual’s health <strong>and</strong> fitness,<br />

designed to make the guests feel significantly better than when they arrived. The combination<br />

of fun, exercise, a <strong>healthy</strong> <strong>and</strong> balanced diet, pampering relaxation, <strong>and</strong> education on<br />

managing stress offers magnificent chance for renewal. According to Zuckerman a spa is a<br />

comfortable environment in which guests learn how to use the tools of life enhancement <strong>and</strong><br />

get motivated to go back into the real world <strong>and</strong> practice what they have learned. 43<br />

M. Joppe emphasizes the holistic aspect of wellness products <strong>and</strong> identifies some of the daily<br />

stressors that drive users to access these services. 44<br />

Some researchers propose that there are four essential ingredients associated with wellness:<br />

• A lifelong approach emphasizing permanent lifestyle changes;<br />

• Taking responsibility for one’s own actions;<br />

• Adding to the quality of one’s life, not simply extending the length of life;<br />

• Making choices that improves an individual’s position on the lifestyle continuum. 45<br />

According to German experts, numerous definitions of wellness share common features: the<br />

importance of life style, self-responsibility for health, <strong>and</strong> the exploitation of a person’s<br />

potential for a better quality of health. 46<br />

By many accounts, wellness can be seen as a state of health featuring the harmony of body,<br />

mind <strong>and</strong> spirit with physical fitness, <strong>healthy</strong> nutrition <strong>and</strong> diet, relaxation, meditation, mental<br />

activity/learning, environmental sensitivity <strong>and</strong> social contacts, a process in which an<br />

individual makes choices <strong>and</strong> engages in activities in a way that leads to health-promoting<br />

lifestyles, which in turn positively impact the multiple dimensions of the individual’s well<br />

being. 47<br />

<strong>Wellness</strong> is a dynamically developing industry in the Czech Republic with start-up around<br />

2000. There is no widely accepted definition of wellness <strong>and</strong> the way how it is perceived is<br />

very different. There are three main views on wellness in the Czech Republic:<br />

• <strong>Wellness</strong> is a heterogeneous element which does not come under spa care <strong>and</strong> had not<br />

had to be a part of health spa facilities or of spa destinations.<br />

• <strong>Wellness</strong> is an appropriate supplement to spa care which can under the correctly<br />

defined condition be a part of spa destinations but not a part of health spa facilities<br />

(some experts accept wellness as a part of health spa facilities).<br />

• <strong>Wellness</strong> is a part of all health spa facilities, with no contradiction between spa care<br />

<strong>and</strong> wellness.<br />

43<br />

Verschuren, F.: Spa <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>: A New Product Portfolio at the Canadian <strong>Tourism</strong><br />

Commission, Canadian <strong>Tourism</strong> Commission, Vancouver 2004.<br />

44<br />

Joppe, M.: The Impact of the <strong>Wellness</strong> Revolution on the Spa Industry. 2003<br />

45<br />

Adapted from: Cardinal, B. J., Krause, J. V.: Physical Fitness: The Hub of the <strong>Wellness</strong> Wheel. Dubuque:<br />

Kendell Hunt Publishing 1989.<br />

46<br />

Mueller, H., Lanz Kaufmann, E.: <strong>Wellness</strong> <strong>Tourism</strong>: Market analysis of a special health tourism segment <strong>and</strong><br />

implications for the hotel industry. University of Berne, Switzerl<strong>and</strong>: Research Institute for Leisure <strong>and</strong> <strong>Tourism</strong><br />

2004. Downloaded from: http://www.lanzkaufmann.ch/doc/pub_art_vacationmeeting.pdf (last accessed 7 March<br />

2010)<br />

47<br />

Finnicum, P., Zeiger, J. B.: <strong>Tourism</strong> <strong>and</strong> wellness: A natural alliance in a natural state. Parks <strong>and</strong> Recreation.<br />

Vol. 31, Issue 9/1996, p. 84


The above mentioned conditions are defined by the German <strong>Health</strong> Spa Association as<br />

follows:<br />

• The wellness facility is managed by a medical doctor;<br />

• The medical doctor is at the disposal of the guests;<br />

• The staff is qualified;<br />

• Integrated concept;<br />

• Stability of offer;<br />

• High quality of equipment;<br />

• Documented quality management. 48<br />

Some experts define “wellness tourism” as a “the sum of all the relationships <strong>and</strong> phenomena<br />

resulting from a journey <strong>and</strong> residence by people whose main motive is to preserve or<br />

promote their health.” 49<br />

<strong>Wellness</strong> tourism activities prevent illness <strong>and</strong> preserve, promote or enhance overall health<br />

<strong>and</strong> well being of people <strong>and</strong> their desire to prevent problems so they stay well, both<br />

physically <strong>and</strong> mentally.<br />

Based on the above remarks, it can be stated that health spa <strong>and</strong> wellness are two different<br />

products although there is a lot of overlap between them, especially in terms of their markets<br />

<strong>and</strong> in terms of the range of services offered.<br />

Tourists who are generally <strong>healthy</strong> are motivated to travel so that they can experience<br />

therapies <strong>and</strong> activities that will promote, enhance, <strong>and</strong> otherwise maintain a sense of well<br />

being. Tourists with various medical conditions are motivated to travel so that they can<br />

experience therapies that will help to make them well or to improve their health.<br />

To be able to consider complementary or competitive relation between health spa <strong>and</strong><br />

wellness in the Czech Republic, a field study took place in November 2009. The field study<br />

comprised a survey consisting of in-depth face-to-face interviews of 25 health spa <strong>and</strong><br />

wellness managers <strong>and</strong> other stakeholders including 50 guests. The management has been<br />

contacted individually. Interviewees were contacted during regular operation days. Each<br />

interview took 25 minutes <strong>and</strong> was conducted in a structured fashion. Each of the topics was<br />

introduced by an open-ended question.<br />

Given the qualitative nature of most of the information gathered <strong>and</strong> the size of the sample,<br />

the survey responses were not amenable to statistical analysis. The findings are, therefore,<br />

generally qualitative <strong>and</strong> descriptive.<br />

The main problem in the field of health spa <strong>and</strong> wellness coexistence, seen by interviewed<br />

managers, is in perception of both by medical doctors managing health spas. Traditionally, a<br />

health spa manager had to be an experienced medical doctor responsible for all parts of<br />

nursing day.<br />

48 Medical <strong>Wellness</strong>. Gemeinsame Erklärung bzw. Letter of Intent. Deutcher Heilbäderverb<strong>and</strong>. Downloaded<br />

from: http://www.deutscher-heilbaederverb<strong>and</strong>.de/cms/pages/positionen/medical-wellness.php (last accessed 7<br />

March 2010)<br />

49 Iibid.


Today´s health spa hotels are mostly managed by managers graduated from <strong>business</strong> or<br />

tourism schools but the investigation <strong>and</strong> treatment part of the hotel is managed by medical<br />

doctors. Most of them represent the conservative approach on health spa <strong>and</strong> they do not<br />

tolerate the coexistence of different forms of health tourism <strong>and</strong> do not consider health spas as<br />

a part of tourism. Their view on wellness as a heterogeneous element which does not come<br />

under spa care <strong>and</strong> had not had to be a part of health spa facilities or of spa destinations is at<br />

the same time a very rigid one.<br />

Managers, who consider health spa as one of the dynamically developing forms of tourism,<br />

underst<strong>and</strong> also the role of wellness as well as an appropriate supplement to spa care or even a<br />

part of health spa facilities.<br />

From the point of view of both approaches there is a difference among complex spa care<br />

guests, allowance spa care guests <strong>and</strong> commercial spa care guests. The complex spa care<br />

guests must fully regularize themselves to complex spa arrangement. The allowance spa care<br />

guests have more free scope in the field of accommodation <strong>and</strong> catering, as well as cultural,<br />

sport <strong>and</strong> other services. They can make changes in treatments with permission of the health<br />

spa medical doctor. Commercial spa care guests are independent guests who have free scope<br />

in the field of accommodation <strong>and</strong> catering, as well as cultural, sport <strong>and</strong> other services. All<br />

changes in treatments must be discussed by a medical doctor.<br />

<strong>Health</strong> spas managed by medical doctors are strongly oriented on particular components of<br />

health spa care system <strong>and</strong> wellness components are incorporated into product offered to<br />

guests as sport activities only. According to diagnosis guests always receive tailored treatment<br />

with the possibility to order additional treatments on a commercial basis.<br />

Managers, who consider health spa as one of dynamically developing forms of tourism,<br />

underst<strong>and</strong> also the role of wellness as an appropriate supplement to spa care or even a part of<br />

health spa facilities. They are regularly innovating products offered to customers <strong>and</strong> looking<br />

for new opportunities as wellness which they incorporate into their offer.<br />

Such health spa facilities offer different types of massages (e. g. thai, reiki, chocolate, honey,<br />

stone, <strong>and</strong> alike) meditation therapies, drum circles, beer or wine bath, salt caves, Nordic<br />

walking, yoga, oxygen therapy, crymotherapy, Finish sauna, Russian bath, Turkish bath,<br />

phototherapy, sound therapy, special food arrangement, possibilities to learn about nutrition<br />

<strong>and</strong> <strong>healthy</strong> food preparation practices <strong>and</strong> alike.<br />

Managers observe some trends in health spa which bring health spa close to wellness <strong>and</strong> can<br />

be defined as follows:<br />

• Shorter length of stay (the most common is a long weekend stay – 3 nights);<br />

• Higher number of frequent visitors (visiting a spa 3 or more time per year);<br />

• Increasing number of guest from 25 – 40 age group;<br />

• Dem<strong>and</strong> for special packages (Eastern, Christmas, New Years Eve, etc.);<br />

• Dem<strong>and</strong> for special events in spas (wedding party, birthday party, etc.);<br />

• Dem<strong>and</strong> for special targeting packages (weight-loosing, anti-stress, managerial,<br />

women, etc.);<br />

• Dem<strong>and</strong> for special/exotic treatments (massages, catering, training, etc.);<br />

• Dem<strong>and</strong> for additional services e. g. cosmetics, manicure, pedicure, visage,<br />

hairdresser;


• Dem<strong>and</strong> for some plastic surgery treatments e. g. botulotoxine, hyalurone acid, laser<br />

therapies, chemical scrubbing, etc.<br />

Based on of visitor survey (commercial health spa care guest have been asked) the following<br />

results can be presented:<br />

• 84.2 % of guest were satisfied with the quality of accommodation services;<br />

• Satisfaction with quality of catering services was pointed out by 81.5 % of guests;<br />

• 78.3 % of guests were comfortable with medical treatment;<br />

• 82.6 % of guest were happy with quality of professional medical staff;<br />

• The health spa environment was satisfactory for 82.7 % of guests;<br />

• 82.9 % of guests were pleased by service staff quality;<br />

• Cultural offer was satisfactory for 58.9% of guests;<br />

• Sport offer was treated as satisfactory by 48.8 % of guests;<br />

• 63.8 % of guests consider shopping facilities as satisfactory;<br />

• Tourist information services were satisfactory for 69.4 % of guests;<br />

• Tourists attractions were consider by 69.1 % of guests as satisfactory;<br />

• Supplementary services were perceived by 59.8 % guest as satisfactory;<br />

• 72.7 % of health spa guests were happy with services as a whole.<br />

To the most frequently indicated remarks belong those on sport, culture, information,<br />

attraction, shopping, <strong>and</strong> supplementary services offer. Today´s guest visiting a health spa<br />

want to combine spa treatment, fun, exercise, a <strong>healthy</strong> <strong>and</strong> balanced diet, education on<br />

managing stress, education on relaxing methods, rejuvenation, image <strong>and</strong> visage counseling,<br />

personal couching, etc.<br />

Based on the results of exploratory research <strong>and</strong> well-founded with showed statistics it can be<br />

stated that there is no competition between health spas <strong>and</strong> wellness in the Czech Republic.<br />

<strong>Wellness</strong> is a complement to health spa <strong>and</strong> in some ways both blend together.<br />

Through industry research ISPA has pinpointed the following spa trends for 2010: 50<br />

• Social Media – Twitter <strong>and</strong> Facebook are used by health spa <strong>and</strong> wellness industries to<br />

attract visitors.<br />

• Customer Service - Consumers are more aware of every coin spent, <strong>and</strong> with that<br />

comes higher expectations on the level of service they receive. Spas will respond by<br />

providing exceptional service <strong>and</strong> making each visits a customized experience for the<br />

guest. Implementation of customer feedback mechanisms <strong>and</strong> customer loyalty<br />

programs should help to win frequent visitors.<br />

• Spa Sampling Menu - Mini services at lower price points are popular ways to get a<br />

taste of treatments offered at health spas <strong>and</strong> wellness as well.<br />

• Preventive Care - According to the World <strong>Health</strong> Organization, by 2020 the top five<br />

diseases will all have the underlying contributing factor of stress. Spa treatments like<br />

massage, acupuncture <strong>and</strong> meditation have been proven to aid in stress reduction <strong>and</strong><br />

recovery time for pre <strong>and</strong> post-op patients.<br />

• Spa Partnerships - Spas are becoming more accessible through partnerships with<br />

established franchises, hotels <strong>and</strong> local <strong>business</strong>es. Popular partnerships include:<br />

developing wellness programs at local hospitals, accommodating guests at local hotels<br />

50 2010 International SPA Association Trend Watch. 11/17/2009. Downloaded from:<br />

http://www.ispaconference.com/articles/index.cfm?action=view&articleID=248&menuID=75 (last accessed 7<br />

March 2010)


without spa facilities <strong>and</strong> service discount trades between spas <strong>and</strong> local <strong>business</strong><br />

employees.<br />

• Cell Phone Applications - Spa-ing is easier than ever with the convenience of doing it<br />

from cell phone. Internet application allows customers to browse health spa or<br />

wellness services <strong>and</strong> check room availability.<br />

• Giving Back - Spas are offering promotions <strong>and</strong> free services to people who serve the<br />

community such as teachers, hospice workers <strong>and</strong> military personnel. Some spas are<br />

teaming up with local hospitals <strong>and</strong> providing wellness education to help educate<br />

consumers on the spa lifestyle. Community outreach is a great way to generate<br />

<strong>business</strong> <strong>and</strong> show how easy it is to incorporate spa into once life.<br />

• The Millennials Take Over - This group now outnumbers the baby boomers. They<br />

grew up in a culture where taking care of themselves, learning proper grooming<br />

techniques <strong>and</strong> leading a <strong>healthy</strong> lifestyle were not options, but the norm.<br />

• Simplified Spa Menus - Everyone is cutting back <strong>and</strong> spa menus are no exception. The<br />

No. 1 spa treatment that people seek out world wide is massage because of its healing<br />

<strong>and</strong> stress-reducing benefits. And, the No. 1 reason people go to the spa is to<br />

relieve/reduce stress <strong>and</strong> relax.<br />

• Beauty Rest - The spa makes rest a priority by offering treatments targeted to get guest<br />

some shut eye. They can actually book time to sleep at the spa or stay after a<br />

treatment to take a nap when they are feeling relaxed.<br />

Conclusion<br />

The Czech Republic combines a number of important attributes as a health spa destination<br />

with a long lasting tradition of health spa culture. More than 30 health spas including climatic<br />

spas, healing hot <strong>and</strong> cold springs, healing torf <strong>and</strong> mud - all for treatment <strong>and</strong> recuperation<br />

<strong>and</strong> a high st<strong>and</strong>ard of services at cost–effective rates makes the Czech Republic an attractive<br />

destination for health spa visitors.<br />

<strong>Wellness</strong> as a part of tourism industry has a shorter tradition in the Czech Republic but<br />

develops fast. It is an important supplement to health spas with a wide spectrum of treatments<br />

<strong>and</strong> services offered to visitors often making each visit a customized experience for them.<br />

The Czech health spa industry is an important part of Czech tourism industry with a wide<br />

potential of development including wellness as a complement to health spa care. Relaxation<br />

<strong>and</strong> stress reduction, <strong>healthy</strong> lifestyle, self-responsibility for health are reasons why people<br />

visit health spas <strong>and</strong> wellness. <strong>Health</strong> spa <strong>and</strong> wellness is not a luxury; it is a necessity to a<br />

<strong>healthy</strong> lifestyle.<br />

Today´s health spa <strong>and</strong> wellness visitor seeks to look <strong>and</strong> feel better; to lose weight; to slow<br />

the effects of aging; to relieve pain or discomfort; to manage stress or depression; to improve<br />

fitness level; to experience holistic, naturopathic, alternative, complementary or eastern<br />

medicinal practices <strong>and</strong>/or therapies. Treatments like massage, acupuncture <strong>and</strong> meditation<br />

often belong to st<strong>and</strong>ard spa <strong>and</strong> wellness offers.<br />

<strong>Health</strong> <strong>and</strong> wellness are all-season activities for visitors. They are booking their stay during<br />

all seasons including off seasons which greatly contributes to making the health spa <strong>and</strong><br />

wellness industry available any time of year.<br />

References


2010 International SPA Association Trend Watch. 11/17/2009. Downloaded from:<br />

http://www.ispaconference.com/articles/index.cfm?action=view&articleID=248&menuI<br />

D=75<br />

Ageing – exploding the myths. Ageing <strong>and</strong> <strong>Health</strong> Program (AHE). Geneva WHO, 1999<br />

Ardell, D.: What is <strong>Wellness</strong>. 2000. Downloaded from: www.seekwellness.com<br />

Attl. P., Nejdl, K.: Turizmus I. VSH, Praha 2005, ISBN 80-86578-37-2, p. 75<br />

European <strong>Health</strong> for All Database. Downloaded from: http://www.euro.who.int/hfadb<br />

Cardinal, B. J., Krause, J. V.: Physical Fitness: The Hub of the <strong>Wellness</strong> Wheel. Dubuque:<br />

Kendell Hunt Publishing 1989<br />

CIA. The World Fact Book – Czech Republic. Downloaded from:<br />

ht