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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 />
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“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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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.toursimag.com/ui/<strong>business</strong>/tourisme de sante/<br />
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 />
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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 />
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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 />
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Unpublished PhD-Thesis, UTAD, Vila Real.<br />
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<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 />
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0106-2
RURAL TOURISM, A FORM OF WELLBEING TOURISM?<br />
Raija Komppula, professor<br />
Juho Pesonen, researcher<br />
Centre for <strong>Tourism</strong> Studies<br />
University of Eastern Finl<strong>and</strong><br />
P.O.Box 86<br />
FI-57101 SAVONLINNA<br />
raija.komppula@uef.fi<br />
juho.pesonen@uef.fi<br />
Abstract<br />
The aim of this paper is to compare rural tourism motivations with the motivations of<br />
wellbeing <strong>tourists</strong>, <strong>and</strong> investigate, if rural tourism could be seen as a form of wellbeing<br />
tourism. A questionnaire was developed based on literature on wellness <strong>and</strong> rural tourism<br />
motivations. Data were collected on a Finnish rural tourism website during summer 2009.<br />
Altogether 727 responses were analysed using K-mean cluster analysis to create segments.<br />
The results show that among Finnish rural <strong>tourists</strong> a segment of rural wellbeing <strong>tourists</strong> can be<br />
distinguished. The segment values significantly more such factors as relaxing away from the<br />
ordinary, escape from a busy everyday life, hassle-free vacation, getting refreshed, having a<br />
sense of comfort, <strong>and</strong> having an opportunity for physical rest than the other segments. A<br />
typical rural wellbeing tourist is a 45-54 year old female, who has lived her childhood in the<br />
countryside. She travels with her spouse less than once a year to a rural destination.<br />
Key words: wellness tourism, wellbeing tourism, rural tourism, tourist motivation, tourist<br />
segmentation<br />
Introduction<br />
Although wellness tourism is one of the most ancient forms of tourism, there has been an<br />
exponential growth in the pursuit of wellness in the history of tourism in recent years (Smith<br />
<strong>and</strong> Kelly 2006). Centuries ago tourism destinations developed around unique natural features<br />
such as mineral healing waters, beach <strong>and</strong> mountain resorts <strong>and</strong> sacred sites (Sheldon & Park<br />
2009). Today wellness tourism comprises a broad range of tourist motivations <strong>and</strong> benefits of<br />
the product. A categorization of Sheldon <strong>and</strong> Bushell (2009) suggest six types of wellness<br />
tourism: medical, health, sport <strong>and</strong> fitness, adventure, wellbeing <strong>and</strong> transformation.<br />
According to Smith <strong>and</strong> Puczkó (2009) the concept of wellness contains elements of lifestyle,<br />
physical, mental, <strong>and</strong> spiritual wellbeing, <strong>and</strong> one’s relationship to oneself, others, <strong>and</strong> the<br />
environment. Several concepts, such as well-being, happiness, quality of life, holistic practice<br />
<strong>and</strong> spiritual beliefs relate to the concept of wellness. (Smith <strong>and</strong> Puczko 2009, 12)<br />
Tourists are pushed by their own motivation towards the places where they expect their needs<br />
will be satisfied (Leiper 1990). The push motivations have been seen to be useful in<br />
explaining the desire for travel, as they are recognized as the starting point of underst<strong>and</strong>ing<br />
<strong>tourists</strong>’ behavior (Crompton, 1979). Pull factors are those that attract people to a specific<br />
destination once the decision to travel has been made. They are destination-specific attributes,<br />
such as natural attractions, food, people, recreation facilities, or activities, which determine<br />
whether the traveler will go to destination A or B, if both destinations fulfill the expectations<br />
derived from the push factors. The aim <strong>and</strong> desired outcome of the tourist product for the
customer is value, which at each given time is a subjective experience (e.g. Gunn 1994).The<br />
basis for value expectancies in tourism can be derived from the person’s underlying holidaytaking<br />
motivations (e.g. Ryan 1997, 28).<br />
In terms of push factors, wellness <strong>tourists</strong> are likely to be ’Active <strong>Health</strong> Seekers’ who are<br />
highly motivated <strong>and</strong> determined to play a role in their own health. Smith <strong>and</strong> Kelly (2006)<br />
present dimensions of wellness tourism, where various motivations refer to different kinds of<br />
wellness tourism locations <strong>and</strong> activities, which refer to pull factors. According to Smith <strong>and</strong><br />
Kelly (2006) the destination in wellness tourism is often an alternative space in which one can<br />
engage in self analysis without the stresses <strong>and</strong> distractions of home. For example, <strong>tourists</strong><br />
motivated by escapism <strong>and</strong> relaxation may prefer beach, spa <strong>and</strong> mountains, <strong>and</strong> those with<br />
existential <strong>and</strong> psychological motivations may be interested in holistic centres focused on self<br />
development <strong>and</strong> philosophical contemplation. According to Kulczycki <strong>and</strong> Lück (2009) a<br />
substantial number of <strong>tourists</strong> highlight the importance of a specific location on their travels.<br />
As wellness tourism is usually connected to luxury products <strong>and</strong> five-star hotels, in Finl<strong>and</strong><br />
the concept of well-being tourism is often used instead, containing products <strong>and</strong> services from<br />
a wider scale than the concept of wellness. It can include pampering, activities <strong>and</strong><br />
experiences of luxury, but is does not necessarily require high-class hotels (Konu et al. 2010).<br />
According to Park <strong>and</strong> Reisinger (2009) luxury may refer to uniqueness, excellency,<br />
sensuality, dream or superior quality <strong>and</strong> high price, but it may also refer to as difficult to<br />
obtain, a means to reach happiness, personally rewarding, providing emotional benefits or<br />
intrinsically rewarding. It must also be noted that luxury is dependent on the subjective <strong>and</strong><br />
situational perceptions of consumers, <strong>and</strong> is also understood differently across cultures (Park<br />
& Reisinger 2009). Wellbeing tourism is mentioned also by Sheldon <strong>and</strong> Bushell (2009) as<br />
being one of the types of wellness tourism. Wellbeing refers to a connection with community<br />
or nature, inner <strong>and</strong> outer beauty therapy, massage, spas, sauna, relaxation, energy balancing,<br />
art, music <strong>and</strong> diverse treatments (p. 10). Nevertheless, Sheldon <strong>and</strong> Bushell do not discuss<br />
the level of quality, price or luxury of the offering in their typology.<br />
According to Konu et al. (2010), the positioning of Finnish wellbeing <strong>and</strong> wellness tourism<br />
should necessarily be based on the best natural resources, namely the lakes. The Lakel<strong>and</strong><br />
Finl<strong>and</strong>, Eastern part of Finl<strong>and</strong>, is an area where rural tourism is a predominant form of<br />
tourism offering. Rural tourism typically refers to tourism outside densely populated areas <strong>and</strong><br />
tourism centres. In some countries, the term farm tourism (agritourism, agrotourism) is<br />
synonymous with rural tourism. In many countries, rural tourism is understood to be more or<br />
less synonymous with nature tourism or at least travelling in nature (Komppula 2007).<br />
A typical Finnish rural holiday includes accommodation in a cottage, local food, sauna <strong>and</strong><br />
some kind of nature activities: swimming, rowing <strong>and</strong> walking in the forest. Rural tourism<br />
establishments are often located in remote countryside, far away from neighbors. Villages <strong>and</strong><br />
services (shops, restaurants etc.) are often in a distance of several kilometers from the site.<br />
Most common is a holiday in a self catering cottage, but also accommodation in B&B<br />
establishments is available as well as half board or full board holidays with versatile services.<br />
The largest intermediary of rural holidays is Finnish Country holidays Ltd, which has around<br />
2700 cottages for rent. Nevertheless, a significant part of around 4000 rural tourism<br />
enterprises sell <strong>and</strong> market their services directly <strong>and</strong> together with regional tourism<br />
organizations to the potential customers.
According to several studies on rural tourism, many of the rural <strong>tourists</strong> are motivated by the<br />
same factors as wellbeing <strong>tourists</strong>: they seek relaxation, escape from busy job, peace <strong>and</strong><br />
quiet, sports, <strong>and</strong> <strong>healthy</strong> gastronomy. A rural holiday as a product means peace <strong>and</strong> quiet, an<br />
easy-going <strong>and</strong> warm atmosphere, nature, scenery <strong>and</strong> activities related to nature.<br />
Interestingly, a new Finnish website www.hyvinvointimatkailu.fi (wellbeingtourism) presents<br />
a wellbeing tourism network of one traditional spa <strong>and</strong> a fitness centre, one college of<br />
physical education <strong>and</strong> five rural tourism enterprises. This is an example of the growing<br />
interest of rural tourism enterprises in developing their services towards wellbeing offering.<br />
Because of this growing interest of rural tourism sector in Finl<strong>and</strong> in developing wellbeing<br />
services there is a need for underst<strong>and</strong>ing customer needs <strong>and</strong> expectations. In this paper, our<br />
aim is to compare rural tourism motivations to the existing research on motivations of<br />
wellbeing <strong>tourists</strong>. The purpose is to investigate if there are similarities in motivations of rural<br />
<strong>and</strong> wellbeing <strong>tourists</strong> <strong>and</strong> if rural tourism could be seen as a form of wellbeing tourism.<br />
Motivations of wellbeing <strong>tourists</strong><br />
Despite the remarkable interest in wellness tourism, motivations influencing consumers’<br />
desire to make a wellness holiday is almost an unexplored phenomenon (Bushell <strong>and</strong> Sheldon<br />
2009, Chen <strong>and</strong> Prebensen 2009). Studies showing empirical evidence of wellness tourist<br />
motivations are few, mostly referring to spa goers or spiritual <strong>tourists</strong> (Smith <strong>and</strong> Puczkó<br />
2009). Out of the 17 wellness tourism case studies in the book of Smith <strong>and</strong> Puczkó (2009)<br />
the great majority is about spas. Also their profiling of wellness visitors has a strong<br />
emphasis on spa goers, differentiating types of wellness into four different types of spas<br />
(traditional spas, hotels <strong>and</strong> day spas, purpose built recreational spas, seaside resorts <strong>and</strong><br />
thalassotherapy centres) <strong>and</strong> five other types of wellness, namely holistic retreat centres, yoga<br />
centres, meditation retreats <strong>and</strong> medical centres (p. 134).<br />
A study of Mak et al. 2009 examines the underlying factors that motivate travelers to search<br />
for spa experiences. Based on the findings from a focus group interview <strong>and</strong> a review of<br />
literature, an instrument consisting of 21 motivating items was developed <strong>and</strong> used in a survey<br />
of Hong Kong spa-goers. From the individual items Seek physical relaxation, Pamper oneself,<br />
Reward oneself for working hard, Seek mental peacefulness, Get away from the pressures of<br />
work <strong>and</strong> social life <strong>and</strong> Improve overall health were the most important motivators.<br />
According to Mak et al. (2009) luxury does not seem to be an indispensable attribute of a spa<br />
experience, since Indulge in luxurious experience was rated only the 10 th important<br />
motivating factor after Seeking spiritual refreshment <strong>and</strong> Getting away from daily routine.<br />
Items relating to family togetherness or fostering friendship ties were rated as less important<br />
factors, <strong>and</strong> the least important were factors relating to loosing weight <strong>and</strong> being fashionable.<br />
Of the five factors identified, Relaxation <strong>and</strong> relief had the highest mean score <strong>and</strong> was<br />
considered as the most important of the motivating factors of spa goers. The Escape factor got<br />
the second highest gr<strong>and</strong> mean. This factor was comprised of the items Get away from the<br />
pressures of work <strong>and</strong> social life <strong>and</strong> Get away from daily routine.<br />
In a study conducted by Koh, Yoo <strong>and</strong> Boeger (2010) the purpose was to identify market<br />
segments among spa goers, based on a set of 21 important reasons for visiting a spa. These<br />
benefit variables were identified through a three-stage process <strong>and</strong> a pilot study. Four factors<br />
were identified, namely Social, Relaxing, <strong>Health</strong>y <strong>and</strong> Rejuvenating. Social factor illustrate<br />
the desire to share a special, pleasant experience with family <strong>and</strong> friends while relaxing <strong>and</strong><br />
meeting other health-conscious people in a spa setting. The factor Relaxing indicates the<br />
desire to relieve stress in a tranquil setting <strong>and</strong> to escape the daily routines. <strong>Health</strong>y equates<br />
the spa experience with improving mental <strong>and</strong> physical health, <strong>and</strong> Rejuvenating focuses on
experiences that renew the spirit. The results of a cluster analysis showed that spa goers could<br />
be grouped into three distinct segments according to benefit variables. One group was named<br />
hedonists due to their extreme responses: for this group “social” rated 4.36, relaxing 4.78<br />
<strong>healthy</strong> 4.65 <strong>and</strong> rejuvenating 4.78 on a five point Likert scale. In contrast, Escapists want to<br />
relax <strong>and</strong> rejuvenate. The third group, Neutralists, only want to relax <strong>and</strong> are not concerned<br />
with socializing, improving their health or rejuvenating.<br />
The results of Chen <strong>and</strong> Prebensen’s (2009) study in three upscale Taiwanese wellness resorts<br />
showed that beyond body pampering, wellness seekers are interested in pursuing other leisure<br />
activities as well. Relaxation, recreation <strong>and</strong> experiencing nature were popular motivators for<br />
Taiwanese wellness <strong>tourists</strong>. In addition, Smith <strong>and</strong> Puczkó (2009) present a review on few<br />
findings about motivations of holistic <strong>tourists</strong>, yoga <strong>tourists</strong>, New age <strong>tourists</strong>, spiritual<br />
<strong>tourists</strong> <strong>and</strong> medical <strong>tourists</strong>. They conclude that there is a clear need for more research on<br />
various sub-sectors of wellness tourism.<br />
Motivations of rural <strong>tourists</strong><br />
Studies on motivations of rural tourism are more common than those of wellness tourism.<br />
According to Cai <strong>and</strong> Li (2009) several earlier studies indicate that rural <strong>tourists</strong> are most<br />
often motivated by opportunities to learn <strong>and</strong> explore nature or different cultures, participate<br />
in outdoor activities or search for peace <strong>and</strong> solitude. They may expect peace <strong>and</strong> quiet,<br />
friendly reception, change from routine <strong>and</strong> good food. In a study of Frochot (2005) in two<br />
Scottish locations one of the four rural tourist segments, which were based on the desired<br />
benefits, was Relaxers, who were mainly seeking relaxation <strong>and</strong> had a lower participation rate<br />
in most activities. They took shorter holidays than the other segments but had a higher<br />
recurrence of countryside holidays. These findings are also supported by Royo-Vela’s (2009)<br />
results in Spanish context.<br />
According to the results of Park <strong>and</strong> Yoon (2009) in Korea rural tourism is an extremely<br />
diverse sector leading to a wide range of visitors’ needs <strong>and</strong> expectations. Relaxation<br />
represented a central distinguishing motivational theme among rural <strong>tourists</strong>, reflecting an<br />
intrinsic emotional element. Relaxation factor consisted of items like getting refreshed, escape<br />
from a busy job, relaxing away from the ordinary, having no rush, being physically active,<br />
<strong>and</strong> feeling at home away from home. Also Molera <strong>and</strong> Albaladejo (2007) share the notion of<br />
rural <strong>tourists</strong> being a heterogenous segment with diverse motivations. In their study push <strong>and</strong><br />
pull motivations were included in the same factor analysis. Items like calm atmosphere, non<br />
crowded place, relaxation, attractive l<strong>and</strong>scape, <strong>and</strong> independency <strong>and</strong> flexibility formed the<br />
factor Nature <strong>and</strong> peacefulness. In their cluster analysis 25 % of respondents put a high value<br />
on this factor, giving a low value to activities. This result is congruent with the findings of<br />
Frochot (2005).<br />
According to Komppula (2005) also Finnish rural <strong>tourists</strong> expect to have a peaceful, quiet <strong>and</strong><br />
rush-free country holiday. For Finns, nature, particularly lake <strong>and</strong> forest scenery, is a selfevident<br />
part of a rural vacation. For both target groups, families <strong>and</strong> those travelling with<br />
other adults, the destination should be such that it is possible, on the one h<strong>and</strong>, to enjoy peace<br />
<strong>and</strong> quiet on one’s own, <strong>and</strong>, on the other h<strong>and</strong>, to have interaction with the other visitors. The<br />
choice of rural tourism as the type of holiday seemed to be related to the respondent’s own<br />
background: the countryside was felt to be part of one’s own roots <strong>and</strong> the countryside<br />
brought back positive childhood memories in the respondents (Komppula 2005). Zamora et<br />
al. 2004 also propose that the rural origin of a tourist has a positive effect on his willingness to<br />
pay for a rural holiday, despite the current settlement in the city.
Method <strong>and</strong> data<br />
In several studies these factors have also been identified as motivators of rural <strong>tourists</strong>. In our<br />
empirical study the aim is to find out if it is possible to distinguish a special wellbeing<br />
segment among customers interested in rural tourism in Finl<strong>and</strong>. The target group of the study<br />
was potential rural tourism customers in Finl<strong>and</strong>, which were supposed to be found among<br />
visitors of the website of Finnish Cottage Holidays, the oldest, biggest <strong>and</strong> best known<br />
intermediary organisation on rural tourism services in Finl<strong>and</strong>.<br />
Data were collected on the Finnish Cottage Holidays website www.lomarengas.fi during<br />
summer 2009. Respondents were asked to state their interest in rural holidays <strong>and</strong> provide<br />
information on what kind of rural holiday they are planning to have or would like to have.<br />
Also a wide range of questions on travel motivation were asked. Altogether 1043<br />
questionnaires were completed by users of the website, of which 316 had to be deleted<br />
because of missing answers. That left 727 filled questionnaires which were suitable for the<br />
analysis methods used in this study.<br />
This study uses k-mean cluster analysis to create segments based on 31 motivation statements<br />
(scale: 7-point Likert, ranging from not at all important to very important) based on the<br />
literature on tourist motivation <strong>and</strong> customer value in tourism, especially in rural tourism<br />
context. The respondents were asked to assess, how important they find the statements when<br />
considering a holiday in the countryside. The variables were based on a literature review on<br />
rural tourism segmentation studies (Frochot 2005, Molera <strong>and</strong> Albaladejo 2007, Park <strong>and</strong><br />
Yoon 2009, Pesonen, Komppula <strong>and</strong> Laukkanen 2009, Royo-Vela (2009) as well as studies<br />
on customer value, <strong>and</strong> experiences in tourism (Otto <strong>and</strong> Ritchie 1996, Tapachai <strong>and</strong><br />
Waryszack 2000, Williams <strong>and</strong> Soutar 2000, Duman <strong>and</strong> Mattila 2003, Komppula 2005,<br />
Sánchez, Callarisa, Rodríguez <strong>and</strong> Molinar 2006, Gallarza <strong>and</strong> Gil 2008).<br />
Typical problem with cluster analysis has been that respondents’ answering pattern affects the<br />
formation of clusters (see e.g. Laukkanen 2007). To avoid this, average mean score across all<br />
motivation statements was calculated for each respondent <strong>and</strong> it was used to calculate relative<br />
importance of each item for each respondent. Final number of clusters was determined by<br />
examining graphical results (dendogram) <strong>and</strong> the best discrimination result between the<br />
groups. Clusters were compared using ANOVA. Because multiple tests were computed based<br />
on the same data sets, p-values had to be Bonferroni corrected (Boksberger & Laesser 2009).<br />
In this analysis in h<strong>and</strong>, attention was paid to motivations usually connected with wellbeing<br />
tourism, namely items that refer to family togetherness, hassle-free time, escape from a busy<br />
everyday life, getting refreshed <strong>and</strong> pampered, relaxing away from the ordinary, having<br />
opportunity to physical rest <strong>and</strong> activities, having sense of comfort, <strong>and</strong> having chance to<br />
meet interesting people.<br />
Results<br />
Different cluster solutions using k-means clustering were used to find the correct number of<br />
segments. Trials with two to seven clusters were executed. Final cluster solution of four<br />
clusters proved to be the most meaningful based on the results of the cluster formation <strong>and</strong><br />
discriminant analyses.<br />
Results of the discriminant analysis reveal that the travel motivations I would like to relax<br />
away from the ordinary, I would have a feeling of romance <strong>and</strong> I could visit places my family<br />
comes from have most discriminating power between all clusters (in descending order). Three<br />
discriminant functions were generated. Function 1 explains 72.3 % of variance with
eigenvalue 3.668, function 2 explains 18.2 % of variance with eigenvalue 0.924 <strong>and</strong> function<br />
3 explains 9.5 % of variance with eigenvalue 0.481. Based on the classification matrix, 95.0<br />
% of all cases are correctly classified.<br />
The results of the cluster analysis are presented in Table 1. Two motivations, I would have a<br />
feeling like I was being pampered <strong>and</strong> I would have an opportunity to be physically active do<br />
not differ statistically across clusters. The other wellbeing motivations however do differ.<br />
Cluster B clearly values wellbeing related motivations more than other segments, not<br />
including statements I would have a chance to meet interesting people, which segment A<br />
values more than any other segment. Member of clusters C <strong>and</strong> D also think wellbeing related<br />
motivations to be important, but not as much as respondents in cluster B, which is the third<br />
biggest segment, containing 22.6 % of all respondents.<br />
Table 1. Cluster analysis results<br />
Travel motivation Overall<br />
mean<br />
A<br />
(N=213)<br />
B<br />
(N=164)<br />
2.256 A,C,<br />
D<br />
Cluster F-value<br />
C<br />
(N=148<br />
)<br />
1.549 A,<br />
D<br />
D<br />
(N=202<br />
)<br />
That I would have a<br />
hassle-free vacation<br />
1.204 0.402<br />
0.891 A<br />
92.783<br />
That I would like to<br />
escape from a busy<br />
everyday life<br />
1.143 0.505<br />
2.281 A,C,<br />
D<br />
1.401 A,<br />
D 0.921 A That I would have a<br />
115.21<br />
2<br />
feeling like I was being<br />
pampered<br />
0.081 0.148 -0.079 0.164 0.079 1.090<br />
That I would get<br />
refreshed<br />
1.400 0.792<br />
2.268 A,C,<br />
D<br />
1.509 A,<br />
D 1.253 A 106.18<br />
0<br />
That I would have an<br />
opportunity for physical<br />
rest<br />
0.979 0.397<br />
1.860 A,C,<br />
D<br />
1.259 A,<br />
That I would have an<br />
D 0.673 56.978<br />
opportunity to be<br />
physically active<br />
-0.121 -0.274 0.049 -0.045 -0.153 2.153<br />
That I would like to have<br />
a sense of comfort<br />
1.369 0.674<br />
2.323<br />
A,C,D<br />
1.509<br />
A,D 1.222 A 171.67<br />
9<br />
That I would like to relax<br />
away from the ordinary<br />
1.598 0.862<br />
2.6463 A,<br />
C,D<br />
1.820 A,<br />
D 1.362 A 253.10<br />
6<br />
That I would have a<br />
chance to meet<br />
interesting people<br />
-0.425<br />
0.482 B,C,<br />
D -1.366 -0.944 B<br />
-<br />
0.238 B,<br />
C<br />
78.848<br />
Superscript in the mean value of a cluster denotes those clusters that have significantly lower<br />
mean score<br />
Profile of rural wellbeing <strong>tourists</strong> is presented in Table 2. A typical representative of the<br />
segment is a female in the age of 45-54 with a college level degree. She has lived her<br />
childhood in a rural area. The annual income of her household is 30 000- 45000 euro, which<br />
can be regarded as an intermediate level. She travels with her spouse less than once a year to<br />
a rural destination.
Table 2. Profile of wellbeing segment<br />
Age Who would you travel with?<br />
Under 25 5 (3.4%)<br />
Spouse 67<br />
(40.9%)<br />
25-34 33 (22.4%)<br />
Family with children under 12<br />
years<br />
32<br />
(19.5%)<br />
35-44 39 (26.5%)<br />
Family with children in several age<br />
groups<br />
29<br />
(17.7%)<br />
45-54 46 (31.3%)<br />
Friends 18<br />
(11.0%)<br />
55-64 21 (14.3%) Alone 7 (4.3%)<br />
65 or older 3 (2.0%) Other 11 (6.7%)<br />
Education<br />
Number of annual visits to rural<br />
holiday destinations<br />
University degree 40 (24.8%)<br />
Less than once a year 68<br />
(41.5%)<br />
Technical / Trade school /<br />
Vocational<br />
94 (58.4%)<br />
Once a year 58<br />
(35.4%)<br />
Upper secondary school 11 (6.8%)<br />
Two or three times a year 36<br />
(22.0%)<br />
Elementary school 16 (9.9%) More than three times a year 2 (1.2%)<br />
Annual income of the<br />
houshold<br />
Rural origins<br />
Less than 15 000 € 8 (5.1%)<br />
I lived during my childhood <strong>and</strong>/or<br />
adolescence in a rural area<br />
I did not live during my<br />
85<br />
(52.8%)<br />
15 000 – 29 999 € 39 (24.7%)<br />
childhood/adolescence in a rural<br />
area, but I visited rural areas often<br />
to see my relatives<br />
52<br />
(32.3%)<br />
30 000 – 44 999 € 40 (25.3%) I have no roots in the countryside<br />
24<br />
(14.9%)<br />
45 000 – 59 999 € 30 (19.0%) Gender<br />
60 000 – 74 999 € 25 (15.8%) Male 15 (9.3%)<br />
75 000 – 89 999 € 11 (7.0%) Female<br />
146<br />
(90.7%)<br />
At least 90 000 € 5 (3.2%)<br />
Discussion<br />
The results show that among Finnish rural <strong>tourists</strong> a segment of rural wellbeing is clearly to<br />
be distinguished. For them the motivating factors relaxing away from the ordinary, escape<br />
from a busy everyday life, hassle-free vacation, getting refreshed, having a sense of comfort<br />
<strong>and</strong> having an opportunity for physical rest represent a significantly higher value than for the<br />
other segments. The profile of the segment shows that this group is quite homogenous in two<br />
aspects, namely 91 % of the segment members are female <strong>and</strong> 85 % have spent a remarkable<br />
part of their youth in a rural environment. It can be argued that this segment may have a rural<br />
place identity, which refers to dimensions of self that define the individual’s personal identity<br />
in relation to a physical environment (Kulczycki <strong>and</strong> Lück 2009, 172)
The results of this study support the findings of Park <strong>and</strong> Yoon (2009) as well as Molera <strong>and</strong><br />
Albaledejo (2007) by confirming the notion of rural <strong>tourists</strong> being a heterogeneous target<br />
group with diverse motivations, needs <strong>and</strong> expectations. It also supports earlier results of<br />
Frochot (2005) <strong>and</strong> Royo-Vela (2009) by showing that among rural <strong>tourists</strong> there may be a<br />
special segment searching for a “lazy” relaxing holiday without an emphasis on any special<br />
activities.<br />
Bushell <strong>and</strong> Sheldon (2009) call for further research on motivations behind wellness tourism.<br />
They distinguish between luxury forms of wellness tourism <strong>and</strong> more holistic attempts to<br />
create wellness for the individual. (p. 221). We argue that there are several sub segments in<br />
wellness as well as in rural tourism. We assume that people seeking to escape <strong>and</strong> relax in<br />
luxury are a separate segment from those pampering themselves with lazy holiday in a rural<br />
environment. They may be same people but behave in a different way depending on their life<br />
situation, <strong>and</strong> other internal <strong>and</strong> external situational factors.<br />
Both wellness <strong>and</strong> rural tourism concepts clearly mean different things in different contexts<br />
<strong>and</strong> countries. Nevertheless, one conclusion can be drawn from this study: rush free rural<br />
settings with nature <strong>and</strong> beautiful l<strong>and</strong>scapes offer an ideal environment for a wellbeing<br />
holiday motivated by search for relaxation, comfort <strong>and</strong> escape, not including any material<br />
luxurious elements. Further research is needed on the characteristics of the segment as well as<br />
their pull motivations.<br />
In the end it can be said that rural tourism indeed is a form of wellbeing tourism, but not for<br />
everyone. In this study one of the four segments, namely segment B, clearly values wellbeing<br />
related motivations more than any other segment. On the other h<strong>and</strong> members of an another<br />
segment, segment A, do not go for a rural holiday in sake of their wellbeing but are motivated<br />
by other factors not examined in this study.<br />
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Predicting factors of <strong>tourists</strong>’ interest towards wellbeing tourism<br />
holidays – A Finnish case<br />
Henna Konu,<br />
University of Eastern Finl<strong>and</strong>,<br />
Centre for <strong>Tourism</strong> Studies<br />
P.O.Box 86,<br />
FI-57101 Savonlinna, FINLAND<br />
henna.konu@uef.fi<br />
Tommi Laukkanen,<br />
University of Eastern Finl<strong>and</strong>,<br />
Department of Business<br />
P.O. Box 111,<br />
FI-80101 Joensuu, FINLAND<br />
tommi.laukkanen@uef.fi<br />
Abstract<br />
Many studies about motivations <strong>and</strong> profiles of health <strong>and</strong> wellbeing <strong>tourists</strong> have focused on<br />
different sub-sectors of health, wellness <strong>and</strong> wellbeing tourism but more general research,<br />
concerning wellbeing <strong>tourists</strong>, has been quite rare. This study aims to investigate tourist<br />
motivations as predictors of <strong>tourists</strong>’ interests in wellbeing tourism holidays as opposed to<br />
<strong>tourists</strong> that are not interested in wellbeing holidays.<br />
Data is collected in Finnish Travel Fair in January 2009. In total 406 effective responses were<br />
used. To evaluate the predictive influence of push <strong>and</strong> pull factors, the data was analyzed by<br />
using logistic regression analysis with backward stepwise method.<br />
Results show that the previous experience of wellbeing holidays, number of annual holiday<br />
trips, together with pull factors “water park <strong>and</strong>/or spa”, “natural sights” <strong>and</strong> “accessibility in<br />
destination”, <strong>and</strong> push factors “refreshing myself”, “experiencing fashionable/trendy places”<br />
<strong>and</strong> “aesthetic experiences” significantly increase the odds of <strong>tourists</strong>’ interest to make<br />
wellbeing holidays.<br />
Keywords: tourist motivations, push <strong>and</strong> pull factors, previous travel experience,<br />
wellbeing/wellness tourism, Finl<strong>and</strong><br />
Introduction<br />
The dem<strong>and</strong> of wellbeing <strong>and</strong> wellness (tourism) services has increased while many people<br />
are stressed of living in work-obsessed, time-pressured, materialistic <strong>and</strong> over-individualistic<br />
societies (Laing & Weiler 2008, Sheldon & Bushell 2009, Smith & Puczkó 2009). People are<br />
seeking more often balance in their busy lives <strong>and</strong> wellbeing <strong>and</strong> wellness services are<br />
thought to be helpful in achieving this balance. For example, it is estimated that in spa tourism<br />
(sub-sector of health <strong>and</strong> wellbeing tourism) there are nearly 100 million active spa-goers<br />
worldwide (ISPA 2007).<br />
There are several wellness <strong>and</strong> wellness tourism definitions some being very wide-ranging<br />
(e.g. Müller & Lanz Kaufmann 2001) <strong>and</strong> some more limited (e.g. Connell 2006). Sheldon
<strong>and</strong> Bushell (2009, 11) have defined wellness tourism as follows: “<strong>Wellness</strong> tourism is a<br />
holistic mode of travel that integrates a quest for physical health, beauty, or longevity, <strong>and</strong>/or<br />
a heightening of consciousness or spiritual awareness, <strong>and</strong> a connection with community,<br />
nature, or the divine mystery. It encompasses a range of tourism experiences in destinations<br />
with wellness products, appropriate infrastructures, facilities, <strong>and</strong> natural <strong>and</strong> wellness<br />
resources.” All in all there is not one widely accepted definition. In the Finnish language the<br />
words wellness <strong>and</strong> wellbeing are complex, especially in the tourism context. Reason for this<br />
is that both words are translated into ‘hyvinvointi’ which causes confusion <strong>and</strong> misuse of the<br />
words. In marketing point of view wellness tourism is usually connected to luxury products<br />
<strong>and</strong> five-star hotels. However, wellbeing tourism can contain products <strong>and</strong> services from a<br />
wider scale as it can comprise pampering, different (sport <strong>and</strong> fitness) activities <strong>and</strong><br />
experiences of luxury. The concept of wellbeing tourism suits better in Finnish context<br />
because the wider content <strong>and</strong> description highlights better the Finnish underst<strong>and</strong>ing of<br />
‘hyvinvointi’. (Kangas & Tuohino 2007, Konu et al. 2010.) Altogether, the definition of<br />
Sheldon <strong>and</strong> Bushell (2009) is suitable for this study as it includes widely motivation factors –<br />
more detailed both push <strong>and</strong> pull factors.<br />
The motivations <strong>and</strong> profiles of health <strong>and</strong> wellbeing <strong>tourists</strong> have been studied rather little.<br />
Some studies have focused on different sub-sectors of health, wellness <strong>and</strong> wellbeing tourism<br />
– such as spa tourism or spiritual tourism (Lehto et al. 2005, Mak et al. 2009, Smith & Puczkó<br />
2009) – but more general research, concerning wellbeing <strong>tourists</strong> in general, has been quite<br />
rare. In addition, most of the studies concentrating on examining wellbeing tourism<br />
motivations have focused on push factors (internal motivations) <strong>and</strong> have ignored the<br />
importance of pull factors. It is necessary to underst<strong>and</strong> both push <strong>and</strong> pull motivations <strong>and</strong><br />
their relationship to market efficiently a particular destination (Baloglu & Uysal 1996).<br />
This study aims to enhance the rather slim body of knowledge on wellbeing tourism by<br />
providing information about the push <strong>and</strong> pull factors that can explain the interest towards<br />
wellbeing tourism holidays. Goal is to investigate possible predictors – push <strong>and</strong> pull factors,<br />
socio-demographical factors <strong>and</strong> previous travel behaviour – of <strong>tourists</strong>’ interests in wellbeing<br />
tourism holidays as opposed to <strong>tourists</strong> that are not interested in above mentioned holidays.<br />
Tourist Motivations – Push <strong>and</strong> Pull Factors<br />
Motivation has for long been a major topic in tourism research (Crompton 1979, Dann 1981,<br />
Mak et al. 2009, Nowacki 2009, Park & Yoon 2009, Pearce 2005). Backman et al. (1995)<br />
emphasised that motivations are interconnected with individuals’ basic needs for developing<br />
preferences, participating diverse activities, <strong>and</strong> expecting satisfaction. The motivations of<br />
wellbeing <strong>and</strong> wellness activities, participating in wellbeing holiday or purchasing wellbeing<br />
<strong>and</strong> wellness products <strong>and</strong> services are also connected to customers’ needs <strong>and</strong> interests.<br />
The push <strong>and</strong> pull model (Crompton 1979) is one of the most popular typology of tourist<br />
motivation. The model emphasizes that tourist’s choice of a travel destination is influenced by<br />
two forces – push <strong>and</strong> pull factors. Push factors are underlying individual motivations that<br />
push individuals from home, <strong>and</strong> pull factors are attributes <strong>and</strong> features of a destination,<br />
service or a product that pull individuals toward a destination. That is to say, people travel<br />
because they are pushed by their internal motives <strong>and</strong> pulled by external forces of a travel<br />
destination (Lam & Hsu 2006). It has been remarked that most push factors derive from<br />
individual’s intrinsic or intangible desires, for instance, from dream fulfilment, rest <strong>and</strong><br />
relaxation, health <strong>and</strong> fitness, desire for escape, adventure seeking, novelty seeking, prestige,<br />
<strong>and</strong> socialization (Chon 1989, Lam & Hsu 2006, Uysal & Jurowski 1993). Pearce <strong>and</strong> Lee
(2005) identified in their study 14 factors of general tourist motivation. These factors were<br />
novelty, escape/relax, relationship (strengthen), autonomy, nature, self-development (host-site<br />
involvement), stimulation, self-development (personal development), relationship (security),<br />
self-actualise, isolation, nostalgia, romance <strong>and</strong> recognition. The push motivations are noticed<br />
to be useful in explaining the desire for travel, as they are recognized as basis of<br />
underst<strong>and</strong>ing <strong>tourists</strong>’ behaviour (Crompton 1979, Kim et al. 2008). Pull factors are more<br />
tangible <strong>and</strong> they are related often to attractiveness of a destination (e.g. Baloglu & Uysal<br />
1996, Bowen & Clarke 2009). Pull factors can be diverse destination attributes (e.g. spa<br />
facilities, high quality accommodation, amusement parks, national parks) <strong>and</strong> activities (e.g.<br />
outdoor activities, courses, excursions) that <strong>tourists</strong> are interested in.<br />
There are only few studies that have concentrated on wellness <strong>and</strong> wellbeing tourism<br />
motivations. These studies are mainly focused on sub-sectors of wellness tourism, such as spa<br />
or spiritual tourism (Koh et al. 2010, Lehto et al. 2005, Mak et al. 2009) or on the push factors<br />
(internal motivations) (Chen & Prebensen 2009, Koh et al. 2010, Mak et al. 2009) <strong>and</strong> Asian<br />
(see Chen & Prebensen 2009, Mak et al. 2009) or US target groups (Lehto et al. 2005).<br />
Mak et al. (2009) have studied underlying motivations for spa visits. They found five<br />
motivation factors among Hong Kong spa-goers. These factors were friendship <strong>and</strong> kinship,<br />
health <strong>and</strong> beauty, self-reward <strong>and</strong> indulgence, relaxation <strong>and</strong> relief, <strong>and</strong> escape. The top five<br />
motivations (mean over 3 on five-point Likert scale) were ‘to seek physical relaxation’, ‘to<br />
pamper oneself’, ‘to reward oneself for working hard’, ‘to seek mental peacefulness’ <strong>and</strong> ‘to<br />
get away from the pressures of work <strong>and</strong> social life’. Koh et al. (2010) have segmented spa<br />
goers using benefit segmentation. The benefit attributes they have used are very similar to<br />
motivation attributes used in different studies. They identified four motivation factors: social,<br />
relaxing, <strong>healthy</strong>, <strong>and</strong> rejuvenating. They also grouped spa goers valuating similar benefits<br />
into three clusters – escapists, neutralists <strong>and</strong> hedonists. For instance, escapists were interested<br />
in improving their health (mean 3,95 on five-point Likert scale) <strong>and</strong> rejuvenating themselves<br />
(mean 3,99). Hedonists were interested the most in relaxing <strong>and</strong> rejuvenating (means in both<br />
4,78).<br />
Lehto et al. (2006) examined motivations of yoga <strong>tourists</strong> by using 18 motivation statements.<br />
They identified four motivation factors in their study 1) seeking spirituality, 2) enhancing<br />
mental wellbeing, 3) enhancing physical condition, <strong>and</strong> 4) controlling negative emotions.<br />
They found out that the top five motivations (measured using five-point Likert scale) were to<br />
renew myself (mean 4,46), to relax (mean 4,46), to be more flexible in body <strong>and</strong> mind (mean<br />
4,42), to let go of stress from a busy life (mean 4,41), <strong>and</strong> to help me gain a sense of balance<br />
(mean 4,38). Kelly <strong>and</strong> Smith (2009) also found out in their case study that the focus of retreat<br />
holidays is “the self”.<br />
Chen <strong>and</strong> Prebenson (2009) have studied wellness motivation attributes for Taiwanese <strong>tourists</strong><br />
by using 16 different variables: health consciousness, physical therapy, social activity,<br />
recreation, enhancement of quality of life, effortless activity, affordable activity, pursuing<br />
multiactivities, relaxation, <strong>business</strong> engagement, word of mouth, curiosity, mental therapy,<br />
attractiveness, experiencing nature, <strong>and</strong> meditation (measured using 7-point Likert scale).<br />
They found out that the most important motivation factors were relaxation (mean 5,40),<br />
pursuing multiple activities (mean 5,24), recreation (mean 5,16), <strong>and</strong> experiencing nature<br />
(mean 5,04). The results show that a stay in a wellness destination or resort is not just for<br />
being pampered, <strong>and</strong> <strong>tourists</strong> are interested in doing also different activities during their<br />
wellbeing holiday (Chen & Prebenson 2009). Smith <strong>and</strong> Puczkó (2009, 262-263) have also
listed reasons in more general level, why people are travelling <strong>and</strong> going to spas <strong>and</strong> wellness<br />
centres. For instance, one of the main motives is stress relief. They also highlight that fitness<br />
<strong>and</strong> exercise have a very important role in wellbeing <strong>and</strong> wellness too. Smith <strong>and</strong> Puczkó<br />
(2009) emphasize as well that trends <strong>and</strong> reasons of individuals of participating wellbeing <strong>and</strong><br />
wellness activities vary considerably, <strong>and</strong> these trends are connected closely to leisure<br />
patterns. Konu <strong>and</strong> Laukkanen (2009) identified in their study that motivation factors<br />
connected to health <strong>and</strong> physical activity <strong>and</strong> self-development were affecting the most to<br />
intention to make a wellbeing trip. Based on the studies presented above, it can be stated that<br />
the main push factors in wellbeing tourism sector seem to be things such as relaxation,<br />
rejuvenation, pursuing multiple activities, experiencing nature, escape, health <strong>and</strong> beauty.<br />
Many studies are highlighting the importance of environment in wellbeing tourism (Kelly &<br />
Smith 2009, Smith & Puzckó 2009). Some of the wellbeing tourism concepts, such as Alpine<br />
<strong>Wellness</strong> (Pechlaner & Fisher 2006) <strong>and</strong> Lake <strong>Wellness</strong> which is under development (Konu et<br />
al. 2010) base strongly on the natural resources of the destination. In addition, some of the<br />
wellbeing <strong>and</strong> wellness services are depend on natural resources. Good examples are hot<br />
springs <strong>and</strong> mineral waters that are believed to have healing powers (Erfurt-Cooper & Cooper<br />
2009). However, it is very difficult to find studies that have actually empirically tested the<br />
importance of pull factors of wellbeing tourism.<br />
In this study more general motivation factors (push <strong>and</strong> pull) are used as the questionnaire is<br />
directed to potential wellbeing <strong>tourists</strong>, <strong>and</strong> as the aim is to find out the motivational<br />
differences between <strong>tourists</strong> who are interested in wellbeing holidays, <strong>and</strong> <strong>tourists</strong> who are<br />
unsure/not interested in wellbeing holidays.<br />
Demographic Variables, Travel Experience, <strong>and</strong> Past Wellbeing <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong><br />
Experiences<br />
Some studies have concentrated on describing demographic profiles of wellbeing <strong>and</strong><br />
wellness <strong>tourists</strong>. Studies have shown that most of the wellbeing <strong>and</strong> wellness <strong>tourists</strong> are<br />
female (Koh et al. 2010, Lehto et al. 2006, Smith & Puzckó 2009), approximately over 30years-old<br />
(Koh et al. 2010, Lehto et al. 2006, Smith & Puzckó 2009), <strong>and</strong> highly educated<br />
(Koh et al. 2010, Lehto et al. 2006). In addition, studies that have examined different subsectors<br />
of wellbeing <strong>and</strong> wellness tourism highlight, for instance, that spa-goers (Koh et al.<br />
2010) as well as yoga <strong>tourists</strong> (Lehto et al. 2006) have high average income.<br />
Pearce (2005, see also Pearce & Lee 2005) has discussed the relationship between past<br />
experience <strong>and</strong> tourist motivation when he developed travel career patterns (TCP) concept.<br />
Pearce argues that all travellers are influenced by the most important travel motives (e.g.<br />
escape/relax <strong>and</strong> novelty) as well as less important motives (e.g. social status <strong>and</strong> isolation).<br />
He also claims that when tourist’s travel career level develops (<strong>tourists</strong> grow older, pass<br />
certain stage in life-cycle <strong>and</strong> gain more experience) the moderately important travel motives<br />
will change from internally-oriented needs to externally-oriented needs. Mak et al. (2009)<br />
studied the relationship between past spa experience <strong>and</strong> tourist motivations. They found out<br />
that spa-goers who had visited spa two to five times during last two years were more<br />
motivated by attributes connected to escape than spa-goers that had visited a spa only once.<br />
Thus, it can be assumed that demographical factors, travelling habits (travel experience) <strong>and</strong><br />
past wellbeing tourism experiences can have roles as explaining factors of wellbeing holidays.
Data <strong>and</strong> Methods<br />
To examine tourist motivations (push <strong>and</strong> pull factors), a computer aided survey was<br />
conducted to potential Finnish <strong>tourists</strong> in Matka 2009 travel fair in Helsinki, Finl<strong>and</strong>.<br />
Altogether 32 push factor statements (mainly Pearce 2005, Pearce & Lee 2005) <strong>and</strong> 20 pull<br />
factors including statements covering the six As (attractions, accessibility, amenities,<br />
available packages, activities, ancillary services) defined by Buhalis (2000) were adapted<br />
from the earlier studies. For the purposes of this study, a total number of 406 effective<br />
responses without missing values were used. The data is divided into two groups using an apriori<br />
segmentation based on the interest respondents have towards wellbeing holidays.<br />
Logistic regression analysis with backward stepwise selection procedure was used, with the<br />
cut-off statistical significance selected at the 0.10 level. The target (dependent) variable is a<br />
binary/dichotomous variable in which 0 = unsure/not interested in wellbeing holidays, <strong>and</strong> 1 =<br />
interested in wellbeing holidays. The independent variables included push <strong>and</strong> pull factors,<br />
demographic factors, travelling habits (how many short <strong>and</strong> long trips taken during last 12<br />
months), <strong>and</strong> past wellbeing tourism experiences. Age as a demographic variable was<br />
excluded from the analysis due to a large number (24%) of missing values.<br />
As Table 1 show, the data is female dominated with 65 percent of females <strong>and</strong> 35 percent of<br />
males, well educated, <strong>and</strong> dominated by singles or couples without children. It seems that the<br />
respondents travel a lot, which is logical in view of the place of data collection. However,<br />
majority of the respondents have not been on a wellbeing holiday but 70 percent of them<br />
appear to be interested in taking part on a wellbeing holiday.<br />
Table 1. Sample profile.<br />
Frequency<br />
Frequency<br />
(%)<br />
(%)<br />
Gender Profession<br />
Male 143 (35.2) Leading position 37 (9.1)<br />
Female 263 (64.8) Official 146 (36.0)<br />
Education Manual worker 79 (19.5)<br />
Comprehensive school 28 (6.9) Entrepreneur 27 (6.7)<br />
Matriculation 69 (17.0) Unemployed 7 (1.7)<br />
Vocational education 91 (22.4) Retired 33 (8.1)<br />
Polytechnic degree 95 (23.4) Student 69 (17.0)<br />
University degree 121 (29.8) Other 8 (2.0)<br />
Other 2 (0.5)<br />
Phase of live<br />
Annual gross<br />
(household)<br />
income<br />
I live alone 118 (29.1) < 15.000 € 57 (14.0)<br />
Couple, no children 103 (25.4) 15.000-29.999 € 75 (18.5)<br />
Children < 7 yr. 25 (6.2) 30.000-44.999 € 81 (20.0)<br />
Children 7-15 yr. 40 (9.9) 45.000-59.999 € 70 (17.2)<br />
Children > 15 yr. 24 (5.9) 60.000-74.999 € 52 (12.8)<br />
Couple, children moved 77 (19.0)<br />
away<br />
75.000-89.999 € 41 (10.1)<br />
Other 19 (4.7) ≥ 90.000 € 30 (7.4)<br />
Short (≤3d) holidays during the past 12 Have you ever been on a wellbeing<br />
months<br />
holiday?<br />
None 15 (3.7) No 226 (55.7)
One 54 (13.3) Yes 180 (44.3)<br />
2-4 216 (53.2)<br />
> 4 121 (29.8)<br />
Long (>3d) holidays during the past 12<br />
months<br />
Are you interested in attending a wellbeing<br />
holiday?<br />
None 51 (12.6) No / unsure 122 (30.0)<br />
One 110 (27.1) Yes 284 (70.0)<br />
2-4 194 (47.8)<br />
> 4 51 (12.6)<br />
Results<br />
In order to test how push <strong>and</strong> pull variables, demographics <strong>and</strong> travelling behaviour influence<br />
on <strong>tourists</strong>’ interests in conducting wellbeing holidays, we inputted 32 push factor variables,<br />
20 pull factor variables, gender, education, profession, phase of life, annual gross income of<br />
the household, the number of short <strong>and</strong> long holidays conducted during the past 12 months,<br />
<strong>and</strong> past wellbeing holiday experience in the model as independent variables. The push <strong>and</strong><br />
pull factors were measured in a five-point Likert scale whereas demographics <strong>and</strong> travel<br />
behaviour variables were categorical.<br />
The results show that customers’ interest in attending a wellbeing holiday can be predicted<br />
with five push factors <strong>and</strong> five pull factors, <strong>and</strong> in addition with all the three travel behaviour<br />
factors inputted in the model (Table 2). However, it seems that demographic variables do not<br />
have as strong explanatory power as the above mentioned variables given that the iteration<br />
process excluded all the demographic variables from the model.<br />
The Wald statistic is commonly used to test the significance of the individual coefficient for<br />
each independent variable in a logistic regression model (Hair et al., 1998). In this case the<br />
Wald statistic shows how well the variable explains the difference between the groups of<br />
respondents. The Wald statistics show that previous experience of a wellbeing holiday (i.e.<br />
has the respondent been on a wellbeing holiday) has the strongest effect in the model,<br />
followed by two Pull Factors namely “Water park <strong>and</strong>/or spa” <strong>and</strong> “The destination is childfriendly”.<br />
However, while previous experience <strong>and</strong> water park/spa have positive effect on the<br />
interest toward a wellbeing holiday, the negative beta (β) value of child-friendly destination<br />
indicates that as the importance of child-friendliness of the destination increases the interest in<br />
wellbeing holidays decreases. This is the case also with another Pull Factor namely<br />
“Possibility for packaged services” <strong>and</strong> two Push Factors, “Viewing the scenery” <strong>and</strong><br />
“Participating physical activities”. The most significant Push Factor motivating customers’<br />
interest in attending a wellbeing holiday is the ability to refresh.<br />
Taking a closer look on the Travel Behaviour variables, the odds ratio [Exp(B)] indicates that<br />
the odds of those having experience on a wellbeing holiday being interested in attending a<br />
wellbeing holiday are 5,5 times greater than the odds of those never been on a wellbeing<br />
holiday. Moreover, the likelihood to be interested in a wellbeing holiday increases<br />
significantly as the number of annual holiday trips increases. This is the case especially in<br />
short holidays as the likelihood of being interested in a wellbeing holiday among those who<br />
have made at least two short (≤ 3 days) holiday trips during the past 12 months is over 9 times<br />
greater than the odds of those who have not made a single holiday during the past 12 months.<br />
However, it seems that those who have made 2-4 long (> 3 days) holidays during the past 12<br />
months are less likely to be interested in a wellbeing holiday than those who have not made
any long holiday trips during this period of time. The case is the opposite among those who<br />
have made one or more than 4 holiday trips during the past 12 months.<br />
Table 2: Logistic regression results<br />
β S.E. Wald Sig. Exp(β)<br />
Constant<br />
Push Factors<br />
-<br />
5.895<br />
1.458 16.348 p3d) holidays during the past 12 - 0.427 0.955 p=0.328 0.659<br />
months (2-4)<br />
0.417<br />
Long (>3d) holidays during the past 12<br />
months (>4)<br />
0.580 0.636 0.833 p=0.361 1.787<br />
Note: -2 Log likelihood=368.784; Cox & Snell R²=0.270; Nagelkerke R²=0.382;<br />
Classification Improvement (%) = 70.0 → 77.6<br />
*Ref. level
Discussions <strong>and</strong> Conclusions<br />
The aim of the study was to find out what factors are the best predictors of <strong>tourists</strong>’ interest to<br />
make wellbeing holidays. The study shows that there are only a small <strong>and</strong> distinct variety of<br />
factors which can be proved as predictors of <strong>tourists</strong>’ interest in wellbeing holidays. The<br />
previous experience of wellbeing holidays had the strongest effect as predictive factor. Also<br />
the other previous travel experience affected positively to interest to make wellbeing holidays.<br />
It can be concluded that the <strong>tourists</strong> that are interested to make wellbeing holidays are rather<br />
experienced travellers.<br />
Results show that the most important predictor of push factors for wellbeing trips is refreshing<br />
(which according to Pearce (2005) belongs to the most important travel motives). This<br />
supports also the findings of Mak et al. (2009) <strong>and</strong> Lehto et al. (2006). In addition, also less<br />
important motives (see Pearce 2005) such as experiencing fashionable/trendy places <strong>and</strong><br />
aesthetic experiences affected positively to odds of the interest to make wellbeing holidays. It<br />
seems that wellbeing <strong>and</strong> wellness destinations are seen as fashionable or trendy places to<br />
visit. In contrast, two push factors lower the odds: viewing the scenery, <strong>and</strong> participating<br />
physical activities. It is little surprising that the participating physical activities had a negative<br />
effect. This is probably due that refreshing is seen to be accomplished by other ways than by<br />
participating physical activities (cf. to the top five motivations Mak et al. 2009 found in their<br />
study).<br />
Pull factors that have positive effect on odds to interest to make wellbeing holidays were<br />
“water park <strong>and</strong>/or spa”, “natural sights” <strong>and</strong> “accessibility in the destination”. The result is<br />
supported by the studies which have shown the importance of nature environment in<br />
wellbeing <strong>and</strong> wellness tourism. Accessibility in the destination seemed to be important too.<br />
This will probably be one central issue in future as people are travelling also older (e.g. baby<br />
boomers) <strong>and</strong> may have some disabilities needing special attention or arrangements.<br />
Wellbeing <strong>and</strong> wellness destinations should thus consider accessibility, for instance, in their<br />
infrastructure (spa <strong>and</strong> wellness facilities, wider walking paths etc.), information (clearly<br />
marked signs etc.) <strong>and</strong> also in marketing (e.g. possibility get bigger letters on the website of<br />
the destination/<strong>business</strong>). All in all, spa facilities as a pull factor had the most positive<br />
influence to the odds. Two pull factors affected negatively to odds to interest to make<br />
wellbeing holidays. These were “destination is child-friendly” <strong>and</strong> “possibility for packaged<br />
services”. This shows that <strong>tourists</strong> that are interested in wellbeing holidays do not necessarily<br />
want to travel places that are meant for children. One reason for this is that respondents that<br />
were interested in wellbeing holiday were most likely going to make wellbeing holiday with<br />
their spouse or with friends. In addition, it seems that <strong>tourists</strong> interested in wellbeing holidays<br />
are interested individual services/wellbeing programmes as they are not interested in ready<br />
made service packages.<br />
It was interesting to find out that socio-demographic factors did not have statistically<br />
significant role in predicting the <strong>tourists</strong>’ interest to make wellbeing holidays. This is<br />
supporting the view that in the fragmented postmodern markets demographic factors can’t<br />
reliably be used to explain differences between diverse market segments (Firaz et al. 1995,<br />
Firaz & Shultz 1997). However, motivations, attitudes <strong>and</strong> other psychographical factors are<br />
becoming <strong>and</strong> have become more important factors when explaining how segments differ<br />
from each other (see. e.g. Cova & Cova 2002).<br />
There are some similarities in the importance of wellbeing tourism motivation factors of this<br />
study compared to wellbeing <strong>and</strong> wellness studies conducted in Asia <strong>and</strong> North America. It
seems that the internal motivations (push factors) of wellbeing tourism are rather same in<br />
different parts of world (e.g. relaxation <strong>and</strong> rejuvenation). There was no possibility to<br />
compare the pull factors of this study to other studies as the authors have no knowledge if the<br />
pull factors of wellbeing tourism have previously been studied. The literature review showed<br />
that there are different motivation batteries <strong>and</strong> statements used in wellbeing <strong>and</strong> wellness<br />
studies, <strong>and</strong> many of them are connected to some particular subsector of wellness tourism, are<br />
focused on push factors or are formed just for the particular study implemented. It would be<br />
important to develop a scale (including push <strong>and</strong> pull factors) that could be used in<br />
international studies <strong>and</strong> wider in wellness <strong>and</strong> wellbeing tourism – not just in some<br />
subsector.<br />
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S<strong>and</strong>, Surf, Spa <strong>and</strong> Spirituality? Examination of a Scoping Study<br />
of Medical <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong> in Australia<br />
Jennifer Laing,<br />
<strong>Tourism</strong> Research Unit, Monash University*<br />
Jennifer.laing@buseco.monash.edu.au<br />
Cornelia Voigt,<br />
School of Management, University of South Australia<br />
Meredith Wray,<br />
School of <strong>Tourism</strong> <strong>and</strong> Hospitality Management, Southern Cross University<br />
Graham Brown,<br />
School of Management, University of South Australia<br />
Betty Weiler,<br />
<strong>Tourism</strong> Research Unit, Monash University<br />
Gary Howat,<br />
School of Management, University of South Australia<br />
Richard Trembath,<br />
School of Management, University of South Australia<br />
Abstract<br />
The strong growth of medical <strong>and</strong> wellness tourism around the globe is the result of a number<br />
of factors, such as the desire of many travellers to try new experiences <strong>and</strong> escape from<br />
increasingly busy lives, the rising health costs in the developed world <strong>and</strong> the number <strong>and</strong><br />
diversity of medical <strong>and</strong> wellness tourism products now available. Australia is no exception to<br />
this trend, with the realisation that there is great potential for promoting the destination around<br />
the medical <strong>and</strong> wellness tourist experience or as a supplement to the traditional attractions of<br />
the Outback, the Reef <strong>and</strong> food <strong>and</strong> wine. However, the paucity of research that currently<br />
exists in relation to this industry needs to be addressed, if full advantage is to be taken of this<br />
worldwide growth. To this end, a scoping study of Australian medical <strong>and</strong> wellness tourism<br />
was commissioned by the Sustainable <strong>Tourism</strong> Cooperative Research Centre, to analyse the<br />
current state of play <strong>and</strong> identify future research needs requiring more in-depth investigation.<br />
A secondary aim was to compare Australia’s current offerings with international examples.<br />
Key findings of this study include identification of the broad range of Australian medical <strong>and</strong><br />
wellness tourism products in existence, exploration of the potential of Australia to provide<br />
niche medical tourism offerings, <strong>and</strong> identification of key success factors <strong>and</strong> barriers for the<br />
Australian medical <strong>and</strong> wellness <strong>and</strong> medical tourism industries. The paper concludes by<br />
suggesting some future research avenues.<br />
Introduction<br />
Australia has traditionally positioned itself as a destination based on natural attractions such<br />
as the Outback, Uluru, <strong>and</strong> the Great Barrier Reef, as well as more the recent highlighting of<br />
its lifestyle <strong>and</strong> culture to potential international visitors (Craik, 2001). In the wake of a global<br />
growth in medical <strong>and</strong> wellness tourism products <strong>and</strong> services, there is interest in exploring<br />
the potential for Australia to promote health <strong>and</strong> wellness tourism to inbound <strong>tourists</strong>, as an<br />
element of a suite of product offerings. These forms of tourism might be argued to be<br />
complementary to the image of Australia as a <strong>healthy</strong> destination, offering a relaxed lifestyle<br />
amid natural beauty (Ross, 1993).
While wellness tourism in Australia is reasonably well-developed, with the number of spas<br />
growing by 129 percent since 2002 (Intelligent Spas, 2008a, 2008b) <strong>and</strong> at least 10-12 percent<br />
of Australians having been to a destination spa or lifestyle resort in 2007 (Research<br />
International, 2009), Australia has yet to develop a niche in the lucrative medical tourism<br />
market. There have been calls for Australia to remedy this state of affairs (ABC, 2008; ATEC,<br />
2008). Reasons given for Australia to become more involved in offering medical tourism<br />
services to international visitors include: (1) the fact that there is a successful model to be<br />
followed in the $10 billion Australian educational tourism industry; (2) excess capacity in our<br />
private health system, which could be utilised by international medical <strong>tourists</strong>, leading to a<br />
reduction in fees <strong>and</strong> private health fund costs for Australians; (3) the ageing profile of key<br />
international visitor markets; (4) Australia’s existing tourism infrastructure <strong>and</strong> strong br<strong>and</strong><br />
image as a quality tourist destination; (5) the quality <strong>and</strong> high st<strong>and</strong>ard of Australian medical<br />
care; (6) Australia’s world-class reputation in a number of niche medical fields such as<br />
fertility treatment, particularly IVF, <strong>and</strong> heart surgery; (7) the comparatively low-cost of<br />
medical treatment compared to major markets such as the United States, even with an<br />
unfavourable exchange rate <strong>and</strong> (8) cultural similarities <strong>and</strong> ties with the U.S. <strong>and</strong> Asia<br />
(Australia <strong>Health</strong> <strong>Tourism</strong>, 2009; Hingerty, Woodbridge & Wilson, 2008; Jones, Lang,<br />
LaSalle, 2008; Towart, 2008). One of the barriers to development of this market is however<br />
the lack of research about the potential for Australia to develop medical tourism services.<br />
Even the strongly-growing Australian wellness tourism market has yet to be examined in<br />
detail from a research perspective (Voigt, 2008; Voigt et al., in press).<br />
To this end, a scoping study of Australian medical <strong>and</strong> wellness tourism was commissioned<br />
by the Sustainable <strong>Tourism</strong> Cooperative Research Centre, to analyse the current state of play<br />
<strong>and</strong> identify future research needs. This paper provides an overview of the findings of this<br />
scoping study. It commences with a brief overview of the literature, including definitions <strong>and</strong><br />
the historical development of medical <strong>and</strong> wellness tourism in Australia, followed by a market<br />
<strong>and</strong> industry analysis. This paper concludes by suggesting some future research avenues.<br />
Literature Review<br />
There is a lack of consistency in the definitions of wellness <strong>and</strong> medical tourism across the<br />
literature <strong>and</strong> their link with health tourism. It would appear however that health tourism is<br />
the overarching term used to describe both medical tourism <strong>and</strong> wellness tourism (Müller &<br />
Lanz Kaufmann, 2001; Smith & Puczkó, 2008). In this study, we focus on medical tourism<br />
<strong>and</strong> wellness tourism as two distinct categories of health tourism, both of which are of interest<br />
to the Australian tourism industry. The concept of wellness is defined as ‘a positive,<br />
psychological state of well-being which is the result of practising a wellness lifestyle based on<br />
the belief in self-responsibility for one’s own health <strong>and</strong> well-feeling’ (Voigt et al., in press).<br />
<strong>Wellness</strong> tourism is defined as ‘the sum of all the relationships resulting from a journey by<br />
people whose primary motive is to maintain or promote their health <strong>and</strong> well-being <strong>and</strong> who<br />
stay at least one night at a facility that is specifically designed to enable <strong>and</strong> enhance people’s<br />
physical, psychological, spiritual <strong>and</strong>/or social well-being’ (c.f. Voigt, 2008). <strong>Wellness</strong> tourist<br />
experiences can be undertaken at three types of facilities – spas, lifestyle resorts <strong>and</strong> spiritual<br />
retreats (Voigt, 2008). While research has been carried out into the beauty spa sector (Mak,<br />
Wong & Chang, 2009; Spivack, 1998; Henderson, 2003), there has been little research to date<br />
on the lifestyle resort <strong>and</strong> spiritual retreat, including the type of tourist that may seek out these<br />
experiences.<br />
<strong>Health</strong>-related tourism has its roots in ancient times, with travel to hot springs <strong>and</strong> baths,<br />
sacred sites or places enjoying more favourable climatic conditions (Douglas, 2001). The
Gr<strong>and</strong> Tour across Europe saw the rise of interest in ‘taking the waters’ at thermal or mineral<br />
spas (Aron, 1999; Lempa, 2008). In Australia, this trend resulted in the development of baths<br />
<strong>and</strong> spa facilities by European immigrants during the nineteenth century, in places such as<br />
Daylesford <strong>and</strong> Hepburn Springs in Victoria (Gervasoni, 2005). This region in Victoria’s<br />
Central Highl<strong>and</strong>s is known as ‘Spa Country’ <strong>and</strong> contains over 80% of Australia’s mineral<br />
water reserves. While there was a decline in the fashion for spas <strong>and</strong> accordingly diminishing<br />
interest in visiting spas over much of the twentieth century, the 1980’s saw a rejuvenation of<br />
the industry in Daylesford, assisted by growing government efforts to promote the region as a<br />
spa destination <strong>and</strong> an escalating array of wellness tourism products, including beauty spas,<br />
health <strong>and</strong> yoga retreats <strong>and</strong> spiritual services such as tarot readings <strong>and</strong> reflexology<br />
(Lawrence & Buultjens, 2009; Voigt et al., in press). Its recent revival <strong>and</strong> growth can also be<br />
partly attributed to societal concerns about mitigating stress <strong>and</strong> burnout <strong>and</strong> an interest in<br />
alternative health therapies. Most of these visitors are daytrippers or domestic <strong>tourists</strong>. In the<br />
year 2008, the Daylesford <strong>and</strong> Hepburn Springs region attracted an estimated 234,000<br />
domestic overnight visitors <strong>and</strong> 520,000 day visitors. International visitation to the destination<br />
was estimated at 4,651 visitors (<strong>Tourism</strong> Research Australia 2009). Other destinations around<br />
Australia that have focused on wellness as a source of competitive advantage include Palm<br />
Cove in Queensl<strong>and</strong> (Scott & Harrison, 2006) <strong>and</strong> the Mornington Peninsula in Victoria<br />
(Laing, 2009). Palm Cove offers an up-market spa experience, while the Peninsula markets its<br />
natural hot springs to visitors. The Peninsula Hot Springs operation opened in 2005 <strong>and</strong><br />
provides visitors with two sources of natural mineral water for bathing, together with an<br />
ancillary facility for beauty treatments, many of which incorporate indigenous healing<br />
techniques or use products that are based on local <strong>and</strong> natural ingredients (Laing, 2009).<br />
Despite the fact that Australia has experienced an increase in health-related tourism products<br />
<strong>and</strong> services during the late twentieth <strong>and</strong> early twenty-first centuries, very little is known<br />
about the structure of the market from both a supply <strong>and</strong> a dem<strong>and</strong> perspective, as well as an<br />
underst<strong>and</strong>ing of future needs to underpin strategic planning <strong>and</strong> development.<br />
Medical tourism is also an under-researched phenomenon (Connell, 2006a; 2006b),<br />
particularly from the dem<strong>and</strong> side. From an Australian perspective, it could be argued that<br />
travel for medical reasons has a long history. Strang (2005, p. 107) refers to Kowanyama<br />
Aboriginal sacred sites associated with water on the Cape York Peninsula of Australia, where<br />
women would travel to a particular water source in the belief that ‘spirit children generated by<br />
the ancestral forces held within the l<strong>and</strong>scape [would] ‘jump up’ from the water <strong>and</strong> enliven<br />
the foetus in a woman’s womb’. In this study, however, we focus on international travel for<br />
medical purposes, rather than domestic travel for medical purposes (see Abdullah <strong>and</strong> Ng,<br />
2006 <strong>and</strong> Garg, 2008). Medical tourism is thus defined as ‘the sum of all the relationships <strong>and</strong><br />
phenomena resulting from a journey by people whose primary motive is to treat or cure a<br />
medical condition by taking advantage of medical intervention services away from their usual<br />
place of residence, while typically combining this journey with a vacation or touristic<br />
elements in the conventional sense’ (Voigt et al., in press). Few tailored products or packages<br />
are available to international medical <strong>tourists</strong> wishing to avail themselves of medical<br />
treatment in Australia, although this has changed with the recent opening of the Cairns<br />
Fertility Clinic in October 2009.<br />
The Clinic is a purpose-built facility in central Cairns that incorporates a two theatre day<br />
hospital, pathology <strong>and</strong> ultrasound services, a scientific laboratory, medical consulting suites,<br />
allied health services such as acupuncture, <strong>and</strong> massages, on-site serviced apartments, a day<br />
spa, retail outlets, <strong>and</strong> a restaurant <strong>and</strong> deli (Yek, 2009). The second theatre will be available<br />
to local surgeons, adding to the medical facilities that are available to local residents in
Cairns, which has been suffering from a shortage of operating theatres <strong>and</strong> is expected to<br />
experience a 21% growth in its population by 2021. In addition to IVF services, patients will<br />
be able to access medical services such as cosmetic surgery, ophthalmology, urology,<br />
gynaecology <strong>and</strong> general surgery through the day hospital. This will provide holistic <strong>and</strong><br />
personalised services in a discreet <strong>and</strong> comfortable environment (Yek, 2009). The destination<br />
was chosen in part for the broad range of activities <strong>and</strong> attractions available, including<br />
proximity to the Great Barrier Reef, <strong>and</strong> the relaxed tropical climate <strong>and</strong> lifestyle, given the<br />
role stress plays in the outcome of IVF treatment (Voigt et al., in press). The opportunities<br />
afforded by this kind of facility to foster medical tourism in Australia require further<br />
examination (Voigt et al., in press), including the role played by location <strong>and</strong> climate <strong>and</strong> the<br />
importance of leveraging off a prominent field of Australian medical expertise – IVF <strong>and</strong><br />
reproductive services.<br />
Methods<br />
The study involved a literature review, stakeholder interviews, analysis of secondary data, a<br />
survey of medical <strong>and</strong> wellness tourism providers <strong>and</strong> in-depth case studies of (1) medical<br />
tourism, (2) destination development, focusing on two Australian destinations closely<br />
associated with medical <strong>and</strong> wellness tourism (Daylesford/Hepburn Springs, Byron Bay) <strong>and</strong><br />
an emerging destination seeking to develop <strong>and</strong> exp<strong>and</strong> current product offerings (Margaret<br />
River), <strong>and</strong> (3) the most successful wellness tourism br<strong>and</strong> in Australia – the Golden Door.<br />
This paper focuses on the interview <strong>and</strong> secondary data.<br />
Stakeholder Interviews<br />
Long interviews were conducted with stakeholders, being individuals or representatives of<br />
organisations that are ‘interested in or affected by’ wellness <strong>and</strong> medical tourism, such that<br />
they had a ‘legitimate interest’ in the outcome of the study (Freeman, 1984; Sautter & Reisen,<br />
1999). Interviews were conducted with representatives of 18 stakeholder organisations, who<br />
were selected on the basis of a set of criteria developed by the project team. All but one of the<br />
13 criteria was satisfied by at least one stakeholder. The criteria for selection of stakeholders<br />
is detailed in Table 1:<br />
Interviews were semi-structured <strong>and</strong> ranged between 30 minutes <strong>and</strong> 1 hour. They took place<br />
in a location of the participant’s choosing – normally a local cafe or the participant’s<br />
workplace. This ensured a casual atmosphere that encouraged participants to feel relaxed <strong>and</strong><br />
thus made the interviews potentially less intrusive (Richards, 2005). All interviews were<br />
recorded <strong>and</strong> later transcribed. Identities of participants were de-identified for the purposes of<br />
confidentiality.
Table 1: Medical <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong> Stakeholders Interviewed<br />
Criteria Description<br />
1 Government - (F) Federal Government, (S) State Government or (L) Local<br />
Government.– F/S/L<br />
2 Medical/Lifestyle Retreat<br />
3 Tourist Attraction focused on medical <strong>and</strong> wellness tourism (i.e. hot springs<br />
facility)<br />
4 Tourist Attraction associated with medical <strong>and</strong> wellness tourism activity (i.e.<br />
winery with spa attached)<br />
5 Accommodation provider offering spa facilities<br />
6 Spiritual retreat<br />
7 Commercial <strong>business</strong> associated with medical <strong>and</strong> wellness tourism (i.e.<br />
specialist travel agent, spa treatments <strong>and</strong> products, spa br<strong>and</strong>, industry<br />
magazine)<br />
8 Medical <strong>and</strong> wellness tourism industry association<br />
9 Medical tourism provider<br />
10 Commercial <strong>business</strong> associated with medical tourism (i.e. specialist travel<br />
agent, industry magazine)<br />
11 Facility offering medical tourism services (i.e. hospital)<br />
12 University offering courses on medical <strong>and</strong> wellness tourism/medical<br />
tourism/wellbeing<br />
13 Destination development organisation<br />
Analysis of Secondary Data<br />
The interview data was supplemented by an analysis of secondary data, encompassing: (1)<br />
International Visitor Survey (IVS) (<strong>Tourism</strong> Research Australia, 2009b); (2) National Visitor<br />
Survey (NVS) (<strong>Tourism</strong> Research Australia, 2009c); (3) Assorted results from the Holiday<br />
Tracking Survey (HTS) (Roy Morgan Research, 2009); (4) The ISPA 2008 Global Spa<br />
Consumer Study (Research International, 2009); (5) The Global Spa Economy (Global Spa<br />
Summit, 2008); (6) Assorted results published by the market research company Intelligent<br />
Spas (Intelligent Spas, 2006, 2008a, 2008b); <strong>and</strong> (7) Medical <strong>Tourism</strong>: Consumers in Search<br />
of Value (Deloitte, 2008).<br />
Results<br />
This section of the paper provides a market <strong>and</strong> industry analysis <strong>and</strong> discusses potential areas<br />
for future research.<br />
Market Analysis - Medical <strong>Tourism</strong><br />
Australia currently offers very little in the way of targeted medical tourism services, although<br />
the NVS, the most conservative estimate, suggests that over a three year period 2006 – 2008<br />
there was an average of 1.04 million domestic overnight trips per annum that were health<br />
related, while the IVS provides an estimate of 7,000 inbound trips per annum on average over<br />
this period which were for medical reasons. It was suggested by one participant that the<br />
market potential for medical tourism could be massive in Australia:<br />
I don’t know of another industrial opportunity in Australia that could provide $7<br />
billion to the GDP, if we took a two to three per cent share of an Asian corridor stake<br />
in a market. That’s data that’s 12, 18 months old now, <strong>and</strong> the game has moved on
significantly from there, so if the market’s double the size, the opportunity [could be<br />
also].<br />
Some of the potential opportunities for developing this market, identified in the stakeholder<br />
interviews, include focusing on niche medical strengths such as fertility treatments, bariatics<br />
(lapb<strong>and</strong> surgery) <strong>and</strong> cardiology. This is the approach adopted by the Cairns Fertility Clinic,<br />
with its IVF services. Australia’s quality medical care extends ‘up <strong>and</strong> down stream’,<br />
including services such as pathology, radiology <strong>and</strong> physiotherapy (Towart, 2008).<br />
Other important success factors identified through the stakeholder interviews include<br />
developing purpose-built private facilities <strong>and</strong> infrastructure, such as the Cairns Fertility<br />
Clinic, <strong>and</strong> promoting the quality, rigorous st<strong>and</strong>ards <strong>and</strong> patient-focus of the Australian<br />
health system to an international audience, particularly from the United States, where the<br />
culture is similar to that of Australia <strong>and</strong> prices are lower, even with the recently strong<br />
exchange rate of the Australian dollar against the US dollar. As one participant observed,<br />
there might be a parallel with the growing popularity of Australia as a destination for higher<br />
education:<br />
Where are the main people coming [to Australia] for education [from]? China, India<br />
<strong>and</strong> other areas. Why are they coming here? Perceived value, safety, personal safety,<br />
cultural safety … So I think those are messages that North Americans will resonate to.<br />
Potential barriers to success include lack of government support <strong>and</strong> community<br />
misconceptions that this type of industry might reduce local access to public healthcare<br />
services. The marketing effort, both domestically <strong>and</strong> internationally, needs to be consistent<br />
<strong>and</strong> coordinated, as illustrated by the following quote:<br />
I would love to see a parallel to the education industry, where we’ve got a<br />
funded body that goes out <strong>and</strong> competes with other government sponsored<br />
entities. SingaporeMedicine has been set up by the Singaporean Government.<br />
It’s got input from the tourism <strong>and</strong> medical industries <strong>and</strong> the Government,<br />
It’s entire [focus] is to go out there <strong>and</strong> promote Singapore as a holistic<br />
[medical tourism] package. What we have right now [in Australia] are all<br />
these well intentioned private initiatives that … collectively aren’t working<br />
together to go <strong>and</strong> do it. So it has to be coordinated.<br />
Industry Analysis – Medical <strong>Tourism</strong><br />
Australia does not yet offer medical tourism services in a systematic <strong>and</strong> organised way,<br />
unlike established medical tourism destinations such as India, Thail<strong>and</strong> <strong>and</strong> Singapore in Asia<br />
<strong>and</strong> Hungary in Europe (Henderson, 2003; Laing & Weiler, 2008; Smith & Puczkó, 2008).<br />
Towart (2008) suggests that Australia should focus on developing ‘centres of excellence’<br />
around specialisations. These services could be offered by distinct facilities as a ‘one-stop<br />
shop’. A few niche product offerings currently exist in Australia, as identified in this study.<br />
For example, some hotels have collaborated with hospitals for post-natal care, such as the<br />
Little Luxuries program run by the Crowne Plaza Coogee Beach in conjunction with the<br />
Prince of Wales Private Hospital (Voigt & Laing, in press). The Cairns Fertility Clinic has<br />
built its own accommodation within the medical facility, but has also developed packages for<br />
medical <strong>tourists</strong> with local accommodation providers such as the Rydges <strong>and</strong> Shangri-La<br />
hotels (Carter, 2009).
Industry strengths include price differentials with countries such as the United States <strong>and</strong> the<br />
quality of the medical services provided by the industry:<br />
Whilst there's great economic value in [medical tourism], ultimately there's got to be a<br />
product of integrity <strong>and</strong> I don't believe that we have to create that in Australia - I<br />
believe it's already [in existence].<br />
Development of a medical tourism industry in Australia may be supported by the strong legal<br />
system, which will give international <strong>tourists</strong> (<strong>and</strong> their insurers where they are involved)<br />
recourse to legal remedies in the case of malpractice or negligence. This peace of mind may<br />
not be available in some developing countries, where legal action may be protracted <strong>and</strong><br />
expensive (Bookman & Bookman, 2007; Towart, 2008).<br />
Market Analysis – <strong>Wellness</strong> <strong>Tourism</strong><br />
In comparison to medical tourism, Australia currently has a stronger foothold in the wellness<br />
tourism market, with a diverse array of different providers identified in the scoping study<br />
across the three dimensions of spas, lifestyle retreats <strong>and</strong> spiritual retreats. The most<br />
conservative estimate of the size of the domestic market can be derived from the NVS data,<br />
which proposes that only 0.3 per cent of all domestic <strong>tourists</strong> visited a ‘health spa or<br />
sanctuary/wellbeing centre’ between 2006 <strong>and</strong> 2008. The RMR profile estimates that 1.3 per<br />
cent of domestic <strong>tourists</strong> engaged in a ‘health resort / spa holiday’ in 2008. These studies are<br />
limited by the fact that the term ‘spa’ has not been defined, <strong>and</strong> may not capture the full<br />
spectrum of health tourism experiences. The size of the international market is also difficult to<br />
quantify, with the IVS data estimating that an average of 152,000 international visitors to<br />
Australia per annum between 2006 <strong>and</strong> 2008 took part in health spa’ activities. This suggests<br />
that numbers of <strong>tourists</strong> engaging in health tourism is still relatively low, although the market<br />
may be larger than these numbers suggest <strong>and</strong> there is potential for further growth based on<br />
global trends. It is also unlikely that health <strong>and</strong> wellness services were the primary trip<br />
motivation, although more research needs to be undertaken in this regard.<br />
Key success factors identified in this study include the range of treatments <strong>and</strong> therapies<br />
available in Australia. As one participant noted:<br />
Australia has adopted bits from everyone. We are a melting-pot because we are so<br />
multicultural. It’s hard to identify our spa culture – we adapt to all things. We often<br />
use our own local ingredients <strong>and</strong> adapt treatments to the location– spas in alpine<br />
areas using red wine or warm treatments; or hot springs. In the Yarra Valley, they use<br />
wine too. Companies like Li’Tiya use local flora in products <strong>and</strong> they are doing well<br />
overseas.<br />
The links with Australia’s image as a destination were also commented upon, although it was<br />
felt that Australia needed to do more to promote this to international visitors:<br />
Australia is not known as a spa destination. We are mainly known for beauty, nature,<br />
clean air, good food <strong>and</strong> wine <strong>and</strong> social population. If we have a good health <strong>and</strong><br />
wellness product, this adds something to the mix <strong>and</strong> is complimentary to these things.<br />
Australians are seen as <strong>healthy</strong> people. We could incorporate health <strong>and</strong> wellness into<br />
our promotion – this could help to meet existing needs, as a mix of many elements.
Other factors raised by participants include the importance of focusing on a particular market<br />
segment <strong>and</strong> developing links with other regional offerings, such as food <strong>and</strong> wine.<br />
The motivations for visiting the different wellness tourism operations were also noted by<br />
participants. Pampering appeared to be the prime reason for visiting beauty spas, as illustrated<br />
by the following quote:<br />
I think it’s about pampering themselves <strong>and</strong> spoiling themselves. I think probably<br />
people that are burnt out is probably only 10 or 20 per cent. I would say most of them<br />
are here because they want something luxurious, they’ve saved their pennies <strong>and</strong> they<br />
just want to spoil themselves <strong>and</strong> feel like a queen for a weekend <strong>and</strong> they’re happy to<br />
spend the money.<br />
The spiritual retreats <strong>and</strong> lifestyle retreats were more attractive for those seeking stress relief<br />
or health benefits, whether physical, mental or emotional. As one participant noted: ‘I think<br />
there’s more of a natural search, I suppose, for [holistic] cures <strong>and</strong> potions <strong>and</strong> things for their<br />
bodies, instead of having to get antibiotics <strong>and</strong> things all the time’. A participant from a<br />
spiritual retreat referred to the trend of the ‘worried well’ visiting their retreat, being people<br />
who are concerned with their long-term health, rather than people who are actually suffering<br />
from existing ailments or diseases.<br />
Industry Analysis – <strong>Wellness</strong> <strong>Tourism</strong><br />
Daylesford <strong>and</strong> Byron Bay were mentioned as some of the leading Australian wellness<br />
tourism destinations, with a range of wellness tourism providers, particularly spiritual retreats<br />
<strong>and</strong> those providers who offer more alternative, holistic wellness services. Future industry<br />
growth however may potentially be limited by the lack of an industry accreditation scheme<br />
<strong>and</strong> the lack of a strong industry voice or lobby group. There have been several attempts by<br />
the Australian-based Australasian Spa Association (ASpa) to develop an accreditation scheme<br />
for the wellness industry, but so far these attempts have failed.<br />
Other barriers to success mentioned by participants include staffing shortages <strong>and</strong> burnout<br />
rates. As one participant observed: ‘There is a huge increase in <strong>business</strong>es within this sector in<br />
Australia <strong>and</strong> I believe more time <strong>and</strong> money needs to be invested in the ongoing training,<br />
support <strong>and</strong> development for the staff or there will be a big drop in the quality of services on<br />
offer’. The burnout rate might be attributed to the emotionally <strong>and</strong> spiritually challenging<br />
nature of wellness industry-related jobs, including the use of ‘feigned intimacy’ by therapists,<br />
the level of physical effort that is required to be expended in such a tactile experience<br />
(Dobson, 2005), the sensitivities of dealing with the naked human body (Paterson, 2005) <strong>and</strong><br />
negotiating sexual boundaries (Dobson, 2005), as well as the exposure to confidential<br />
information (Sass, 2000) <strong>and</strong> potential for over-involvement (Williams, 2001). This link<br />
between spa tourism <strong>and</strong> emotional labour is a potential issue for exploration in future<br />
research.<br />
Conclusion<br />
The study upon which this paper is based attempts to fill some of the gaps in knowledge about<br />
medical <strong>and</strong> wellness tourism in Australia. The scoping study is a first step towards a more detailed<br />
examination of Australia’s health tourism industry <strong>and</strong> the future directions such an industry might<br />
take, including the implications for Australian tourism development more broadly.
Some of the potential opportunities for developing the medical tourism industry in<br />
Australia, identified in the stakeholder interviews, include focusing on niche medical<br />
strengths that are already associated with Australia, developing purpose-built facilities for<br />
medical <strong>tourists</strong>, promoting the quality of the Australian health system <strong>and</strong> price benefits<br />
compared to US or European destinations for medical services <strong>and</strong> emphasising the legal<br />
protection inherent in undertaking procedures in Australia, in comparison with some<br />
developing countries. Potential barriers to success might however include limited support<br />
from government for developing this industry <strong>and</strong> the need to overcome community concerns,<br />
albeit misguided, that offering these services to medical <strong>tourists</strong> might lead to reduced access<br />
to healthcare services by the resident population. The focus on medical tourism as a niche<br />
offering concords with the views of Bookman <strong>and</strong> Bookman (2007, p. 41), who are blunt in<br />
their assessment of medical tourism as a ‘niche’ offering: ‘Such tourism does not draw masses<br />
but rather it appeals to a select number of people whose dem<strong>and</strong> is big enough to generate<br />
sufficient <strong>business</strong>’.<br />
The wellness tourism industry in Australia has various strengths identified in this study, such<br />
as a diverse product offering <strong>and</strong> links with existing tourism products <strong>and</strong> services, as well as<br />
a destination image that is associated with health <strong>and</strong> relaxation. Barriers to development <strong>and</strong><br />
growth however include the lack of industry accreditation <strong>and</strong> high turnover of staff,<br />
attributed to burnout.<br />
Areas of future research identified through this study include the need to underst<strong>and</strong> the medical<br />
tourist in greater depth, including their motivations; the role played by lifestyle resorts <strong>and</strong> spiritual<br />
retreats in tourism; the development of a profile of <strong>tourists</strong> who engage in medical <strong>and</strong> wellness<br />
tourism activities; the use of medical <strong>and</strong> wellness tourism as a context for destination br<strong>and</strong>ing<br />
<strong>and</strong> development; exploring the potential <strong>and</strong> prevalence of health tourism as the prime focus for<br />
international visitation <strong>and</strong> examining the potential link between emotional labour <strong>and</strong> burnout of<br />
therapists. Many of these areas of research are important in a global context, in addition to a focus<br />
on the particular issues <strong>and</strong> factors pertinent to Australia.<br />
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The Impact of a Festive Event on Residents’ Quality of Life<br />
Marc LeBlanc<br />
École de kinésiologie et de récréologie, Ceps, Université de Moncton<br />
Moncton, E1A 3E9, New Brunswick, Canada<br />
marc.leblanc@umoncton.ca<br />
François de Gr<strong>and</strong>pré<br />
Université du Québec à Trois-Rivières<br />
Trois-Rivières, Québec, Canada<br />
Abstract<br />
The purpose of this study is to measure the impact of a large scale event on residents’ quality<br />
of life in an essentially rural area of the province of New Brunswick, Canada. Initially<br />
developed in 1994, the World Acadian Congress (WAC) is organized every five years in a<br />
different region inhabited by Acadians. The 2009 WAC was held in the Acadian Peninsula, an<br />
area encompassing 102 communities with an overall population of 55,000 residents.<br />
Respondents said that the Congress brought a feeling of wellbeing in the region, improved<br />
quality of life in the community, <strong>and</strong> contributed to their personal happiness <strong>and</strong> wellbeing.<br />
Respondents did not perceive any negative impacts from the WAC, as indicated by the low<br />
scores given to loss of privacy, inappropriate behaviours, <strong>and</strong> disturbance of daily life.<br />
Overall, the presence of the World Acadian Congress proved to be beneficial for the quality<br />
of life of residents in the Acadian Peninsula.<br />
Keywords: tourism, social impact, event, festival, Acadian, World Acadian Congress<br />
Introduction<br />
Festivals are becoming increasingly popular in different regions of the world (Getz, 1993<br />
&1997; Thrane, 2002; Gusoy, Kim & Uysal, 2004) <strong>and</strong> this type of event is an important<br />
tourism development tool in these areas (Goeldner & Ritchie, 2000). The popularity of<br />
festivals can be explained by the fact that <strong>tourists</strong> are attracted by them <strong>and</strong> local residents<br />
agree to invest human <strong>and</strong> financial resources in them.<br />
The willingness to organize a festival results in the presence of organizers who perceive its<br />
advantages. Mayfield <strong>and</strong> Crompton (1995) studied the reasons why such organizers choose<br />
to stage festivals. They identified eight impact categories, namely recreation/socialization,<br />
culture/education, tourism, internal revenue generation, natural resources, agriculture, external<br />
revenue generation <strong>and</strong> community pride/spirit. Gursoy, Kim <strong>and</strong> Uysal (2004) also studied<br />
organizers’ perceptions of the impacts of festivals or events <strong>and</strong> combined them into four<br />
categories: community cohesiveness, economic benefits, social incentives, <strong>and</strong> social costs.<br />
Moscardo (2007) analyzed the role of festivals <strong>and</strong> events in regional development <strong>and</strong><br />
identified “building social capital” <strong>and</strong> “enhancing community capacity” as two of the three<br />
major benefit categories (the other being economic). Small (2007) identified six underlying<br />
dimensions of the social impacts of community festivals: inconvenience, community identity<br />
<strong>and</strong> cohesion, personal frustration, entertainment <strong>and</strong> socialization opportunities, community<br />
growth <strong>and</strong> development, <strong>and</strong> behavioural consequences. Durrett (2008) states that a festival<br />
can even promote resilience “through sharing values, interests <strong>and</strong> traditions central to the<br />
host community” (p. 107), adding that “such festivals are thus an expression of local identity
<strong>and</strong> reflect the internal life of community, not withst<strong>and</strong>ing they are impacted <strong>and</strong> influenced<br />
by external forces” (p. 107).<br />
In his research, Reid (2007) is particularly interested in the social benefits of festivals in rural<br />
settings. He reiterates the underlying elements of the social benefits listed by other authors,<br />
explaining that they relate to social satisfaction, attitudes, beliefs, values, <strong>and</strong> lifestyle. He<br />
divides the social benefits of special events in a rural setting into the following five<br />
categories: networks <strong>and</strong> interactions, affective, learning <strong>and</strong> developing, socioeconomic, <strong>and</strong><br />
physical domain.<br />
Other researchers wanted to better define the social benefits by developing various<br />
measurement tools. These were mostly inspired by the tools used to measure the social<br />
benefits of tourism, such as Lankford <strong>and</strong> Howard’s (1994a, 1994b) <strong>Tourism</strong> Impact Attitude<br />
Scale. Among the instruments used to evaluate the social benefits of festivals (Delamere,<br />
1997, 2001; Fredline, E., Jago, L. & Deery, M., 2003), we chose Delamere’s (2001) Festival<br />
Social Impact Attitude Scale. This tool allows us to partially measure a festival’s influence on<br />
the quality of life of the host community’s residents.<br />
The purpose of this study is to measure the impact of a major event on residents’ quality of<br />
life in an essentially rural area of the province of New Brunswick, on Canada’s east coast. To<br />
our knowledge, the above-mentioned sources have not been used in a context as extensive as<br />
the 2009 World Acadian Congress, which encompassed over 400 events taking place in 102<br />
rural communities.<br />
What is the World Acadian Congress?<br />
The World Acadian Congress (WAC) is a large gathering of Acadians from all over the<br />
world. Acadians are French descendents who arrived in America in 1604 to establish their<br />
permanent residence there. In 1755 however, Engl<strong>and</strong> decided to deport the Acadians who<br />
refused to pledge allegiance to the British Crown. Thus, nearly 10,000 Acadians were<br />
deported mostly to Louisiana, while others were returned to France. Others still hid in the<br />
forest <strong>and</strong> were able to survive there for a few years with the help of the Natives. Throughout<br />
the years, many returned to the territory currently known as l’Acadie.<br />
Acadians were able to preserve their French language despite the fact that they are constantly<br />
confronted with the reality of Canada’s strong English-speaking majority. There are<br />
approximately 280,000 Acadians in the Atlantic Provinces, distributed as follows: 235,000 in<br />
New Brunswick (33% of the population); 35,000 in Nova Scotia (4% of the population);<br />
5,500 on Prince Edward Isl<strong>and</strong> (4% of the population); <strong>and</strong> 2,000 in Newfoundl<strong>and</strong> <strong>and</strong><br />
Labrador (0.05% of the population). The Acadian diaspora also numbers approximately one<br />
million descendants living elsewhere around the world, mostly in Quebec <strong>and</strong> Louisiana.<br />
The WAC is held every five years. According to its organizers, “it is a unique opportunity for<br />
people (from the host region) to showcase themselves for the entire world to see <strong>and</strong> to meet<br />
their Acadian cousins from across the planet to celebrate their common history.”<br />
(www.cma2009.ca)<br />
The WAC program, which runs for 15 days, coincides with National Acadian Day on<br />
August 15 th <strong>and</strong> revolves around four types of activities, including family reunions, public<br />
celebrations, thematic <strong>and</strong> community events, <strong>and</strong> scientific <strong>and</strong> popular conferences. These<br />
events must offer something of interest to all Acadians, young <strong>and</strong> old alike.
The mission of the World Acadian Congress is to develop closer ties among Acadians from<br />
all over the world. (www.cma2009.ca)<br />
The WAC was one of the most important cooperative developments for Acadians at the end<br />
of the 20 th century. Despite the absence of specific boundaries delimiting l’Acadie, there is a<br />
true sense of belonging to this “territory”, whether it be in New Brunswick, Prince Edward<br />
Isl<strong>and</strong>, Nova Scotia or Louisiana. As mentioned by Doucet (2005), the l<strong>and</strong> of the Acadians<br />
may be hard to circumscribe, but you feel it when you’re there. The World Acadian Congress<br />
is one of those moments that transcend the notion of territory.<br />
The first Congress was held in 1994 in south-eastern New Brunswick, Canada. A total of nine<br />
municipalities hosted the event. A second congress took place in Louisiana, USA, in 1999, in<br />
22 communities of the Acadiana region. The third edition was held on Nova Scotia’s<br />
“Acadian territory” in 2004. And lastly, the fourth WAC, which is the subject of this study,<br />
took place in August 2009 in New Brunswick’s Acadian Peninsula.<br />
A Few WAC Numbers<br />
The 2009 WAC program included over 400 events <strong>and</strong> attracted a total of 75,000 people<br />
(45,000 local residents <strong>and</strong> 30,000 <strong>tourists</strong>), for a total attendance of 220,000 people at its<br />
various events. Overall, the event generated more than 22 million Canadian dollars (14<br />
million Euros) in economic spin-offs (LeBlanc & de Gr<strong>and</strong>pré, 2009).<br />
Organizers of previous events summarily estimated attendance at 200,000 participants for the<br />
1994 WAC (cnc.virtuelle.ca/congres/) <strong>and</strong> approximately 300,000 in Nova Scotia in 2004<br />
(www.pch.gc.ca/pgm). We were unable to find relatively reliable data for the 1999 WAC held<br />
in Louisiana. It should be noted that a systematic <strong>and</strong> rigorous measurement instrument was<br />
used to estimate attendance at the 2009 World Acadian Congress.<br />
For information purposes, the 2009 WAC attracted 34,000 individuals at its various family<br />
reunions, which brought together approximately 50 Acadian families (e.g. the LeBlancs, the<br />
Cormiers, the Deveaus, etc.). A LeBlanc family reunion can attract as many as 6,000 people,<br />
whereas other more modest reunions might attract less than 500. The major public<br />
celebrations, for their part, attracted more than 100,000 participants <strong>and</strong> the thematic events,<br />
approximately 81,000 (LeBlanc & de Gr<strong>and</strong>pré, 2009).<br />
Methodology<br />
As indicated earlier, we chose to use Delamere’s (2001) Festival Social Impact Attitude Scale<br />
as it best reflects Canadian reality <strong>and</strong> has already been validated at events in other areas of<br />
the country. Also, it allows us to assess, in part, the influence of a festival on the quality of<br />
life of its host residents. This instrument takes into account both the positive <strong>and</strong> negative<br />
impacts on a festival’s host community.<br />
A telephone survey was carried out with residents of the Acadian Peninsula ten (10) days after<br />
the WAC. This region is made up of 102 small communities (five communities with<br />
somewhat less than 5,000 residents, <strong>and</strong> villages numbering a few hundred to less than a<br />
thous<strong>and</strong> inhabitants). In total, the Acadian Peninsula has 51,975 residents spread out over<br />
2,150 km 2 (Statistics Canada, 2006). The survey sample included 300 individuals who<br />
accepted to complete a 28-question survey.
Respondents were generally over 20 years of age, with a greater proportion in the 55-64<br />
(31.7%) <strong>and</strong> 45-54 (29.7%) age groups. Seven out of ten respondents were female. The<br />
language spoken by respondents was mostly French (96.7%), which is representative of the<br />
French-speaking proportion of the Acadian Peninsula’s population. Few Anglophones live in<br />
this region, which is considered the most homogenous in New Brunswick from a linguistic<br />
point of view. Respondents from rural communities (with a population of 1,000 or less)<br />
represented 58% of the sample, compared to 42% for respondents from one of the five<br />
communities with 5,000 inhabitants.<br />
Participation Profile<br />
Overall, 84.7% of the respondents took part in at least one WAC event. Extrapolated to the<br />
Peninsula’s general population, this percentage represents 43,938 people on a possible total of<br />
51,875.<br />
Nearly four out of five respondents (78.7%) indicated personally knowing at least one<br />
volunteer, employee or artist who was part of the program.<br />
Very few residents (2%) decided to leave the Peninsula during the WAC. And finally,<br />
respondents have lived in the Acadian Peninsula for an average of 45.04 years.<br />
Positive Social Impacts<br />
Using a Likert-type scale (where 1 means totally disagree <strong>and</strong> 5 means totally agree),<br />
respondents gave each of the 15 statements a score of over 4 on a 5-point scale.<br />
Results suggest that the success of this congress has given the region’s population confidence<br />
in its ability to host major artistic <strong>and</strong> cultural events, since 90.3% of respondents chose 5 on a<br />
scale of 1 to 5 in response to this question. Respondents recognize that the WAC provided<br />
artists with a personal sense of pride <strong>and</strong> recognition (86.6%). It should be noted that most of<br />
the hundred or so artists who performed on stage or displayed in exhibit halls were area<br />
residents. Others were Acadians from other Acadian regions.<br />
From the very beginning of the planning process, organizers <strong>and</strong> part of the population<br />
wanted it to be known that the Acadian Peninsula was able to host a gr<strong>and</strong> event despite its<br />
economic challenges <strong>and</strong> the exodus of its youth to major centers elsewhere in New<br />
Brunswick <strong>and</strong> Canada. According to respondents, it would appear that this goal was<br />
achieved, as 86.3% believe that the CAW provided the Acadian Peninsula region with<br />
positive recognition from visitors.<br />
A bit more than half of the respondents totally agree that the region’s quality of life had<br />
improved (54.4%). The same proportion felt that the WAC contributed to their personal<br />
enjoyment <strong>and</strong> wellbeing (52%). Almost half the respondents felt that the WAC led to the<br />
improvement of the region’s current cultural facilities or the development of new ones. One<br />
might imagine that the respondents considered certain facilities needed at least to be improved<br />
in order to host the event (e.g. temporary setup of tents, gr<strong>and</strong>st<strong>and</strong>s, etc.).<br />
The table below demonstrates that respondents are more in favour of social impacts that affect<br />
the overall region (the Acadian Peninsula) compared to those that affect their own daily life.<br />
For instance, they believe the WAC brought a sense of wellbeing to the Peninsula population<br />
in general more so than to themselves personally.
Table 1<br />
Positive social impacts of the 2009 World Acadian Congress (n = 300)<br />
Percentage (%)<br />
of respondents<br />
The World Acadian Congress showed that the Acadian<br />
Peninsula region can host major artistic <strong>and</strong> cultural<br />
events.<br />
The World Acadian Congress provided artists with a<br />
personal sense of pride <strong>and</strong> recognition.<br />
The World Acadian Congress provided the Acadian<br />
Peninsula region a positive recognition from people<br />
visiting.<br />
The World Acadian Congress provided the Acadian<br />
Peninsula a chance to celebrate.<br />
The World Acadian Congress brought money into the<br />
region.<br />
The World Acadian Congress provided opportunities to<br />
meet with artists <strong>and</strong> various persons involved in the<br />
event.<br />
The World Acadian Congress brought the whole<br />
Acadian Peninsula region together to strengthen the<br />
community identity.<br />
The World Acadian Congress resulted in an enhanced<br />
image of the region.<br />
The World Acadian Congress provided people in the<br />
region with an exposure to a variety of cultural<br />
experiences.<br />
The World Acadian Congress provided residents from<br />
the region with the opportunity to learn new things<br />
about arts <strong>and</strong> culture.<br />
The World Acadian Congress provided a sense of wellbeing<br />
to the Acadian Peninsula’s population.<br />
The World Acadian Congress provided the opportunity<br />
for region residents to experience something new.<br />
During the World Acadian Congress, the quality of life<br />
in the region improved.<br />
The World Acadian Congress contributed to your<br />
personal enjoyment <strong>and</strong> well-being.<br />
Associations will benefit as a result of the World<br />
Acadian Congress, through new or improved cultural<br />
facilities.<br />
who answered 5<br />
Average<br />
score<br />
out of 5<br />
90.3 4.86<br />
86.6 4.83<br />
86.3 4.82<br />
85.7 4.81<br />
80.7 4.74<br />
80.3 4.73<br />
78.0 4.69<br />
76.3 4.69<br />
75.1 4.68<br />
71.3 4.64<br />
64.2 4.51<br />
61.0 4.47<br />
54.4 4.30<br />
52.0 4.12<br />
48.5 4.18<br />
Negative Social Impacts<br />
Table 2 includes the negative impacts usually associated with the hosting of a festival. As can<br />
be seen, few respondents perceived negative impacts. Although mentioned by very few<br />
(23.7%), the most negative impact involves the volunteers being overworked. Overall,<br />
respondents did not perceive the congress as being a source of inconvenience or annoyance in
their daily lives, whether in their daily routine, the use of cultural facilities, overcrowding in<br />
stores or streets, noise or other unfortunate incidents.<br />
Table 2<br />
Negative social impacts of the 2009 World Acadian Congress (n = 300)<br />
Percentage (%)<br />
of respondents<br />
who answered 5<br />
Average<br />
score<br />
out of 5<br />
Congress organizers <strong>and</strong> volunteers were overworked. 23.7 3.31<br />
Local cultural facilities were too crowded during the<br />
Congress.<br />
15.7 2.63<br />
The Congress disrupted normal routines in the region. 15.0 2.58<br />
Motor vehicle traffic increased to unacceptable levels<br />
during the Congress.<br />
12.7 2.26<br />
During the Congress, the region experienced crowding<br />
at certain places like parking lots <strong>and</strong> stores.<br />
10.0 2.40<br />
There was too much litter <strong>and</strong> garbage left during the<br />
Congress.<br />
8.7 1.90<br />
The arrival of visitors to attend the Congress reduced<br />
privacy in the region.<br />
8.0 1.87<br />
Noise levels increased to an unacceptable level during<br />
the Congress.<br />
7.7 1.82<br />
The Congress created too many incidents of disruptive<br />
behaviour.<br />
6.0 1.66<br />
Statistical tests run on different groups of respondents (those living near the main venues<br />
versus those living further away, or respondents aged 54 <strong>and</strong> under versus those 55 <strong>and</strong> up)<br />
did not produce any statistically significant differences.<br />
Discussion<br />
Results indicate that the organization <strong>and</strong> hosting of the World Acadian Congress were a<br />
success in the eyes of Acadian Peninsula residents. They confirm comments heard during <strong>and</strong><br />
after the event to the effect that it was an all-round success. Residents had a wonderful<br />
experience <strong>and</strong> the perception of their quality of life, generally <strong>and</strong> collectively, was<br />
improved. Positive impacts largely surpassed the negative impacts expressed in the instrument<br />
used for the survey.<br />
There are surely various factors which can explain this favourable perception by the local<br />
population. Firstly, there are geographical considerations, since the activities weren’t<br />
concentrated in the limited periphery of one single community. Indeed, the 400 events took<br />
place in most of the 102 communities. The extent of the territory <strong>and</strong> the distance between the<br />
venues <strong>and</strong> residences were sometimes several kilometres.<br />
The type of events can also explain the positive impacts, as most of them were family or<br />
community oriented (e.g. meals, presentations, displays <strong>and</strong> indoor shows). The major<br />
outdoor events, which are often the cornerstone of festivals, were few in number <strong>and</strong> attracted<br />
approximately 5,000 people in less densely populated areas within the municipalities (such as<br />
an ocean wharf).
The Acadians’ quest for pride <strong>and</strong> affirmation is explicitly included in the WAC organizing<br />
committee’s mission statement. It is therefore not surprising to see such a positive collective<br />
impact in this area. It might have been different if the theme had focused on a smaller portion<br />
of the population. Remember that close to nine out of ten Peninsula residents are Acadian,<br />
therefore directly affected by the congresses’ theme.<br />
Three main roads were closed to automotive traffic to allow participants (5,000 to 8,000<br />
people) to walk <strong>and</strong> experience a carnival-like atmosphere for at least half a day on each<br />
occasion. Two events attracted over 20,000 people: the tintamarre (major gathering on the<br />
main thoroughfare for the purpose of making noise for an hour so that Acadians can make<br />
known their presence as a nation) <strong>and</strong> the outdoor concert held immediately following this<br />
explosion of noise. Both of these events were held in Caraquet, the flagship community of the<br />
Acadian culture.<br />
These mass events (with road closures <strong>and</strong> traffic diversion) were preceded by consultation<br />
sessions between organizers <strong>and</strong> the local population to discuss changes in traffic patterns,<br />
<strong>business</strong> hours of certain services <strong>and</strong> noise related constraints. Many residents actively<br />
participated in these meetings, helping organizers adapt their plans <strong>and</strong> thus minimize, even<br />
slightly, the negative effects of these events. The meetings also allowed organizers to gather<br />
feedback on how to improve the hospitality aspect of the WAC <strong>and</strong> the content of its various<br />
events.<br />
Secondly, one of the factors which might explain the « social » success of the congress is the<br />
organizers’ willingness, right from the start, to have the population take ownership of the<br />
event <strong>and</strong> make it a major celebration first for the community, <strong>and</strong> then inviting “visitors” to<br />
join. Consequently, one of the organizers’ initial objectives was that each municipality<br />
organize at least one community event during the congress. That is how many community<br />
events came to be designed by local residents.<br />
Hinch <strong>and</strong> Delamere (1993) suggest that the success of a festival probably depends on the<br />
host community’s control of the event rather than its ownership by the tourism industry. In the<br />
case of the WAC, it appears evident that the positive impacts are a result of this major<br />
involvement, where barely a dozen full time paid staff was hired to organize 400 activities. It<br />
goes without saying that local volunteers played a major role in the entire planning <strong>and</strong><br />
management process. Indeed, our observations since the beginning of the WAC organization<br />
process (in 2004) have allowed us to note that organizers made every effort to communicate<br />
with volunteers <strong>and</strong> the general population on a regular basis. According to Byrd, Bosley <strong>and</strong><br />
Dronberger (2009), this aspect of communications is one of the secret ingredients for<br />
promoting the positive impacts of tourism.<br />
Through the local population’s involvement, people perceived the congress as being a<br />
gathering for everyone: youth, seniors, families, etc. Indeed, Huang, Li <strong>and</strong> Cai (2010)<br />
mention that the success of a festival, even from a tourist’s point of view, depends on the local<br />
community’s support <strong>and</strong> more precisely on the need for this host community to reflect the<br />
image of a place where family life is valued.<br />
Allen, Long et al. (1988) identified a correlation between the number of years a person lives<br />
in an area <strong>and</strong> his or her perception of the presence of <strong>tourists</strong>. Since residents of the Acadian<br />
Peninsula have lived there on average for 45 years, they may have a better underst<strong>and</strong>ing of<br />
the importance of an event such as the WAC for their community.
The results of the survey indicate that 84% of local residents took part in at least one event<br />
during the congress. This level of involvement is considerable <strong>and</strong> confirms, in our view, the<br />
local population’s positive perception of the congress. At least one study (Anderek, Valentine<br />
et al., 2005) suggests that those who benefit from tourism activities are favourable to the<br />
existence <strong>and</strong> hosting of such events. The benefits, in this case, are the social impacts, since<br />
Acadians from the Peninsula seem to confirm that the community benefited from some form<br />
of enjoyment <strong>and</strong> well-being thanks to the congress. A study by Allen, Hafer et al. (1993)<br />
indicated that local residents were more in favour of recreational activities than tourism<br />
development. Do residents of the Acadian Peninsula see the value of the congress more so as<br />
a recreational activity than a tourism initiative? They probably do, since the involvement<br />
required to organize an activity in their community focused first on the recreational nature of<br />
the activity <strong>and</strong> then on its tourism aspect. Indeed, economic spin-offs were only listed in 5 th<br />
position among the benefits of the Congress.<br />
It would appear, as suggests Durrett (2008) in his writings on festivals, that the Congress<br />
allowed the Peninsula’s Acadian population to demonstrate its resilience in that it faced its<br />
economic <strong>and</strong> social challenges by showing, through the WAC, that it st<strong>and</strong>s strong <strong>and</strong><br />
proud. There is no doubt in our minds that the benefits of World Acadian Congress will be<br />
sustainable <strong>and</strong> open the door to other social or economic activities which will promote the<br />
region’s overall development.<br />
It is interesting to note that respondents perceived positive impacts more so for the<br />
community than for themselves. This altruism was also evident with regards to negative<br />
impacts, where respondents gave top billing to the efforts made by their fellow citizens who<br />
were involved as volunteer.<br />
The survey undertaken after the World Acadian Congress provided a better underst<strong>and</strong>ing of<br />
the impacts of a major event in a rural setting where activities took place over a large<br />
territory. It would be interesting to examine the social impacts in more detail in a rural setting<br />
where activities would be closer together in time <strong>and</strong> space. Organizers of the next WAC,<br />
which will be held simultaneously in another region of New Brunswick (Madawaska-<br />
Victoria, or north-western NB), Maine (USA) <strong>and</strong> Québec (Témiscouata) in 2014, should<br />
repeat this type of survey to determine their social success <strong>and</strong> try to see if any evolution is<br />
showing up since 2009!<br />
Those organizers would also be well advised to follow the 2009 approach of consulting the<br />
public to establish the community programming as well as communicating with members of<br />
the community throughout the process. The initial idea of organizing activities for residents of<br />
the host community first <strong>and</strong> foremost, while ensuring that visitors (<strong>tourists</strong>) still experience<br />
quality <strong>and</strong> hospitality, probably prompted more people to get involved in the congress in one<br />
way or another.<br />
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www.pch.gc.ca/progs
Analysis <strong>and</strong> classification of wellness hotels in Austria<br />
Ivo Ponocny, Dagmar Lund-Durlacher<br />
MODUL University Vienna, Am Kahlenberg 1, 1190 Wien, Austria<br />
dagmar.lund-durlacher@modul.ac.at<br />
ivo.ponocny@modul.ac.at<br />
Abstract<br />
Austrian wellness hotel web pages have been analyzed on the basis of a r<strong>and</strong>om sample of<br />
134 hotels enumerated in the Relax <strong>Wellness</strong> Guide. Dominant features were found to be<br />
mountainous surroundings, being operated by independents <strong>and</strong> promoting non-wellness<br />
activities such as skiing as well. Surprisingly many enterprises focus on families as the target<br />
population, especially in mountainous areas. Quite often there is no particular distinguished<br />
wellness specialization, but wellness is taken as an add-on to other options or activities.<br />
Correspondingly, wellness offers are much closer tied to beauty offers than to genuine<br />
medical treatments, which allow discriminating between a “soft” <strong>and</strong> “hard” profile, whereby<br />
the former emphasizes relaxing <strong>and</strong> feeling well <strong>and</strong> the latter more specific health-related<br />
treatments. Alternative medicine is applied in almost half of the hotels, with a strong tendency<br />
that hotels which offer alternative medicine offer beauty treatments as well. However,<br />
sophisticated concepts of wellness or characteristic profiles are lacking in most cases.<br />
Background<br />
<strong>Wellness</strong> is a worldwide trend which in the year 2010 led to around 900 health <strong>and</strong> wellness<br />
hotels in Austria. There are 28 thermal baths with 6.75 billion visitors per year as well as 200<br />
private hospitals <strong>and</strong> rehabilitation centers. About 12 percent of all <strong>tourists</strong> in Austria make<br />
health-oriented holidays (ABA Invest in Austria).<br />
<strong>Wellness</strong> offers in Austria differ widely <strong>and</strong> there is no clear categorization for the consumer<br />
of what to expect from the variety of wellness hotels. Being still a young concept, health <strong>and</strong><br />
wellness tourism lacks commonly recognized definitions <strong>and</strong> categorizations. Inspired by a<br />
study of Mueller <strong>and</strong> Lanz-Kaufmann (Müller, Lanz-Kaufmann 2001), which analyzed the<br />
wellness hotel market in Switzerl<strong>and</strong> <strong>and</strong> revealed four types of wellness hotels there, the<br />
need for investigating the wellness supply in Austria was seen by the researchers.<br />
Research question<br />
The aim of the project is to discover <strong>and</strong> define different categories of the health <strong>and</strong> wellness<br />
accommodation sector by analyzing health <strong>and</strong> wellness establishments in Austria with a<br />
predefined set of criteria which can be used for classification of the health <strong>and</strong> wellness<br />
supply market.<br />
Characteristics of interest are formal ones such as hotel category, location, ownership, price,<br />
size, properties <strong>and</strong> general hotel facilities as well as the core marketing concept <strong>and</strong> the<br />
target groups addressed explicitly or implicitly. The main focus of interest lies on the health<br />
<strong>and</strong> wellness facilities which are advertised <strong>and</strong> on the detailed list of health <strong>and</strong> wellness<br />
offers (treatments, therapies, packages, trainings, courses, retail areas). Another area of<br />
inquiry refers to the promised effects of the wellness supply offered (such as mitigation or<br />
improvement, relaxation, spiritual experience, beauty), <strong>and</strong> to the promises connected with<br />
this supply. The fundamental concept behind the orientation of the treatments shall be<br />
assessed <strong>and</strong> analyzed in the context of available natural resources, unique selling position
<strong>and</strong> other characteristics of the hotels, delivering a detailed picture of similarities <strong>and</strong><br />
differences across the Austrian wellness sector. Further interest lies on the relationship<br />
between scientific <strong>and</strong> alternative medicine. Finally, the hotel descriptions are analyzed<br />
referring to the sustainability aspect. The presence of an explicit focus on sustainability (e.g.<br />
in the mission statement) is evaluated as well as the documentation of tangible evidence of<br />
sustainable behavior.<br />
Based on the analyses, it was expected to find certain types of hotels together with a set of<br />
descriptors for each of these types of accommodation, or to conclude that the Austrian<br />
wellness sector cannot be segmented into types satisfyingly because of a lack of distinguished<br />
hotel profiles.<br />
Research design<br />
A sample of 134 Austrian hotels was r<strong>and</strong>omly drawn from the Relax <strong>Wellness</strong> Guide website<br />
(http://relax-guide.com/), which is an online compilation of wellness hotels that currently<br />
contains 900 hotels in Austria <strong>and</strong> is believed to constitute a very reliable <strong>and</strong> exhaustive<br />
sampling frame. The data collection was carried out by students who attended a course on<br />
health <strong>and</strong> wellness tourism, whereby a data entry sheet was provided which contains a total<br />
of 183 characteristics to be filled in using the information from the websites. The catalogue of<br />
characteristics was formed by a priori reasoning according to the research question (such as<br />
location, hotel category etc.) as well as by text analytical procedures applied to the hotels’<br />
homepages.<br />
Results<br />
Generally speaking, the analysis shows that – in spite of the differences in the offers – the<br />
various possible properties of the wellness hotels are rather individualistically combined,<br />
without strong partitions into different types <strong>and</strong> without overarching, stable sets of common<br />
characteristics. However, some remarkable relationships could be observed.<br />
Formal characteristics<br />
Regarding the hotel category, there is much homogeneity resulting in a vast majority of 4 star<br />
hotels (81%) or 4 star superior (5%), followed by 3 star (9%) <strong>and</strong> 5 star hotels (3%). The most<br />
contributing state by far is Tyrol (52 hotels), followed by other mountainous areas such as<br />
Carinthia, Salzburg <strong>and</strong> Styria. In the total sample, there are 65% of hotels in a mountainous<br />
surrounding, in contrast to only 5 in a city centre. Again 65 % are year-round hotels, the rest<br />
are mainly 2-season hotels. The typical wellness hotel is family/independently-operated<br />
(81%), 12% are operated <strong>and</strong> owned by a hotel chain. Price levels are moderate: two third<br />
have been classified as mid-market (between 80 <strong>and</strong> 300 EUR room rate/double occ.), a sixth<br />
as economy <strong>and</strong> another sixth as luxury.<br />
The size of the hotels speaking in terms of room numbers was difficult to be assessed because<br />
in half of the cases there was no information given on the homepages. From those hotels<br />
where the room numbers are known it can be concluded that there is a highly significant (p <<br />
0.001) relationship between size of the hotel <strong>and</strong> how it is run (Cramer’s V = 0.532), but still<br />
far from being deterministic: 24 % of the large hotels (more than 100 rooms) are run by<br />
independents, but 86 % of the smaller hotels (<br />
Table 1).
Table 1: Size of hotel <strong>and</strong> operator<br />
Familyoperated<br />
No Yes Total<br />
Size 100 16 5 21<br />
Total 26 38 64<br />
A similar relationship can be found between operator <strong>and</strong> seasonality (p = 0.005, V = 0.245),<br />
with a clear but again non-deterministic tendency of seasonal hotels to be family-operated<br />
(Table 2). There is a clearly visible connection between type of ownership <strong>and</strong> price level. A<br />
cluster analytical classification according to seasonality, size <strong>and</strong> type of ownership suggests<br />
to segment the set of hotels in 1) small family owned hotels with a large seasonality share, 2)<br />
large year-round hotels run by chains <strong>and</strong> 3) small, family owned but also whole-year open<br />
hotels. On the other h<strong>and</strong>, except for the number of stars the price level is not visibly related<br />
to size, seasonality or ownership.<br />
Table 2: Operator <strong>and</strong> seasonality<br />
Familyoperated<br />
No Yes Total<br />
Seasonality no 38 49 87<br />
yes 9 38 47<br />
Total 47 87 134<br />
Location <strong>and</strong> surroundings<br />
The vast majority of Austrian wellness hotels lie in mountainous areas (70%), whereby in 9<br />
cases there are mountainous surroundings as well as a lake (which is coded as “mountainous”<br />
in
Figure 1). Many of the hotels take advantage of the natural resources, the most important of<br />
them being the possibility to ski (48 %) <strong>and</strong> the availability of thermal water or hot springs<br />
(18%). Only 41 % of hotels do not make use of any of these two benefits. Also many thermal<br />
hotels lie in mountainous areas, but not as many as for hotels where there is no natural hot<br />
water available.
Figure 1: Number of hotels in different surroundings<br />
Surrounding<br />
region of<br />
the hotel<br />
Table 3: Thermal springs <strong>and</strong> surroundings<br />
Thermal<br />
spring<br />
no yes Total<br />
City centre 4 1 5<br />
Suburb 3 0 3<br />
Mountainous<br />
area<br />
77 13 90<br />
Lake/River 14 2 16<br />
Countryside 9 8 17<br />
Total 107 24 131<br />
Not surprisingly, skiing possibilities are strongly related to mountainous surrounding, where<br />
57% of the hotels praise alpine sport options on their homepages. At the same time, there is<br />
also increased seasonality in mountainous surroundings <strong>and</strong> accordingly as well for skiingoffering<br />
hotels. Skiing promotion is particularly popular in family-owned seasonal hotels<br />
(71%), but less popular in chain-owned, year-round hotels (26%; in the other types the share<br />
is about 50:50, which creates in a significant relationship between skiing focus <strong>and</strong> operator, p<br />
= 0.002). This reflects the fact that in mountainous areas family-owned hotels dominate much<br />
more clearly (71%) than in other regions (53%), which stresses the importance of seasonal<br />
family-operated mountainous skiing hotels in the Austrian wellness sector. The centrality of<br />
this combination is not only supported by cluster analytical considerations but also by<br />
configuration frequency analysis: In fact, 23 hotels show all 4 properties literally, whereas 16<br />
show none of them which forms a clearly significant type (expected value for having all 4<br />
properties under independence assumption would be 9.5, p < 0.001).<br />
Unlike the promotion of skiing activities, the availability of thermal water is not visibly linked<br />
with any of the other structural characteristics as mentioned thus far.
Target groups<br />
As shown in Figure 2, the most frequently directly addressed target populations are families<br />
<strong>and</strong> couples. Correlation structure together with multidimensional scaling (Figure 3) suggests<br />
to group the strategies into single/couples/wellness, <strong>business</strong>/conferences/50+ <strong>and</strong> families.<br />
The vertical dimension might be interpreted as tranquility, the horizontal one as<br />
representativeness. The correlations between the targeting families <strong>and</strong> other groups are very<br />
small indicating that addressing families is independent from addressing the other targets.<br />
There is in general no visible tendency to specialize on particular groups exclusively.<br />
Figure 2: Target groups<br />
A remarkable dominance of family orientation can be noted which is striking because the<br />
classical wellness hotel would not be expected to focus on families. A context analysis of web<br />
pages, on the other h<strong>and</strong>, reveals that many of the hotels seem to emphasize feeling well <strong>and</strong><br />
relaxing more than undergoing distinguished treatments, <strong>and</strong> the wellness section is not<br />
central there but one among many others. In fact, hotels which target families offer<br />
significantly less items from a pre-defined list of medical treatments (0.6 instead of 1.0,<br />
Mann-Whitney p = 0.04, one-tailed), whereas there are no statistically relevant differences<br />
regarding wellness or beauty treatments, courses, trainings or promoted activities.<br />
Figure 3: Configuration of target groups in a two-dimensional space<br />
What can be observed in the data is that families are particularly targeted in mountainous<br />
areas (especially Salzburg, the Tyrol <strong>and</strong> Carinthia), whereas there is hardly any <strong>business</strong><br />
orientation in family-operated hotels (3 out of 64 (!) family-operated, 10 out of 36 other).<br />
Similarly, family-owners seem to concentrate less on seminars <strong>and</strong> conferences. Most<br />
interestingly, there seems to be no direct relationship between being family-run <strong>and</strong> focusing
on families. Furthermore, the availability of thermal water is no predictor for any of the<br />
targeting strategies, neither is the size or the price level.<br />
Broadness of wellness offers<br />
The broadness of wellness offers was assessed by a sum score mapping how many treatments<br />
of a pre-defined list are offered per hotel. The list was generated by a priori-reasoning as well<br />
as by extracting <strong>and</strong> aggregating frequently mentioned treatments such as classical or Asian<br />
massages, hot stone treatments, baths, lymph drainage, <strong>and</strong> similar. Analyzing bivariate<br />
relationships, price level is the most marked variable to predict the broadness of offers<br />
(moderate relationship), followed by type of ownership. Not surprisingly, higher price level<br />
corresponds to a broader range of wellness offers. Most interestingly, all other variables<br />
considered by now do not play an important role regarding the broadness, especially not the<br />
availability of thermal water, <strong>and</strong> neither the addressed target group nor the size of the hotel.<br />
A multivariate consideration reveals a particular interaction: narrow offers are typical for<br />
hotels which are the perfect anti-type to the mountainous seasonal family-operated skiing<br />
hotel as discussed above, which means they are frequently found in year-round hotels which<br />
are neither family-operated nor in the mountains <strong>and</strong> not promoting skiing.<br />
Judging from the websites, the most popular wellness offers are – apart from the more or less<br />
ubiquitous baths or packages – Asian <strong>and</strong> classical massages, lymph drainage (all between 25<br />
<strong>and</strong> 31 %) <strong>and</strong> hot stone treatments (14 %). Many features such as acupuncture are only<br />
offered by very few hotels, producing an extensive list of treatments which are found in at<br />
least one of the hotels under consideration. However, cluster analytic <strong>and</strong> factor analytic<br />
investigation could not reveal strong characteristic profiles or typical treatment combinations;<br />
rather the composition of offers seems idiosyncratic or, to put it bluntly, looks somewhat<br />
arbitrary.<br />
Broadness of beauty offers<br />
Similarly to the broadness of wellness offers, a characteristic for the broadness of beauty<br />
offers (facials, manicure, pedicure <strong>and</strong> similar) was defined <strong>and</strong> computed. As the most<br />
striking result, the broadness of wellness <strong>and</strong> beauty offers show an extremely large<br />
correlation (Spearman correlation � = 0.63, p < 0.001). This might not necessarily be due<br />
to the real treatment situation–it probably reflects to some part the general thoroughness of<br />
the hotel’s homepage, as well. Whatsoever, the relationship to price level is similar strong<br />
as the one of broadness of wellness offers. There is again <strong>and</strong> even slightly closer a<br />
connection to the mountainous seasonal family-operated skiing hotel type: generally<br />
speaking, the more characteristics of a hotel match this type, the more beauty treatments<br />
are offered by the websites.<br />
The most popular beauty features are facial treatments (47 %), followed by manicure (33<br />
%) <strong>and</strong> pedicure (31 %). Manicure <strong>and</strong> pedicure are highly interrelated (Cramer’s V =<br />
0.950), but with much weaker links to facial treatments (V = 0.424 or 0.380, resp.).<br />
Structure of offers<br />
Analyzing the structure of offers emphasizes the impression that wellness often appears as<br />
an add-on, as one feature additionally provided. For the analysis, the numbers of items<br />
from certain pre-defined target lists were evaluated per hotel, whereby there were separate<br />
lists for wellness treatments, beauty treatments, medical treatments, educational courses,<br />
training courses <strong>and</strong> promoted activities (such as sports outside the hotel). The largest<br />
correlation was between beauty <strong>and</strong> wellness treatments (Spearman correlation � = 0.63,<br />
p < 0.001), whereas numbers of wellness <strong>and</strong> medical treatments only showed � = 0.28 (p<br />
= 0.001). The mere size of the hotel (operationalized by the number of rooms) didn’t seem
to have an influence on these correlations <strong>and</strong> can be ruled out as relevant confounder.<br />
The factor analytical structure (Table 4) based on two components (with 57 % explained<br />
variance) splits these variables into one group stressing wellness, beauty <strong>and</strong> promoted<br />
activities, <strong>and</strong> one stressing medical treatments <strong>and</strong> educational courses. Training courses<br />
somehow range in between.<br />
Table 4: Factorial structure of offers<br />
Factor loadings<br />
Factor Factor<br />
1 2<br />
<strong>Wellness</strong><br />
treatments<br />
0.78 0.24<br />
Beauty treatments 0.83 0.11<br />
Medical treatments 0.09 0.71<br />
Educational<br />
courses<br />
-0.05 0.79<br />
Training courses 0.49 0.47<br />
Promoted activities 0.62 -0.22<br />
A multidimensional scaling visualization (based on z-st<strong>and</strong>ardized values) points out the<br />
similarity between wellness <strong>and</strong> beauty in the sample very drastically, in a two-dimensional<br />
mapping of the 6 characteristics the numbers of wellness <strong>and</strong> beauty offers are immediate<br />
neighbors to each other, whereas the distance between wellness <strong>and</strong> medical offers is much<br />
larger (Table 5). An illustrative example may be the presence of nutrition courses which<br />
correlates moderately with the number of medical treatments (� = 0.231, p = 0.007) but close<br />
to zero with the number of wellness or beauty treatments.<br />
Table 5: Configuration of offers in a two-dimensional space<br />
Indeed, the contrast between wellness/beauty/activities vs. medical treatments/educational<br />
courses as indicated by factor analysis can be related to other characteristics of the hotels. A<br />
linear regression analysis identified three predictors for a wide offer of “soft” applications<br />
(wellness <strong>and</strong> beauty area): being family-operated, promoting skiing <strong>and</strong> being expensive<br />
(adjusted r² = 0.13, p < 0.001;<br />
Table 6). Accordingly, broadness of wellness <strong>and</strong> beauty offers is specific for family-operated<br />
hotels which promote other activities such as skiing as well – <strong>and</strong> which have high room rates.
Table 6: Predictors for the number of "soft" treatments<br />
Coefficients<br />
Predictor<br />
pvalu<br />
Unst<strong>and</strong>ardized St<strong>and</strong>ardized e<br />
Familyoperated<br />
1.60 0.17 0.03<br />
Skiing 1.73 0.19 0.02<br />
Price 1.87 0.24 0.01<br />
The number of medical treatments <strong>and</strong> educational courses (“hard” treatments), on the other<br />
h<strong>and</strong>, could be significantly predicted by 5 characteristics (adjusted r² = 0.32, p < 0.001;<br />
Table 7). Medical orientation is found in large hotels which specialize on meeting the needs<br />
of older people rather than on families or couples, <strong>and</strong> is typical for hotels with thermal water.<br />
Table 7: Predictors for the number of "hard" treatments<br />
Coefficients<br />
Predictor Unst<strong>and</strong>ardized St<strong>and</strong>ardized p-value<br />
Couples targeted -0.66 -0.21 0.03<br />
50+ targeted 1.05 0.30 0.01<br />
Families targeted -0.59 -0.19 0.05<br />
Thermal water 1.04 0.28 0.01<br />
Number of rooms 0.48 0.26 0.02<br />
Regarding the particular wellness offers per hotel, no common pattern could be found which<br />
would indicate different sophisticated philosophies. An inspection of the web pages shows<br />
that the majority of hotels do not profile themselves with an individual wellness concept, so<br />
the wellness focus is seldom used to create a distinguished USP. As already mentioned above,<br />
in many cases wellness is treated as synonym for relaxing <strong>and</strong> feeling well.<br />
This is further demonstrated by an analysis of the promised effect of the treatments offered. It<br />
is clearly seen that relaxation, beauty <strong>and</strong> general health (vitality, fitness, refreshing,<br />
strengthening the immune system) are the most widespread effects by far, whereas specific<br />
health programs, educational efforts or spiritual approaches play, in comparison, a marginal<br />
role (Table 8).<br />
Table 8: Promised effects<br />
Aim/Promise Percentage<br />
Relaxation 29<br />
Spiritual/Mental health 5<br />
Harmony between body <strong>and</strong> soul 10<br />
<strong>Health</strong> in general 24<br />
Specific health treatments 7<br />
Change of behavior or thinking 4<br />
Beauty 29
Purification 11<br />
Application of alternative medicine<br />
Many of the treatments involve procedures which have to be subsumed under the notion<br />
“alternative medicine”, whereby every approach is subsumed here for which a scientific<br />
confirmation of the effectiveness is not documented (in contrast to the so-called “evidencebased<br />
medicine”). These offers can be classified into two categories: 1) treatments following<br />
an approach which would in principle be consistent with a natural science point of view but<br />
without effect control studies acknowledged by the scientific community (such as certain<br />
lymph drainages or detoxifications), <strong>and</strong> 2) treatments with a background exceeding natural<br />
science approaches, such as traditional Asian concepts involving the diagnosis of energy<br />
balances or similar. In the sample of 134 hotels, 75 (56 %) do not promote any kind of<br />
alternative medicine on the homepage, 17 only type 1), 16 type 2) <strong>and</strong> 26 hotels both types.<br />
So if type 1) is applied, the probability that also type 2) is applied is doubled (Cramer’s V =<br />
0.432, p < 0.001).<br />
In general, the broader the offer, the more alternative medicine is contained. All Mann &<br />
Whitney-tests comparing the broadness of wellness/beauty offers between hotels applying/not<br />
applying alternative medicine result in p-values smaller than 0.001. As another example, there<br />
is a marked positive correlation (r = 0.345, p < 0.001) between the availability of classic <strong>and</strong><br />
Asian massage offers.<br />
However, the presence of alternative medicine is hardly predictable by any other of the<br />
characteristics considered by now, so it seems to be a st<strong>and</strong>-alone characteristic completely<br />
independent of any other assessed property of the hotels – but for two exceptions: The one is<br />
the price, the more expensive, the more alternative medicine of type 1 (V = 0.325, p = 0.001;<br />
Table 9). As the most striking observation, there is hardly any cheap hotel offering type 1<br />
treatments. Additionally, this only holds for type 1), type 2) is not visibly related to the price<br />
level (V = 0.067, p = 0.75).<br />
Table 9: Price level <strong>and</strong> type 1-treatments<br />
Type 1<br />
offered<br />
Price<br />
level no yes Total<br />
Economy 21 1 22<br />
Mid- 56 30 86<br />
market<br />
Luxury 9 12 21<br />
Total 86 43 129<br />
The other exception is the presence of a beauty focus. If there is one, this raises the<br />
probability that alternative medicine is applied drastically. This statements holds for both of<br />
its types (Type 1: V = 0.31, p < 0.001, Type 2: V = 0.26, p = 0.002). The presence of a beauty<br />
focus obviously corresponds to less confinement to evidence-based procedures (Table 10).<br />
Table 10: Beauty treatments <strong>and</strong> alternative medicine<br />
Type 1<br />
Type 2<br />
Beauty offered<br />
offered<br />
treatments no yes Total no yes Total<br />
no 51 10 61 50 11 61
yes 40 33 73 42 31 73<br />
Total 91 43 134 92 42 134<br />
Sustainability<br />
Sustainability issues were addressed only by a small minority of hotels (8 of 134) which<br />
makes it impossible to go into thorough analysis. However, the data indicate by no means that<br />
larger or more expensive hotels would show more sensibility for sustainability on their web<br />
pages (descriptively speaking, the few hotels which do are mainly cheaper ones). Even if<br />
sustainability topics are mentioned explicitly, there is no elaborate concept published; mostly<br />
only allusions such as “regional orientation” or “according to ecological guidelines” are<br />
found, clear-cut information like “growing in-house vegetables” <strong>and</strong> “recycling” is quite rare.<br />
Conclusion<br />
Analyzing the structure of the Austrian wellness hotels shows that the market is rather<br />
heterogeneous with rarely clearly positioned wellness hotels. <strong>Wellness</strong> offers appear as an<br />
additionally provided feature by hotels which otherwise position themselves on other<br />
dimensions. Referring to Austria’s geographical situation, family operated mountainous<br />
skiing hotels play a major role in the Austrian wellness sector. Related to that fact are the<br />
main target groups of the wellness hotels which are couples <strong>and</strong> surprisingly families which<br />
are focused by many hotels in addition to the classical wellness target groups. Many hotels<br />
seem to mainly emphasize on relaxation where the wellness offer is not central to the guests.<br />
Analyses show that wellness offers can be split in two groups, one focusing on wellness,<br />
beauty <strong>and</strong> other leisure activities, the other stressing medical treatments <strong>and</strong> educational<br />
courses. The broadness of the wellness <strong>and</strong> beauty offers is strongly related to the price level<br />
whereas again no clear patterns of specific wellness <strong>and</strong> beauty treatments could be<br />
discovered. It seems that wellness hotels do not have a clear strategy for their offered<br />
wellness portfolio but rather combine offers arbitrarily or according to availability of<br />
therapists. It is also obvious that offers are following certain trends <strong>and</strong> range from numerous<br />
Asian massages <strong>and</strong> treatments to lymph drainage <strong>and</strong> reflexology. Only a few hotels<br />
specialize on local treatments which are based on Austrian traditional healing approaches.<br />
There are exemptions which strongly refer to local <strong>and</strong> regional resources, but they are few.<br />
Most of the wellness hotels offer a broad mix of therapies stemming from different cultural<br />
backgrounds. Based on the findings it can be said that there are many opportunities for<br />
wellness hotels to clearly position themselves with a focused offer taking into account the<br />
local <strong>and</strong> regional resources not only in their wellness as well as F & B offer but also in their<br />
hotel concept such as architecture <strong>and</strong> design. <strong>Wellness</strong> suppliers have to be aware that often<br />
their wellness supply is only an add-on to other attraction factors <strong>and</strong> therefore have to be<br />
carefully integrated in the overall strategy <strong>and</strong> concept of the hotel.<br />
References<br />
ABA Invest in Austria: <strong>Health</strong> <strong>Tourism</strong> retrieved on 15.3.2010 from<br />
http://www.aba.gv.at/EN/Sectors/<strong>Wellness</strong><strong>Tourism</strong>/<strong>Health</strong>+<strong>Tourism</strong>.aspx<br />
Cohen, M. <strong>and</strong> Bodeker, G. (2008). Underst<strong>and</strong>ing the Global Spa Industry: Spa<br />
Management. Oxford: Elsevier.<br />
Bushell R., Sheldon, P.J. (2009). <strong>Wellness</strong> <strong>and</strong> <strong>Tourism</strong>. Mind, Body, Spirit, Place. New<br />
York: Cognizant.<br />
Smith, M. <strong>and</strong> Kelly C. (2006). <strong>Wellness</strong> <strong>Tourism</strong>. <strong>Tourism</strong> Recreation Research. Vol. 31(1),<br />
2006: 1-4<br />
Smith, M., Puczko L. (2009). <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>. Oxford: Elsevier.
Mueller H. <strong>and</strong> Lanz-Kaufmann E. (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): 5-17
Forming groups of European destinations based on bednight statistics<br />
- using factor analysis <strong>and</strong> multidimensional scaling techniques<br />
Carl Marcussen<br />
Centre for Regional <strong>and</strong> <strong>Tourism</strong> Research, Bornholm<br />
Denmark<br />
marcussen@crt.dk<br />
www.crt.dk<br />
Abstract<br />
This paper uses applies a technique called multidimensional scaling (MDS) to illustrate how<br />
European destinations are positioned in relation to each other. The basis for doing so is<br />
bednight statistics from Eurostat for the period 1998 to 2009 for 33 European destinations<br />
(countries, nations). For each destination bednights are registered in four categories: domestic<br />
hotel guests, foreign hotel guests, domestic guests at other types of accommodations, <strong>and</strong><br />
foreign guests at other types of accommodation. With bednights on a monthly basis, this<br />
makes a data matrix with 12*12*4=576 cases. The variables are the destinations, up to 28 of<br />
them, when combining a few of them. Months or quarters are dummy-variables, <strong>and</strong> so are<br />
the guest type, <strong>and</strong> type of accommodation. A series of MDS diagrams are shown. Factor<br />
analysis is used to form groups of destinations, which are also visible in the MDS diagrams.<br />
The European destinations for international visitors may be grouped by major language<br />
spheres.<br />
Keywords: Factor analysis; multidimensional scaling; destinations; competitors.<br />
Introduction<br />
This paper applies a technique called multidimensional scaling (MDS) to illustrate how<br />
European destinations are positioned in relation to each other. The data which will form the<br />
basis for the MDS analyses are bednight statistics for 33 European destinations, i.e. EU27,<br />
EFTA4 plus Turkey <strong>and</strong> Croatia. The statistics are from Eurostat <strong>and</strong> cover the period 1998-<br />
2009. The data are the monthly bednights at all commercial accommodations, i.e. both hotels<br />
<strong>and</strong> other types of collective accommodations. For each of these two main groups of<br />
accommodations, the statistics are recorded for residents <strong>and</strong> for non-residents.<br />
The purpose of this paper is to visualize how European destinations are positioned in relation<br />
to each other <strong>and</strong> how destinations can be grouped based on bednight statistics.<br />
Research questions:<br />
1. Based on time series of bednight statistics, which destinations are somewhat similar,<br />
<strong>and</strong> how can this be illustrated, using a multidimensional scaling technique?<br />
2. Based on bednight statistics, which destinations can be grouped, using factor analysis?<br />
Literature Review<br />
Readers are assumed to be familiar with factor analysis. However, the basics both about factor<br />
analysis <strong>and</strong> multidimensional scaling (MDS) sometimes referred to as Principal Component<br />
Analysis (CPA), can be read in Green & Tull (1978). Factor analysis forms groups of<br />
variables which are correlated with each other, whereas the resulting principal components<br />
(factors) are uncorrelated. In statistical programs such as SPSS / PASW (Neulman & Heiser<br />
2009), factor analysis is in the dimension reduction category.
The term multidimensional scaling (MDS) was coined by Torgerson in the early 1950’s<br />
(Torgerson 1952). The technique started with metric MDS, i.e. based on interval or ratio<br />
scaled data. Later on non-metric MDS was developed, based on rank-order scales (Kruskal<br />
1964), which became <strong>and</strong> remains popular within psychometrics.<br />
Since the late 1970’s more than 30 travel <strong>and</strong> tourism journal articles have used MDS. One of<br />
these, Mazanec (1995), used bednight statistics for European cities, as a basis for visualizing<br />
how these presumably competing cities were positioned in relation to each other. This will<br />
also be done in this study, although the destinations here will be countries rather than cities.<br />
The incumbent MDS procedure from the late 1970’s is called ALSCAL, an Alternating Least<br />
Squares approach to Scaling (Young et al. 1978). Later on a more effective MDS algorithm<br />
has been implemented in the SPSS / PASW Categories procedure called PROXSCAL<br />
(Meulman & Heiser 2009), Proximity Scaling, from the late 1990’s in SPSS Categories 10<br />
<strong>and</strong> onwards. A few tourism or travel related journal articles have appeared, explicitly<br />
applying PROXSCAL (Ahmed & Miller 2007; Wöber 2007; Wolk & Wöber 2008; Burns<br />
2009).<br />
Methdology <strong>and</strong> Data<br />
MDS is capable of visualizing – typically in a two dimensional diagram – how multiple<br />
variables are related. The diagram is referred to as the common space. Each variable is<br />
represented in the MDS diagram by a dot, referred to as an object point. Closely related<br />
variables are placed close together in the MDS diagram <strong>and</strong> vice versa. Factor analysis is<br />
capable of forming groups of variables. Presumably, variables which are grouped together by<br />
the factor analysis will be placed close together in the MDS diagram(s).<br />
The data used in this study are bednight statistics for European destinations at the country<br />
level according to Eurostat. These are reported for different types of accommodation. Hotel<br />
<strong>and</strong> similar accommodations form the main category. There are three other types of<br />
accommodation in Eurostat, <strong>and</strong> they will here be called “other” under one. So there will be<br />
two main groups of accommodation. There are only to source markets in the Eurostat data,<br />
namely bednights by domestic <strong>and</strong> non-domestic visitors (foreigners).<br />
The bednight statics are reported in Eurostat on a monthly basis, <strong>and</strong> annually of course. The<br />
monthly numbers have been used to capture seasonal variations. A 12 year period 1998-2009<br />
has been selected. For some countries data is missing for some years. In place of missing data<br />
the corresponding numbers for the (corresponding month of the) preceding year or the<br />
following year have been used, or the average between the preceding <strong>and</strong> the following year,<br />
if both of those were available.<br />
With monthly data for a 12 year period, for hotels <strong>and</strong> for other commercial accommodations,<br />
<strong>and</strong> for residents <strong>and</strong> non-residents in both categories, this makes 12*12*4=576 records in a<br />
data matrix. The 33 destinations are variables, columns, in the data matrix. Additional<br />
variables (dummy-variables) indicate if the type of accommodation is hotels or not, the<br />
visitors are residents or not. Furthermore dummy variables indicate the month <strong>and</strong> quarter of<br />
visit, <strong>and</strong> there is a variable for the year. – Figure 1 shows the bednights per destination in<br />
1998, 2009 <strong>and</strong> in average for all the years.
Figure 4 Bednights in commercial accommodations per year in Europe 1998-2009<br />
Source: Based on Eurostat. Own elaboration.<br />
Figure 1 shows that Italy, Spain, Germany, France <strong>and</strong> the United Kingdom are the five<br />
largest destinations in Europe based on all bednights (hotels plus other commercial<br />
accommodations). Figure 2 shows the seasonal pattern for overnight stays at commercial<br />
accommodations in Europe (EU27, EFTA4 plus Turkey <strong>and</strong> Croatia).<br />
Figure 5 Bednights by month: Season – all of Europe – all years under one 1998-2009<br />
Source: Based on Eurostat.
Figure 3 shows the split of bednights on international <strong>and</strong> domestic visitors by destination, for<br />
all types of commercial accommodations under one. August <strong>and</strong> July are the busiest months.<br />
Figure 6 Split of bednights on international <strong>and</strong> domestic visitors, by destination in<br />
Europe 2009<br />
Source: Based on Eurostat.<br />
Figure 4 shows the split of bednights by type of accommodation.<br />
Figure 7 Split of bednights on hotels <strong>and</strong> other types of accommodations, by destination<br />
in Europe 2009<br />
Source: Based on Eurostat.<br />
Table 1 shows that hotels <strong>and</strong> similar establishments accounted for 69% of the registered<br />
bednights for the period 1998-2009 in average, other commercial/collective accommodations<br />
31%.
Table 11 Split of bednights in Europe 2009 by source <strong>and</strong> type of accommodation<br />
2009<br />
(%) Domestic International Total<br />
Hotels 37,3 31,9 69,2<br />
Other 20,4 10,4 30,8<br />
Total 57,7 42,3 100,0<br />
Source: Based on data from Eurostat supplemented by own elaborations.<br />
Note: Total is 2444 million bednights.<br />
Results<br />
In figure 5 there are 32 object points, i.e. 28 destinations or combinations of destinations plus<br />
a pair of object points indicating seasons (the vertical axis), <strong>and</strong> another pair indicating a<br />
domestic-international dimension (the horizontal axis). The rather few bednights in<br />
Lichtenstein has been added to those of Switzerl<strong>and</strong>. The three Baltic states of Estonia,<br />
Latvia, <strong>and</strong> Lithuania have been combined here, so have Belgium <strong>and</strong> Luxembourg, <strong>and</strong> the<br />
two destinations outside of the EU/EFTA areas Turkey <strong>and</strong> Croatia. The reason for the two<br />
latter combinations is that Luxembourg <strong>and</strong> Croatia would appear as a separate factor, if no<br />
combining was undertaken, which would not be convenient here.<br />
Figure 8 Position of European Destinations – based on all collective accommodations –<br />
1998-2009 – including seasons <strong>and</strong> origin markets<br />
Source: Based on data from Eurostat supplemented by own elaborations.
Note: Objects: 32. Proximities: 496 ((32*(32-1)/2). Normalized Raw Stress: 0.0316.<br />
N=576. Dispersion Accounted For: 1-0.0316=0.9684. PROXSCAL has been applied.<br />
In Figure 6 the 28 destinations are shown without the supplementary object points. Stress is<br />
very low in both Figure 5 <strong>and</strong> Figure 6, but lower in Figure 6 than in Figure 5 because there<br />
are fewer object points in Figure 6 than in Figure 5. One minus normalized raw stress is<br />
dispersion accounted for, which is very high in all MDS diagrams shown here. There appears<br />
to be some groupings of the destinations. A factor analysis, the result of which is shown in the<br />
left part of Table 2, indicates that there are three groups of destinations. The three groups are<br />
labelled as follows:<br />
1. The hot or generally international destinations.<br />
2. The cool destinations.<br />
3. Destinations dominated by domestic visitors.<br />
The three factors account for 85% of the total variation in bednight statistics, of which factor<br />
one 39%, factor two 24%, <strong>and</strong> factor three 22%.<br />
Figure 9 Position of European Destinations – based on bednights of all visitors<br />
Source: Based on data from Eurostat supplemented by own elaborations.<br />
Note: Objects: 28. Proximities: 378 ((28*(28-1)/2). Normalized Raw Stress: 0.0141.<br />
N=576. Dispersion Accounted For: 0.9859. PROXSCAL has been applied.
In Figure 7 the included bednights are those for international visitors only. Under this<br />
condition, many neighbouring destinations are positioned next to each other, for example<br />
Denmark, Sweden, Norway, <strong>and</strong> somewhat to the west Icel<strong>and</strong>. The alpine destinations<br />
Austria <strong>and</strong> Switzerl<strong>and</strong> are positioned next to each other, <strong>and</strong> so are Netherl<strong>and</strong>s <strong>and</strong><br />
Belgium, France <strong>and</strong> Italy, Germany <strong>and</strong> the Czech Republic, Irel<strong>and</strong> <strong>and</strong> the United<br />
Kingdom. There is a rim of Mediterranean destinations in the top left corner of Figure 7.<br />
Many Polish people work in the British Isles. In recent years additional air links have been<br />
established between these destinations.<br />
Figure 10 Position of European Destinations – international visitors only, all types of<br />
accommodation<br />
Source: Based on data from Eurostat supplemented by own elaborations.<br />
Note: Objects: 28. Proximities: 378 ((28*(28-1)/2). Normalized Raw Stress: 0.0232.<br />
N=288. Dispersion Accounted For: 0.9768. PROXSCAL has been applied.<br />
A second factor analysis was undertaken (see the right part of Table 2), based on international<br />
(non-domestic) bednights only. The results indicated that there are also three groups of<br />
destinations for international visitors. These are:<br />
1. The English sphere, around the British Isles, <strong>and</strong> countries with English as first foreign<br />
language<br />
2. The German language sphere, mostly with countries bordering Germany, or <strong>business</strong><br />
partners<br />
3. Other European destinations: Latin (French, Italian), Flemish, <strong>and</strong> Sc<strong>and</strong>inavian.
Group one account for 37% of the variation in international (non-domestic) bednights in<br />
Europe, group two 28%, <strong>and</strong> group three 26%, i.e. 91% in total, cf. Table 2. - With half as<br />
many observations (N) in Figure 7, than in Figure 6, stress is a little higher in Figure 7 than in<br />
Figure 6.<br />
Table 12 Result of two factor analyses, one with all visitors, <strong>and</strong> one with non-residents<br />
only<br />
Conclusion<br />
Three multidimensional scaling (MDS) diagrams were presented. The first one included 32<br />
dots, object points, representing 28 separate destinations, plus four additional object points<br />
indicating foreign vs. domestic guests, <strong>and</strong> summer versus winter season. Of Europe’s five<br />
largest destinations by number of bednight (Italy, Spain Germany, France <strong>and</strong> the United<br />
Kingdom) Spain is most oriented towards the international markets. Destinations such as<br />
Belgium, Denmark, Netherl<strong>and</strong> <strong>and</strong> Pol<strong>and</strong> are generally summer destinations, while others<br />
such as Switzerl<strong>and</strong> <strong>and</strong> Austria have dual peak seasons.<br />
A second MDS diagram based on all bednights, i.e. both domestic <strong>and</strong> international visitors,<br />
showed (with the help of a first factor analysis) that three main groups of European<br />
destinations can be identified. The first group is the hot or internationally oriented<br />
destinations including most of the Mediterranean destinations plus some destinations mostly<br />
oriented towards the international markets. The second group are cooler destinations in<br />
middle or northern Europe. The third group of European destinations are those with large<br />
domestic markets, or mainly domestic markets.<br />
A third MDS diagram included only the bednights by international (non-domestic) visitors.<br />
With the help of a second factor analysis three groups of destinations for international visitors<br />
were identified. The first group with the United Kingdom <strong>and</strong> Spain as the largest destinations<br />
have English either as a first language or English as a first foreign language. The second<br />
group of destinations for international visitors included Germany <strong>and</strong> other German speaking<br />
destinations, <strong>and</strong> other destinations familiar with the German language. The third group
included the rest of the European destinations, including the three Sc<strong>and</strong>inavian countries, the<br />
population of which are able to underst<strong>and</strong> each other’s languages, Dutch/Flemish, <strong>and</strong> the<br />
Latin languages French (France, Belgium, Luxembourg) <strong>and</strong> Italian.<br />
MDS has many applications, <strong>and</strong> grouping of destinations is one of them. MDS can be<br />
supported by factor analysis, which is helpful in the interpretation of the MDS diagrams.<br />
Proximity – nearness or distance – between the variables in the original data set <strong>and</strong> in the<br />
resulting diagrams are central in MDS analyses. – Neighbouring countries are typically top<br />
ranking foreign destinations. Thus nearness <strong>and</strong> easy access (low costs in terms of time <strong>and</strong><br />
money) plays a role in <strong>tourists</strong>’ choice of destination. So do climate, be it for a summer or a<br />
winter holiday, resulting in short summer seasons in northern Europe, or longer <strong>and</strong> more sun<br />
safe holidays in southern Europe. Also the ability to be understood well at the holiday or<br />
<strong>business</strong> destination <strong>and</strong> an element of cultural overlap clearly plays a role in destination<br />
choice.<br />
References<br />
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Usage Mining Exercise, pp. 77-86. In: Information <strong>and</strong> Communication Technologies in<br />
<strong>Tourism</strong> 2007, Proceedings of the International Conference in Ljubljana, Slovenia. Edited<br />
by: Marianna Sigala, Luisa Mich, Jamie Murphy. Springer. – Available at<br />
books.google.com.<br />
Young, F. W., Takane, Y., Lewyckyj, R. (1978). ALSCAL: A nonmetric multidimensional<br />
scaling program with several individual difference options. Behavior Research Methods<br />
<strong>and</strong> Instrumentation, 10, 451-453. (Also in Journal of Marketing Research, 1978, 15,<br />
612-615 <strong>and</strong> in American Statistician, 1980, 34, 117-118).
Measurement of <strong>Tourism</strong>-oriented Aspects of Quality of Life<br />
Gábor Michalkó<br />
Geographical Research Institute, Hungarian Academy of Sciences<br />
Hungary<br />
michalko@iif.hu<br />
Johanna Giczi<br />
Central Statistical Office<br />
Hungary<br />
johanna_giczi@yahoo.co.uk<br />
Tamara Rátz<br />
Kodolányi János University of Applied Sciences<br />
Hungary<br />
tratz@uranos.kodolanyi.hu<br />
Abstract<br />
A society’s <strong>and</strong> individuals’ quality of life has long been in the focus of social science<br />
research. The subjective aspect of one’s quality of life is usually assessed through a person’s<br />
perceived satisfaction with their own life. In comparison, the indicators <strong>and</strong> methodological<br />
approaches used by researchers trying to objectively measure quality of life are more varied<br />
<strong>and</strong> complex. However, both the correct identification of the factors influencing objective<br />
quality of life <strong>and</strong> the longitudinal evaluation of quality of life on the local level have<br />
remained a serious challenge.<br />
The paper presents the results of a study carried out by the HAS Geographical Research<br />
Institute in co-operation with the Kodolányi János University of Applied Sciences that aims to<br />
provide deeper underst<strong>and</strong>ing of tourism-oriented quality of life in Hungary. Although the<br />
research raised a large number of new questions as well, in this paper we discuss the<br />
development mechanisms of an indicator system that may fit within the currently used system<br />
of social indicators <strong>and</strong> may provide useful information on the interrelationship of tourism<br />
<strong>and</strong> quality of life. The development of the indicator system includes the delineation of the<br />
research area, the creation of the related dimensions <strong>and</strong> sub-dimensions, <strong>and</strong> finally the<br />
identification of indicators within the sub-dimensions. The indicator system is based on data<br />
available at the Hungarian Central Statistical Office, derived from regular data collection<br />
methods. Due to the obvious symbiosis of health <strong>and</strong> quality of life, a special emphasis is put<br />
on measuring tourism-oriented quality of life factors at Hungarian health tourism destinations.<br />
Introduction<br />
The concept of quality of life – in our underst<strong>and</strong>ing: happiness – has been a subject of<br />
thinking since millennia past (Aristotle 1997). In spite of this, scientific research of the topic<br />
only started in the second half of the twentieth century (Fekete 2006). Although we may find<br />
references to the responsibility of politics in Aristotle's Ethics of Nicomachus, it was not<br />
before the 1960s that the improvement of the quality of life of any society being the duty of<br />
wielders of power became political evidence (Kopp & Skrabski 2008). Post-industrial<br />
societies gradually recognised that it was not enough to ensure access to goods (guaranteeing<br />
consumption <strong>and</strong> level of subsistence), it is essential that the citizens are able to live their<br />
everyday life in a positive way (Royo 2007). Satisfaction with one’s life is crucial, since the<br />
negative mental state of those who are dissatisfied – who are experiencing a deep gulf
etween their actual <strong>and</strong> expected living conditions – may lead to a deterioration of their<br />
physical health (Kopp & Pikó 2006). The overall social consequence of the resulting illness<br />
(loss of productivity, replacement, medication, etc.) will be a heavy burden imposed on state-,<br />
local government- <strong>and</strong> household budget. It is no coincidence that research in Hungary related<br />
to quality of life almost invariably focuses on health-oriented issues (Kopp & Kovács 2006).<br />
No matter if it is mental or physical health that is examined, its status will be affected by<br />
whether leisure time is spent travelling: levels of mental <strong>and</strong> physical health are affected<br />
indirectly by leaving the everyday paths of movement behind. Utilising the ever-increasing<br />
range of offers of medical tourism can contribute directly to preserving, even restoring mental<br />
<strong>and</strong> physical fitness levels (Richards 1999, Neal et al. 2007).<br />
If, based on the literature, we accept that there is a relationship between tourism <strong>and</strong> quality of<br />
life, then it is justified to expect a method for measuring the qualities of this relationship. For<br />
this reason, the present study aims at laying the theoretical <strong>and</strong> methodological foundations<br />
for the development of an index which can be used to measure the impact of a person’s<br />
involvement in (or exclusion from) tourism on their quality of life. Given the government<br />
dem<strong>and</strong> as set out in the current Hungarian National <strong>Tourism</strong> Strategy (2005) for<br />
optimalization of the impact of tourism on quality of life (especially in relation to society,<br />
cultural heritage <strong>and</strong> natural environment), the statistical assessment of changes is considered<br />
desirable, even on the municipal level.<br />
This study offers a short summary of the theoretical <strong>and</strong> methodological literature discussing<br />
the relationship of quality of life <strong>and</strong> tourism. The authors explore the methodological<br />
foundations of selected definitions, thereby producing the set of indicators which, by fitting<br />
into the framework of social indicator systems, are capable of measuring the relationship<br />
between tourism <strong>and</strong> quality of life. This set of indicators will later provide the basis for the<br />
index measuring the relationship between tourism <strong>and</strong> quality of life.<br />
As indicated above, a close link is evident between quality of life <strong>and</strong> health. In order to be<br />
able to show the relationship of this link to tourism, the study examines aspects of quality of<br />
life in the population of settlements that are involved in wellness tourism.<br />
Subjective well-being as a basis of study<br />
Subjective well-being research has difficulties in defining the concept. Although subjective<br />
well-being, happiness <strong>and</strong> life satisfaction may be treated as synonymous categories, certain<br />
distinctions can be made between these concepts. Following definitions of the concepts<br />
introduced by Lengyel <strong>and</strong> Janky (2003), differences may best be understood if we accept the<br />
notion that people associate personal happiness rather with their personal micro-surroundings:<br />
family, children, or social relationships - while life satisfaction is seen as something of a<br />
broader concept, related to work, institutions <strong>and</strong> live history. Other than the clarification of<br />
concepts, subjective assessment of well-being has another cornerstone: its apriori experience.<br />
When examining the relationship between objective <strong>and</strong> subjective well-being one may find it<br />
convenient to extend these concepts in such a way that the former is associated with material<br />
prosperity, <strong>and</strong> the latter is paired to individual happiness; for this reason the majority of<br />
studies on subjective well-being have focused on the relationship between these two<br />
phenomena (e.g. Molnár & Kapitány 2006). This relationship can not be avoided when<br />
investigating the connection of tourism <strong>and</strong> subjective well-being, even though – as also<br />
stated in the introduction – the primary aim of our study is not the demonstration of the<br />
discrepancy between objective <strong>and</strong> subjective well-being.
Social indicator systems<br />
Social indicators may be grouped under different criteria. The grouping is primarily<br />
determined by what phenomenon the indicators are used to represent. Horn (1993) has these<br />
indicators grouped according to the following criteria:<br />
A. Objective type:<br />
1. Univariate approach: based on a single variable time series (for example, the<br />
number of guest-nights at the town)<br />
2. Multivariate "simple" approach: the formation of a combined index from<br />
heterogeneous indicators (e.g. the distribution of foreign <strong>tourists</strong> visiting Hungary,<br />
by nationality)<br />
3. Multivariate "complex" approach: based on a complex approach of a socioeconomic<br />
phenomenon, combining a variety of aspects (e.g., changes in long-term<br />
trends of domestic tourism)<br />
B. Derived, or subjective, type: according to Horn's theory, these indicators do not directly<br />
measure the social phenomenon, but use the so-called substitute (proxy) indicators for that<br />
purpose. These derived or inherited social indicators are based on individual perception of<br />
living conditions, or subjective assessment of social facts<br />
An objective-subjective distinction of social indicators is important because the models of<br />
social indicators can be distinguished according to the preference for the type of indicators<br />
they use to describe social phenomena. The summary below displays how, according to these<br />
criteria, a separate index for tourism is used in existing models of social indicators, <strong>and</strong> how<br />
the topic of tourism is linked with that of quality of life (Bukodi 2003).<br />
The emergence of tourism in social indicator models<br />
Some models use both descriptive <strong>and</strong> analytical approach at the same time. The resourcebased<br />
(Sc<strong>and</strong>inavian) model is strictly descriptive in nature. Primarily intended to describe<br />
how all kinds of resources – financial, economic, related to way of living (health, social<br />
network, education) – are distributed along different grouping criteria, it reveals in an<br />
analytical framework the main reasons why social differences manifested in living conditions<br />
exist. The Swedish model uses a relatively large group of objective indicators for each of<br />
these reasons to try to describe living conditions of the affected population.<br />
The approach with the set of social indicators called quality of life took root when scientists<br />
set out to study individual <strong>and</strong> social well-being– <strong>and</strong> the question arose whether it was<br />
sufficient to assess only objective living conditions, or there was also a need to examine these<br />
objective circumstances from the individual’s point of view (as it was alluded to earlier, when<br />
defining subjective well-being). The function of social indicators in the ‘quality of life'<br />
approach to the model was to measure the gap between aspirations <strong>and</strong> reality.<br />
According to the methodological foundations of the component model developed by English<br />
researchers (also called the English model), social phenomena marked by the "living<br />
conditions" concept can be divided into components (e.g. employment, household, health<br />
status), <strong>and</strong> these components can be studied by statistical tools separately. Application of the<br />
Component (or English) model has a double aim: on the one h<strong>and</strong> it provides a cross-sectional<br />
social map of the time given, <strong>and</strong> on the other h<strong>and</strong>, it displays the nature <strong>and</strong> direction of<br />
temporal changes regarding certain social phenomena 51 (Bukodi 2001).<br />
51 A description of these models can be found in more detail in: Bukodi Erzsébet: Társadalmi jelzőszámok –<br />
Elméletek és megközelítések, Szociológiai Szemle 2001/2. 35–57 o.
All models mentioned above contain some sort of component involving lifestyle or leisure<br />
time that includes a few basic indicators related to tourism:<br />
1. In the leisure <strong>and</strong> recreation group of the resource-based Sc<strong>and</strong>inavian model we have<br />
"the number <strong>and</strong> ratio of participants on holidays <strong>and</strong> vacation during the past year”<br />
2. In the German model called the “Quality of life” (QOL), leisure time is paired with<br />
media consumption<br />
3. The English component-based approach works with the lifestyle category.<br />
However marginally, the effect on quality of life created by tourism <strong>and</strong> travel is therefore<br />
present in all social indicator models.<br />
Examining the link between tourism <strong>and</strong> quality of life<br />
Methodological dilemmas <strong>and</strong> the question of database<br />
One can examine the link between tourism <strong>and</strong> quality of life from two aspects. First, we can<br />
look at the individual's relationship to tourism (<strong>and</strong> the nature of involvement); second, we<br />
can study the way that participation in the tourism sector influences the individual's subjective<br />
well-being; we may call this the personal perception. This subject has already been dealt with<br />
in several studies (e.g. Neal et al 2004, Michalkó et al 2009).<br />
There is, however, a possible area of analysis arising from the assumption that people living at<br />
frequented tourist destinations are happier than those living at areas less frequented by<br />
<strong>tourists</strong>. This hypothesis could be justified by a specific study only, which would require<br />
questioning an appropriate number of inhabitants of both popular <strong>and</strong> unpopular tourist<br />
destinations about how happy they are. Existing research results on "happiness" or "subjective<br />
well-being” used neither the kind of sampling method nor the sort of database that would be<br />
appropriate for our research on the relationship to be investigated. What existing research may<br />
support is only a kind of aggregate data: we may formulate some claims on individual<br />
happiness <strong>and</strong> its correlations with various elements of life, but only on a national, possibly<br />
regional level, <strong>and</strong> strictly along st<strong>and</strong>ard socio-demographic characteristics (gender, age,<br />
education, settlement type <strong>and</strong> economic activity).<br />
Another possible direction of research is to deduce the happiness of the inhabitants of a<br />
settlement from the urban characteristics of their home town, <strong>and</strong> from the socio-demographic<br />
indices of their population. In other words, we may try to measure subjective well-being at the<br />
level of objective data, naming such an indicator system "objective quality of life". Of course<br />
we are aware that these indicators are also influenced by a number of other mechanisms, <strong>and</strong><br />
that in many cases, the causal relationships may become juxtaposed. In spite of this we shall<br />
make the attempt to either confirm or deny our hypothesis.<br />
A further important aspect is that our model must have such a set of indicators that are easily<br />
produced from the existing databases, thus eliminating the need for special or expensive data<br />
surveys. According to this criterion we used the Hungarian Central Statistical Office (HCSO)<br />
Time Use Survey 1999/2000 database <strong>and</strong> the HCSO TSTAR 2000 database for our research.<br />
Determinants of subjective well-being<br />
Using the theoretical basis, first we identified those areas <strong>and</strong> the range of indicators which do<br />
affect subjective well-being of the individual. As mentioned earlier, people associate<br />
subjective well-being or happiness with their personal micro-habitat primarily (Janky &<br />
Lengyel 2003). Other literature (Lelkes 2003, Alesina et al 2001) show us that some factors<br />
clearly affect the feeling of happiness. Based on the data of the HCSO Time Use Survey
1999/2000, Table 1. presents the means of scores given assessing individual happiness along<br />
certain socio-demographic characteristics (on a scale of 1-4, where 1 = very unhappy, 4 =<br />
very happy).<br />
Pairing (operationalizing) aspects of micro-habitat with socio-demographic characteristics, we<br />
may draw the following conclusions:<br />
• Looking at age groups, going from younger to older, less <strong>and</strong> less respondents<br />
considered themselves happy.<br />
• Looking at marital status, the happiest are the married <strong>and</strong> the single (in the latter case<br />
the appropriate age effect shall also be considered), while the widowed <strong>and</strong> the<br />
divorced are the least happy.<br />
• In the case of education, the rule seems to be that the more educated people are, the<br />
happier they admit to be.<br />
• Economic activity results show that the happiest are those on maternity leave <strong>and</strong><br />
students (again, assuming the age effect), as well as employed people <strong>and</strong> those having<br />
a job besides pension; <strong>and</strong> the least happy are the disabled pensioners, those on social<br />
benefit <strong>and</strong> the unemployed.
Table 1. Assessment of individual happiness along certain socio-demographic<br />
characteristics, 1999/2000, mean<br />
At<br />
settlements<br />
Mean At settlements concerned<br />
concerned in in wellness<br />
tourism tourism<br />
Age group<br />
14-19 years 3.04 3.03 3.07<br />
20-29 years 3.00 3.01 3.01<br />
30-39 years 2.94 2.96 2.94<br />
40-49 years 2.86 2.86 2.86<br />
50-59 years 2.81 2.8 2.82<br />
60-69 years 2.80 2.81 2.8<br />
70-84 years<br />
Family status<br />
2.78 2.81 2.81<br />
Single 2.95 2.97 2.99<br />
Married 2.94 2.94 2.93<br />
Widowed 2.70 2.68 2.71<br />
Divorced<br />
Education<br />
2.66 2.66 2.69<br />
Less than primary school 2.68 2.72 2.63<br />
Primary school 2.83 2.82 2.85<br />
Uncompleted secondary school 2.89 2.89 2.85<br />
Secondary school 2.97 2.99 2.96<br />
Postsecondary school 2.98 2.96 3.05<br />
College, university<br />
Economic activity<br />
3.01 3.04 3.08<br />
Active income earning 2.96 2.97 2.97<br />
Retired, with employment 2.91 2.95 2.99<br />
Retired 2.79 2.81 2.81<br />
Disabled pensioner 2.61 2.53 2.61<br />
Maternity leave 3.05 3.01 2.97<br />
Unemployed 2.73 2.76 2.73<br />
Social benefit 2.53 2.4 2.21<br />
Housewife 2.97 3.02 2.96<br />
Student 3.06 3.05 3.06<br />
Other dependent 2.76 2.77 2.84<br />
Other inactive 2.8 2.82 3<br />
Note: The question asked in the questionnaire: “All in all, what is your well-being<br />
nowadays?” Answer: on a 1-4 scale, where 1 = very unhappy, 2 = unhappy, 3 = happy, 4 =<br />
very happy.<br />
Source: Time Use Survey 1999/2000. HCSO. Own calculations.
However, according to Table 1, it appears that inhabitants of settlements involved in<br />
"tourism" or "wellness tourism" do not differ significantly from the national average in<br />
assessing their personal happiness (53% of subjects in our sample were living at a settlement<br />
involved in tourism; 23% lived at a wellness tourism destination). This appears to<br />
demonstrate that micro-habitat factors affect the individual's subjective well-being more than<br />
their macro-habitat.<br />
Defining the indicator of “objective welfare of settlement”<br />
Beyond a simple analysis of the available database, we are trying to determine the factors that<br />
impact (individual) perception of happiness. Since our ultimate goal is to set up a ranking<br />
among settlements in Hungary in terms of happiness of their inhabitants, we must first<br />
determine the range of variables that influence subjective well-being. In order to do the same<br />
for objective well-being, we must define those indices that will clearly have an impact on<br />
subjective well-being at the individual level as well as at the municipal level. In other words,<br />
if we find, for example, that moving into a new home has a positive impact on the individual's<br />
subjective well-being, then our municipal level indicator measuring the construction of new<br />
housing will receive a higher weight in our index for objective well-being.<br />
Table 2 summarises the indicators used as explanatory variables in our model.<br />
Number Dimensions affecting perceived Indicators affecting perceived<br />
subjective well-being<br />
subjective well-being<br />
1. Socio-demographic indicators Age<br />
2. Marital status<br />
3. Highest level of education<br />
4. Economic activity<br />
5. Urban characteristics (facilities) Railway station<br />
6. Long-distance bus station<br />
7. Post Office/P.O.B, postal agencies<br />
8. Bank<br />
9. Market<br />
10. Pharmacy<br />
11. Old persons’ home<br />
12. GP<br />
13. Kindergarten<br />
14. Primary school<br />
15. Library<br />
16. <strong>Tourism</strong> exists in the settlement<br />
17. City status<br />
Note: socio-demographic characteristics are from HCSO Time Use Survey 1999/2000, source<br />
of local settlement features from database TSTAR CSO 2002<br />
The dependent variable of our logistic regression model is a binary variable that is created<br />
from a previous model, which had earlier been prepared to measure "happiness" on a fourlevel<br />
scale 52 .<br />
52 This was a question in the questionnaire: values of the dependent variable were created by aggregation. 1=<br />
happy; 0=unhappy
As some of the settlement characteristics were not significant in explaining the dependent<br />
variable, over a number of steps we dropped them from the model (one by one), hence<br />
increasing the explanatory power of the model.<br />
After omitting variables that did not fit in the model , the final equation became:<br />
Happiness=b0+b1*agegroup+b2*familystat+b3*educat+b4*econact+b5*market+b6*GP+b7<br />
*nursery+b8*library.<br />
3.4. Measuring the impact of tourism on subjective well-being<br />
In order to set up the equation, we need to find those settlements first that play an important<br />
role in tourism. According to the classical approach, a settlement’s role in tourism is assessed<br />
by the number of „guest nights” (Michalkó 2007). Therefore, the total number of guest nights<br />
is the key indicator of tourism in our study. Settlements registering even a single guest night<br />
are therefore considered "tourism-affected" settlements.<br />
In addition, our analysis distinguished "wellness tourism-affected" settlements. This group<br />
included all settlements that possessed some sort of medical or thermal spa or cave bath.<br />
Results<br />
Settlement-level approach: creation of a “happiness index” on the settlement level<br />
In addition to assessing the factors that influence individual happiness, we would like to see<br />
what kind of hierarchy can be established among settlements, when we look at the happiness<br />
of the people who live there. In the model presented previously we were using variables<br />
affecting subjective happiness that would apply on a settlement level also.<br />
Why is this level of abstraction needed? It is easy to see that no ranking can be established<br />
among settlements if we only consider individual happiness of their inhabitants; not unless we<br />
also use a database that includes enough related data for each <strong>and</strong> every settlement. Such<br />
database does not exist unfortunately, therefore we must tackle the problem differently.<br />
Variables of the regression model on the database of answers on individual happiness are<br />
“translated” into a settlement level, <strong>and</strong> are then weighted with the odds ratios from that<br />
model. We can establish a ranking among the settlements then by simply averaging values<br />
from the weighting.<br />
Based on the HCSO TSTAR database, as settlement-level equivalents of variables in the<br />
regression model, we used the indicators summarised in Table 3.<br />
Table 3. Equivalents of determinants of subjective well-being on the settlement level<br />
Number. Socio-demographic characteristics Settlement level indicators<br />
1.<br />
influencing the individual’s subjective<br />
well-being<br />
Age Proportion of the age group within the<br />
population of the town<br />
2. Marital status Ratio of the population of given family status<br />
within the population of the town<br />
3. Highest level of education Proportion of population of a given education<br />
level within the population of the town<br />
4. Economic activity Ratio of population of given economic<br />
activity within the population of the town
Since the TSTAR database does not have the detail of data that we previously used in our<br />
model, in the case of the variable for economic activity we applied the following aggregation:<br />
TSTAR categories TUS categories<br />
Employed → Pensioner, also active wage earner<br />
Unemployment → Unemployment benefit<br />
Pensioner → Pensioner, disabled pensioner<br />
Inactive wage earner → Maternity leave, social benefit<br />
Dependent → Housewife, other dependents, other inactive<br />
Student → Students, children under school age<br />
Since settlement characteristics did not play a major role in explaining happiness, the only<br />
indicators we used in the following model (Table 4) were socio-demographic.<br />
Table 4. Results of the regression model<br />
Sig. Exp(B)<br />
Age group, Reference category: 60 years<br />
<strong>and</strong> older<br />
15-29 years 0.011 1.815<br />
30-39 years 0.583 0.897<br />
40-59 years 0.013 0.705<br />
Marital status. reference category: single<br />
Married 0.000 3.316<br />
Widowed 0.171 1.287<br />
Divorced 0.485 0.877<br />
Education, Reference category: school,<br />
apprenticeship, without graduation<br />
Elementary School: 8 or less classes 0.083<br />
completed<br />
0.759<br />
Elementary School, 8 classes completed 0.146 0.834<br />
Baccalaureate 0.000 1.763<br />
Baccalaureate & postsec. 0.011 1.978<br />
Degree 0.000 2.433<br />
Economic activity, Reference category:<br />
active wage earner<br />
Unemployed 0.000 0.322<br />
Pensioner 0.000 0.455<br />
Inactive wage earner 0.003 0.490<br />
Dependent 0.030 0.594<br />
Student 0.003 2.300<br />
Constant 0.000 4.107
The exclusion of settlement characteristics slightly reduced the explanatory power of the<br />
model. The results show that the „trends” described in the previous model have not changed:<br />
it is only the odds ratios of the new model that show a difference.<br />
Definition of a ranking among Hungarian settlements, as a function of perceived<br />
subjective well-being of their inhabitants<br />
The socio-demographic variables we used in our model are coming from the 2001 Census<br />
database, as summarized on a settlement level. The HCSO TUS data only contain answers<br />
from subjects aged 14 years or older; accordingly, we ignored TSTAR Census data related to<br />
population younger than 15 years.<br />
To determine the index, following categories of variables as set in the model, we first<br />
calculate the percentage of population to that of each settlement, as defined by the given<br />
indicator. Each category of indicators will then have an odds ratio from the above model (in<br />
case of the reference category the odds ratio will be a 1). We must then calculate an average<br />
from each value thus obtained.<br />
Figure 1. Hungarian settlements with the highest quality of life<br />
The result are shown in Figure 1 which displays the hundred happiest Hungarian settlements.<br />
It is clear from the figure that most (83%) of these settlements are located in Central Hungary<br />
<strong>and</strong> the Danube region, while the ratio of happy towns <strong>and</strong> villages in East Hungary is<br />
significantly lower (17%). Regarding the regional concentration of the settlements in the<br />
sample, areas of higher density are the Budapest Agglomeration, the Lake Balaton region, the<br />
Hungarian-Austrian border region, <strong>and</strong> around the mountains of Mátra <strong>and</strong> Bükk, all being<br />
key recreation areas in the country. Considering the above settlements’ role in tourism, 71 of
the hundred happiest settlements registered overnight tourist dem<strong>and</strong>, <strong>and</strong> 16 of the 71 are<br />
involved in mainly domestic spa <strong>and</strong> health tourism.<br />
Summary <strong>and</strong> conclusions<br />
Keeping track of changes in the quality of life is not a task normally taken up by official<br />
statistical data collection surveys. This is probably explained by the fact that the basic data<br />
these studies ought to start with - namely: the question „how are you today”, or „how satisfied<br />
are you with your life?” – will invariably give a body of information that is not exact enough<br />
to serve as the foundation for a methodologically correct evaluation. Nevertheless, from time<br />
to time the surveys of the Hungarian Central Statistical Office do have, as part of their<br />
attempts to measure quality of life, a few questions pertaining to the topic.<br />
As quality of life is a function of a great number of factors, the role played out by these has<br />
been in the centre of interest of scientists representing various disciplines. Hungarian research<br />
is centred upon aspects of quality of life that are related to health – we know much less about<br />
how leisure travel, for example, contributes to the happiness of the Hungarian citizen. Within<br />
this circle of issues, tourism research must look at how direct involvement in leisure travel<br />
change the perceived quality of life, <strong>and</strong> to what extent living in a tourist destination does the<br />
same.<br />
Starting from the social indicator system, the present study aims at revealing those Hungarian<br />
towns <strong>and</strong> villages that show the highest indicators of quality of life. Supported by the 2001<br />
Census <strong>and</strong> the 2000 TUS survey, using an index given by mathematical-statistical methods it<br />
presents the one hundred settlements in Hungary with the happiest citizens. Spatial<br />
distribution of these settlements shows a geographical correlation with distinguished holiday<br />
districts.<br />
Acknowledgements<br />
The survey forming the basis of this study was supported by the OTKA (K67573)<br />
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Managing Cost, Revenue <strong>and</strong> Yield in the <strong>Tourism</strong> <strong>Wellness</strong> Industry<br />
Patrizia Modica<br />
Department of Economics <strong>and</strong> Business Studies, School of Economics<br />
University of Cagliari<br />
Viale S. Ignazio 17, 09123 Cagliari<br />
Italy<br />
modica@unica.it<br />
Elisa Scanu<br />
PhD School of Management <strong>and</strong> Accounting<br />
University of Cagliari<br />
Viale S. Ignazio 17, 09123 Cagliari<br />
Italy<br />
Abstract<br />
The tourism wellness industry is a rapidly growing sector facing a number of challenges in<br />
today’s fast-paced world, where people are looking for solutions to their wellness needs.<br />
Management of this dem<strong>and</strong> requires the implementation of a robust strategy in order to<br />
maximise profitability <strong>and</strong> customer experience. This study considers the application of yield<br />
management as a suitable approach, which is tested in this case in day spas as part of the<br />
wellness industry. The viability of yield management in this field is investigated using a case<br />
study approach, considering particularly the conditions required, <strong>and</strong> whether this managerial<br />
method can generate significant benefits.<br />
Keywords: <strong>Tourism</strong> wellness industry; Spas; Yield management; Pricing policies<br />
Introduction<br />
A <strong>healthy</strong> lifestyle plays an important role in the culture of individuals. Having a good<br />
appearance, a good state of health, <strong>and</strong> a sporty lifestyle are personal desires that lead to<br />
specific actions <strong>and</strong> behaviours. This is in contrast to attracting <strong>and</strong> opposite forces that lead<br />
to un<strong>healthy</strong> choices, for example, bad food or overeating, a sedentary lifestyle, or excessive<br />
drinking. <strong>Health</strong>y behaviours are generally prevalent in developed societies <strong>and</strong> this is<br />
reflected in a sense of personal harmony with the environment. The need for wellbeing is<br />
widespread <strong>and</strong> stimulates people to express a dem<strong>and</strong> for health <strong>and</strong> wellness products. This<br />
dem<strong>and</strong> tends to accompany a person in everyday life – at home <strong>and</strong> away, at work, during<br />
free time <strong>and</strong> in leisure moments. A combination of health, wellness <strong>and</strong> tourism can naturally<br />
contribute to relaxation, exploration, socialisation, a sense of self-worth (McIntosh et al.<br />
1984) <strong>and</strong>, moreover, quality of life (Bushell et al. 2009).<br />
The wellness industry has emerged <strong>and</strong> grown in recent decades around the world (Erfurt-<br />
Cooper et al. 2009, Smith et al. 2009), providing services for both resident <strong>and</strong> non-resident<br />
customers. These services are provided by spas, gyms, beauty salons <strong>and</strong> adventure or<br />
sporting travel organisations, among others. In the tourism wellness sector this industry<br />
attracts different, economically-promising segments of dem<strong>and</strong>. The management of the<br />
dem<strong>and</strong> for tourism wellness products can represent a challenge for entrepreneurs,<br />
shareholders <strong>and</strong> managers. The tourism wellness industry needs to identify the characteristics<br />
of this dem<strong>and</strong>, which can contribute to the management of costs, revenues <strong>and</strong> profits, thus<br />
revealing industry performance. The dem<strong>and</strong> for tourism wellness products is generally
variable, unstable <strong>and</strong> seasonal, with high fixed costs <strong>and</strong> fixed capacity over the short term<br />
on the supply side – as can be seen in the tourism industry in general (Vanhove 1994). Tourist<br />
products are intangible, perishable, diverse <strong>and</strong> simultaneous to their production. This<br />
demonstrates the need to manage a limited product <strong>and</strong> a changeable dem<strong>and</strong> for it.<br />
Yield (or revenue) management is considered a key tool for advantageously using the<br />
resources invested in capacity-constrained firms in the tourism sector, reaching the actual <strong>and</strong><br />
potential dem<strong>and</strong> <strong>and</strong> hence maximising profitability (Modica et al. 2009). It is particularly<br />
seen in airlines, hotels <strong>and</strong> car rental firms, <strong>and</strong>, less frequently, in other tourism <strong>business</strong>es.<br />
Yield management is a strategic approach that optimises unit of inventory availability <strong>and</strong><br />
price, based on consumer behaviour prediction, with the objective of maximising revenues<br />
<strong>and</strong> profitability, improving services <strong>and</strong> then customer perceived value (Cross 1997,<br />
Donaghy et al. 1995). Kimes (2000) found evidence that yield management is often<br />
implemented in service organisations as a tactical, rather than strategic, approach, for<br />
example, proposing discounted rates to customers in slow periods outside a coherent strategy.<br />
A set of strategic levers have to be adopted to improve the flow of customer dem<strong>and</strong> <strong>and</strong> thus<br />
performance, including knowledge of clientele segments, time of reservation, appropriate use<br />
of capacity <strong>and</strong> a change in prices over time.<br />
Some conditions that are present in the tourism service industry favour the effectiveness of<br />
yield management. Yield management is suitable for those entities managing their constrained<br />
capacity, their perishable products, their variable but predictable dem<strong>and</strong>, their high fixed<br />
costs <strong>and</strong> their pricing structures (Kimes et al. 1998).<br />
This study involves the application of some aspects of yield management to the wellness<br />
industry, specifically spa firms, <strong>and</strong> an analysis of the effectiveness of revenue management<br />
strategies in this context. The spa industry seems to possess all the attributes to apply yield<br />
management successfully. Spa <strong>business</strong>es present similarities to hotels, airlines, car rental<br />
firms, cruise lines, etc., as regards the conditions mentioned above. Spa pricing policies are<br />
different, since spa treatment price tends to be fixed <strong>and</strong> has not yet been manipulated with<br />
the sophistication that scientific yield management requires. Differential pricing can be<br />
managed, gaining the opportunities that yield management can provide (Phillips 2005, Nagle<br />
et al. 2006, Reece et al. 2000). Dem<strong>and</strong> levels influence the way treatments are priced.<br />
Moving from fixed to variable prices can permit spas to increase clientele numbers <strong>and</strong><br />
purchases, revenues <strong>and</strong> profits.<br />
For the research, a case study approach was adopted, based on a day spa located in Cagliari on<br />
the southern Sardinian coast. In the provision of spa services in Sardinia, as in many other<br />
parts of the world (Kimes et al. 2009), revenue management techniques are not implemented<br />
to contrast variable dem<strong>and</strong> towards profitability results. To construct the case study, the<br />
management practices of the spa were analysed, considering also occupation, treatment<br />
duration <strong>and</strong> pricing, through semi-structured interviews with the owner/manager <strong>and</strong> key<br />
staff members <strong>and</strong> a questionnaire. During these interviews <strong>and</strong> through the questionnaire the<br />
current performance <strong>and</strong> the variables determining that performance were also acquired. The<br />
case study tested the dem<strong>and</strong> for a specific service <strong>and</strong> the related effects on revenues. This<br />
was followed by a comparison with non-discriminating pricing policies practiced for the same<br />
service <strong>and</strong> the related dem<strong>and</strong>. As a result, the potential of yield management in improving<br />
customer dem<strong>and</strong>, occupation, revenues <strong>and</strong>, consequently, profits in the spa industry can be<br />
evaluated.
Method: A Case Study Approach<br />
The aim of this research is to analyse the effectiveness of revenue management in the<br />
wellness industry, particularly in spa firms. For this purpose a case study approach is<br />
appropriate, as this method permits exploration of the use of revenue management, <strong>and</strong> the<br />
development of recommendations for the management of the wellness industry based on the<br />
findings. A case study is defined as “a study of events within their real life context” (Yin<br />
2009). This research looked at “Beauty Center Valentino”, a prominent day spa located in a<br />
charming villa in the centre of Cagliari, the capital of Sardinia. The case study looked at a<br />
single organisation representative of spa firms around the world <strong>and</strong> attempts to answer the<br />
following research questions: first, are all the conditions to apply yield management to the<br />
tourism wellness spa industry present?; second, is it possible for yield management to be<br />
implemented <strong>and</strong> developed into this segment of the market?; <strong>and</strong> third, can yield<br />
management improve profitability, <strong>and</strong> improve <strong>and</strong> maintain customer satisfaction?<br />
To build the case study different types of data were required: capacity characteristics of the<br />
day spa; dem<strong>and</strong> characteristics; available services; cost structure; pricing policies <strong>and</strong><br />
revenue performance.<br />
A six step approach was used to collect this data.<br />
1. A conversation with the owner/manager to obtain general information about the spa<br />
<strong>and</strong> explain the research project.<br />
2. A semi-structured interview with the owner/manager <strong>and</strong> head receptionist about spa<br />
policies <strong>and</strong> performance.<br />
3. A questionnaire delivered to the head receptionist to complete regarding the spa’s<br />
performance data <strong>and</strong> customer typology.<br />
4. A focused interview regarding the cost structure to identify a fair margin product to<br />
discount in February 2010.<br />
5. Further interviews regarding the status of the study.<br />
6. A further focused interview to collect the results, discuss the test, <strong>and</strong> obtain<br />
information regarding the Italian wellness market.<br />
First Step<br />
The conversation was an opportunity to meet the owner/manager <strong>and</strong> obtain information<br />
regarding the characteristics of the spa supply (services offered), capacity, pricing policies<br />
<strong>and</strong> discounting, <strong>and</strong> customer typology, with particular regard to income, age, gender <strong>and</strong><br />
time <strong>and</strong> price sensitivity. The concept of yield management was explained, as well as the<br />
importance of its implementation in the wellness industry to maximise profits <strong>and</strong> benefit<br />
customers. It was requested that the spa test a particular discounting policy on a product for a<br />
period of one month. This test is a simplified opportunity to observe the effects of the<br />
implementation of some aspects of yield management in the short-term.<br />
Second <strong>and</strong> third step<br />
Yin (2009) regards the interview as “one of the most important sources of case study<br />
information”, in particular suggesting the use of semi-structured, or guided, conversations<br />
rather than structured queries, though still following a line of inquiry. Furthermore, the use of<br />
a semi-structured, as opposed to a totally unstructured, interview better suits the addressing of<br />
specific issues (Bryman-Bell 2007) <strong>and</strong> the acquisition of specific information.
A semi-structured interview was conducted with the owner/manager <strong>and</strong> head receptionist<br />
regarding personnel policy <strong>and</strong> the spa’s performance. Information was also gathered on<br />
occupation levels, treatment durations <strong>and</strong> pricing.<br />
The questionnaire was also explained in detail <strong>and</strong> then given to the head receptionist to<br />
complete <strong>and</strong> return at the next meeting to collate quantitative data. The questionnaire was<br />
comprised of two sections. The first section covered the spa’s data for specified periods (a<br />
Monday <strong>and</strong> Friday between 9:00am <strong>and</strong> 11:00am, <strong>and</strong> 1:30pm <strong>and</strong> 3:30pm in one week in<br />
July, September <strong>and</strong> November 2009 respectively). The data included the number of<br />
treatment rooms, the number of available therapists, the total possible hours to be sold, the<br />
number of clients, <strong>and</strong> information regarding performance at those times. The second section<br />
dealt with the clients: gender, age, residence, their time <strong>and</strong> price sensitivities, day of<br />
reservation, attendance, <strong>and</strong> preferred treatments.<br />
Fourth step<br />
In the fourth step information was gathered regarding the products’ cost structure (revenues,<br />
direct expenses – labour, professional products <strong>and</strong> supplies – <strong>and</strong> treatment contribution),<br />
<strong>and</strong> then a product to which a discount could be applied was identified. This information<br />
gathering approach is modelled on the Uniform System of Financial Reporting for Spas,<br />
developed in 2005 by Schmidgall, which provides a uniform system for spas around the world<br />
to accurately <strong>and</strong> efficiently manage <strong>and</strong> control their accounts. The identified product was<br />
advertised on day spa Valentino’s website, <strong>and</strong> a notice put in each of the treatment rooms<br />
<strong>and</strong> at reception.<br />
Fifth step<br />
On 1 st February 2010 the study test began. Further meetings were then held with the<br />
owner/manager <strong>and</strong> the head receptionist to find out about the test’s progress <strong>and</strong> to conduct a<br />
comparison of the spa’s performance in the same month of the previous year.<br />
Sixth step<br />
In the final step a further focused interview was held with the owner/manager to collect the<br />
test results <strong>and</strong> discuss the process. In order to consider the case study in a larger context,<br />
information was also gathered regarding the Italian wellness market, particularly<br />
characteristics of competitors <strong>and</strong> their performances.<br />
Findings<br />
Day spa Valentino started its activity in 1984. It was originally located in a small premises in<br />
Cagliari with a total capacity of 4 treatment rooms <strong>and</strong> 3 therapists. The <strong>business</strong> exp<strong>and</strong>ed in<br />
1998 to its current premises, due to an increase in clientele numbers, <strong>and</strong> to offer services in a<br />
larger, more comfortable environment, avoiding lengthy appointment waiting times. The new<br />
premises has a fixed capacity of 12 treatment rooms, each available from 9:00am to 8:00pm,<br />
Monday to Saturday. The number of therapists changes throughout the year, with an increase<br />
in spring/summer, <strong>and</strong> a decrease in autumn/winter. Services offered vary from facial <strong>and</strong><br />
body treatments, to different types of massage, sauna, solarium <strong>and</strong> make-up.<br />
In discussion with the owner/manager, a number of best practice competitors were identified,<br />
all of which are based in mainl<strong>and</strong> Italy <strong>and</strong> are the top day spas in the country. Day spa<br />
Valentino is a well-regarded spa <strong>and</strong> considered one of the most prominent day spas in<br />
Sardinia. Information about the competitors revealed that in the Italian market few spas apply<br />
discounted pricing policies, instead using research into products, services, techniques <strong>and</strong>
methodologies, <strong>and</strong> educational travel (workshops <strong>and</strong> seminars) to maintain <strong>and</strong> grow their<br />
<strong>business</strong>es, as does the owner/manager of day spa Valentino. The owner/manager also<br />
reported that in her opinion the day spa industry in Italy is in a good state of health due to the<br />
tendency of owners to also undertake the roles of manager <strong>and</strong> therapist, their competencies,<br />
creativity <strong>and</strong> innovation in this field, <strong>and</strong> the propensity of Italian women to spend time <strong>and</strong><br />
money on maintaining <strong>and</strong> improving their appearance.<br />
The case study findings can be subdivided into the following sections.<br />
1. Dem<strong>and</strong> data.<br />
2. Pricing policies.<br />
3. Cost structure.<br />
4. Performance data.<br />
Dem<strong>and</strong> data<br />
The following tables show the customer dem<strong>and</strong> details for the three months specified in the<br />
study – July, September <strong>and</strong> November 2009.<br />
Table 1 Total customers: male/female segmentation<br />
9:00-<br />
11:00<br />
Monday<br />
1:30-<br />
3:30<br />
JULY SEPTEMBER NOVEMBER<br />
Male Female Male Female Male Female<br />
/ 100% / 100% / 100%<br />
10% 90% 16.7% 83.3% / 100%<br />
Friday<br />
9:00-<br />
11:00<br />
1:30-<br />
3:30<br />
/ 100%<br />
23.1% 76.9%<br />
/<br />
/<br />
100%<br />
100%<br />
60% 40%<br />
12.5% 87.5%<br />
Table 2 Total customers: resident/non-resident segmentation<br />
9:00-<br />
11:00<br />
Monday<br />
1:30-<br />
3.30<br />
Friday<br />
9:00-<br />
11:00<br />
1:30-<br />
3:30<br />
JULY SEPTEMBER NOVEMBER<br />
Resident Nonresident<br />
Resident Nonresident<br />
Resident Nonresident<br />
100% 0% 100% 0% 100% 0%<br />
100% 0% 100% 0% 100% 0%<br />
100% 0% 100% 0% 100% 0%<br />
77% 23% 84.6% 15.4% 100% 0%
Table 3 Attendance<br />
Monday<br />
9:00-<br />
11:00<br />
1:30-<br />
3:30<br />
9:00-<br />
11:00<br />
Friday<br />
1:30-<br />
3:30<br />
Day spa Valentino’s customers tend to be local residents, female, predictable in terms of<br />
reservation time <strong>and</strong> arrival, <strong>and</strong> aged around forty, their preferred services being body<br />
treatments, nails <strong>and</strong> waxing. This demographic changes in summer when more <strong>tourists</strong><br />
dem<strong>and</strong> spa services. Resident customers tend to have a high level of disposable income, visit<br />
the spa frequently, <strong>and</strong> can be both time <strong>and</strong> price sensitive.<br />
Table 4 Female time <strong>and</strong> price sensitive customers<br />
Monday<br />
9:00-<br />
11:00<br />
1:30-<br />
3.30<br />
JULY SEPTEMBER NOVEMBER<br />
Time Price Time Price Time Price<br />
0% 50% 0% 0% 100% 0%<br />
22% 100% 20% 80% 57% 57%<br />
Friday<br />
9:00-<br />
11:00<br />
1:30-<br />
3:30<br />
50%<br />
30%<br />
100%<br />
100%<br />
0%<br />
38.5<br />
100%<br />
100%<br />
0%<br />
42.9%<br />
50%<br />
28.6<br />
%<br />
Table 5 Male time <strong>and</strong> price sensitive customers<br />
Monday<br />
Friday<br />
JULY SEPTEMBER NOVEMBER<br />
Show<br />
s<br />
Noshows<br />
9:00-<br />
11:00<br />
1:30-<br />
3.30<br />
9:00-<br />
11:00<br />
Cancella<br />
tions<br />
Shows Noshows<br />
Cancella<br />
tions<br />
JULY SEPTEMBER NOVEMBER<br />
Time Price Time Price Time Price<br />
/ / / / / /<br />
0% 100% 0% 0% / /<br />
/ / / / 0%<br />
Show<br />
s<br />
Noshows<br />
100% 0% 0% 100% 0% 0% 100% 0% 0%<br />
100% 0% 0% 100% 0% 0% 100% 0% 0%<br />
1:30- 0% 100% / / 100% 0%<br />
3:30<br />
The number of customers varies throughout the year, with a higher number in spring <strong>and</strong><br />
summer, <strong>and</strong> fewer in autumn <strong>and</strong> winter. Of the months for which data was collected, July<br />
experienced the highest number of customers, with a lower number in September, <strong>and</strong> the<br />
fewest in November. The number of customers also varies per day <strong>and</strong> per hour. For the days<br />
66.7<br />
%<br />
Cancell<br />
ations<br />
100% 0% 0% 100% 0% 0% 80% 0% 20%<br />
100% 0% 0% 100% 0% 0% 100% 0% 0%
<strong>and</strong> times the data was collected, Friday experienced more customers than Monday, <strong>and</strong><br />
1:30pm to 3:30pm saw more customers than 9:00am to 11:00am.<br />
The owner/manager reported that she was unsatisfied with the dem<strong>and</strong> levels, but this was<br />
likely due to her additional role in marketing <strong>and</strong> promoting services, whilst also acting as<br />
owner, manager <strong>and</strong> therapist, <strong>and</strong> the extra time required for this, as well as the therapists’<br />
lack of underst<strong>and</strong>ing <strong>and</strong> participation in the marketing <strong>and</strong> promotion of the spa. She also<br />
felt that the local clientele demographic was responsible, with women over the age of fifty<br />
having more disposable income but less tendency to visit the spa, <strong>and</strong> women aged thirty to<br />
forty having the motivation, but a lower level of disposable income.<br />
The case study revealed differences in the dem<strong>and</strong> data (see Table 11 in 3.4). February is a<br />
winter month <strong>and</strong>, accordingly, dem<strong>and</strong> is typically low at day spa Valentino during this<br />
month. The introduction of a discounted product as part of the study prompted an increase in<br />
dem<strong>and</strong> for that product throughout the month. Week one of February 2010 saw three times<br />
as many sales of the specified product as the corresponding week in 2009, week two, six<br />
times as many, week three, five times as many, <strong>and</strong> week four, four times as many. In 2009<br />
for the specified product the customer typology was 100% female, 100% resident with an<br />
average age of forty. During the test period the typology changed, with 4.5% male clients,<br />
9.1% non-resident <strong>and</strong> an average age of forty. Customers who bought the products during the<br />
case study test period were, predominantly, price-sensitive, reporting that they purchased the<br />
product in direct response to the discounted rate, with only 20% of these customers having<br />
tried the product before. Both in 2009 <strong>and</strong> 2010 the customers were frequent visitors to the<br />
spa.<br />
Table 6 February 2009: Customer dem<strong>and</strong> details for the specified product at a fixed<br />
price<br />
Ma<br />
Non-<br />
Female Resident<br />
le Resident<br />
Reservation - Reservation<br />
Time Price<br />
Walk<br />
More than 1 -Less than 1<br />
sensitive sensitive<br />
-in Shows<br />
week week<br />
No- Cancel<br />
shows -lations<br />
I<br />
0% 100% 100%<br />
week<br />
0% 100% 100% 0% 100% 0% 100% 0% 0%<br />
II<br />
0% 100% 100%<br />
week<br />
0% 0% 100% 0% 100% 0% 100% 0% 0%<br />
III<br />
0% 100% 100%<br />
week<br />
0% 0% 100% 0% 100% 0% 100% 0% 0%<br />
IV<br />
0% 100% 100%<br />
week<br />
0% 0% 100% 0% 100% 0% 0% 0% 100%<br />
Table 7 February 2010: Customer dem<strong>and</strong> details for the specified product at a<br />
discounted price<br />
Ma Femal<br />
le e<br />
Resident Non-<br />
Resident<br />
Reservation - Reservation -<br />
Time Price<br />
Walk NoCancel- More than 1 Less than 1 Shows<br />
sensitive sensitive<br />
-in showslations week week<br />
I<br />
0% 100% 100%<br />
week<br />
0% 25% 75% 0% 100% 0% 75% 0% 25%<br />
II<br />
0% 100% 100%<br />
week<br />
0% 33.3% 66.7% 0% 100% 0% 100% 0% 0%<br />
III<br />
week<br />
25<br />
% 75% 75% 25% 0% 75% 0% 100% 0% 100% 0% 0%<br />
IV<br />
0% 100% 87.5%<br />
week<br />
12.5%% 12.5% 62.5% 0% 100% 0% 75% 0% 25%
Although day spas, including Valentino, don’t tend to segment or analyse their market data,<br />
the historical dem<strong>and</strong> data regarding time-variable <strong>and</strong> predictable dem<strong>and</strong> gathered in this<br />
case study demonstrates that segmentation is possible, therefore satisfying the necessary<br />
criteria for applying yield management.<br />
Pricing policies<br />
It was discovered that day spa Valentino uses a fixed pricing policy for all of its products <strong>and</strong><br />
services, except for one body treatment, which is offered at a discounted rate between October<br />
<strong>and</strong> January each year. This practice of implementing a fixed pricing policy is frequent in the<br />
international spa wellness industry, which does not favour yield management as it requires a<br />
variable pricing policy to enable its implementation.<br />
Cost structure<br />
The following pie charts show the cost structure for some treatments offered at day spa<br />
Valentino before the test took place in February 2010.<br />
PROFESSIONAL PRODUCTS 30.00%<br />
SALARIES AND WAGES 13.62%<br />
SUPPLIES 2.00%<br />
PROFESSIONAL PRODUCTS 4.80%<br />
SALARIES AND WAGES 21.80%<br />
CONTRIBUTION 71.40%<br />
Figure 1 Cost structure for facial- percentage Figure 2 Cost structure for massage -<br />
percentage on revenue on revenue<br />
SALARIES AND W AGES 48.47%<br />
SUPPLIES 0.50%<br />
CONTRIBUTION 29.80%<br />
SUPPLIES 0.73%<br />
CONTRIBUTION 55.80%<br />
PROFESSIONAL PRODUCTS 21.00%<br />
SALARIES AND WAGES 36.35%<br />
PROFESSIONAL PRODUCTS 7.60%<br />
CONTRIBUTION 47.30%<br />
SUPPLIES 8.75%<br />
Figure 3 Cost structure for manicure – percentage Figure 4 Cost structure for waxing<br />
- percentage on revenue on revenue<br />
The pie charts below show the cost structure for the case study product, a Damascan Rose<br />
Scrub <strong>and</strong> Massage, at a fixed price <strong>and</strong> at the discounted price. The data shows a high<br />
treatment contribution by each service studied. This is consistent with yield management<br />
which is suitable for <strong>business</strong>es with high fixed costs as the treatment contribution can be<br />
used to cover the remaining costs.
SALA RIES AN D W AGES 18.17%<br />
PROFESSIO NAL PRODU CTS 6.33%<br />
SUPPLIES 0.50%<br />
CO NTRIBUTIO N 75.00%<br />
Figure 5 Cost structure for Damascan Rose Scrub <strong>and</strong> Massage at a fixed-price –<br />
percentage on revenue<br />
S A L A R IE S A N D W A G E S 1 8 .1 7 %<br />
P R O F E S S IO N A L P R O D U C T S 6 .3 3 %<br />
S U P P L IE S 0 .5 0 %<br />
C O N T R IB U T IO N 3 8 .3 3 %<br />
A L L O W A N C E S 3 6 .6 7 %<br />
Figure 6 Cost structure for Damascan Rose Scrub <strong>and</strong> Massage at a discounted price –<br />
percentage on revenue<br />
Performance data<br />
Spas can measure performance by calculating the number of customers, the average spend per<br />
guest, the occupancy rate, or the revenue per available treatment hour (RevPath). The<br />
following table shows day spa Valentino’s average spend per guest, calculated as a percentage<br />
change from month to specified month in the study.<br />
Table 8 Average spend per guest rate of change<br />
Mond<br />
ay<br />
Frida<br />
y<br />
9:00-<br />
11:00<br />
1:30-3.30<br />
9:00-<br />
11:00<br />
1:30-3:30<br />
July/September September/Nov<br />
ember<br />
-20.00% 30.07% -3.90%<br />
-44.71% -21.86% +1.31%<br />
November/July<br />
400.00% -56.00% -54.54%<br />
3.81% 66.08% -42%<br />
In order to calculate day spa Valentino’s performance in July, September <strong>and</strong> November<br />
2009, two measures were used: occupancy rate (treatment rooms occupied/available);<br />
RevPath. The occupancy rate measures treatment room supply efficiency, that is the capacity<br />
of the spa to sell its units. Based on the results the capacity of the spa is not well-utilised, with<br />
a consistently low occupancy rate, which surpasses 50% only in the busiest month of July,<br />
<strong>and</strong> the lowest rate on the Monday tested in September. The owner/manager explained that<br />
this occupancy rate is due to a number of the treatment rooms being sole-use, for example, the<br />
solarium <strong>and</strong> the sauna, with only seven treatment rooms available for multi-use purposes.<br />
Another important measure is the RevPath, which measures revenue per available treatment
hour <strong>and</strong> “combines information from the average customer expenditure <strong>and</strong> treatment room<br />
use to provide a measure of flow of revenue (…) <strong>and</strong> to indicate how effectively a spa is using<br />
its productive capacity” (Kimes 2009). This measure is complementary to the occupancy rate<br />
as it also considers revenues. A manager’s purpose is not only to increase occupancy. Indeed,<br />
an indiscriminate discounting policy can increase the number of treatment rooms occupied yet<br />
have little influence on revenues.<br />
The following tables show day spa Valentino’s occupancy rate; RevPath during the three<br />
months studied, shown as a percentage based on the highest RevPath level achieved on the<br />
Monday in July from 1:30pm to 3:30pm.<br />
Table 9 Day spa Valentino’s occupancy rate in 2009<br />
Monday<br />
9:00-<br />
11:00<br />
Friday<br />
9:00-<br />
11:00<br />
Monday<br />
1:30-<br />
3:30<br />
Friday<br />
1:30-<br />
3:30<br />
JULY SEPTEMBER NOVEMBER<br />
8% 6% 8%<br />
17% 17% 16%<br />
42% 17% 33%<br />
58% 42% 50%<br />
spa to be unsatisfactory, though she<br />
believes the clientele base of the spa<br />
industry will increase significantly in<br />
the coming decade, with men, <strong>and</strong><br />
women in their twenties becoming<br />
regular spa users.<br />
The performance data generated by the<br />
case study is shown in the table below.<br />
Table 10 Day spa Valentino’s<br />
RevPath in 2009<br />
Monday<br />
9:00-<br />
11:00<br />
Friday<br />
9:00-<br />
11:00<br />
Monday<br />
1:30-<br />
3:30<br />
Friday<br />
1:30-<br />
3:30<br />
The owner/manager gave information on<br />
the personnel policy at day spa<br />
Valentino, which can affect the RevPath.<br />
For example, in the summer months<br />
customers are more likely to visit the spa<br />
in the afternoon <strong>and</strong> visit the beach in the<br />
mornings, so the spa has fewer therapists<br />
working at these quieter times. She also<br />
reported difficulties in increasing the<br />
number of therapists whilst dem<strong>and</strong><br />
levels are low. The owner/manager was<br />
also surprised at the performance data<br />
figures, despite having a general feel for<br />
the performance of the spa <strong>and</strong> having<br />
full capacity in the multi-use treatment<br />
rooms at some points during the week.<br />
She considered the performance of the<br />
JULY SEPTEMBER NOVEMBER<br />
27.64% 31.58% 13.90%<br />
6.33% 31.58% 13.92%<br />
100% 33.17% 30.26%<br />
59.1% 57.00% 58.30%
Table 11 Treatment <strong>and</strong> revenue rate of change for February 2009 <strong>and</strong> February 2010<br />
February 2009/2010<br />
WEEK<br />
1<br />
WEEK<br />
2<br />
WEEK<br />
3<br />
WEEK 4<br />
2009/2010 Treatments 200% 500% 400% >300%<br />
2009/2010 Revenue 128% 356% 280% >204%<br />
As can be seen, there is a dramatic increase in revenues (up 356% in week two) <strong>and</strong> the<br />
number of treatments dem<strong>and</strong>ed (up 500% in week two) during the case study (as shown in<br />
3.1). The owner/manager was positive about the possibility of improving revenues <strong>and</strong><br />
customer dem<strong>and</strong> using discounted pricing policies, <strong>and</strong> was very satisfied with the results.<br />
She does believe, however, that the results could be improved still further with increased<br />
marketing <strong>and</strong> promotion of the discounted service.<br />
Concluding Remarks<br />
Personal interest in health <strong>and</strong> wellbeing has grown in recent years <strong>and</strong> is expected to further<br />
increase in the coming decades. People’s lifestyles are constrained by a fast pace of life <strong>and</strong><br />
this is in contrast to a natural inclination towards slower living, which represents a challenge<br />
for the wellness industry. The dem<strong>and</strong> for wellness, including from spa services, health<br />
services, <strong>and</strong> sports <strong>and</strong> fitness services, needs to be met with appropriate marketing <strong>and</strong><br />
management strategies in order to maximise the potential of this sector. This study has<br />
considered yield management as a possible approach to managing this sector more efficiently<br />
<strong>and</strong> profitably, in this case testing the theory on day spas. Day spa Valentino, located in a<br />
popular tourist destination, allowed the testing of a discounted pricing policy as a part of yield<br />
management techniques. A case study approach was used, with semi-structured interviews<br />
<strong>and</strong> a questionnaire addressed to the day spa management. Characteristics <strong>and</strong> baseline<br />
performance for 2009 were acquired, together with dem<strong>and</strong> data <strong>and</strong> the services cost<br />
structure. A fair margin discounted product was tested in February 2010 <strong>and</strong> considerable<br />
results were attained. The clientele of the day spa demonstrated an appreciation of the benefits<br />
of the discounted service <strong>and</strong> their price sensitivity led to a significant increase in sales in<br />
February 2010, with a number of first-time purchasers of the product, despite all the<br />
customers being frequent visitors to the spa. The owner/manager was very satisfied with the<br />
results <strong>and</strong> has since introduced a number of discounted packages on other products offered<br />
by the spa, encouraging customers to purchase products in bulk, purchase more products <strong>and</strong><br />
try services they have not previously bought. The new pricing policy has shown immediate<br />
results with an exceptionally high amount of total revenue in February compared to the other<br />
months studied.<br />
The effects of this simplified application of yield management are worth considering with<br />
regards to the wellness industry as a whole. The strength of yield management in improving<br />
customer dem<strong>and</strong> is evident from the study <strong>and</strong> this has the potential to be carried over into<br />
other areas of the industry. The dimensions of some spas around the world can create<br />
difficulties in implementing the complexities of an information system as yield management<br />
requires, as the necessary competencies <strong>and</strong> investment may not be present. However, the<br />
sophistication of yield management can be high requiring the application of information<br />
systems or “in a more limited way with an intelligently developed <strong>and</strong> applied set of pricing<br />
<strong>and</strong> organisational practices” (Anderson et al. 2007).<br />
The spa wellness industry has so far been constrained within a fixed price strategy model,<br />
whilst managing a fixed capacity with perishable products, losing the manoeuvrability
equired to fully reach its profitability potential. As the spa wellness industry is currently<br />
considered the fastest growing tourism sector industry in the world (Haden 2007), it is<br />
essential that it begins to seriously consider the implementation of yield management<br />
strategies in order to maximise profitability <strong>and</strong> customer experience.<br />
References<br />
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Measurement of the Economic Impacts of <strong>Health</strong> <strong>Tourism</strong> Development in<br />
Hungary<br />
Margit Mundruczó<br />
College for Modern Business Studies<br />
Hungary<br />
mundruczo.gyorgyne@mutf.hu<br />
Introduction<br />
Nowadays the health tourism is one of the most dynamic sub-sector of tourism. There are<br />
many reasons for this both on dem<strong>and</strong> <strong>and</strong> on supply side. The key dem<strong>and</strong> drivers of tourism<br />
are variables such as wellness, beauty, harmony of body <strong>and</strong> soul, <strong>and</strong> recently the growing<br />
needs for medical tourism. These dem<strong>and</strong> trends have pushed the owners of traditional<br />
thermal bath <strong>and</strong> spa hotels to start the development tourism services <strong>and</strong> facilities based on<br />
the thermal water sources.<br />
There are two major financial support sources of Hungarian health tourism development:<br />
1. Government funding – Széchenyi Development Program (replaced by the New<br />
Hungary Development Plan since 2007). In 2001 the Hungarian Government<br />
established the Széchenyi <strong>Tourism</strong> Development Program with 115M Euro (31bn<br />
HUF, 1 euro = 270 HUF) to support spa <strong>and</strong> wellness/medical hotel development. The<br />
objective of the development program was to utilize the tourist development multiplier<br />
effect <strong>and</strong> level out the regional development differences between tourism<br />
destinations.<br />
2. EU funding. In 2004 Hungary has joined the EU <strong>and</strong> established the National<br />
Development Program (NDP) to define the national development objectives <strong>and</strong><br />
establish supporting financial funding to development project aligned with those<br />
objectives. A major component of this program is the funding of health tourism<br />
developments.<br />
In the first phase of the National Development Program (NDP1 - 2004-2006) 2,7% of all EU<br />
financial support (113M Euro = 30,5bn HUF) was dedicated to the tourism related programs.<br />
The 2 nd phase of the plan (NDP2 – 2007-2013) provides 4% of all EU funding to the tourism<br />
related program, part of which is health tourism program. In 2007-2008, 270M Euro (73bn<br />
HUF) were awarded to 278 projects. The major objective of EU support was to improve lower<br />
developed regions through attraction <strong>and</strong> accommodation development. (ÖTM, 2008)<br />
In order to monitor the development projects objectives <strong>and</strong> results achieved, the government<br />
monitoring system provides few simple tourism performance indicators. (MTA-RKK, Raffay<br />
et al) However the noted volume of tourism funding <strong>and</strong> the nature of tourism developments<br />
require more complex measurement of the economic impacts.<br />
The author of this article has first conducted an economic impact research study in 2004<br />
focusing on 11 Széchenyi Program projects in 11 cities to examine the local economic<br />
impacts of health tourism development (Munduczó et al, 2005).<br />
Later in 2009, on request of the Research Institute of the State Audit Office, Hungary the<br />
author conducted a detailed study of the economic impact of 10 tourism related projects (4<br />
spas, 4 wellness hotels <strong>and</strong> 2 cultural <strong>and</strong> natural attractions) in 7 cities. This study is<br />
currently being finalized.
These two research studies together cover 6 of the 7 statistical planning regions of Hungary.<br />
The main objectives of the research studies were:<br />
• examine the local economic impacts of tourism investments financially supported by<br />
the government or EU to measure their multiplier impacts.<br />
• introduce the operational characteristics <strong>and</strong> local/national impacts of the new tourism<br />
investments (e.g.: new jobs created, growth of operational revenue, growth of local<br />
<strong>and</strong> central budget revenue generated by the new health tourism projects).<br />
• introduce quantitative indicators of the dem<strong>and</strong> <strong>and</strong> its structure with seasonal<br />
characteristics<br />
• underst<strong>and</strong> the perception of locals <strong>and</strong> entrepreneurs about the tourism investments<br />
• estimate the economic impacts of health tourism development at national level.<br />
Research methods<br />
Both research studies have relied on the same approach <strong>and</strong> methodology. This included the<br />
following components:<br />
• Collect relevant statistical data (desk information) on tourism projects prior to <strong>and</strong><br />
after developments such as:<br />
o Capacity <strong>and</strong> tourist flow of collective accommodation at the examined<br />
destinations.<br />
o Number of tourism enterprises at the examined cities/towns<br />
o Growth of own tax revenue (inc. <strong>Tourism</strong> taxes) of local government<br />
These data were obtained from the Central Statistical Office, Hungary.<br />
• Information <strong>and</strong> statistical data produced by primary research such as<br />
o Investment data of health development projects<br />
� Projected, actual investment values<br />
� Characteristics of construction<br />
� Share of import<br />
o Estimated/projected investment values of indirect <strong>and</strong> induced tourism<br />
investment in the following 4-5 years.<br />
• Operational data<br />
o Number of new jobs generated by health tourism investments<br />
o Operational revenue of new units<br />
o Quantitative dem<strong>and</strong> indicators of new developments, seasonility <strong>and</strong> structure<br />
of tourist flow<br />
o Local <strong>and</strong> central budget taxes paid by new health tourism<br />
The primary research was based on focused statistical data request (data sheets designed<br />
specifically for the studies) <strong>and</strong> interviews with local government representatives <strong>and</strong> unit<br />
managers.<br />
While the approach <strong>and</strong> methodology was the same in the two studies, there were some<br />
unique factors <strong>and</strong> the research timeframe <strong>and</strong> project macro-environments were different.<br />
Next we present a short summary of the studies with key characteristics.<br />
• 2004 research study<br />
o Scope: 11 health tourism projects, financially supported by Széchenyi<br />
Program.<br />
o Research timeframe: base year of 2001 <strong>and</strong> first full operational year in 2004<br />
o Széchenyi Program was the only tourism development program in Hungary in<br />
the research timeframe
o The macro <strong>and</strong> micro environment remained the same during the research<br />
timeframe<br />
o Examined development projects completed <strong>and</strong> operations started at nearly the<br />
same time<br />
o The studied project investment value was over 15% of total project investment<br />
value, which allowed for estimation of national impacts.<br />
• 2009 research study<br />
o Scope: 10 tourism projects, out of which 4 financially supported by Széchenyi<br />
Program <strong>and</strong> 6 projects financially supported by EU Regional Operational<br />
Program (ROP).<br />
o Research timeframe: 8-year timeframe with different project start <strong>and</strong> end<br />
dates (2004-2008).<br />
o The 2008-2009 economic crisis impacted 6 EU supported projects’ first<br />
operational data.<br />
Major findings<br />
This section will present the major findings of the two studies. First the focus will be on the<br />
investment multiplier, than on the operational impacts of health tourism project (from<br />
employment impacts, through revenue impacts dem<strong>and</strong> indicators <strong>and</strong> taxation).<br />
Investment multiplier<br />
Both studies focused on analyzing the impacts of the investments in generating further<br />
investments <strong>and</strong> calculated the investment multipliers for the projects in focus.<br />
2004 research study major findings:<br />
• <strong>Tourism</strong> investment multiplier value of 2,7 based on indirect <strong>and</strong> induced investments<br />
– 11 projects with 77,8M Euro (21bn HUF) investment generated additional 118,5M<br />
Euro (32bn HUF) investment, altogether 196,3M Euro (53bn HUF) investment over 5<br />
year period.<br />
• 100 HUF government financial support of health tourism development generated 550-<br />
500 HUF private capital investments in tourism over the 5 years.<br />
• The induced <strong>and</strong> indirect investments were primarily in accommodation development<br />
(e.g. wellness hotel near the spas, pensions) <strong>and</strong> spa/thermal bath developments<br />
further enhancing facilities <strong>and</strong> services.<br />
2004 research study - investment multiplier<br />
(data in 1000 HUF)<br />
22 620 000 ; 43%<br />
9 700 000 ; 18%<br />
Actual investment value (2001-2003)<br />
Indirect Investment value (2001-2003)<br />
Induced investment value (2004-2006)<br />
(Source: Research study, 2004)<br />
20 935 016 ; 39%
2009 research study major findings:<br />
• <strong>Tourism</strong> investment multiplier value of 1,49 based on indirect <strong>and</strong> induced<br />
investments. Spa <strong>and</strong> aqua park investment multiplier of 2,4, wellness hotel multiplier<br />
of 0,33, other attraction multiplier of 2,66.<br />
• Out of the studied projects, the highest investment multiplier value belonged to St.<br />
Gotthard Spa, located on the Hungarian-Austrian border. The high multiplier value<br />
may be explained by the fact that the city did not have active tourism until recently.<br />
This spa project was the first step in building of the city tourism infrastructure, which<br />
was soon followed by multiple city projects.<br />
• Indirect investments related to cultural <strong>and</strong> natural attraction developments (e.g.<br />
accommodation) were found to be minimal, however the induced impacts (e.g. aqua<br />
park) still generate a high multiplier value.<br />
2009 research study - investment multiplier<br />
(data in 1000 HUF)<br />
12 238 000;<br />
39%<br />
6 428 350;<br />
21%<br />
Actual investment value (2001-2008)<br />
Indirect investment value (2002-2008)<br />
Induced investment value (2003-2012)<br />
(Source: Research study, 2009)|<br />
12 536 001;<br />
40%<br />
Major conclusions:<br />
• Spa <strong>and</strong> aqua park investments have high investment multiplier values (between 2,4<br />
<strong>and</strong> 2,7). These facilities have also fulfilled tourism attraction functions.<br />
• <strong>Wellness</strong> hotel developments have a low investment multiplier value. This may be<br />
attributed to the fact that these hotels provide services in-house <strong>and</strong> do not generate<br />
other tourism investments outside the unit.<br />
• Due to the increased <strong>business</strong> risks, the economic crisis decreased the multiplier<br />
values of the tourism investments.<br />
Operational impacts of health tourism projects<br />
Operational impacts were identified based on the last full operational year of each unit (base<br />
year) <strong>and</strong> the first year of full operation after the project completed.<br />
In case of the 2004 research, 2001 was the common base year for all projects <strong>and</strong> 2004 was<br />
the first full operational year.<br />
In case of the 2009 study, the base year <strong>and</strong> first full operational year were different project<br />
by project. The wellness hotel projects with EU financial support (4 units) have had only 1-2<br />
years of operation at the time of the study. It is well known that the first years of new hotel<br />
operations are introductory years with lower prices, lower occupancy rates as compared to<br />
later years. This is further impacted by the economic crisis started in 2008 Q4.<br />
Next we will look at the employment impacts, the operational revenue impacts, the<br />
quantitative dem<strong>and</strong> indicators, taxation <strong>and</strong> local economy impacts of the tourism projects.
Employment impacts<br />
During our analysis of employment generation impacts of health tourism projects we relied on<br />
the following data:<br />
• Average number of full time employees in units<br />
• Number of part time employees in units<br />
• Number of employees (full time <strong>and</strong> part time) at the outsource partners e.g.: fast<br />
food restaurant within the thermal bath unit, security services, gardening, etc.<br />
Major findings:<br />
• In the 2004 research study, 457 new full time jobs <strong>and</strong> 690 part time jobs had been<br />
generated by the examined health tourism projects. In the project applications, the<br />
projected new positions totaled only 387. The majority of these projects were thermal<br />
bath/aqua parks (10), <strong>and</strong> a few small wellness/spa hotels (3). Two spas have had<br />
small hotels too.<br />
The investment required per one new full time employee was 166,7k (thous<strong>and</strong>) Euro<br />
(45 million HUF) - without part-time employees. This indicator would have been<br />
much lower with the calculation of the number of part-time employees.<br />
The government’s subsidy on average was 59,3k Euro (16 million HUF) per new job.<br />
• In 2009 research study, 363 new full time jobs had been created for employees by the<br />
tourism projects in focus. Interestingly, relatively few outsource jobs were offered for<br />
employees within the health tourism units. The numbers of part-time employees were<br />
65, mainly trainees, waiters/waitresses <strong>and</strong> hostesses.<br />
The investments required per one new full time job in the case of thermal bath/aquapark<br />
was 111k Euro (30M HUF) on average. In the case of middle size wellness hotels<br />
this indicator was between 133-159k Euro (36-43M HUF), <strong>and</strong> 56-74k Euro (15-20M<br />
HUF) of small hotels. We can state that the larger the hotel capacity, the larger the<br />
investment costs of job creation.<br />
The financial subsidy provided by the government or EU for job creation in the case of<br />
thermal bath/aqua park was between 52-122k Euro (14-33M HUF), the private<br />
investors of wellness hotels received 11-33k Euro (3-9M HUF) for established new<br />
workplace.<br />
The next graph shows the job creation impact of 11 health tourism projects from the 2004<br />
study:<br />
2500<br />
2000<br />
1500<br />
1000<br />
500<br />
0<br />
Be fore proje ct<br />
inve s tm e nt<br />
(Source: Research study, 2004)<br />
Employe e s in 11 proje cts<br />
Afte r proje ct<br />
inve s tm e nt<br />
Outs ource<br />
In fa cility
Operational revenue of health tourism projects<br />
The revenue of unit operations depends by large on the size of the unit, the types of core<br />
<strong>business</strong>es, the market segments <strong>and</strong> market opportunity of the unit.<br />
The operational revenue is one of the most important basic <strong>business</strong> performance indicators in<br />
the view of the economic impact. Partly because it is the source of costs <strong>and</strong> expenses (e.g.<br />
payroll related direct expenses paid to the central budget) <strong>and</strong> certain local taxes directly<br />
based on the operational revenue (e.g.: local operational tax). It’s growth also shows the<br />
<strong>business</strong> success of the examined tourism property.<br />
In the 2004 research study, 3 new health tourism projects were examined out of 11<br />
developments. The other projects were renovation of existing services for a higher service<br />
level, enlargement (more pools inside <strong>and</strong>/or outside) of the unit, development of medical<br />
treatment facilities <strong>and</strong> wellness facilities.<br />
Major findings of 2004 research study:<br />
• The total operational revenue of 11 examined health tourism projects increased by<br />
130% (with an extra of 3,35bn HUF) compared to the base year’s operational revenue.<br />
• We could see a synergy effect of the new health tourism developments. It means that<br />
the new developments have not reduced the operational revenue of their competitors,<br />
thus they have resulted an extra tourism dem<strong>and</strong> for the region. The yield of wellness<br />
<strong>and</strong> spa hotel is much higher than the yield of thermal bath <strong>and</strong> aqua park. It is due to<br />
the daily expenditure of visitors.<br />
• Operational revenues per one new full time employee was 24k Euro (6,6M HUF)<br />
7,000,000<br />
6,000,000<br />
5,000,000<br />
4,000,000<br />
3,000,000<br />
2,000,000<br />
1,000,000<br />
-<br />
(Source: Research study, 2004)<br />
Operational revenue in 11 facitities<br />
(data in 1000 HUF)<br />
2001 2004<br />
Major findings of 2009 research study:<br />
• Despite that the majority (7 out of 8 projects) of the examined health tourism projects<br />
were new developments they generated 4,8 M Euro (1,3bn HUF) extra operational<br />
revenue – at the price level of the first full operational year.<br />
• The operational revenue per one full time employee was 13,7k Euro (3,7m HUF). The<br />
lower labor productivity indicator is due to lower discretional income of Hungarians<br />
<strong>and</strong> the economic recession mentioned earlier.
• The examined wellness hotels were strongly influenced by the economic crises started<br />
in 2008.<br />
Quantitative dem<strong>and</strong> indicators<br />
Quantitative dem<strong>and</strong> indicators are commonly used in market analysis. The main indicators<br />
are the following: number of visitors (in thermal bath/aqua park), number of tourist arrivals at<br />
accommodation (in hotels), number of tourist nights (in hotels). These indicators with the<br />
actual prices directly influence the operational revenue <strong>and</strong> the occupancy rate of hotels. In<br />
the case of thermal bath <strong>and</strong> aqua park we use the number of visitors, in the case of hotels the<br />
best volume indicator is the number of tourist nights.<br />
Below we explain the key volume dem<strong>and</strong> indicators of the examined units.<br />
The 2004 research study finding may be summarized as follows:<br />
• The number of visitors of the examined 11 projects in the first full operational year<br />
was higher with 60% (+ 2,16M HUF) compare to the base year (2001).<br />
• The market share of domestic visitors out of total number of visitors were 70%<br />
• The new health tourism developments reduced the seasonal fluctuations of tourism<br />
dem<strong>and</strong>.<br />
• The thermal baths <strong>and</strong> aqua parks are very popular attractions among the locals.<br />
80% of the examined cities’ population had already visited the new health tourism<br />
units <strong>and</strong> 50% of the local visitors regularly attend the thermal bath. Most of the<br />
primary <strong>and</strong> secondary schools’ students have their gymnastic class in the<br />
swimming pool of the thermal bath.<br />
• The health tourism developments of Széchenyi Program resulted 10 million extra<br />
domestic visitor numbers yearly.<br />
We present the findings of 2009 research study:<br />
• Debrecen Aquaticum has shown the greatest volume <strong>and</strong> the most dynamic<br />
increase since their opening. This unit provides 60% of the total visitor numbers of<br />
the examined 4 thermal bath/aqua parks. It caused by the size of tourism<br />
development <strong>and</strong> its attractiveness.<br />
• The examined 4 new wellness hotels with conference facilities (618 room of total<br />
room capacity) provided 60,000 tourist nights in the first full operation year. The<br />
room occupancy rate was relatively high between 32-40% on yearly.<br />
• MICE (Meeting, Incentive, Conference, Event) market segment provides the major<br />
dem<strong>and</strong> driver with 40% of total tourist nights generated, while the market share of<br />
foreign <strong>tourists</strong> was relatively low (between 10-30%).<br />
Taxation<br />
As with all enterprises, health tourism enterprises pay various direct <strong>and</strong> indirect taxes. The<br />
direct tourism taxes paid are local operational tax (if the enterprise has an operating profit),<br />
property tax, <strong>and</strong> other taxes, etc. Indirect taxes paid to the central budget excl. VAT are<br />
mainly payroll related expenses: income tax, social insurance, employee tax, employer tax,<br />
etc.)<br />
There are three important taxes paid by hotels: operational tax which is a few percent of the<br />
net revenue, real estate tax, <strong>and</strong> the most important, the tourism tax which amounts to 0.9 –<br />
1.3 Euro (250-350 HUF) per night /tourist. The latter is to be paid by <strong>tourists</strong>, however, due to<br />
the price competition between hotels often undertaken by the hotel.
We present the direct tax revenues (excl. VAT) of health tourism projects based on the 2009<br />
research data:<br />
• Research data shows that local tax revenues of the examined projects depend on the<br />
projects’ specifics <strong>and</strong> their ownership. Most thermal bath <strong>and</strong> aqua parks in Hungary<br />
are city government owned, thus during the first years of operation they are usually<br />
exempt from local taxes. However later this local operational tax is a large<br />
• On average, about 20% of the net revenue of health tourism project are paid as a direct<br />
taxes. (The 2004 study showed the same data.) Based on the studied projects, 5-10%<br />
of thermal bath <strong>and</strong> aqua park revenues <strong>and</strong> 12-25% of hotel revenues are paid to the<br />
local governments.<br />
• The amount of local tax revenues of particularly small city governments, are greatly<br />
influenced by the examined tourism facilities. The examined 4 new wellness hotels<br />
generated 110M Euro (30bn HUF) local tax for the city governments. The local tax<br />
paid by the examined thermal bath <strong>and</strong> aqua parks (with the same investment value)<br />
was only 55% of the wellness hotels’ local taxes.<br />
The impacts of health tourism development on the local economy<br />
<strong>Health</strong> tourism development has significant impacts the local economy both directly <strong>and</strong><br />
indirectly. Direct impact includes local tax revenues <strong>and</strong> job creation; indirect effects are the<br />
multiplier effect of the investment, the development of the city as a tourism destination <strong>and</strong><br />
the associated increased visits of tourist. Further direct effects are increased local tax revenues<br />
<strong>and</strong> increased scope of activity <strong>and</strong> prosperity of local <strong>business</strong>es. Below, through the results<br />
of the 2009 study, we will show you these direct effects in three different size cities in<br />
different regions of the country. These cities are:<br />
• Debrecen (located in North Hungary), population of 206,000, new aqua park<br />
development (2003)<br />
• Szentgotthárd (located in West Hungary), population of 9,000, new thermal bath <strong>and</strong><br />
aqua park development (2007)<br />
• Tiszafüred (located in Lake Tisza region), population of 11,000, new wellness hotel<br />
development (2007)<br />
Accommodation capacity <strong>and</strong> dem<strong>and</strong> volume<br />
As it was mentioned earlier the accommodation capacity <strong>and</strong> the number tourist arrivals at<br />
commercial accommodation expresses the size tourism at the visited destination. Below we<br />
illustrate the impact of health tourism development in three examined cities, namely:<br />
Debrecen, Szentgotthárd <strong>and</strong> Tiszafüred.<br />
Total number of available beds Total number of tourist nights spent<br />
(accommodation supply side)<br />
(accommodation dem<strong>and</strong> side)<br />
Debrecen. In early 2000 the commercial accommodation capacity stagnated in Debrecen. Due<br />
to the higher level of quality accommodation development, the number of hotel rooms<br />
increased but it did not translate to a bed capacity increase. Partly as a result of the<br />
introduction of the aqua park, hotel utilization increased until 2006. Hotels provide 2/3 of total<br />
commercial accommodation nights. Since 2006, accommodation utilization slightly declined<br />
due to a decrease in foreign tourist. This trend fits with the experience in Hajdú-Bihar County<br />
where Debrecen is located. Both the capacity <strong>and</strong> quality of commercial accommodation<br />
satisfies the need, which explains the low number of bed & breakfast accommodation.
Total number of available beds<br />
(accommodation supply side)<br />
8 000<br />
7 000<br />
6 000<br />
5 000<br />
4 000<br />
3 000<br />
2 000<br />
1 000<br />
0<br />
Debrecen<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Magán szállás férőhely<br />
Egyéb ker. férőhely<br />
Szállodai férőhely<br />
Total number of tourist nights spent<br />
(accommodation dem<strong>and</strong> side)<br />
450 000<br />
400 000<br />
350 000<br />
300 000<br />
250 000<br />
200 000<br />
150 000<br />
100 000<br />
50 000<br />
0<br />
Debrecen<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Magán szálláshelyi vendég éjsz.<br />
Egyéb ker. vendég éjsz.<br />
Belföldi száll. vendég éjsz.<br />
Külföldi száll. vendég éjsz.<br />
Szentgotthárd: the city’s accommodation capacity increased due to the building of smaller<br />
hotels <strong>and</strong> pensions as an indirect effect of the examined health investment. This also effected<br />
the influx foreign tourist nights. This is the likely explanation of the continued growth of<br />
tourism in Szentgotthárd through 2008.<br />
500<br />
450<br />
400<br />
350<br />
300<br />
250<br />
200<br />
150<br />
100<br />
50<br />
0<br />
Szentgotthárd<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Magán szállás férőhely<br />
Egyéb ker. férőhely<br />
Szállodai férőhely<br />
25 000<br />
20 000<br />
15 000<br />
10 000<br />
5 000<br />
0<br />
Szentgotthárd<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Magán szálláshelyi vendég éjsz.<br />
Egyéb ker. vendég éjsz.<br />
Belföldi száll. vendég éjsz.<br />
Külföldi száll. vendég éjsz.<br />
Tiszafüred: until the opening the Hotel Tisza Balneum, there was no hotel in town. In 2008,<br />
guest nights influx increased significantly due to the new 4 star wellness & conference hotel.<br />
This private hotel investment stimulated other commercial accommodation utilization <strong>and</strong><br />
dem<strong>and</strong> for bed & breakfast accommodation.<br />
4000<br />
3500<br />
3000<br />
2500<br />
2000<br />
1500<br />
1000<br />
500<br />
0<br />
Tiszafüred<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Magán szállás férőhely<br />
Egyéb ker. férőhely<br />
Szállodai férőhely<br />
80 000<br />
70 000<br />
60 000<br />
50 000<br />
40 000<br />
30 000<br />
20 000<br />
10 000<br />
0<br />
Tiszafüred<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Magán szálláshelyi vendég éjsz.<br />
Egyéb ker. vendég éjsz.<br />
Belföldi száll. vendég éjsz.<br />
Külföldi száll. vendég éjsz.
Local tax revenue generated by tourism<br />
<strong>Tourism</strong> related local tax revenue<br />
Debrecen<br />
Comments<br />
Debrecen<br />
The tourism related tax revenue of city<br />
700 000<br />
government started to increase from the<br />
600 000<br />
second year of the new aqua park operation<br />
500 000<br />
due to the indirect investment multiplier effect<br />
400 000<br />
Idegenforgalmi váll. Iparűzési adója (000) (e.g.: hotel investments). The graph shows that<br />
Idegenforgami adó utáni állami támogatás ('000)<br />
300 000<br />
Idegenforgalmi adó (000)<br />
the tourism enterprises pay a significant<br />
200 000<br />
amount of local operational tax.<br />
100 000<br />
0<br />
1 2 3 4 5 6 7 8<br />
Szentgotthárd<br />
18 000<br />
16 000<br />
14 000<br />
12 000<br />
10 000<br />
8 000<br />
6 000<br />
4 000<br />
2 000<br />
Tiszafüred<br />
0<br />
40 000<br />
35 000<br />
30 000<br />
25 000<br />
20 000<br />
15 000<br />
10 000<br />
5 000<br />
0<br />
Szentgotthárd<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Tiszafüred<br />
2001 2002 2003 2004 2005 2006 2007 2008<br />
Ideg enforga lm i v áll. Iparűz és i adója (000 )<br />
Ideg enforga mi a dó u táni állam i támogatá s<br />
(' 000)<br />
Ideg enforga lm i adó (000)<br />
Ideg enforga lm i v áll. Iparűz és i adója (000 )<br />
Ideg enforga mi a dó u táni állam i támogatá s<br />
(' 000)<br />
Ideg enforga lm i adó (000)<br />
<strong>Tourism</strong> related tax data are available from<br />
2006. The graph shows a dynamic growth of<br />
local tourism tax revenue <strong>and</strong> government<br />
subsidy based on the actual tourist nights in<br />
the city’s accommodation.<br />
Hotel Tisza Balneum has influenced the<br />
city’s tourism tax revenue significantly,<br />
resulted by the increased tourist nights <strong>and</strong><br />
by the government subsidy based on the<br />
actual tourist nights.<br />
Conclusion: The tourism indicators show that the examined health tourism developments have<br />
increased the volume <strong>and</strong> the level of tourism infrastructure, they have influenced the growth<br />
of tourism dem<strong>and</strong>, <strong>and</strong> resulted significant surplus tax revenue for the city government.<br />
Summary<br />
• The studies found that the investment multiplier largely depends on the type of<br />
development (attraction, aqua park, accommodation, etc). Other factors include the<br />
ratio of financial support <strong>and</strong> private capital, the tourism potential of the region <strong>and</strong><br />
the macro economic environment <strong>and</strong> general tourism trends. Spa/aqua park health<br />
tourism development investments have an investment multiplier of 2,4-2.7. In the case<br />
of accommodation developments the investment multiplier was found to be 0,37 in a<br />
time of economic crisis.
• Our analysis showed that new job generation as a KPI to measure the impacts of<br />
tourism developments have important shortcomings, which makes it’s calculation<br />
more difficult. In the case of the number of newly created jobs one needs to take into<br />
account the outsourcing of services – the additional jobs generated outside the unit at<br />
service partners.<br />
• In the case of the studied projects we found that the investment cost of creating a new<br />
job is 110k – 150k Euro (~30-40M HUF), in case of small hotels this value was 55k –<br />
66k Euro (15-18M HUF). The financial support per new job was found to be in the<br />
range of 11k-55k Euro (3-15M HUF).<br />
• Both studies found that 1 unit of health tourism financial support generated altogether<br />
6 unit of investment.<br />
• The highest profit generation was found in hotel developments. Hotels also generated<br />
the highest revenue <strong>and</strong> tax payments.<br />
• <strong>Tourism</strong> units pay 15-24% of their revenue to the central budget <strong>and</strong> the local<br />
government. Local governments receive ~20% of all taxes paid by the units.<br />
• When analyzing the local government revenues, we found that over the study<br />
timeframes, the tourism related revenue increased consistently which was still further<br />
increased by the tourism tax.<br />
• The studied tourism development projects generated dynamic tourism developments in<br />
the host cities (which yielded significant local government revenue increase).<br />
• <strong>Tourism</strong> activity in general is sensitive to the macro-economic environment. This was<br />
confirmed by our analysis: in 2006 the Hungarian Government introduced fiscal<br />
restrictions <strong>and</strong> later in 2008 Q4 the world economic crisis further depressed the<br />
economic environment. Unemployment increased, companies cut back on spending<br />
<strong>and</strong> events. As a result new hotels experienced a fall in guest nights, which further<br />
increased the difficulties of the introductory years.<br />
• The dynamic increase of tourism <strong>and</strong> tourism related revenues at the host cities clearly<br />
show the indirect impacts of tourism development projects.<br />
References:<br />
Medlik, S – Ingram, H (2000): The Business of Hotels, BH Fourth Edition<br />
Mundruczó Györgyné – Szennyessy Judit (2005): A Széchenyi Terv egészségturisztikai<br />
beruházásainak gazdasági hatásai. Turizmus Bulletin IX. évfolyam 3. szám<br />
Mundruczó Györgyné (2010): A támogatott turisztikai beruházások gazdasági hatásai.<br />
Résztanulmány, ÁSZKUT<br />
Raffay et al (2007): A ROP Program intézkedések hatékonyságjavítását célzó értékelő<br />
tanulmány. Kutatási zárójelentés.<br />
Tribe, J (1999): The Economic of Leisure <strong>and</strong> <strong>Tourism</strong>, Butterworth-Heinemann, 2 nd Edition<br />
www.ksh.hu, Regionális adatok, 2001-2008<br />
www.otm.hu EU-ROP pályázati adatok
Famous spas in Budapest facing the challenges of change<br />
Andrea Nemes<br />
<strong>Tourism</strong> Competence Center, CUB<br />
Hungary<br />
<strong>and</strong>rea.nemes@uni-corvinus.hu<br />
Abstract<br />
This paper aims at presenting the famous historical spas life cycle in Budapest in the last<br />
years. It seeks to broach the issue of one type of the heritage of historical monuments, the spas<br />
in Budapest <strong>and</strong> their usage in the tourism market. The paper is intended to provide an<br />
overview of the famous historical spas, <strong>and</strong> to analyse its services in a competitive <strong>and</strong><br />
changing environment. The article also includes empirical findings on guest’s surveys <strong>and</strong><br />
interviews with the management of the spas.<br />
Design/ methodology /approach - Comparative case studies were elaborated for the most<br />
famous historical spas in Budapest based on secondary <strong>and</strong> primary sources. The data consists<br />
of statistics, interviews <strong>and</strong> other documents.<br />
Findings - Nowadays it seems to be the only way for the management of the spas in Budapest<br />
to make innovations <strong>and</strong> improve the level of their services, <strong>and</strong> focusing not only to the<br />
Hungarian but to the international market.<br />
It summarizes the basic information’s, <strong>and</strong> previews ongoing innovations to the state of the art<br />
level, to take into consideration the life cycle of the area <strong>and</strong> the products.<br />
Keywords: national heritage conservation, competitiveness, spa tourism, product<br />
development, life cycle of destinations, Budapest, Hungary.<br />
Introduction<br />
Nowadays the basic conditions of tourism <strong>and</strong> the health awareness of tourist <strong>and</strong> inhabitants<br />
of spa cities <strong>and</strong> towns are changing. Due to economic difficulties, in view of changing travel<br />
behaviour towards shorter <strong>and</strong> less holidays, health awareness, <strong>and</strong> strong individualization as<br />
well as increasing quality awareness of the customers, it becomes clear that tourist<br />
destinations face an even more difficult situation. It is the case in the spa cities <strong>and</strong> spa towns<br />
too. Change in tourist destinations is driven by various events, institutions or actors, which<br />
exert pressure or indicate new directions (Beritelli & Reinhold 2010). From the other h<strong>and</strong> the<br />
changing health care system in Hungary require new conformation from the spa cities <strong>and</strong><br />
towns with the new planed regulation on the health mobility within the European Union.<br />
<strong>Health</strong> tourism is one of the most visibly <strong>and</strong> rapidly developing product of domestic tourism<br />
<strong>and</strong> is currently one of the world’s most innovative <strong>business</strong> sectors. Within the tourism sector<br />
the development of health tourism can significantly enhance the number of guest, guest-nights<br />
<strong>and</strong> the actual spending of guests. The spa city of Budapest has a special character <strong>and</strong> plays a<br />
special role in this context. The development of health tourism <strong>and</strong> spas in Budapest seems to<br />
be a good combination for wellness <strong>and</strong> cure purposes based on thermal water.<br />
The definition of a tourism product is most often understood as a tourism destination in the<br />
tourism literature, <strong>and</strong> looked through a tourism area life cycle point of view. In this study the
City of Budapest is seen as a tourist destination, <strong>and</strong> the famous spas in Budapest are the<br />
tourism products.<br />
First change, competition <strong>and</strong> the concept of area life cycle <strong>and</strong> product life cycle will be<br />
presented as a theoretical foundation, followed by a short overview of the spa heritage in<br />
Budapest <strong>and</strong> the specific characteristic of the product. In addition four famous historical spas<br />
in Budapest, namely the Gellért Spa, the Széchenyi Spa, the Lukács Spa <strong>and</strong> the Rudas Spa<br />
will be presented separately according to the empirical case studies of these four spas in<br />
Budapest. The selected case study research method has several methodological limitations<br />
(Yin, 2003), namely limited rigor, <strong>and</strong> limited potential for generalization. To weaken the<br />
limitations we analyze each case both separately <strong>and</strong> in cross-case comparison. The case<br />
study reflects national context with nowadays political, economic <strong>and</strong> cultural settings.<br />
In the process interviews were conducted with managers of spas <strong>and</strong> questionnaires were<br />
filled out by guests visiting the spas which provided the basic data for the results shown in the<br />
article.<br />
Thus, the article aims at responding to the following questions: What challenges do the<br />
management of the spas in Budapest have to face nowadays. Which role has an area <strong>and</strong> a<br />
product life cycle model in this context?<br />
Literature Research<br />
In our global world economy every district (settlement, region) is forced to compete with<br />
other districts in order to gain economic advantage over them. They are endeavouring to<br />
provide the most favourable conditions for <strong>business</strong> corporations, industrial establishments,<br />
consortiums, scientific research centres, investors, <strong>tourists</strong>, conventions <strong>and</strong> conferences, in<br />
order to increase the number of jobs, income, to boost commerce, investments, <strong>and</strong> growth.<br />
(Kotler/Raider/Rein, 1994, p. 24) „In countries with a market economy the communities<br />
themselves are markets. In consequence they must find ways to market their resources in a<br />
way to benefit from a competitive advantage in order to establish new companies <strong>and</strong> thus<br />
survive economically.” (Blakely, 1989, p. 57)<br />
The trends mentioned above sharpen the competition between individual settlements <strong>and</strong><br />
regions, which is realised on different levels <strong>and</strong> fields throughout Europe, consequently in<br />
Hungary as well. Settlements <strong>and</strong> regions are competing with each other at an ever increasing<br />
rate as economic zones; residential areas; locations for work, shopping, <strong>and</strong> recreation; <strong>and</strong><br />
finally holiday resort areas. (Horner, 1991, p. 394) Economic factors can only achieve success<br />
for settlements <strong>and</strong> regions when they are coupled with social <strong>and</strong> cultural factors. The extent<br />
to which this is influenced <strong>and</strong> formed by the communities becomes part of the settlement <strong>and</strong><br />
regional marketing concept. Besides the economic strength, the st<strong>and</strong>ard of living in the<br />
settlements <strong>and</strong> regions must also be improved, in order to make them attractive industrial,<br />
commercial, <strong>and</strong> recreational areas (Nemes, 2010, 11.).<br />
The Hungarian settlements <strong>and</strong> regions need innovative development <strong>and</strong> promotion concept<br />
to take advantage of the global competition <strong>and</strong> change for residence to encourage economic<br />
growth. The increasing attractiveness of settlements <strong>and</strong> regions, the boosting of the image<br />
<strong>and</strong> thus the development of a unique profile is only possible through the integrated<br />
assessment <strong>and</strong> proper h<strong>and</strong>ling of the needs of the participants (Nemes, 2010, 11.)
The phenomenon “change” is associated with many different notions from various research<br />
traditions <strong>and</strong> steams of management research (Baumöl, 2008). Pettigrew (1990) consider<br />
change as a dynamic process. Lewin (1951) see change as a linear input-to-output model <strong>and</strong><br />
suggested a three-step model of change. There is no single dominant theory in the change<br />
management literature upon which academics agree (Baumöl, 2008). Regarding a tourist<br />
destination over a longer period, a life cycle can be determined, which ranges from an<br />
investigation <strong>and</strong> development phase of a destination to a consolidation <strong>and</strong> stagnation phase.<br />
Achieving this point, a new phase of revival can follow in the case of successful repositioning<br />
<strong>and</strong> new market-product combination.<br />
The product life cycle model is one of the most famous theoretical models in the research of<br />
marketing <strong>and</strong> strategic management (Goncalves & Aguas, 1997, 1; Mercer 1993, 269).<br />
According to Holloway <strong>and</strong> Robinson (1995, 79) the model is also applicable to the tourism<br />
product. In the literature the often presented product life cycle has four stages: introduction<br />
followed by growth, maturity <strong>and</strong> decline stages (e.g. Goncalves & Aguas, 1997, 13; Kotler,<br />
2000, 304) or introduction, growth, competitive turbulence, maturity <strong>and</strong> decline (Wilson<br />
1995, 167). Sometimes the product development stage is added to the life cycle (e.g. Kotler,<br />
Bowen & Makens, 1999, 304-306). The stages of the product life cycle are identified points in<br />
the sales history. The life cycle curve finds strong theoretical support from Rogers’s<br />
innovation adoption theory (Rogers, 1995).<br />
At the introduction stage, a new product is introduced to the market. The price of the product<br />
tends to be high <strong>and</strong> sales volume will be low. Usually, the profits are negative or low,<br />
because of the low sales <strong>and</strong> heavy promotion expenses (Kotler, 2003, 330.). In the growth<br />
stage, the sales curve is rapidly rising (Norgan, 1994). There are a growing number of<br />
customers, an early majority following early adopters. New competitors enter the market,<br />
attracted by the opportunities for large volumes <strong>and</strong> profits. They introduce new product<br />
features. The prices remain or fall slightly <strong>and</strong> the promotional expenditures are maintained at<br />
the same level or are slightly raised (Kotler, 2003, 332.).<br />
In the competitive turbulence stage, the cumulative sales penetration approaches market<br />
capacity <strong>and</strong> the rate of the sales is decelerating, although primary dem<strong>and</strong> is still growing.<br />
The target group is now the majority of the market <strong>and</strong> the competitive climate becomes more<br />
aggressive (Wilson, 1995; Lambing, 1993.). At some point, sales growth will slow down, <strong>and</strong><br />
the product will enter a stage of maturity. This stage normally has the longest duration. The<br />
slowdown rate of the sales growth impacts on declining numbers of competitors (Kotler,<br />
2003, 333.). At the decline stage, the saturation level of the market has occurred <strong>and</strong> absolute<br />
sales of the product decline. Because of the overcapacity in the industry, there is a strong<br />
competitive warfare, which is manifested in several promotion battles using price competition<br />
<strong>and</strong> advertising. As sales <strong>and</strong> profits decline further, companies withdraw from the market<br />
(Kotler, 2003, 337; McNamee, 1988.).<br />
The most widely known application of Product Life Cycle in the tourism field is the tourist<br />
area life cycle (Butler, 1980). In the literature, very often the concept tourist product life cycle<br />
is used, although writers refer to Butler’s model (see e.g. Goncalves & Aguas, 1997). Butler’s<br />
(1980) tourist area life cycle model includes six stages: exploration, involvement,<br />
development, consolidation, stagnation <strong>and</strong> decline or rejuvenation. The model applies the<br />
product life cycle concept compensating sales by the amount of visitors. Visitors will come to<br />
an area in small numbers initially, restricted by lack of access, facilities, <strong>and</strong> local knowledge.<br />
As facilities are provided <strong>and</strong> awareness grows, the amount of visitors increases. Familiarity
of the area will also grow by marketing efforts <strong>and</strong> development facilities. Eventually, the rate<br />
of increase in visitor numbers will decline as the levels of carrying capacity are reached. With<br />
new or improved attractions the rejuvenation may occur, instead of the decline stage with<br />
small interest among vacationers. (Butler, 1980, 6-9.)<br />
TALC has been critiqued <strong>and</strong> developed (Haywood; 1998, 273-285; Puczkó & Rátz, 2005,<br />
41.). Buhalis (2000, 105) has exp<strong>and</strong>ed the life cycle theory by describing typical features in<br />
destination, <strong>and</strong> economical, social <strong>and</strong> environmental impacts of tourism on the destination<br />
area at different life cycle stages. He also differentiates the supply <strong>and</strong> dem<strong>and</strong> curves of the<br />
destination. He suggested a destination life cycle model with five stages: introduction, growth,<br />
maturity, saturation <strong>and</strong> decline.<br />
Innovations in the product of the spas in Budapest were generated by the international <strong>and</strong><br />
Hungarian tourism market <strong>and</strong> by the inhabitants at the beginning of 2000. Therefore in this<br />
study, the maturity, the saturation <strong>and</strong> the decline stage is important. Following Buhalis<br />
(2000), the saturation stage is used in this study between the maturity <strong>and</strong> decline stages. This<br />
approach is helpful when utilising qualitative features like attitudes of locals. In interpreting<br />
the life cycle, it is important to underst<strong>and</strong> that the boundaries of stages are not clear <strong>and</strong><br />
different stages can appear partly at the same time. There can also be features typical for<br />
different stages at the same life cycle stage (Berry, 2001.).<br />
In this study, a combination of the product life cycle <strong>and</strong> the destination life cycle theories is<br />
used <strong>and</strong> the following stages of the life cycle are applied: product development, introduction,<br />
growth, maturity, saturation <strong>and</strong> decline or new growth (see Hakulinen, Komppula &<br />
Saraniemi 2007). Thus, a general view of a life cycle of the spas in Budapest product is<br />
generated. The life cycle stages are based on the foregoing literature, particularly the division<br />
by Buhalis (2000). The context of stages applies e.g. features proposed by Buhalis (2000),<br />
Kauppila (1995), Butler (1980) Kotler et al. (1999), Cohen (1972), Plog (1974; 2001), Thurot<br />
(1973, in Pearce, 1995), Strapp (1988), Rogers (1995) <strong>and</strong> Doxey (1975, in Järviluoma,<br />
1993).<br />
The underlying prerequisite for a successful tourist product development is a continuous<br />
service system development, which involves continual development of the strategy<br />
(Edvardsson et.al 2000). So the “augmented tourist product” (mentioned by e.g. Middleton<br />
<strong>and</strong> Clarke 2001, see also Kotler et. al 1999, <strong>and</strong> Lumsdon 1997) in this case is the spa<br />
product in Budapest itself, its reputation <strong>and</strong> image.<br />
The research methodology<br />
The research has covered the four most important spas in Budapest, namely the Széchenyi<br />
Spa, the Gellért Spa, the Lukács Spa <strong>and</strong> the Rudas Spa, which belong to the municipality of<br />
Budapest as an owner <strong>and</strong> to the Budapest Healing Baths <strong>and</strong> Hot Springs Co. Ltd. (Budapest<br />
Gyógyfürdői és Hévizei Zrt.), as a management company, owed by the municipality of<br />
Budapest.<br />
In the study both qualitative <strong>and</strong> quantitative techniques were used in order to illustrate the<br />
product life cycle <strong>and</strong> the needed fields for innovation <strong>and</strong> quality improvement.<br />
The data consists interviews with visitors, who are already visited the spas <strong>and</strong> interviews<br />
with managers of the Budapest Healing Baths <strong>and</strong> Hot Springs Co. Ltd. (Budapest<br />
Gyógyfürdői és Hévizei Zrt.).
More than 400 interviews were made with the visitors in the 4 spas at the end of last year, in<br />
November <strong>and</strong> December 2009. In choosing interviews with the managers, we focused on the<br />
following two levels: the central management office of the spas as a head quarter <strong>and</strong> the<br />
management level of the different spas, namely the Széchenyi Spa, the Gellért Spa, the<br />
Lukács Spa <strong>and</strong> the Rudas Spa.<br />
The description of the spas <strong>and</strong> tourism in Budapest are based on secondary data sources. For<br />
the illustration of the life cycle we have used statistical data.<br />
Spa heritage in Hungary <strong>and</strong> in Budapest<br />
The Carpathian Basin, with Hungary at its centre, is one of the biggest sedimentary basins in<br />
the world <strong>and</strong> has an extensive geothermal system. The main geothermal reservoir systems in<br />
Hungary are the Mesozoic carbonate-karstic basement rocks <strong>and</strong> the Pliocene-Upper<br />
Pannonian porous sedimentary formations. Their wells produce water that is mostly in the<br />
low-to-medium temperature range (30-100 ºC) (Árpási, 2003, 371-377). According to<br />
different assessments of its geothermal resources (Boldizsár, 1967; Bobok et al., 1988),<br />
Hungary has the biggest underground thermal water reserves <strong>and</strong> low-to-medium enthalpy<br />
geothermal potential in Europe.<br />
Geothermal gradient in Hungary is 5ºC/100 m as average, which is about one <strong>and</strong> half times<br />
as high as the worldwide average. The mean temperature is about 10ºC on the surface <strong>and</strong><br />
with the geothermal gradient the rock temperature is 60ºC at the depth of 1 km <strong>and</strong> 110ºC at<br />
the depth of 2 km together with the water contained by them. The geothermal gradient is<br />
higher than the countrywide average in the southern part of the Transdanubian region <strong>and</strong> in<br />
the Lowl<strong>and</strong>, while it is lower in the Kisalföld region <strong>and</strong> in the hilly areas of the country.<br />
In Hungary the wells <strong>and</strong> springs of higher than 30ºC wellhead water temperature are<br />
considered as geothermal springs, thermal water. Waters of such temperature can be explored<br />
on the 70 % of the area of the country from the known geological formations.<br />
Since ancient times, springs have been surrounded by a respect, usually attributed to holy<br />
sites. Water, as a revitalising element, has been revered since antiquity. Though medical<br />
science has endeavoured to discover empirical sources of diseases <strong>and</strong> methods of healing, an<br />
uninterrupted interest in natural healing effects of water rem<strong>and</strong>ed. Through prehistoric times,<br />
healing practices were passed along from generation to generation.<br />
Hungary’s spa culture has a long history in Budapest, where people have been bathing in the<br />
thermal baths for nearly 2000 years. Excavated remains of bath houses in Budapest show that<br />
the Romans used the thermal springs. The next stage of development of our baths was brought<br />
along by the Turkish occupation. Community buildings were built on the healing waters,<br />
bearing a particular style, <strong>and</strong> incorporating a culture of individual bathing. The third period<br />
in the history of Budapest bathing culture occurred during the Age of Enlightenment. As early<br />
as in the first half of the 1700s, one can find early studies about the usefulness of the Buda hot<br />
spring. In 1772, a decree was issued by Maria Theresia, Queen of Hungary <strong>and</strong> Empress of<br />
Austria to have all mineral water analysed <strong>and</strong> recorded in a list at the expense of the<br />
Treasury. In the early 1930s, Budapest, as the capital possessing the most healing thermal<br />
water springs in the world, was awarded the title “Spa City”.<br />
Among the best known Budapest baths are the Gellért Baths, the Széchenyi Bath, the Lukács<br />
Bath <strong>and</strong> the Rudas Bath where our research was made. In the following the short description
of the case studies will be presented. In 1990 the former ownership of the baths was<br />
transferred to local governments except the Rudas baths which were considered public<br />
monuments <strong>and</strong> remained in state ownership, but the Metropolitan Local Government<br />
retained their use free-of-charge. These properties are managed by the Budapest Gyógyfürdői<br />
és Hévizei Zrt. which owner is the Metropolitan Local Government.<br />
In Hungary, health care is based on a compulsory <strong>and</strong> comprehensive social insurance<br />
scheme. <strong>Health</strong> services are financed by the National <strong>Health</strong> Insurance Administration in our<br />
country. Nowadays health resorts <strong>and</strong> spas offer a new spa product in the form of health<br />
tourism. The sustainable development of spas will be achieved by implementing local<br />
development strategies, which have been formulated according to development tendencies of<br />
the domestic spa market.<br />
In accordance with current legal regulation, nine kinds of various bath treatments can be<br />
obtained by medical prescription, for the purpose of rehabilitation in these four thermal baths:<br />
thermal healing pool, thermal tub-bath, mud package, weight bath, carbonic acid bath,<br />
medical healing massage, underwater water-beam massage, underwater healing gymnastics in<br />
groups <strong>and</strong> complex healing bath facilities. Thermal bath therapies can be ordered by<br />
physicians specialising in rheumatology, physiotherapy <strong>and</strong> rehabilitation of the organs of<br />
locomotion.<br />
The Gellért Bath<br />
We can find records about the springs spurting up on the territory of the Bath from as early a<br />
date as the 15 th century. These springs were favoured <strong>and</strong> used by the Turks as well. The<br />
Gellért Thermal Bath <strong>and</strong> Hotel was built in secession style in 1918 <strong>and</strong> was exp<strong>and</strong>ed in<br />
1927 by the wave-bath <strong>and</strong> in 1934 by the effervescent bath. The modernization followed, the<br />
different pools were renovated <strong>and</strong> equipped with a state-of the art water filtering <strong>and</strong><br />
circulation device. The bath offers complex bath facilities, daytime, outpatient hospital.<br />
The water is hot spring water with calcium, magnesium <strong>and</strong> hydrogen-carbonate as well as<br />
sulphate-chloride, also containing sodium <strong>and</strong> fluoride ions. Therapeutic is suggested for<br />
degenerative joint diseases, spinal deformity, chronic <strong>and</strong> sub-acute arthritis, discus hernia,<br />
neuralgia, vasoconstriction, circulatory disturbances <strong>and</strong> inhalation for the chronic diseases of<br />
respiratory organs.<br />
The bath has 3 parts, the man part, the women part <strong>and</strong> a swimming pool part, with whirlpool,<br />
sitting pool, wave pool, adventure pool, children’s pool <strong>and</strong> thermal baths. The water<br />
temperature is between 26 – 36 ºC. All together 83 people are working in the bath.<br />
There are some tasks which are centralized in the central office, the finance <strong>and</strong> the human<br />
research activities. The centralization has advantage, but many disadvantages too. The<br />
important decisions will be made at the central level <strong>and</strong> not at the bath level, which need<br />
more time. Nowadays the bath provides medical, wellness <strong>and</strong> medical wellness services too,<br />
to be able to exp<strong>and</strong> the guest circle. In the frame of the new Hungary Development Plan<br />
2007 investment in the value of 1.5 billion Hungarian forint was made.<br />
Both, the domestic <strong>and</strong> the international market are important for the bath. The guests are<br />
mostly satisfied with the product <strong>and</strong> with the services. There are some fields which have to<br />
be developed. These are the level of services <strong>and</strong> the foreign language knowledge of the<br />
personal.
The Széchenyi Bath<br />
The Széchenyi Thermal Bath in one of the largest spa complexes in Europe which was built in<br />
1913. The bath was exp<strong>and</strong>ed in 1927 with a public bathing department for gentlemen <strong>and</strong><br />
ladies <strong>and</strong> a beach site. In the middle of the 1960s, a daytime hospital was built. The<br />
reconstruction of the pools of the swimming section was completed in 1999. Further<br />
reconstructions <strong>and</strong> product innovations were made during the last years.<br />
The water of the bath contains calcium, magnesium, hydro-carbonate, sodium <strong>and</strong> sulphate,<br />
with a significant content in fluoride <strong>and</strong> metaboric acid. Therapeutic is suggested for<br />
degenerative joint diseases, chronic <strong>and</strong> sub-acute arthritis.<br />
The bath has a swimming pool with water filtering <strong>and</strong> circulation device, adventure pool, <strong>and</strong><br />
thermal sitting pool, group thermal bath with adventure pool <strong>and</strong> group stream-baths. The<br />
water temperature is between 27 – 38 ºC.<br />
The tasks of marketing finance, controlling <strong>and</strong> administration are centralised, the bath is<br />
responsible for the daily operation. The bath provides daily hospital, medical <strong>and</strong> wellness<br />
services. There are two main target audience, the domestic <strong>and</strong> the international markets. In<br />
the frame of the different investment plans 3.5 billion Hungarian forint was invested into the<br />
renovation of the bath <strong>and</strong> the development of services. The guests are mostly satisfied with<br />
the services. There are some fields which have to be developed. These are the level of<br />
services <strong>and</strong> the foreign language knowledge of the personal.<br />
The Lukács Bath<br />
In the 12 th century, knights of the order of Saint John engaging in curing the sick settled in the<br />
area of today’s Lukács Bath. The bath operated through the time of Turks but the energy of<br />
the springs were used primary to produce gunpowder <strong>and</strong> for grinding wheat. The first<br />
department to ensure complex thermal bath facilities, daytime hospital was established in<br />
1979 in the Lukács Thermal Bath. The swimming pools were rebuilt <strong>and</strong> modernised from<br />
1999 in more phases.<br />
The hot spring water contains calcium, magnesium, hydrogen-carbonate <strong>and</strong> sulphate,<br />
chloride, sodium <strong>and</strong> fluoride ions. Therapeutic is suggested for degenerative diseases,<br />
chronic <strong>and</strong> sub-acute arthritis, spinal deformity, discus hernia, neuralgia <strong>and</strong> post-accident<br />
rehabilitation. The bath has swimming pools, adventure pool, thermal bath <strong>and</strong> underwater<br />
traction bath. The Lukács Bath profile is a medical bath.<br />
In three beat between 2005 – 2009 all together 2,7 billion Hungarian forint was invested in the<br />
development of the Lukács bath., which affected the daily hospital, the thermal bath, the sun<br />
suit <strong>and</strong> the wellness services. The centralisation is the same than in the case of Gellért <strong>and</strong><br />
Széchenyi bath. The guest are coming mostly from the domestic market, the bath is not<br />
familiar for the international guests. The guest’s satisfaction is lower in the Lukács bath as in<br />
the Gellért <strong>and</strong> Széchény bath.<br />
The Rudas Spa<br />
The centrepiece of the bath today, the Turkish bath, was built during the 16 th century in the<br />
period of the Turkish occupation. Below the 10 m diameter dome, sustained by 8 pillars, there<br />
is an octagonal pool. The thermal bath has been visited from 1936 on exclusively by men. The<br />
swimming pool, operating as a therapeutic swimming facility <strong>and</strong> with a sauna, was built in<br />
1896.
The water is radio-active <strong>and</strong> contains calcium-magnesium-hydrogen-carbonate, sodium,<br />
sulphate <strong>and</strong> fluoride ions. Therapeutic is suggested for degenerative joint diseases, chronic<br />
<strong>and</strong> sub-acute arthritis, discus hernia <strong>and</strong> neuralgia. The bath has steam pools <strong>and</strong> swimming<br />
pool. The water temperature is between 16 – 42 ºC.<br />
The bath the similar services as the mentioned 3 baths. The difference is the activity on the<br />
programs for the Jung generation, for example the Cinetrip SParty. The centralisation is the<br />
same than in the Gellért, in the Széchenyi <strong>and</strong> in the Lukács bath. The domestic <strong>and</strong> the<br />
international market are equally important for the bath.<br />
As mentioned above in three spas are daily hospitals, in the Gellért bath, in the Széchenyi<br />
bath <strong>and</strong> in the Lukács bath, which is a separate part in the bath. It determines the profile of<br />
the bath too. Complex therapies are needed <strong>and</strong> constant doctor attendance. Cooperation with<br />
National <strong>Health</strong> Service, with the hospitals has to be stronger. Also connections with foreign<br />
(public) health funds can cause an increment in the number of visitors in the future.<br />
Nowadays prevention is important as well, <strong>and</strong> therefore the bath has to focus not only on the<br />
ill, elder people. The product innovation <strong>and</strong> the services have to focus on the need of the<br />
inhabitants of Budapest, the domestic <strong>and</strong> the international market as well.<br />
Results<br />
This research noted measures the historical evolution of the spa market in Budapest <strong>and</strong> the<br />
curve of dem<strong>and</strong> by the number of guests visiting the most important spas in the capital city<br />
of Hungary in the years 1995 – 2008. We analysed the number of guest arrivals at the public<br />
accommodation in Budapest, to prepare a destination life cycle for the capital city of Hungary<br />
<strong>and</strong> the number of visitors’ at the most important spas in Budapest to prepare a product life<br />
cycle for the spas. We can see on Figure 1 that the destination life cycle of Budapest is in the<br />
stagnation phase. After an increase from 2002 the guest flow stabilized in the years of 2004-<br />
208.<br />
Figure 1<br />
3000000<br />
2500000<br />
2000000<br />
1500000<br />
1000000<br />
500000<br />
0<br />
Tour i st a r r i v a ls of publ i c a c c omoda t i ons in B uda pe st be t we e n 2 0 0 2 - 2 0 0 9<br />
2002 2003 2004 2005 2006 2007 2008 2009<br />
year s<br />
Source: Central Statistical Office, own illustration<br />
Inter national tour ist ar r ivals<br />
Domestic tour ist ar r ivals<br />
Total
The product life cycle of the spas in Budapest shows (see Figure 2) a decline phase of the<br />
curve which means that the total number of visitors in the four most important spas is<br />
declining. However there is a difference between the different spas.<br />
Figure 2<br />
Source: Budapest Gyógyfürdői és Hévizei Zrt., own illustration<br />
The Széchenyi Spa realizes the highest visitor number between the four spas where the guest<br />
flow is stabile. In figure 1, the life cycle of the area Budapest is illustrated. In figure 2, the life<br />
cycle of Spas in Budapest product is illustrated. We have prepared a shorter <strong>and</strong> a longer time<br />
row to be able to analyze a longer time square. We have collected the data of the visitors from<br />
the year 1995 which present clear that a product need more innovation <strong>and</strong> adaptation to the<br />
current market tendencies or the managers has to market the product better to be able to step<br />
into the new growth phase. It is absolute necessary.<br />
Figure 3<br />
3000000<br />
2000000<br />
1000000<br />
Number of visitors<br />
0<br />
Number of vis itors in the different s pas in Budapes t between<br />
2002-2008<br />
Source: Central Statistical Office, own illustration<br />
2002 2003 2004 2005 2006 2007 2008<br />
G ellért S pa S z échenyi S pa<br />
Lukács S pa R udas S pa<br />
Total<br />
3500000<br />
3000000<br />
2500000<br />
2000000<br />
1500000<br />
1000000<br />
500000<br />
Number of visitors in the different spas in<br />
Budapest between 1995-2008<br />
0<br />
1995<br />
1997<br />
1999<br />
2001<br />
2003<br />
years<br />
2005<br />
2007<br />
Gellért Spa<br />
Széchenyi Spa<br />
Lukács Spa<br />
Rudas Spa<br />
Total
Conclusions<br />
In our changing environment the spas in Budapest are facing with problems regarding the<br />
turnover <strong>and</strong> the guest number which has to be solved. The number of guest is decreasing<br />
instead of big investment which was made in the last period in the spas. Solution should be a<br />
better <strong>and</strong> more professional marketing activity, the development of unique profile through<br />
proper h<strong>and</strong>ling of the needs of participants (inhabitants <strong>and</strong> <strong>tourists</strong>), guest oriented<br />
innovation in the services, improvement on the field of human resource <strong>and</strong> service quality.<br />
The Budapest Healing Baths <strong>and</strong> Hot Springs Co. Ltd. have to further develop a segmented,<br />
well-br<strong>and</strong>ed spa product in Budapest. A strategy would be required for the br<strong>and</strong> creation.<br />
According to this study, combining a traditional product life cycle <strong>and</strong> a destination life cycle<br />
is useful. The best results are obtained by using both quantitative <strong>and</strong> qualitative indicators.<br />
Factors utilised in this study related to tourist, product, competition, destination <strong>and</strong> tourism<br />
in the area were the most applicable measures in describing a tourist product life cycle.<br />
This study underpins the proposal that customers are often involved with the innovation<br />
process (Alam & Perry, 2002; Belz & Bieger, 2004 in Bieger & Weiner, 2006). As Holloway<br />
& Robinson (1995) stated, new products often are improvements of the old ones. During the<br />
life cycle, the core product changed, being today a need to the prevention.<br />
The main theoretical contribution of this study is the experiment to the application of a<br />
combined life cycle model.<br />
References<br />
Árpási, Miklós (2003), Geothermal development in Hungary – country update report 2000-<br />
2002, Geothermics 32, Elsevier Ltd, pp. 371-377.<br />
Beritelli, Pietro & Reinhold, Stephan (2010), Explaining Decisions for Change in Tourist<br />
Destinations: The Garbage Can Model in Action, Erich Schmied Verlag, pp.137-152<br />
Buhalis, D. (2000), Marketing the competitive destination of the future. <strong>Tourism</strong><br />
Management, Vol.21, No.1, pp.97-116.<br />
Butler, R.W. (1980), The concept of a tourist area cacle of evolution: Implications for<br />
management of resourches. Canadian Geographer, 24(1), 5-12.<br />
Goncalves, V.F.Da C., Aguas, P.M.R. (1977), The concept of life cycle: An application to the<br />
tourist product. Journal of Travel Research, Vol.36, No.2, pp.12-23.<br />
Haywood, Michael (1998), Economic <strong>business</strong> cycles <strong>and</strong> the tourism life-cycle concept; in<br />
The Economic Geography of the Tourist Industry; Routledge, pp.273-285.<br />
Kotler P. (2000), Marketing Management. The Millennium Edition. Prentice-Hall, Upper<br />
Saddle River.<br />
Kotler P. (2003), Marketing Management. International Edition. Upper Saddle River,<br />
Prentice-Hall.<br />
Kotler, P. Bowen, J. Makens, J.,(1999), Marketing for Hospitality <strong>and</strong> <strong>Tourism</strong>. Second<br />
Edition. Upper Saddle River, Prentice-Hall.<br />
Nemes, Andrea (2010), Increasing the attraction of economic regions: settlement <strong>and</strong> regional<br />
marketing, Hungarian Academy of Sciences, Institute of Sociology <strong>and</strong> Institute for<br />
Political Sciences, Series of European Social Survey, <strong>Tourism</strong> <strong>and</strong> Society<br />
Yin, R.K. (2003), Case Study Research, Design <strong>and</strong> Methods (3 rd .ed.), Sage, Thous<strong>and</strong> Oaks<br />
CA.<br />
Puczko, Laszlo & Ratz, Tamara (2005) – A turizmus hatásai, Aula Kiadó Kft.<br />
Rogers, E.M. (1995), Diffusion of Innovation. Fourth edition. New York.
Should Private <strong>Health</strong>care Insurance Providers in the UK Outsource<br />
Surgery?<br />
A Case Study of Hip <strong>and</strong> Knee Replacements in India<br />
Rina Parmar, Anthony Brown, Olivia Cleevely, Akira Fukutomi, Katharine Hanan,<br />
Eleanor Rowl<strong>and</strong>.<br />
Imperial College London, Business School, South Kensington Campus, London, SW7 2AZ,<br />
United Kingdom<br />
rina.parmar08@ic.ac.uk<br />
Abstract<br />
Objective – To determine the relevant benefits of outsourcing treatment, for both private<br />
health care insurance providers <strong>and</strong> potential patients in the UK, using a case study of India.<br />
Aims<br />
1. To establish the perceptions of the UK public on private healthcare insurance <strong>and</strong> their<br />
views on the outsourcing of treatment<br />
2. Perform a cost analysis comparing private healthcare providers in India <strong>and</strong> in the UK with<br />
respect to hip <strong>and</strong> knee replacements<br />
3. To determine whether or not outsourcing hip <strong>and</strong> knee replacements to India would<br />
compromise the quality of treatment the patient receives<br />
4. To measure patient satisfaction of UK citizens getting hip <strong>and</strong> knee replacements in India<br />
Methodology<br />
Spire <strong>Health</strong>care in the UK was used as a point of comparison to the Apollo Hospitals Group<br />
in India.<br />
- Face-to-face questionnaire survey of 100 people to obtain a sample of public<br />
perceptions to health insurers outsourcing treatment.<br />
- Cost data was compiled from various sources with comparisons made between the two<br />
organisations.<br />
- Fieldwork was carried out in India. Information was collected regarding quality<br />
st<strong>and</strong>ards, patient satisfaction <strong>and</strong> hospital management through interviews with staff<br />
<strong>and</strong> patients. Comparable data for the UK was obtained from published sources.<br />
Results <strong>and</strong> Conclusions<br />
People were shown to be price sensitive towards insurance policies. Overall, there was a<br />
willingness to accept outsourcing as a means of reducing premiums. India was shown to have<br />
reduced price mark-ups, lower costs of equipment <strong>and</strong> medication as well as the lower wages<br />
dem<strong>and</strong>ed by staff compared to the UK. Patient satisfaction <strong>and</strong> quality of care were not<br />
compromised in India, although follow-up care was identified as being unsatisfactory.<br />
Overall it was concluded that there is clear potential for health insurers to outsource elements<br />
of treatment in order to exp<strong>and</strong> their target market.<br />
Keywords: Medical, <strong>Tourism</strong>, Outsourcing, Private, <strong>Health</strong>care, Insurance, Bupa, Apollo<br />
Introduction<br />
In the current economic climate, many <strong>business</strong>es are seeking strategies to reduce costs to<br />
gain a competitive advantage (Aron <strong>and</strong> Singh, 2005). The healthcare insurance <strong>business</strong> is
no exception. Already, patients are travelling abroad for treatment such as coronary artery<br />
bypass surgery (CABG) to countries such as India where it costs £3950 (Taj Medical Group,<br />
2008) compared to an English cost of £1700 (Spire <strong>Health</strong>care, 2008). However, it is<br />
uncertain whether this practice could prove beneficial for private healthcare insurance<br />
companies who could potentially provide low-cost packages which included treatment being<br />
outsourced.<br />
It was deemed appropriate to consider hip <strong>and</strong> knee replacements being carried out both in the<br />
UK <strong>and</strong> in India to ensure a broad demographic range was considered whilst looking at a<br />
country that was already receiving patients from abroad for medical <strong>and</strong> surgical treatment.<br />
The objectives of the project were divided into four categories: market determination,<br />
financial savings, patient satisfaction (including cultural issues) <strong>and</strong> quality of care.<br />
Due to the recent emergence of outsourcing in healthcare, limited published literature is<br />
available, although some US based literature exists.<br />
At present there are no UK insurers that outsource surgery abroad, although there are private<br />
companies such as The Taj Medical Group who specifically focuses on sending UK patients<br />
to India, providing fully inclusive packages <strong>and</strong> work in partnership with the Indian<br />
Government to help regulate medical tourism, such as offering medical visa’s to patients, as<br />
well as tax incentives to hospitals.<br />
Deloitte found in their Survey of <strong>Health</strong> Care Consumers (2008) that nearly 40% of US<br />
citizens would travel abroad for treatment, as long as the st<strong>and</strong>ard of care was comparable <strong>and</strong><br />
the cost was 50% of that in the US. However despite this, it was found that only 3% of<br />
Americans have travelled for treatment. Horowitz <strong>and</strong> Rosensweig (2007) believe that the<br />
number of Americans travelling for treatment is set to soar, predicting that by 2010 the<br />
number will have increased from 750,000 to 6 million per year.<br />
The Medical <strong>Tourism</strong> Association Survey conducted in August 2007, shows that India is by<br />
far the cheapest country for the majority of surgical procedures listed. If the quality of care<br />
<strong>and</strong> patient satisfaction were uncompromised, India would be the most cost effective country<br />
to outsource to.<br />
At present there are various internationally recognised accreditations for the st<strong>and</strong>ards of care,<br />
such as the Joint Commission International (JCI) or the International Organization for<br />
St<strong>and</strong>ardization (ISO). Although there is a distinct lack of primary research on the subject,<br />
the quality of care in India appears to be of equal or greater st<strong>and</strong>ard than that of the US. For<br />
example, an elective CABG in California has a mortality rate of 2.91% compared to less than<br />
1% for the same operation in Apollo hospitals in India (Milstein <strong>and</strong> Smith, 2007)<br />
US literature cannot be solely used to predict the success of outsourcing treatment in the UK,<br />
as the UK <strong>and</strong> US have vastly different health systems. Due to the National <strong>Health</strong> Service in<br />
the UK, it is likely that far fewer people in the UK would be willing to pay for treatment<br />
compared to people in the US. However, with the rise in medical tourism there is scope for<br />
UK private health insurers to capture a new segment of the healthcare market.<br />
Methodology<br />
Spire <strong>and</strong> Bupa were selected as examples within the project as they are market leaders for<br />
private healthcare provision in the UK however both Bupa <strong>and</strong> Spire felt unable to participate
with this research due to the sensitivity of data required <strong>and</strong> the conflicts between the project<br />
<strong>and</strong> their overall <strong>business</strong> plan. As such, data from the UK health insurance market was<br />
collected from published sources.<br />
Apollo Hospitals Group was chosen as an example of foreign hospitals as it is the largest <strong>and</strong><br />
most established private hospital group in India, already widely used by UK patients seeking<br />
healthcare abroad. A field research trip was organized to collect accurate primary research<br />
from India in the form of observations <strong>and</strong> interviews. For consistency, all interviews were<br />
carried out by the same person using a semi-structured, face-to-face format, which were<br />
digitally audio-recorded <strong>and</strong> transcribed.<br />
Market determination<br />
A face-to-face interviewer-led questionnaire survey was carried out to establish public<br />
perceptions of medical treatment both in the UK <strong>and</strong> abroad.<br />
This questionnaire had a quantitative focus <strong>and</strong> consisted of 20 questions. A sample size of<br />
100 participants was selected using a non-r<strong>and</strong>omised, quota-sampling method. It was aimed<br />
to include 10 males <strong>and</strong> 10 females within each of the five age groups (20-29, 30-39, 40-49,<br />
50-59, <strong>and</strong> over 60). Age stratification was used, as different age groups often have marked<br />
differences in health service requirements <strong>and</strong> would therefore have different views<br />
concerning past <strong>and</strong> future medical care.<br />
Initial piloting of the questionnaire was carried out, of which revisions of the questions were<br />
made prior to implementing the questionnaire across the 100 participants.<br />
Participants were selected on the basis that they lived in the UK <strong>and</strong> did not currently have<br />
health insurance. The data was collected over three weeks at different times <strong>and</strong> locations<br />
across London.<br />
The questionnaire responses were coded using an alphanumerical code <strong>and</strong> entered into<br />
Microsoft Excel. Thematic analysis was carried out on all qualitative data. Quantitative data<br />
was tabulated in order to categorise the responses, <strong>and</strong> was represented graphically to assist<br />
analysis. Statistical tests (un-paired t-test at 95% significance level) were carried out to<br />
determine any statistical significance between different groups.<br />
Financial savings<br />
An Interview with Apollo’s financial department manager provided information regarding<br />
price mark-ups <strong>and</strong> the costs of different components of hip or knee replacements<br />
Information regarding the costs for hip replacements in the UK was compiled from two<br />
different sources. Firstly, published accounts from Spire’s own website (Spire <strong>Health</strong>care,<br />
2009) were used for an estimation of hospital running costs. Secondly, information on staff<br />
<strong>and</strong> equipment costs was gathered from various sources such as Jobsformedical.com (2009)<br />
<strong>and</strong> NICE (2000). Information from both Spire <strong>and</strong> Apollo was tabulated to provide a total<br />
cost of treatment. This enabled a cross-comparison between the data from Spire <strong>and</strong> Apollo,<br />
allowing observations of where savings had been made by Apollo.<br />
Quality of care<br />
Interviews were conducted with orthopaedic surgeons at Apollo to explore their level of<br />
professional experience <strong>and</strong> to highlight their motivations for working in India. Additionally,<br />
professional profiles of those doctors interviewed were obtained from Apollo’s website.<br />
Quality control managers were also interviewed to determine how Apollo ensures the quality<br />
of treatment provided.
Data regarding levels of training of orthopaedic surgeons in the UK was obtained from<br />
professional profiles accessible from Spire’s own website (Spire <strong>Health</strong>care, 2009).<br />
Data regarding Spire’s surgical success rates were obtained from published data from both<br />
Spire’s own publications <strong>and</strong> those of external monitoring bodies. Apollo were able to<br />
provide these details directly. The recovery times, infection rates <strong>and</strong> complication rates from<br />
both Apollo <strong>and</strong> Spire were compared directly.<br />
Patient satisfaction (including cultural issues)<br />
Three patients, who had previously undergone hip replacements in India, were interviewed<br />
via email <strong>and</strong> telephone correspondence to determine their satisfaction with treatment<br />
provided <strong>and</strong> the overall experience of care in India. Semi-structured interviews were<br />
performed.<br />
Data regarding patient satisfaction with treatment received at Spire was collected from Spire’s<br />
website (Spire <strong>Health</strong>care, 2009), the Independent <strong>Health</strong>care Advisory Service (IHAS,<br />
2009), the Welsh Independent Hospitals Association (WIHA, 2009) <strong>and</strong> the Scottish<br />
Independent Hospitals Association (SIHA, 2009). The published data provided information<br />
on satisfaction with the hospital, staff <strong>and</strong> willingness to recommend treatment. This data was<br />
then compared with the data from Apollo to highlight discrepancies <strong>and</strong> allow conclusions to<br />
be drawn.<br />
Results<br />
Market determination<br />
The survey looked at participants’ views on whether they would travel abroad for medical<br />
treatment. On initial questioning (Question 9a) 57% of participants said that they would<br />
either probably or definitely consider travelling abroad for treatment in the future. India was<br />
the most popular non-Western country to be chosen for the participant’s destination with 31%<br />
choosing it as one of their ideal locations. When asked whether they would take out a health<br />
insurance policy where foreign treatment was provided (in question 13a), a slightly lower<br />
proportion suggested they would, with 53% saying that they probably or definitely would take<br />
out cover if premiums were cheaper as a result.<br />
Figure 1- Comparison of overall answers from question 9a <strong>and</strong> question 13a
However, when comparing answers to questions 9a <strong>and</strong> 13a (shown in figure 1), there was<br />
less certainty amongst respondents who answered positively to taking out insurance with the<br />
addition of healthcare abroad rather than simply travelling abroad for treatment in general.<br />
‘Definite yes’ responses fell by almost half from 17% to 8% of all responses.<br />
When those willing to travel abroad were further questioned regarding their answer to<br />
question 9a, the answers given fell into one or more of five main themes:<br />
1. Seen as cheaper to have surgery abroad than arrange it privately in the UK (26% of<br />
responses)<br />
2. Quality in other countries is potentially better than the UK (23% of responses)<br />
3. Urgent treatment should be undertaken anywhere in the world that can offer it<br />
fastest (21% of responses)<br />
4. Willing to seek treatment in other countries if not available in the UK (19% of<br />
responses)<br />
5. A belief that certain health conditions receive a st<strong>and</strong>ard level of care worldwide<br />
(11% of responses)<br />
The cheaper cost of treatment abroad was the most common factor in decisions to go abroad<br />
for surgery.<br />
Similarly, negative responses to Question 9a were grouped into themes. Four main reasons<br />
were given by those who were disinclined to travelling abroad:<br />
1. Satisfied with the UK healthcare system. This included the NHS <strong>and</strong> private health<br />
care networks (46% of responses)<br />
2. Negative connotations associated with receiving medical care in a different culture<br />
to that of the UK (24% of responses)<br />
3. Problems associated with follow-up <strong>and</strong> aftercare after returning from the country<br />
of treatment (10% of responses)<br />
4. Poor perceptions of quality in foreign countries (10% of responses)<br />
5. Other (10% of responses)<br />
The answer most readily given as to why respondents would not travel for medical care was<br />
overwhelmingly due to satisfaction with the UK healthcare system, with it being a factor in<br />
46% of responses.<br />
When asked: “What is the maximum price you would pay per month for private health<br />
insurance?” - 75% of participants would pay a maximum of £50 per month for insurance<br />
covering a broad range of coverage (shown in figure 2).
Figure 2 - Graph showing price willing to pay for insurance<br />
Age Analysis<br />
When asked how much they would be willing to pay for health insurance, 50-59 year olds had<br />
the highest mean of £67.00. Lowest mean price was from the 20-29 age category, at £31.59.<br />
The three oldest age groups had the largest number of ‘definitely no’ responses for<br />
willingness to travel abroad for treatment in the future. The 50-59’s were the least willing to<br />
travel abroad with 60% of individuals answering ‘no’. The 20-29’s <strong>and</strong> the 30-39’s were the<br />
most inclined to travel abroad with over 70% of individuals in both age categories answering<br />
‘yes’ to the question (either ‘probably’ or ‘definitely’).<br />
The introduction of the concept of treatment abroad reducing the cost of health insurance<br />
premiums did not increase positive responses to travelling for health treatment in any age<br />
group.<br />
Occupation Analysis<br />
The mean price that the executives would be willing to pay was the highest at £75. The next<br />
highest means were amongst the professionals <strong>and</strong> skilled labourers at around £50. All other<br />
groups fell into a range of around £25-35. Despite the apparent marked difference between the<br />
mean prices that different occupations were prepared to pay, t-test results showed no<br />
significance at the 95% level.<br />
For travelling abroad for treatment the unskilled labourers had the highest proportion of<br />
‘definitely yes’ at 45% with the Executives following closely with 38%. Contrary to this, the<br />
most certain ‘no’s’ were amongst the Admin <strong>and</strong> Clericals <strong>and</strong> the Retired individuals. The<br />
student groups were the most uncertain with less than 10% ‘definitely yes’ <strong>and</strong> no ‘definitely<br />
no’ responses.
<strong>Health</strong> Issue Analysis<br />
From the sample selected, the group that considered themselves to have current health issues<br />
were generally willing to pay less for a health insurance premium than the <strong>healthy</strong><br />
participants, with a mean price of £47.36 in the <strong>healthy</strong> group, <strong>and</strong> £39.62 in the group with<br />
health issues.<br />
<strong>Health</strong> Insurance Analysis<br />
The participants were grouped into those who had previous health insurance, <strong>and</strong> those who<br />
have never had health insurance. Those with previous insurance appeared to be willing to pay<br />
more for insurance at a mean value of £60.54, compared to £39.21 in those who have never<br />
been insured.<br />
When asked whether they would travel abroad for medical treatment in the future, those that<br />
had previous insurance gave less positive responses, with 47% of responses either ‘probably’<br />
or ‘definitely yes’, compared to 61% in those that had not previously been insured.<br />
Financial savings<br />
From the interview with the Finance Department at Apollo, it is clear that costs are reduced in<br />
several areas which enable the hospital to charge patients on average of £4,000 (Taj Medical<br />
Group, 2009) for a hip replacement compared to the £12,000 charged in the UK.<br />
Apollo claim a price mark-up of treatment of 17-18%. The price mark-up at Apollo is<br />
dependent on the category of room that a patient chooses. It is observed by Apollo that<br />
international patients are those most likely to dem<strong>and</strong> the higher categories of treatment<br />
allowing for higher profit margins (greater than 20% mark-up).<br />
A further explanation of the lower cost of treatment offered in India is accounted for by the<br />
lower wages of professionals throughout India. The Apollo Finance Department claim that a<br />
surgeon would be expected to charge 35-40,000 INR per operation which is equivalent to a<br />
range of approximately £469 - £536. In the UK a surgeon would be expected to charge double<br />
this.<br />
The Apollo Finance Department state how they are able to obtain medicines at one tenth of<br />
the cost of the UK for various different reasons. India’s ability to obtain medicines at such a<br />
low cost is claimed to be due to their proximity to the countries of production <strong>and</strong> the fact that<br />
they use ‘generic’ br<strong>and</strong>s. In comparison, medicines are sold to the UK with a large profit<br />
margin.<br />
The interview with the Apollo Finance Department provided various details regarding the<br />
equipment, hospital <strong>and</strong> staff costs. This has been analysed <strong>and</strong> tabulated in Table 1. The<br />
approximations of actual costs for Spire has been tabulated in Table 2. Spire’s most recent<br />
figures state that they charge patients between £9,680 <strong>and</strong> £15,230. Using an average price of<br />
£12,455, with costs of £6,131, it is evident that the mark up of treatment is over 103%.
Table 13 – Typical hospital costs for hip replacements at Apollo<br />
Items Costs<br />
Surgeon £500<br />
Anaesthetist £125<br />
Prosthesis £1,205<br />
Assistant surgeon £50<br />
Further<br />
costs<br />
hospital<br />
£675<br />
TOTAL £2,555<br />
Table 14 – Typical hospital costs for hip replacements at Spire<br />
Items Costs<br />
SURGERY COSTS<br />
Surgeon x2<br />
£1,060<br />
(£530/surgeon)<br />
Nurse x2 £408 (£204/nurse)<br />
Anaesthetist £400<br />
Prosthesis £2,000<br />
INPATIENT COSTS<br />
Nurse £1,920<br />
Consultation fees £300<br />
HOSPITAL AND<br />
ADMINISTRATION<br />
FEES<br />
Other associated costs £43<br />
TOTAL £6,131<br />
Quality of care<br />
With respect to treatment provided in India compared to the UK, there appeared to be no<br />
significant difference in levels of medical staff training as all the doctors that we interviewed<br />
had training <strong>and</strong>/or working experience in either America or the UK. The infection rates <strong>and</strong><br />
surgical outcomes at Apollo scored better in all aspects compared to the NHS average, <strong>and</strong><br />
many measures were better than Spire (shown in table 3).
Table 3 - Surgical outcomes of Apollo, Spire <strong>and</strong> the NHS<br />
Measure Apollo Spire NHS average<br />
3 year revision rate - hip replacements 1.17% 0.8% 1.3%<br />
3 year revision rate - knee replacements 0.0% 1.0% 1.3%<br />
Mortality rate - hip replacements 0.0% 3.2% 6.4%<br />
Mortality rate - knee replacements 0.0% 3.6% 6.3%<br />
C. difficile rate (per 1,000 bed days) Nil 0.02 1.56<br />
Wound infection rate - hip replacements 0.6% 0.3% 0.9%<br />
Wound infection rate - knee replacements 0.42% 0.04% 0.5%<br />
Both Apollo <strong>and</strong> Spire hospitals are regulated by external bodies, ensuring st<strong>and</strong>ards are<br />
maintained. In both the UK <strong>and</strong> India, patients were satisfied with the treatment received.<br />
UK citizens receiving treatment in India are prepared to recommend treatment at Apollo.<br />
However, the follow-up care currently provided by Apollo does not meet the guidelines<br />
recommended by the British Orthopaedic Association (BOA).<br />
Patient satisfaction (including cultural issues)<br />
Interviews with patients revealed that patients sought treatment in India due to the low cost,<br />
high level of expertise in India, previous experience of difficulties within the NHS <strong>and</strong> long<br />
waiting lists in the NHS. Apollo was specifically chosen by the patients due to the hospital’s<br />
reputation <strong>and</strong> efficiency with regards to dealing with patients’ needs.<br />
The patients interviewed stated that prior to travelling to Apollo their expectations were<br />
higher than what they initially experienced stating that they were slightly nervous when they<br />
arrived. This was due to the chaotic nature of the hospital when they arrived at 3am. However,<br />
they went on to state that their expectations were met when they had settled in to their private<br />
ward. All staff exceeded their expectations in the service they delivered.<br />
Cultural barriers were not reported at Apollo, there were no language barriers due to the<br />
English speaking policy within the hospital <strong>and</strong> services such as catering were tailored to the<br />
patient, with a wide range of choices available. When asked if they would advise others to<br />
travel to India they responded positively<br />
As interviews were not possible with patients who have had treatment at Spire, information<br />
from the Independent Advisory Services was used. SIHA who showed that in private<br />
hospitals in Scotl<strong>and</strong> 98% of patients would recommend the hospital to others (Independent<br />
<strong>Health</strong>care Advisory Services, 2008). The WIHA found that the average was closer to 88%<br />
(Independent <strong>Health</strong>care Advisory Services, 2008), whereas the IHAS found that 97% of<br />
people would recommend the hospital that provided their care (Independent <strong>Health</strong>care<br />
Advisory Services, 2008).<br />
Discussion<br />
The survey conducted confirmed that cost was the most common identifiable reason for<br />
influencing discretionary health spending. Although it was theorised that due to the highly<br />
price sensitive nature of health insurance, people willing to pay the least for insurance would<br />
be the most likely to accept treatment abroad due to cost implications, the survey indicated
that people willing to pay slightly more for health insurance were also more likely to view<br />
going abroad for treatment more favourably. Highly positive perceptions of foreign treatment<br />
also gave further evidence that there is a market for outsourced surgery as a component of<br />
health insurance, with only 6% of respondents citing poor quality treatment outside of the UK<br />
as a reason for not travelling for treatment.<br />
There were three main areas which accounted for the large discrepancy between the prices<br />
charged for a hip replacement between Spire <strong>and</strong> Apollo hospitals. Firstly, the profit margin<br />
at Spire for each procedure was estimated as being five times that of the same procedure in an<br />
Apollo hospital. This is likely to be due to different strategies pursued by each hospital to<br />
attract <strong>business</strong> <strong>and</strong> maintain profitability. Secondly, fees for the clinical workers in Indian<br />
hospitals were a fraction of the costs attributed to costs due to the hiring of UK staff. Thirdly,<br />
favourable drug licensing laws in the developing world allow more widespread use of<br />
cheaper, generic drugs. A reduced proximity to global manufacturing centres in the Far East<br />
also leads to cheaper medication <strong>and</strong> equipment.<br />
Professional training of doctors at Apollo was found to be comparable to the UK, as many of<br />
the staff had direct clinical experience with the NHS or other western medical organisations.<br />
Apollo also have achieved recognition by the JCI which seek to ensure st<strong>and</strong>ards of<br />
healthcare in institutions are met <strong>and</strong> comparable between hospitals in different countries.<br />
Similarly, Spire must comply with the UK’s Care Quality Commission (CQC) to ensure that<br />
st<strong>and</strong>ards of patient care remain at the highest levels. One area of concern is the nature of<br />
follow-up care in foreign medical institutions. Geographical separation would make it<br />
difficult to treat long term complications, <strong>and</strong> it is likely that this aspect will need to remain in<br />
the UK, possibly under the care of a UK partner of the foreign hospital to ensure continuity of<br />
care.<br />
From the data relating to both Apollo <strong>and</strong> Spire it can be seen that patients are satisfied with<br />
treatment provided by both organisations. Of significant note is that patients appear to be no<br />
less satisfied with treatment provided by Apollo than Spire, or other UK independent<br />
healthcare providers.<br />
Perceived cultural differences have been minimised by stressing importance on pre-journey<br />
communication with the patient to ensure a personalised service, as well as specialist<br />
language <strong>and</strong> cultural training for all hospital staff. Hospitals are also built to western<br />
st<strong>and</strong>ards to ensure patients are treated in a familiar setting. Foreign medical centres do have<br />
to operate in an unstable <strong>business</strong> climate, with factors such as global war, terrorism <strong>and</strong> the<br />
effect of economic cycles having a huge impact on their profitability. Reduction in overseas<br />
travel for any reason could be detrimental to their <strong>business</strong> model; however it is possible that<br />
the potential for cost savings in those that have already decided to pursue private medical<br />
treatment may still result in <strong>business</strong> potential for these health centres. The continued<br />
economic growth of India may limit the long term applicability of these cost savings as the<br />
economy matures <strong>and</strong> costs of living <strong>and</strong> conducting <strong>business</strong> continue to rise.
Conclusion<br />
Summary of comparison between India <strong>and</strong> the UK<br />
India UK<br />
Price<br />
£3,575 - £4,750<br />
£9,680 - £15,230<br />
Quality<br />
Quality of staff<br />
Infection rates<br />
Surgical outcomes<br />
Satisfaction<br />
Follow-up care<br />
Strategic<br />
positioning<br />
(Taj Medical Group, 2009)<br />
Monitoring bodies: Joint Commission<br />
International <strong>and</strong> the International<br />
Organization for St<strong>and</strong>ardisation<br />
Employ high quality doctors with<br />
worldwide training.<br />
C. difficile: nil<br />
Wound infection (Hip) : 0.6%<br />
Wound infection (Knee): 0.42%<br />
Revision Rates (Hip) : 1.17%<br />
Revision Rates (Knee) : 0.00%<br />
Mortality Rates (Hip): 0.00%<br />
Mortality Rates (Knee) : 0.00%<br />
4 of 4 patients would recommend<br />
Apollo to others <strong>and</strong> would return<br />
themselves for future treatment<br />
Does not meet the BOA recommended<br />
follow-up treatment guidelines<br />
Likely to be positively affected by<br />
recession as people seek cost-cutting<br />
alternatives to expensive treatments in<br />
the UK.<br />
(Spire <strong>Health</strong>care, 2009)<br />
Monitoring bodies: Care Quality<br />
Commission <strong>and</strong> Independent<br />
health care: national minimum<br />
st<strong>and</strong>ards<br />
Employ high quality doctors<br />
with worldwide training.<br />
C. difficile: 0.02 per 1,000<br />
bed days<br />
Wound infection (Hip):<br />
0.30%<br />
Wound infection (Knee) :<br />
0.04%<br />
Revision Rates (Hip) : 0.8%<br />
Revision Rates (Knee) : 1.0%<br />
Mortality Rates (Hip): 3.2%<br />
Mortality Rates (Knee) : 3.6%<br />
85% of patients would<br />
recommend Spire’s services to<br />
others.<br />
Unclear as to whether follow<br />
BOA st<strong>and</strong>ards<br />
Likely to be negatively affected<br />
by recession as disposable<br />
incomes are reduced.<br />
Outsourcing surgery has the potential to increase br<strong>and</strong> equity <strong>and</strong> market share for insurance<br />
providers in the UK without compromising patient satisfaction or quality of care. However,<br />
the following conditions should be met in order to gain maximum advantage from this<br />
strategic direction:<br />
Create an appropriate pricing strategy<br />
The luxury image associated with private healthcare in the UK may conflict with the<br />
competitive costing approach that outsourcing provides; sub-br<strong>and</strong>s or cash-back systems<br />
may be helpful.<br />
Creating the right package tailored to the individual<br />
Customers should have the option of receiving certain treatments in the UK, with foreign<br />
treatment only for procedures that they would be willing to travel for. A package which<br />
includes flights <strong>and</strong> accommodation would help maintain br<strong>and</strong> image by ensuring the whole<br />
experience is of a high st<strong>and</strong>ard.<br />
Outsource to an accredited reputable hospital<br />
Independent assurance of quality is essential. However, accreditations are only beneficial if<br />
patients are aware of the existence of these awards <strong>and</strong> the level of quality they represent.
Continue follow-up care in the UK<br />
Follow-up care is a major concern to both patients <strong>and</strong> doctors. Insurance companies should<br />
use their established networks of private healthcare providers in order to ensure pre- <strong>and</strong> post-<br />
operative care is offered in the UK irrespective of where surgery takes place.<br />
Recommendations:<br />
• Questionnaire survey: a larger sample size is required to enable examination of a<br />
greater social demographic range.<br />
• To ensure validity of the cost analysis results, accurate <strong>and</strong> detailed cost breakdowns<br />
of treatment are required.<br />
• A wider survey of patients who have previously travelled for surgery would be<br />
beneficial.<br />
• Direct comparison of the accreditation systems currently in use in both India <strong>and</strong> the<br />
UK would ensure that the st<strong>and</strong>ard of treatment provided could be accurately<br />
compared.<br />
• Quality of treatment could be further investigated through the analysis of 10 year<br />
revision rates of hip <strong>and</strong> knee replacements in both the UK <strong>and</strong> India.<br />
• Increasing the scope of the entire project to include the NHS would confirm whether<br />
the conclusions of the project can be applied to the UK healthcare market in its<br />
entirety.<br />
References<br />
Aron, R., Singh, J., (2005) Getting offshoring right Harvard Business Review [Online] 83(12)<br />
135-143 Available from:<br />
http://web.ebscohost.com/ehost/pdf?vid=2&hid=113&sid=7e658504-dc9b-46d5-bd18-<br />
597c367d324d%40sessionmgr103 [Accessed 8th May 2009]<br />
Taj Medical Group (2008) The Taj Medical Group - Our Fully Inclusive Prices. [Online]<br />
Available from: http://www.tajmedicalgroup.co.uk/prices.html#orthopaedic [Accessed<br />
5th December 2008]<br />
Spire <strong>Health</strong>care. (2008) Guide prices for self-pay treatment. [Online] Available from:<br />
http://www.spirehealthcare.com/selfpay/Guide-prices/ [Accessed 5th December 2008]<br />
Deloitte, (2008). Medical <strong>Tourism</strong>: 2008 Survey of <strong>Health</strong> Care Consumers. [Online].<br />
Available from:<br />
http://www.deloitte.com/dtt/article/0%2C1002%2Ccid%25253D192707%2C00.html<br />
[Accessed 9th February 2009].<br />
Horowitz, M.D., Rosensweig, J.A., (2007) Medical <strong>Tourism</strong> – <strong>Health</strong> Care in the Global<br />
Economy. The Physician Executive, 33 (6), pp. 24-30.<br />
Medical <strong>Tourism</strong> Association (2008) Your Guide To Medical <strong>Tourism</strong>; Issue 2, [E-magazine]<br />
Florida, Medical <strong>Tourism</strong> Association Inc. Available from:<br />
http://www.medicaltravelauthority.com/Medical-<strong>Tourism</strong>-Magazine-Issue-2.pdf<br />
[Accessed 7th May 2009]<br />
Milstein, A., Smith M. (2007) Will the surgical world become flat? <strong>Health</strong> Affairs, 26 (1), pp.<br />
137–141.<br />
Jobs4medical Ltd. (2009) Orthopaedics Job Search [Online] Available from:<br />
http://www.jobs4medical.co.uk/job-vacancies/Orthopaedics-Jobs [Accessed 4th May<br />
2009]<br />
Jobs4medical Ltd. (2009) Anaesthesia/pain management jobs [Online] Available from:<br />
http://www.jobs4medical.co.uk/search.php?SEARCH_SPECIALITY%5B%5D=7&SEA<br />
RCH_COUNTRY%5B%5D=207&SEARCH_LOCATION%5B%5D=207.0&SEARCH_<br />
START=Search&form_identifier=SEARCH&SEARCH_ID=&SEARCH_JOBFIELD=1
&SEARCH_CONTRACT=&SEARCH_KEYWORD=&SEARCH_NHS [Accessed 4th<br />
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Available from:<br />
http://www.jobs4medical.co.uk/search.php?SEARCH_GRADE%5B%5D=63&SEARCH<br />
_SPECIALITY%5B%5D=370&SEARCH_COUNTRY%5B%5D=207&SEARCH_LOC<br />
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Institute for Clinical Excellence [Online] Available from:<br />
http://www.nice.org.uk/guidance/index.jsp?action=download&o=32007 [Accessed 4th<br />
May 2009]<br />
Spire <strong>Health</strong>care (2009) Our Consultants [Online] Available from:<br />
http://www.spirehealthcare.com/Cambridge/Our-Facilities-Treatments-<strong>and</strong>-<br />
Consultants/Our-Consultants/ [Accessed 18th May 2009]<br />
Spire <strong>Health</strong>care (2009) Our <strong>Health</strong>care st<strong>and</strong>ards [Online] Available From:<br />
http://www.spirehealthcare.com/Patient-Information/Our-<strong>Health</strong>care-St<strong>and</strong>ards/<br />
[Accessed 4th May 2009]<br />
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[Accessed 26th May 2009]<br />
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London, Independent <strong>Health</strong>care Advisory Services<br />
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Hospitals Association, 2007-2008 Credentials Document, London, Independent<br />
<strong>Health</strong>care Advisory Services
HEALTH TOURISM IN IZMIR: POTENTIAL, STRATEGIES AND<br />
SUGGESTIONS<br />
İge Pırnar<br />
Yaşar University, Turkey<br />
ige.pirnar@gmail.com<br />
Onur İçöz<br />
Yaşar University, Turkey<br />
Abstract<br />
<strong>Health</strong> tourism which includes several branches such as, medical tourism, thermal tourism,<br />
SPA <strong>and</strong> wellness, aged-tourism, h<strong>and</strong>icapped-tourism,<strong>and</strong> sports tourism is one of the fastest<br />
growing sub-sectors of the international tourism industry, since it has a constant annual<br />
increase of 20% with a considerable dem<strong>and</strong> potential. This is an original study which<br />
attempts to make a preliminary SWOT analysis of health tourism in Izmir which is considered<br />
as a very suitable type for the regions’ resources. In addition applicable strategies are<br />
predicted for each of the different conditions (like. S/O, W/O, S/T <strong>and</strong> W/T strategies).<br />
Introduction<br />
Izmir is in excellent location for health tourism due to the unique natural <strong>and</strong> thermal<br />
resources the area owns. The interest to Izmir’s health tourism potential is increasing<br />
gradually by the fastest growth in private health sector, the increasing number of modern<br />
lodging facilities, very good value-price ratio, high percentage of repeat health guests,<br />
qualified thermal <strong>and</strong> health service, the good results from thermal treatments, friendliness,<br />
hospitality <strong>and</strong> tolerance to different cultures.<br />
<strong>Health</strong> <strong>Tourism</strong> in General<br />
<strong>Health</strong> tourism’s definition stated in Erfurt-Cooper & Cooper’s textbook (2009:6) by Ross<br />
(2001) <strong>and</strong> Tabacchi (2003) is as “any kind of travel to make yourself or a member of your<br />
family healthier” Another resource defines the health <strong>and</strong> wellness tourism industry together<br />
as “products <strong>and</strong> services made accessible to people travelling from their place of residence<br />
for health reasons. In addition to conventional healthcare (medical), this definition<br />
encompasses health & wellness, spa tourism, convalescent addiction treatment, retirement<br />
communities, <strong>and</strong> some alternative health services” (Caribbean Export Development Agency,<br />
2008). It is indicated that health tourism has a huge target potential including visitors with<br />
health problems, visitors who are looking for medical /thermal or spa treatments <strong>and</strong> visitors<br />
who are trying to preserve <strong>and</strong> promote their wellness <strong>and</strong> fitness (Ülker, 1994; Gurkan et. al,<br />
2007:479; Erfurt-Cooper & Cooper, 2009:8). Thus it includes operations <strong>and</strong> services like;<br />
cosmetic surgery, medical surgery, operations like dental, eye or IVF operations, physical<br />
fitness, spa treatments, beauty care, <strong>healthy</strong> nutrition <strong>and</strong> diet issues, relaxation, rehabilitation,<br />
meditation <strong>and</strong> mental activity (Pırnar, 2007). Thus it involves many segments <strong>and</strong> the basis<br />
do vary from organization to organization. Eg. “health <strong>and</strong> wellness tourism market in the<br />
Caribbean can be divided into four segments (Caribbean Export Development Agency, 2008):<br />
(1) medical tourism;<br />
(2) wellness <strong>and</strong> spas;<br />
(3) nursing <strong>and</strong> elderly care; <strong>and</strong><br />
(4) research <strong>and</strong> diagnostic services”, <strong>and</strong> HT8 (or <strong>Health</strong> <strong>Tourism</strong> 8) refers to the<br />
industry segments where ht8 is a concept <strong>and</strong> approach introduced in 2008 by healthCare
cybernetics (an international <strong>Health</strong> <strong>Tourism</strong> Sector think <strong>and</strong> do tank)<br />
(Constantinides,2009:13);<br />
1) Medical <strong>Tourism</strong><br />
2) Dental <strong>Tourism</strong><br />
3) Spa (<strong>and</strong> Thalassotherapy) <strong>Tourism</strong><br />
4) <strong>Wellness</strong> <strong>and</strong> Fitness <strong>Tourism</strong><br />
5) Sports <strong>Tourism</strong><br />
6) Culinary <strong>Tourism</strong><br />
7) Accessible <strong>Tourism</strong><br />
8) Assisted Residential <strong>Tourism</strong><br />
Typologies of health <strong>and</strong> wellness tourism vary as does the health, medical <strong>and</strong> wellness<br />
tourism. “Several scholars do not differentiate between wellness tourism <strong>and</strong> medical tourism<br />
<strong>and</strong> subsume wellness-related categories under medical tourism. For instance, one typology<br />
suggests the four medical tourism categories of ‘Illness’ (e.g. medical check-ups, medical<br />
surgery, dental treatment), ‘<strong>Wellness</strong>’ (e.g. beauty care, spa treatment, yoga, herbal healing),<br />
‘Enhancement’ (e.g. cosmetic surgery) <strong>and</strong> ‘Reproduction’ (e.g. fertility treatment <strong>and</strong> birth<br />
tourism) (Voight et. al, 2010:30). As another example, in their textbook typologies of health<br />
<strong>and</strong> wellness tourism is stated as (Smith & Puckzo, 2009:85): Leisure Spa tourism (e.g.<br />
therapeutic medical, hotel, resort, resting, day spa) Holistic tourism (e.g. retreat, yoga centre)<br />
Medical tourism (e.g. surgery) Spiritual tourism (e.g. pilgrimage, meditation, yoga, retreat,<br />
spiritual quest) Occupational wellness tourism (e.g. life-coaching, recuperation, stress<br />
management)<br />
The global health tourism industry revenuer make up to US$40 billion 2005, US$60 billion in<br />
2006 <strong>and</strong> is projected to grow at US$ 100 billion in 2012 <strong>and</strong> US$ 188 billion in 2013<br />
according to different resources (Zoref, 2006; Herrick, 2007:1). The growth is due to; aging<br />
populations, high cost of medical services, shortage of health care professionals <strong>and</strong> long<br />
waiting periods in developed countries, <strong>and</strong>, on the other, improved medical technology,<br />
competitive healthcare prices, <strong>and</strong> rest & relaxation in exotic destinations in developing<br />
countries.<br />
In order to attain customer satisfaction in health tourism, it is important that the supplier does<br />
meet the individual expectations of the patient since each patient may have different<br />
individual expectation some of the individual expectations may be (Edelheit, 2009);<br />
1) the customer looks for less costly treatment / procedure than his/her own country,<br />
2) may be embarrassed to get surgery at home (eg. wants to keep it secret that he/she had<br />
cosmetic surgery)<br />
3) may want privacy during treatment <strong>and</strong> recovery processes,<br />
4) may look for high st<strong>and</strong>ards <strong>and</strong> level of quality which is unaffordable at home.<br />
The basic expectations for health <strong>and</strong> wellness <strong>tourists</strong> do vary a lot, <strong>and</strong> some may be added<br />
below in addition to the ones stated before (Kaur, 2007:421; Yıldırım, 2005; Pırnar, 2007:35-<br />
38):<br />
• Hygienic environment<br />
• St<strong>and</strong>ardization <strong>and</strong> quality of the services<br />
• Range of services<br />
• Highly qualified staff ( trained technically as well as in soft skills)<br />
• Value proposition<br />
• Customization
• Service provided within the insurance coverage<br />
• Stability for long periods<br />
• Connectivity<br />
• Availability of different touristic attractions<br />
• Alternative tourism products<br />
• International st<strong>and</strong>ard certification<br />
• Low cost / Price advantage<br />
• Extraordinary <strong>and</strong> unique surgery or treatment methods.<br />
The prices of the health tourism products do vary a lot from region to region <strong>and</strong> from one<br />
country to another, which creates a very sold the dem<strong>and</strong> for health tourism which makes a<br />
very important differential advantage for the health tourism marketing countries. Table below<br />
shows a range of countries price lists for different health tourism products.<br />
Table 1 - Distribution of medical service fees according to countries($)<br />
USA Paid by Patient USA Insurance Turkey** India Thail<strong>and</strong> Singapore<br />
Angio $ 98,618 $ 44,268 $ 3,500 $ 11,000 $ 13,000 $ 13,000<br />
Bypass $ 210,842 $ 94,277 $ 12,000 $ 10,000 $ 12,000 $ 20,000<br />
Cardiac $ 274,395 $ 122,969 $ 12,000 $ 9,500 $ 10,500 $ 13,000<br />
valve surgery<br />
Hip surgery $ 75,399 $ 31,485 $ 13,000 $ 9,000 $ 12,000 $ 12,000<br />
Knee surgery $ 69,991 $ 30,358 $ 15,000 $ 8,500 $ 10,000 $ 13,000<br />
Spine $ 108,127 $ 43,576 $ 15,000 $ 5,500 $ 7,000 $ 9,000<br />
Mastectomy $ 40,832 $ 16,833 $ 9,000 $ 7,500 $ 9,000 $ 12,400<br />
Resource: TUSIAD- DEIK (2009). “The Economic Dimension <strong>and</strong> Other Effects of<br />
Medical <strong>Tourism</strong> in Terms of Turkey”, TUSIAD_ DEIK <strong>Health</strong> <strong>Tourism</strong> Report, <strong>Health</strong><br />
<strong>Tourism</strong> Journal, Sağlık Turizmini Geliştirme Derneği, 2(8):32. (Medical <strong>Tourism</strong>: Global<br />
Competition in <strong>Health</strong> Care”, Devon M. Herrick – National Center for Policy Analysis **:<br />
Quoted from TAIK).<br />
<strong>Health</strong> <strong>Tourism</strong> in Izmir<br />
Global competitiveness researches indicate that the international <strong>tourists</strong> looking for<br />
differentiated tourism experiences is increasing rapidly, <strong>and</strong> health tourism is one of the<br />
fastest growing sub-segments. Taking the Izmir city in consideration, it used to be an<br />
important destination of Turkish tourism though its' been loosing popularity to Antalya <strong>and</strong><br />
Istanbul It could be said that the long-term competitiveness of the Izmir’s’ tourism as a global<br />
tourist destination may depend on product innovation <strong>and</strong> improving access to high value<br />
niche. When the resources <strong>and</strong> potentials of the region are taken into consideration, the health<br />
tourism seems to be the innovative product which is very suitable for the region. Thus when<br />
Izmir was a c<strong>and</strong>idate for EXPO 2015 the theme selected was “health” since this theme is<br />
very suitable with what the city can offer.<br />
Methodology<br />
In this study, interview technique is preferred. The interview questions were open ended <strong>and</strong><br />
structured (see appendix 1) <strong>and</strong> interviews were held face to face where the replies were<br />
written by the interviewees to the blanks spaces provided under ach specific question. the<br />
population of the study consisted of 22 people who are experts of both Izmir city’s health<br />
tourism potential, medical aspects <strong>and</strong> tourism industry. The data gathered through qualitative<br />
techniques was analyzed <strong>and</strong> a SWOT analysis table was derived from answers which<br />
involves a detailed examination of the strengths <strong>and</strong> weaknesses of the region’s potential, <strong>and</strong>
the opportunities <strong>and</strong> threats in the environment within which it belongs. As an addition to<br />
SWOT Analysis table prepared, S/O, W/O, S/T <strong>and</strong> W/T strategies were also derived <strong>and</strong><br />
added adjunct to the analysis table, since they were also included within the interview<br />
questions asked. If applied properly <strong>and</strong> with the help of contingency plans, SWOT analysis<br />
of health tourism potential of Izmir, may help the development <strong>and</strong> implementation processes.<br />
SWOT Analysis of <strong>Health</strong> <strong>Tourism</strong> in Izmir<br />
A SWOT analysis is a procedure generally carried out before the development of a <strong>business</strong><br />
plan. It involves a detailed examination of the strengths <strong>and</strong> weaknesses of the organization,<br />
<strong>and</strong> the opportunities <strong>and</strong> threats in the environment within which it operates. SWOT can<br />
provide an insightful executive summary of the different elements of strategic analysis (Tribe,<br />
2010:118-121). Appropriate strategies are likely to;<br />
• Capitalize <strong>and</strong> align on opportunities <strong>and</strong> strengths<br />
• Strengthen, eliminate or transform weaknesses <strong>and</strong><br />
• Overcome threats.
Table 2 - SWOT Analysis of <strong>Health</strong> <strong>Tourism</strong> in Izmir<br />
Strengths (S)<br />
1. Unique thermal / natural<br />
resources<br />
2. Richness <strong>and</strong> variety of<br />
thermal resources<br />
3. Suitable climate<br />
4. Modern hospitals<br />
5. Qualified health staff with<br />
necessary academic,<br />
operational <strong>and</strong> linguistic<br />
skills<br />
6. Transportation<br />
7. Existence of tourist<br />
attractions of national <strong>and</strong><br />
international significance<br />
8. City being an industry <strong>and</strong><br />
trade center<br />
9. Number of high quality<br />
hotels<br />
10.Society is health<br />
conscious<br />
11. Long coastal zones<br />
12.High awareness <strong>and</strong><br />
positive consumer perception<br />
in market<br />
13. Product has potential for<br />
differentiation<br />
14. Availability of unique<br />
<strong>and</strong> tremendous historical,<br />
cultural <strong>and</strong> religious<br />
attractions<br />
15. Destination’s location<br />
(near to EU health tourism<br />
dem<strong>and</strong>)<br />
16. Existence of popular IVF<br />
centers, dentistry <strong>and</strong> eye<br />
care clinics, transplantation<br />
units, etc.<br />
17. Composed of multi<br />
cultural groups<br />
18. Comparatively low cost<br />
19. Value proposition ( Good<br />
price / quality ratio)<br />
20. Support from local<br />
people<br />
21. Complicated surgical<br />
procedures possible at 1/10th<br />
the cost<br />
Weaknesses (W)<br />
1.Lack of coordination<br />
among related organizations<br />
2. Lack of projected plans<br />
3.Lack of destination<br />
management plans<br />
4. Lack of mission, vision<br />
<strong>and</strong> related strategies for<br />
improvement<br />
5. Need for cooperation<br />
among related establishments<br />
6. Inefficient marketing plans<br />
7. Need for focusing <strong>and</strong><br />
effective target marketing<br />
8. Need for accreditation,<br />
st<strong>and</strong>ardization <strong>and</strong><br />
certification of health service<br />
providers<br />
9. Need for specific designed<br />
health packages<br />
10. Need for cooperation<br />
with foreign insurance<br />
companies<br />
11. Benchmarking <strong>and</strong><br />
modern management<br />
applications not utilized<br />
12.Need for linguistic<br />
improvement (2 nd 3 rd foreign<br />
languages requirement for all<br />
staff)<br />
13.Public hospitals lack<br />
necessary infrastructure<br />
14. Research is needed to<br />
figure out the trends,<br />
potential, market<br />
effectiveness etc.<br />
15. Legislation problems<br />
16. Need for an integrated<br />
approach for health tourism<br />
developments
Opportunities (O)<br />
1. Growing global dem<strong>and</strong><br />
for health tourism (%30<br />
annual increase)<br />
2. Global healthcare is<br />
worlds largest after<br />
retailing, revenue US$ 2.8<br />
trillion<br />
3. Long waiting lines for<br />
some medical treatments<br />
<strong>and</strong> periods in developed<br />
countries like UK, USA<br />
etc.<br />
4. High prices for health<br />
services in developed<br />
countries<br />
5. Insurance unaffordable<br />
leading to semi insured <strong>and</strong><br />
uninsured population – US<br />
6. Limited specialized care<br />
in less developed countries<br />
7. There is a healthcare<br />
crisis in some of the<br />
developed countries where<br />
people cannot afford health<br />
insurance <strong>and</strong> the<br />
government does not<br />
provide healthcare to a<br />
majority of the population.<br />
8. <strong>Health</strong> care costs<br />
continuing to rise – Crisis<br />
getting worse with no<br />
solution in sight.<br />
9. Economic crisis makes<br />
low cost products more<br />
dem<strong>and</strong>able especially if<br />
they have a st<strong>and</strong>ard<br />
quality<br />
10.Young spa users<br />
increasing in numbers<br />
11. Spas becoming places<br />
to socialize<br />
12. Fitness <strong>and</strong> wellness<br />
issues are very popular<br />
13. Increased concern in<br />
corporate wellness<br />
14. Increase in the 3 rd age<br />
group who are interested in<br />
health tourism<br />
15. Aging generation in EU<br />
S/O Strategies<br />
1. Exp<strong>and</strong> in existing<br />
markets, penetrate in new<br />
markets by using differential<br />
aspects of the health tourism<br />
product<br />
2. Establishing a br<strong>and</strong> name<br />
for Izmir’s health tourism<br />
product<br />
3. Establish a unified br<strong>and</strong><br />
<strong>and</strong> image for health tourism<br />
in Izmir.<br />
4. Apply co-br<strong>and</strong>ing with<br />
new partnerships<br />
5. Apply successful market<br />
penetration techniques<br />
6. Attract new market<br />
segments (older people,<br />
sportsmen) by using existing<br />
products, well trained staff,<br />
<strong>and</strong> product differentiation<br />
<strong>and</strong> by introducing new<br />
products to the whole market<br />
6.Use cultural <strong>and</strong> heritage<br />
beauties as a differential<br />
image of the region<br />
7.Research about what<br />
region/patients you want to<br />
attract <strong>and</strong> how you will<br />
market to those patients<br />
8.Make sure for every patient<br />
that comes they have an<br />
amazing experience, - word<br />
of mouth marketing.<br />
9. Promote the quality <strong>and</strong><br />
price differentials for<br />
region’s health care product.<br />
10. Integrate the medical <strong>and</strong><br />
beauty aspects of spas <strong>and</strong><br />
wellness establishments.<br />
W/O Strategies<br />
1.Overcome inefficient<br />
marketing applications by<br />
using opportunities of<br />
growing industry <strong>and</strong> new<br />
markets,<br />
2.By getting help from<br />
environmental groups <strong>and</strong><br />
training try to overcome the<br />
pollution problems<br />
3. By decreasing red tape <strong>and</strong><br />
increasing the speed in<br />
beaurocratic activities,<br />
support the technological<br />
improvement in already built<br />
hospitals <strong>and</strong> health services.<br />
4.Get support for the<br />
construction of specific new<br />
health tourism establishments<br />
5.Increase the specialty<br />
education in medical,<br />
wellness <strong>and</strong> nursing issues.<br />
6. Improve coordination <strong>and</strong><br />
cooperation among related<br />
bodies<br />
7. Focus on niche medical<br />
strengths such as fertility<br />
treatments or regional unique<br />
thermal therapies<br />
8. Provide opportunity for<br />
strategic partnerships or<br />
alliances between<br />
international healthcare<br />
providers, insurance groups,<br />
tour operators <strong>and</strong> the local<br />
hospitals<br />
9. Establish quality by<br />
certifying investment <strong>and</strong><br />
enterprise documentation
16. Increasing interest in<br />
alternative treatments<br />
17. Increasing interest in<br />
staying young <strong>and</strong> <strong>healthy</strong><br />
Threats (T)<br />
1. Competition (especially<br />
when offers better quality/<br />
sophisticated service)<br />
2. Dem<strong>and</strong> for highest<br />
quality, luxury, comfort<br />
3. Wars <strong>and</strong> conflicts near<br />
the region<br />
4. Terrorist attacks all over<br />
the world<br />
5. Prices dropping in<br />
competitive suppliers<br />
6. Crises related to diseases<br />
like swine flue, etc.<br />
7. Natural deterioration &<br />
pollution in thermal<br />
regions<br />
8. Water pollution, air<br />
pollution, soil pollution<br />
S/T Strategies<br />
1.Keep up with the trends<br />
<strong>and</strong> satisfy changing<br />
customer dem<strong>and</strong>s<br />
2. Market aggressively <strong>and</strong><br />
have a strategic marketing<br />
plan.<br />
3. Application of industry<br />
accreditation st<strong>and</strong>ards<br />
4.Use new management,<br />
unique product <strong>and</strong> br<strong>and</strong><br />
power, <strong>and</strong> new partnerships<br />
to match competition’s<br />
increasing power<br />
5.Use product’s differential<br />
advantage, apply marketing<br />
strategies to build br<strong>and</strong><br />
loyalty.<br />
6.Offer interesting, tailormade<br />
<strong>and</strong> unique travel<br />
packages alternatives for<br />
health <strong>tourists</strong>.<br />
7. Consider ways to package<br />
<strong>and</strong> promote visitor<br />
experiences to potential<br />
international spa <strong>and</strong><br />
wellness visitors<br />
W/T Strategies<br />
1.Special attention should be<br />
given to hygine <strong>and</strong> quality<br />
issues<br />
3.Use crisis management<br />
tools for overcoming<br />
inconsistent image of the<br />
region<br />
4.Form a consistent message,<br />
to match competitions image<br />
as being better in terms of<br />
quality- value proposition<br />
etc.<br />
5. Use all the combinations<br />
of 8 P’s that is suitable<br />
6. Apply a coordinated<br />
regional policy <strong>and</strong><br />
promotional approach to<br />
develop health tourism in<br />
Izmir<br />
7.Establish intra regional<br />
cooperation to enhance<br />
productivity <strong>and</strong> take<br />
advantage of economies of<br />
scale<br />
Findings <strong>and</strong> Conclusion<br />
The findings indicated that health tourism is indeed a very suitable tourism sub sector for<br />
Izmir since all respondents mentioned so. There seems to be huge potential since the city<br />
strong points like unique <strong>and</strong> curable thermal resources, already established health tourism<br />
centers, proper climate that is suitable all year long, unique geography <strong>and</strong> heritage resources,<br />
base for clustering in health tourism, appropriate infrastructure. The replies on the optimal<br />
usage though showed that the interviewee mostly (only 3 disagreed) believed that though the<br />
city has a huge potential for health tourism to improve, this potential is not utilized fully. The<br />
reasons were stated as;<br />
• The framework of health tourism in Izmir is very narrowly defined<br />
• Most of the existing hotels are not designed specific to health tourism st<strong>and</strong>ards<br />
<strong>and</strong> requirements<br />
• There is a lack of coordination among responsible bodies<br />
• There is a need for common policy regarding the health tourism<br />
• Izmir needs proper positioning, imaging <strong>and</strong> br<strong>and</strong>ing for health tourism.
Many respondents suggested strategies to match these strengths with opportunities. Some<br />
were quite creative strategies which may show an initial path for the practioners S/T<br />
strategies were found to be especially useful in today’s period of economic crisis. The<br />
findings indicated that coordination of related groups, planning, targeted promotion <strong>and</strong> local<br />
interest are very important for the development of health tourism in the Izmir city. Some of<br />
the weak points mentioned were; lack of focus on planning issues, lack of st<strong>and</strong>ardization,<br />
inappropriate promotion <strong>and</strong> marketing strategies <strong>and</strong> limited bed capacity. Professional <strong>and</strong><br />
centralized marketing <strong>and</strong> managing of the issue were identified as vulnerable points where a<br />
special focus of attention should be given to. W/O strategies were found to be especially<br />
useful for this process. It was indicated that thus there is a huge potential for the development<br />
of health tourism in Izmir, the resources are not fully utilized <strong>and</strong> with the application of<br />
proper strategies <strong>and</strong> measures, it may become one of the important health tourism destination<br />
in the global market.<br />
References<br />
Caribbean Export Development Agency (2008). <strong>Health</strong> & <strong>Wellness</strong> <strong>Tourism</strong>: Ten Strategıes<br />
For Success Wıthın The Carıbbean Sıngle Market & Economy (Csme), Available at:<br />
http://www.onecaribbean.org/content/files/10StrategySeriesHWFINALCbbnExport.pdf,<br />
accessed at: 10th oh June 2010.<br />
Constantinides C. (2009). “Congress Report”, <strong>Health</strong> <strong>Tourism</strong> Journal, Sağlık Turizmini<br />
Geliştirme Derneği, 2(8):13.<br />
Edelheit J. (2009). “Opportunities in Medical <strong>Tourism</strong> & Underst<strong>and</strong>ing the US<br />
Marketplace”, Service Summit, Guatemala City 10- 12 September 2009.<br />
Erfurt-Cooper P.<strong>and</strong> M. Cooper (2009) , <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>: Spas <strong>and</strong> Hot<br />
Springs, Channel View Publications<br />
Gürkan Günay Çetin, Musa Albayrak ve Emel Gönenç Güler (2007), “Turizmde Yeni Trend:<br />
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Üniversitesi, Kongre Bildiri Kitabı, Detay Yayıncılık, Ankara.<br />
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<strong>and</strong> Opportunities”, International Marketing Conference on Marketing & Society, 8-10<br />
April, 2007, IIMK<br />
Pirnar İge, “Sağlık Turizmi, Özellikleri ve İzmir İçin Potansiyel” V. Ulusal Turizm<br />
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BİMER, 25-26 Ekim 2007, İzmir, Bildiriler Kitabı: 31-41, Beta Basın Yayım Dağıtım<br />
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Bakanlığı, Yorum Matbaası, Ankara.<br />
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ASEAN.
APPENDIX 1<br />
Interview Questions<br />
1. May Izmir be regarded as a suitable destination for health <strong>and</strong> wellness tourism?<br />
2. Do you thing the health <strong>and</strong> wellness potential of Izmir is utilized in full for health tourism<br />
purposes? If no, why do you think that is?<br />
3. State the;<br />
a. strong points (strengths) of Izmir’s health <strong>and</strong> wellness tourism<br />
b. weak points (weaknesses) of Izmir’s health <strong>and</strong> wellness tourism<br />
4. In order to promote <strong>and</strong> improve the health tourism market in Izmir name the;<br />
a. opportunities<br />
b. threats<br />
taking into consideration the impacts that may come from all the economic, politic, social,<br />
legistlative, cultural <strong>and</strong> technological external environments.<br />
5. a According to you, what should be the S/O <strong>and</strong> W/O strategies applicable for Izmir’s<br />
health tourism improvement?<br />
5. b. According to you, what should be the S/T <strong>and</strong> W/T strategies applicable for Izmir’s<br />
health tourism improvement?
Conscious or trendy? How do fashions <strong>and</strong> trends influence consumer’s<br />
selection criteria in health-related tourism?<br />
Krisztina Priszinger – Katalin Formádi – Peter Mayer<br />
University of Pannonia<br />
8200 Veszprém, Egyetem u. 10.<br />
priszinger@turizmus.uni-pannon.hu<br />
Abstract<br />
With the raising preferences of being <strong>healthy</strong>, fit, environmentally sensitive, wellness became<br />
more popular in our societies. This loosely defined term includes desirable ends such as a<br />
dynamic lifestyle, mental <strong>and</strong> physical harmony, but also the means enabling the achievement<br />
of the ends: services related to spending leisure time <strong>and</strong> holiday actively. <strong>Wellness</strong> became a<br />
diversified <strong>and</strong> a holistic product which might be a key component to a long-term health <strong>and</strong><br />
wellness.<br />
<strong>Wellness</strong> – beside being aimed in everyday life – also constitutes a motivation for a certain<br />
type of tourism: the health <strong>and</strong> wellness tourist product. This can take various forms,<br />
including both indoor <strong>and</strong> outdoor activities, taking place in spas, wellness hotels or even in<br />
rural settings. A key trend in Western European destinations, medical wellness can still be<br />
considered as a niche market in Central-<strong>and</strong> Eastern Europe. Suppliers are mostly underinformed<br />
on the exact content of medical wellness <strong>and</strong> the needs of medical-wellness <strong>tourists</strong>.<br />
As a consequence, the actual supply does not fit yet this dem<strong>and</strong>.<br />
On the other h<strong>and</strong>, we can appoint that the dem<strong>and</strong> for traditional wellness-tourism plays an<br />
important role in this region. Dem<strong>and</strong> for wellness tourism is based on the generally<br />
increasing importance of health-awareness <strong>and</strong> health-related lifestyle.<br />
The focus of this paper is first, to identify trends <strong>and</strong> meta-trends in the media that may<br />
influence consumer’s decision making. This part of the research is based on content analysis<br />
of life-style print magazines <strong>and</strong> home pages. The secondary research is extended with<br />
quantitative research based on a questionnaire carried out among spa visitors in one of the<br />
most known Hungarian spa, in Zalakaros to point out the level of health-consciousness. The<br />
targeted sample size is around 300 visitors. With that we examined whether visiting spas <strong>and</strong><br />
spending holidays in wellness hotels are “just” a trendy way of travelling or a healthconscious<br />
step towards a healthier lifestyle. With that the study will examine the level of<br />
health-consciousness from various perspectives. In reference to the actual product consumed<br />
we discuss the facilities used, as well as the individual time spent on wellness services.<br />
Furthermore, we investigate visitors’ decision making paying attention to the selection criteria<br />
they apply as well as the general importance of this criteria in their everyday life.<br />
Meaning of wellness<br />
With the trends towards a greater preference for of being <strong>healthy</strong>, fit, environmentally<br />
sensitive, wellness became more popular in our societies. <strong>Wellness</strong> has various meanings for<br />
many people but it refers to the feeling of wholeness <strong>and</strong> health. Generally wellness is related<br />
to the physical condition of a person as people’s aim is to achieve a good health condition <strong>and</strong><br />
minimize the risk of illnesses. Nevertheless wellness goes far beyond physical condition or<br />
health. Certainly it starts with the physical health (doing exercises, cooking healthier,<br />
consuming organic food etc.) but extends to other areas of people’s lives. From a holistic
point of view it means wholeness as all spheres of life come into balance: including the<br />
working time, family- <strong>and</strong> leisure time.<br />
The terminology of wellness is widely used in everyday life <strong>and</strong> in professional literatures as<br />
well. Therefore wellness is defined in many different ways by many different people. The<br />
problem arises as the wellness concept is closely related to the terms of health <strong>and</strong> well-being<br />
– as all follow the same philosophy however the wellness implies a balance of different life<br />
areas. The relationship between the lifestyle <strong>and</strong> state of health are closely linked - being fit,<br />
not smoking has an impact on our well-being <strong>and</strong> health condition. <strong>Wellness</strong> is not the mere<br />
absence of disease, it is rather a proactive, preventive approach designed to achieve the above<br />
mentioned balance, <strong>and</strong> also a positive approach to environmentally conscious <strong>and</strong> <strong>healthy</strong><br />
living. It is important to note that the good physical condition does not necessarily constitute<br />
an overall state of wellness or vice versa, a person may have an illness but he/she could reach<br />
the balance in his/her life between the working, leisure or emotional dimensions.<br />
Charles Corvin defined wellness “as a multidimensional state of being described the existence<br />
of positive health in an individual as exemplified by quality of life <strong>and</strong> sense of well-being”<br />
(http://www.definitionofwellness.com). The mentioned multi-dimensions of wellness fall into<br />
broader categories, achieving the balance of all aspects or sub-dimensions. The National<br />
<strong>Wellness</strong> Institute (Smith-Puczkó, 2009:55) defined wellness also as an active process<br />
through which people become aware of, <strong>and</strong> make choices towards, a more successful<br />
existence. They advocate a positive, optimistic outlook <strong>and</strong> a holistic <strong>and</strong> balanced approach<br />
to life.<br />
Illing (2009) made a differentiation in term of wellness between CEE <strong>and</strong> US. According to<br />
him, the difference is in the motivation background – CEE people are less interested in<br />
intervention <strong>and</strong> health-consciousness, they quest the long-term balance of body <strong>and</strong>/or mind<br />
on one h<strong>and</strong>, <strong>and</strong> a quick gratification of their needs on the other h<strong>and</strong>.<br />
The complexity of wellness has other impacts on everyday life: the health- <strong>and</strong> environment<br />
conscious lifestyle makes it necessary to adapt new life-coaching “techniques” either by using<br />
professional life-coach services (eg. life-style packages by hotels or using coaching services<br />
or lifestyle consultant) or “learning by experiencing” throughout the person’s own life (eg.<br />
how to deal with everyday stress). It suggests that wellness is a continuum rather than a<br />
specific fixed state (Miller, MTW, 2008).<br />
If we connect the dimensions of wellness to tourism, we find a spectrum of wellness offers<br />
<strong>and</strong> wellness destinations which focus on the synergy of body-mind-spirit-environment. The<br />
choice is depending on the visitors’ priorities which dimensions they want to experience <strong>and</strong><br />
focus during the travel. As Adams stated in 2003 (Smith-Puczkó, 2009:54) wellness is<br />
relative, subjective or perceptual – so in this approach, more of a psychological than a<br />
physical state of wellness is emphasized.<br />
<strong>Wellness</strong> also constitutes a motivation for a certain type of tourism: the health <strong>and</strong> wellness<br />
tourist product. This can take various forms, including both indoor <strong>and</strong> outdoor activities, take<br />
place in spas, wellness hotels or in rural settings. The rapidly growing HWT sector includes<br />
traditional spas, health centres, wellness-hotels <strong>and</strong> wellness-related accommodations (e.g.<br />
farm accommodations with a focus on natural healing or relaxation). As the sector is<br />
relatively diversified <strong>and</strong> in Central-Europe spas represent an important element of the<br />
wellness offer, we focused only on the wellness spas.
As consumers intend to slow down, to relax <strong>and</strong> relieve stress <strong>and</strong> search for new lifestyle<br />
experiences, which could be achieved by various spa experiences (individual, tailor-made,<br />
intimacy or just simply having fun services etc.). Market trend analysis (Mintel, WTO, ISPA)<br />
strongly points out the boom in the usage of spas worldwide. This is strengthened by the fact<br />
that the awareness of the health benefits of spas increase <strong>and</strong> target markets become more<br />
inclusive. More active spa-goers are measured <strong>and</strong> also the proportion of consumers going on<br />
spa holidays is growing.<br />
However, as Erfurt-Cooper <strong>and</strong> Cooper (2009) summarize, all interpretations of wellness<br />
“have its origin in a natural <strong>and</strong> holistic approach to health that includes the use of water <strong>and</strong><br />
minerals within it”.<br />
Yet more issue to address is the fact that wellness itself became a powerful notion. Due to the<br />
success of using wellness associated with fun <strong>and</strong> also luxury, it became an effective<br />
marketing tool for other products. The following advertisements exemplify how wellness<br />
became a br<strong>and</strong> component of various products from other sectors:<br />
“This is<br />
what one<br />
now calls<br />
wellness.”<br />
“Astra—<br />
got<br />
anything<br />
against<br />
it?”<br />
Figure 1. <strong>Wellness</strong> as a slogan for other sectors Source: Miller, MTW, 2008<br />
“The first<br />
wellness<br />
concept based<br />
on motor oil.”<br />
“We build<br />
your car —<br />
the new Opel<br />
Signum.”<br />
The success behind wellness as an advertising tool is explained by a German advertising<br />
expert Marc Schwieger: “<strong>Wellness</strong> exudes an irresistible sense of pleasure. <strong>Health</strong> is<br />
connected with illness, fitness is connected with exertion, well-being sounds too much like a<br />
couch-potato existence. <strong>Wellness</strong>, on the other h<strong>and</strong>, sounds dynamic, because it originated in<br />
America” (Formádi-Miller, MTW, 2008). Thus, the use of wellness to market other<br />
prestigious <strong>and</strong>/or hedonic products further strengthens its positive reception. As a result,<br />
wellness is developing both in its scope <strong>and</strong> its differentiation.<br />
Methodology<br />
In order to get insight into the actual wellness trends <strong>and</strong> to unfold from these, the underlying<br />
meta-trends of changing consumer interests we applied content analysis of lifestyle<br />
magazines. We selected all articles which have been, in any form, related to any of the aspects<br />
of wellness (as outlined in table 1.). The sample involved all 2008 issues of the following<br />
Hungarian <strong>and</strong> international printed <strong>and</strong> online lifestyle magazines:
Men Women<br />
International<br />
Playboy, Men’s <strong>Health</strong><br />
Elle Man<br />
Cosmopolitan<br />
Elle<br />
CKM (online)<br />
Éva, Patika, Nők Lapja Egészség,<br />
Hungarian Deluxe (online)<br />
Vital Magazin<br />
Diéta és fitness<br />
Table 1 Lifestyle magazines analysed<br />
All in all 147 articles have been involved into the analysis. The texts have been carefully read<br />
to identify any wellness-related issues. Major characteristics of discussing wellness were<br />
noticed to create a list of issues. In a second step, these issues were discussed by the authors<br />
to synthesise appearances of emerging trends <strong>and</strong> meta-trends. Finally, evidence from other<br />
social science research fields (as demography, or the sociology of consumption) were sought<br />
to underpin the outreach of the trends experienced in wellness.<br />
The secondary research is extended with quantitative research based on a questionnaire<br />
carried out among spa visitors in one of the most well known Hungarian spas, in Zalakaros to<br />
point out the level of health-consciousness. The sample size was 330 spa visitors at the Gránit<br />
<strong>Health</strong> Spa in Zalakaros. The data were collected between the 1st <strong>and</strong> 9th of May, 2009 based<br />
on a questionnaire. Our main assumption was that the fun water is the more searched for<br />
element for the Hungarian spa-goers rather than the regenerating or healing waters. The<br />
Hungarian wellness spa-goers have not developed complex health-conscious attitude, they are<br />
visiting spas because they seek enjoyment, fun <strong>and</strong> recreation but not for health reasons. The<br />
importance of health-consciousness could be measured by the number of services used by the<br />
visitors. If spa-goers pay only for the entrance fee <strong>and</strong> not for using wellness services from the<br />
offer then they seek the entertainment elements only. Simply they visit the spas because it is<br />
trendy <strong>and</strong> fashionable.<br />
Fashions <strong>and</strong> trends in the magazines<br />
In the following we unfold a number of meta-trends <strong>and</strong> trends associated with wellness as<br />
emerging in over mentioned lifestyle magazines, first, to develop our knowledge about the<br />
needs <strong>and</strong> desires of consumers, <strong>and</strong>, second, provide insights into possible soft product<br />
development opportunities for the CEE spa sector. In this section we first describe the metatrend<br />
in general, then, second, provide insight into the product development trends based on<br />
the meta-trends, <strong>and</strong>, third we provide examples for the trends raised.<br />
� Balance. <strong>Wellness</strong> is more <strong>and</strong> more (re-)discovered as an approach rather than mere a<br />
set of activities. It is widely argued that wellness should address the lifestyle in general<br />
<strong>and</strong> not a few days in a year only. The former approach which offered wellness (trips) as<br />
an escape from everyday life is going to be replaced by considering a wellness holiday as<br />
a tool to modify the course of life, to find balance – in all aspects of life. This trend also<br />
involves taking a holistic approach to wellness, which is addressing more or all aspects of<br />
wellness together, as related to each other, as impacting upon each other.<br />
o Work/life balance: This is a widely discussed issue, from daily time management to<br />
the burn-out syndrome. <strong>Wellness</strong> is seen as a help to learn managing multiple<br />
challenges – both the do-it-yourself practices <strong>and</strong> the range of professional<br />
consultancy. Bad Blumau, a luxury spa <strong>and</strong> hotel in Styria, Austria offers several<br />
packages in the name of relaxation in a really de-stressing area (e.g. “Relaxation under<br />
palm trees”, “Feel good”, ‘A woman’s job” or “Time for Two”).
o Body in balance: Formerly the body has been contrasted to the optimal body, as seen<br />
on TV or in movies – young, slim, energetic <strong>and</strong> sun-tanned. <strong>Wellness</strong> meant getting<br />
closer to this ideal picture through treatments, exercises <strong>and</strong> cosmetic products. This is<br />
gradually giving place to a more accepting approach to the body, emphasizing<br />
individual differences, multiple beauty idols, as well the mind/soul/body balance.<br />
Nutrition is central to discourses about the body: instead of eating less, eating<br />
differently – <strong>healthy</strong>, organic, rich in flavours <strong>and</strong> experimental, <strong>and</strong>, in some cases,<br />
even more. Mountain Track, the Super Natural Spa (Canada) is not a fat farm but a fit<br />
farm, offering both physical <strong>and</strong> nutrition programs to change lifestyle. FitPath is the<br />
spa’s special methodology, which build on active participation of guests. The program<br />
goes on for 3 weeks, with special diet <strong>and</strong> exercise-programs tailor-made for every<br />
guest.<br />
o Offers for couples: The discourse on wellness does more <strong>and</strong> more accept the idea that<br />
at the quality of intimate partnership lies at the heart of well-being. A successful <strong>and</strong><br />
balanced partnership provides joie-de-vivre through sexual satisfaction, psychological<br />
support, self confidence <strong>and</strong> security. <strong>Wellness</strong> should thus provide the opportunity to<br />
enhance the quality of partnerships, with offering both gender-specific, but jointly<br />
consumable services <strong>and</strong> programmes, but also opportunities to relaxed enjoy each<br />
other <strong>and</strong> deepen the intimate relationship.<br />
� Masculine emancipation. Metrosexuality is finding its way to the spa. Today’s men do<br />
not have to live a grey, emotion-free life, demonstrating power <strong>and</strong> rigidness all the time.<br />
Whereas issues like beauty <strong>and</strong> health, as well visiting spas in general have been seen as<br />
female issues <strong>and</strong> activities before. Nowadays it is evident that men are targeted<br />
indirectly through the female consumer (as men’s wellness discussed in women’s<br />
magazines), but it is also clear that there is a growing interest among men to underst<strong>and</strong><br />
the own body <strong>and</strong> soul, <strong>and</strong> to tackle – instead of dismiss – the problems faced in<br />
everyday life.<br />
o Men’s beauty: Man taking care of their outfit is a typical metrosexual orientation.<br />
Contemporary cosmetic industry, clothing, etc. offer a range of product lines specially<br />
designed for men. The selection form <strong>and</strong> the use of men’s products is a topic theme<br />
of both men’s magazines – as a kind of quick guide to a new world. Men’s topics also<br />
emerge in woman’s magazines, as how-to-help-<strong>and</strong>-guide-him articles. Also, the spa<br />
sector develops more <strong>and</strong> more special packages for men. A spa is thus not a place to<br />
send wives while men are working hard: it is an oasis for him, as well. Hotel<br />
Loipersdorf Spa <strong>and</strong> Conference (Austria) offers in their Spa Days For Him package<br />
massage, foot treatment <strong>and</strong> body pack.<br />
o Men’s health: <strong>Health</strong> is an emerging issue in men’s magazines. It is now widely<br />
accepted that men face specific health problems – both common minor problems (e.g.<br />
hair or skin problems) <strong>and</strong> more serious, but yet mass diseases like cardiovascular<br />
problems <strong>and</strong> the like. Sophisticated health schemes as medical wellness <strong>and</strong><br />
especially prevention measures specifically tackle these male issues. DAS GOGERS<br />
Golf –und Spa Hotel’s (Austria) offer contains vitality face treatment <strong>and</strong> medical<br />
pedicure with herbal bath only for men, which can be completed by one of massages<br />
(like chocolate or golf massage), anti-stress treatments or body peeling.<br />
� Age equality. Modernity is a youth regime. For the first time in history, youth, beauty,<br />
ambiguous, innovativeness <strong>and</strong> the ability to change became higher valued then age,<br />
experience, secure, determined <strong>and</strong> the ability to possess. In a fast changing society <strong>and</strong><br />
economy adaptation became the life maxima. Youth became the idol – middle-aged <strong>and</strong>
elderly wanted to look like, to act like <strong>and</strong> to be accepted like the youth. Although feeling<br />
<strong>and</strong> looking young is still tempting – <strong>and</strong>, most probably, always will be – it is loosing its<br />
absolute guidance in consumer trends. In late or post-modernity it is more <strong>and</strong> more<br />
accepted that every age has its specific joys <strong>and</strong> pains <strong>and</strong> that it is an oversimplification<br />
to push the youth-solution forward in all cases. On the contrary, lifestyle magazines<br />
themselves tend to specialize, with some having a distinctively middle-aged character<br />
(e.g. Éva <strong>and</strong> Nők Lapja) whereas others keep promoting the youth (e.g. Cosmopolitan<br />
<strong>and</strong> Joy). Although not in CEE yet, in Western Europe <strong>and</strong> North America some lifestyle<br />
magazines specialized into the 60+ age group (e.g. Zoomers). Also, the problems <strong>and</strong><br />
opportunities of each age group are discussed in a new way: first there are no taboos,<br />
second all groups became self-referent. There are as many subsequent trends as age<br />
groups, we only highlight three changes that exemplifies the meta-trend.<br />
o Children spa: Most spas accept children as being important customers. First, because<br />
the notion of children friendly service is got accepted, it is now obvious for everyone<br />
that children have special needs, they’re just different form the adults. Second,<br />
because parents – who make decisions about vacations <strong>and</strong> pay – consider services for<br />
children the most important decision factor. A special example for babies-childrenfamily<br />
oriented parks is Sonnenthereme in Lutzmannsburg-Frankenau, Austria.<br />
Babyworld <strong>and</strong> Funny Waters indicators the main target groups of the spa – all<br />
services are centralized on the difference in the needs of babies <strong>and</strong> kids, e.g. Babypools,<br />
Nursing Cocoon, Children’s Nap Room, Baby Kitchen for the youngest; or<br />
Children’s Sauna, Children’s Playroom, Adventure Pools <strong>and</strong> Activity Pool for<br />
younger.<br />
o Children health: For some years still health tourism was something for the elderly, the<br />
weak <strong>and</strong> the ill. Growing health consciousness <strong>and</strong> development in research brought<br />
widespread knowledge about childhood reasons of adult health problems. Paying<br />
attention to issues like overweight children – a mass problem in advanced societies –<br />
is a good example of this new approach to health. Also, HWT provides solutions for<br />
overweight children – a typical example of addressing new segments with old<br />
products. Czech Podebrady spa offers a special package for overweight children<br />
o Third age: Also called 60+, this has been the number one target group of health<br />
tourism. Whereas age still matters, there are a series of products <strong>and</strong> services<br />
specifically addressing third age consumers. They do not have to provide performance<br />
as their gr<strong>and</strong>children anymore – a range of solutions offers positive experiences for<br />
them.<br />
Conscious or trendy?<br />
In the second part of the research we aimed to demonstrate the effects of the above displayed<br />
trends <strong>and</strong> metatrends on consumers’ consciousness.<br />
Two-thirds of the interviewed spa-visitors were women, 35.8% were men. The average age of<br />
respondents was 40 years old with a big variance: the oldest respondent was born in 1935,<br />
while the youngest in 1990.
Table 2. Year of birth of the respondents (in %). Source: own research, 2009<br />
More than half of the respondents had secondary education (54.6%) <strong>and</strong> 40.7% had college or<br />
university degree. The respondents came from various locations: most visitors in our sample<br />
lived in the capital city, Budapest, which is 200 km from Zalakaros (29 spa-visitor) or arrived<br />
from the nearby big cities within 75 km circle such as Nagykanizsa (28 person), Kaposvár (18<br />
person), Zalaegerszeg (15 person).<br />
Surprisingly none of the visitors came alone to the spa: 93.8% visited the spa with families,<br />
6.2% with friends. As the age of children is essential from the used type of services, we<br />
examined that factor as well. A significant portion of spa-goers (half of the family visitors)<br />
had 6 years old or younger children <strong>and</strong> only 4% had 18 years old or older kids. The average<br />
children age is 7.5 years old: with big variation, as the youngest child was 3 months old, while<br />
the oldest “child” is 32 years old with parents.<br />
Table 3 The age of the children (in %). Source: own research, 2009<br />
One-tenth of the family spa visitors had two kids where the average age of the second child is<br />
10 years old, 4 visitors arrived with 3 kids– at this case the third child is 12,5 years old. Only<br />
8% (25 people) of the interviewed spa-visitors answered to the duration of the spa-visit<br />
question: they stay on average 2 days in the spa (variation between 1 <strong>and</strong> 6 days, with 1.5<br />
st<strong>and</strong>ard deviation) <strong>and</strong> on the examined day they spent on average 4.5 hours in the spa<br />
(between 1 <strong>and</strong> 8 hours variation, 2.2 st<strong>and</strong>ard deviation).<br />
Generally visitors have experience 4,5 services (with 2,5 st. deviation) during a spa visit. The<br />
list of services includes the 4 various pools so it shows that mainly those used by the visitors.
Table 4. The number of experienced spa services during a spa visit. Source: own<br />
research, 2009<br />
By examining the spa services experienced, 75 % of the visitors declared to use the wellness<br />
pool <strong>and</strong> 50% use the thermal water/medical pool. No matter what the weather is, the outside<br />
pool is very attractive in all season: 78.2 % of the respondents used in their spa-visit. Using<br />
the pools seems to be obvious in case of a spa visit, but sauna <strong>and</strong> massage is clearly the most<br />
popular service offered by spas. 49.1% of the 14.2% of the asked spa-visitors had healing<br />
massage <strong>and</strong> 9.1% of them the wellness massage. The beauty treatments are less frequently<br />
used by the examined spa-goers: only a small percent of the visitors purchased eg. a manicure,<br />
pedicure or facial treatment or body scrub service. We can identify these services belonging to<br />
“balance” metatrend, namely to an elementary level of “work/life balance” <strong>and</strong> “body in<br />
balance” trends.<br />
As the proportion of families is high among the visitors, the use of the children pool is very<br />
high (57.5%). Among the experience-oriented services, the slides are very popular, 57% of<br />
the visitors used it. We can highlight the “children’s spa” trend in this case, but the services<br />
used by spa-goers of “children’s spa”-area is considerably close – in is confined to pools <strong>and</strong><br />
slides, <strong>and</strong> to playing room.<br />
One-fifth of the visitors used the salt-cave services. In case of other healing elements,<br />
acupuncture or medical treatment are rarely used among the respondents. The basic services<br />
of the examined spa are based on “third age” guest, although the used services are<br />
concentrating only on a few types of them.<br />
All of the services were rated very good on a 1-5 scale according to the scale rating where 1 is<br />
the worst <strong>and</strong> 5 is the best. All services by the users were rated above 4.3.
Table 5 The experienced spa services (the number of mentions). Source: own<br />
research, 2009<br />
Conclusions<br />
Presently the examined spa (as well, as, most of Hungarian <strong>and</strong> CEE spas) incorporate only<br />
few of the metatrends <strong>and</strong> trends, identified above, in their wellness offers. A key<br />
characteristic of these spas is that they concentrate on the physical aspects of wellness such as<br />
equipment variety, water quality <strong>and</strong> interior design. The underlying spiritual aspects <strong>and</strong> the<br />
resulting sophistication of the soft service components are not addressed yet. Some of these<br />
are missing completely: there are few gender-specific services <strong>and</strong> where such exists, these<br />
are offered to women only. Similarly ‘balance” in its wider meaning is rarely discussed. The<br />
most existent trend is that of serving children – these offers however address fun <strong>and</strong><br />
experiences, but not health.<br />
However this does not seems to be a disadvantage on current markets as actual visitors do<br />
require trend-related offers. Guests would require more services related to the food <strong>and</strong><br />
beverages component of the spas (to have healthier or green food, child friendly menus, good<br />
cafeteria <strong>and</strong> good selection of wines). Even though it has not been formulated in this way, it<br />
is easy to identify the trend of “body in balance” behind these wishes. As a second group of<br />
missing services, the visitors mentioned the need for more specialized wellness services such<br />
as different massages offers, more sport <strong>and</strong> fitness services for the younger generation too –<br />
which we linked to the “work/life balance” trend. Families with young children would<br />
require baby services such as babysitting or kindergarten in the spa, playground, according to<br />
“children’s spa”. As contrasted to the few such ideas, the majority of the guests mentioned<br />
different infrastructure items, as more pools, more resting beds with tables – these can’t be<br />
classified to trends.<br />
The research showed that visiting a spa became a trendy way of spending leisure time for lots<br />
of people. The visitors experienced the spa in general (the thermal basin <strong>and</strong> wellness pools),<br />
with a few wellness services. More complex <strong>and</strong> multi-layered wellness experiences are rarely<br />
sought of.<br />
Based on the above findings we can draw the conclusion that the development of wellness in<br />
Hungary is mostly media-driven. Neither spa services nor the visitors reflect on the<br />
metatrends <strong>and</strong> trends identified in life-style media. Thus media coverage is not based on<br />
existing offers but rather envisages the – possible – future of wellness in Central Europe. It
emains an open question when the sharp competition among recently opened spas will force<br />
these establishments to compete on the level of innovative service developments.<br />
Summarizing our issues, we can draw the following inferences:<br />
� According to Illing, Hungarian spa-goers have different motivations behind visiting<br />
spas, than US guests (or even Western-European visitors). Regeneration <strong>and</strong><br />
rejuvenation is in focus only among a few visitors, most of them are interested only in<br />
pampering or having fun with friends <strong>and</strong>/or family.<br />
� The metatrends <strong>and</strong> trends identified in online <strong>and</strong> printed magazines are not<br />
commonplaces among Hungarian tourist, neither among spas. Some of the trends are<br />
not present at all (e.g. masculine emancipation), but as it turned out from the research,<br />
spa-goers don’t even miss these services.<br />
� The trends highlighted in magazines are not catching out in present spa-supply, but<br />
they show the future, on one h<strong>and</strong> in dem<strong>and</strong>, on the other in spa supply. This<br />
induction is underpinned by the growing importance of children <strong>and</strong> their needs in a<br />
spa.<br />
References<br />
Formádi, K., Miller, J. [2008] Making <strong>Tourism</strong> Work. Final report to the Leonardo da Vinci<br />
pilot project. University of Pannonia, Veszprém<br />
Erfurt-Cooper, P., Cooper, M. [2009] <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong>. Spas <strong>and</strong> Hot Springs.<br />
Aspects of <strong>Tourism</strong>, edited by Cooper, Ch., Hali, C. M., Timothy, D. J. Channel View<br />
Publications, Bristol<br />
Illing, K. T. [2009] Gesundheitstourismus und Spa-Management Oldenbourg Verlag,<br />
München<br />
Miller, J. <strong>Wellness</strong>. Educational Material for the Making <strong>Tourism</strong> Work: An Initiative for the<br />
health <strong>and</strong> wellness tourism sector. Leonardo da Vinci pilot course, 2006-2008<br />
Smith, M., Puczkó, L. [2009] <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong> Elsevier, London<br />
Definition of wellness http://www.definitionofwellness.com/<br />
Internet<br />
www.beautifulbreak.com<br />
www.bultins.com<br />
www.blumau.com<br />
www.merchantcircle.com<br />
www.sarvarfurdo.hu<br />
www.sonnentherme.at<br />
www.whynotmenspa.com<br />
www.annabelkarmel.com
FITNESS AND WELLNESS DEMAND AND OFFER DURING A CITY BREAK IN<br />
BARCELONA<br />
The (mis)match of the wellness <strong>and</strong> fitness offer of Barcelona for Dutch <strong>tourists</strong> who practice<br />
fitness in their daily life <strong>and</strong> how Barcelona can develop itself into a wellness destination<br />
Xavier Puertas<br />
Escola Universitaria d'Hoteleria i Turisme<br />
Barcelona<br />
Spain<br />
xavier.puertas@cett.es<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 />
Keywords: fitness, wellness, dem<strong>and</strong>, supply, destination concepts<br />
Dutch dem<strong>and</strong><br />
Nearly 25% of the Dutch inhabitants practices fitness during their daily life 53 <strong>and</strong> often use<br />
the wellness facilities offered in their gym. The main focus in this research is the question to<br />
what extent this target group is looking for a fitness <strong>and</strong> wellness offer during a city break in<br />
Europe, especially in Barcelona. Research has been carried out amongst 334 Dutch fitness<br />
practitioners between the ages of 18 <strong>and</strong> 45 years old 54 . Sixty two percent of the respondents<br />
visited Barcelona, <strong>and</strong> 71% of them would like to visit Barcelona again.<br />
The sample consists of three different groups, depending on their monthly membership fee<br />
they pay for their membership per month: budget (>30 euro ), middle (31 – 60 euro) <strong>and</strong> high<br />
(< 61 euro), 46% use the wellness facilities frequently. There is a significant difference in<br />
the use between men (38%) <strong>and</strong> women (53%). The more they pay for their membership, the<br />
more often they use wellness facilities: low budget 28% <strong>and</strong> high budget 85%. Another<br />
significant gender difference turns out to be the fact that women (45%) use wellness facilities<br />
in order to relax, whilst for men this is 33%, men find the recuperation of their muscles more<br />
important (38%) against only 12% of the women. Core values they all share are: taking care<br />
of one’s own health, striving for a tight body <strong>and</strong> developing muscles.<br />
Sixty nine percent of the respondents has been on a city break at least two times during the<br />
last two years, 11% of them even 4 to 10 times. For approx. Seventy percent think that a city<br />
break consists of 3 to 4 days. Twenty five percent want to pay 300 to 400 euros for such a<br />
trip <strong>and</strong> 23% is willing to spend 400 to 500 euros for a city break in Europe. Funny enough<br />
the men have a preference to go during the autumn <strong>and</strong> winter, <strong>and</strong> the women prefer to go<br />
during spring <strong>and</strong> summer. Almost 50% brings sports cloths with them on a city break, men<br />
more often than women. When using wellness facilities in the hotel, 75% of them would like<br />
this to be an offer that is all inclusive with the price of their staying. High budget practitioners<br />
(64%) are willing to pay more for fitness <strong>and</strong> wellness facilities in their hotel <strong>and</strong> find such an<br />
offer very important, this against 26% of the low budget respondents. Only 9% of the<br />
respondents think of Barcelona as an active <strong>and</strong> sports city, most of them consider Barcelona<br />
more as a place to wonder around, visit the main attractions <strong>and</strong> sense its cultural atmosphere.<br />
53 Fitness in The Nederl<strong>and</strong>s 2008-2009, GFK Panel, NRIT Media
Most important criteria when booking a hotel are the price (83%) <strong>and</strong> location (93%) of the<br />
hotel. <strong>Wellness</strong> facilities are important for 33% of them (women more than men) <strong>and</strong> 28% of<br />
them would like to use fitness facilities in their hotel.<br />
The more often respondents are practicing fitness , the more often they would like to get<br />
informed about fitness, wellness <strong>and</strong> <strong>healthy</strong> nutrition.<br />
Barcelona wellness <strong>and</strong> fitness offer<br />
Although Barcelona does not st<strong>and</strong> out as a wellness tourist destination, it has a significant<br />
potential in this sector that may be able to transform it into an excellent supplement for the<br />
new tourist trends, <strong>and</strong> specially for Dutch people.<br />
To analyze the wellness <strong>and</strong> fitness offer of the city, we applied a SWOT analysis to find out<br />
that the most important strengths are the identity of the city, the culture <strong>and</strong> its climate. In<br />
terms of opportunities for Barcelona the fact that wellness/fitness is an exp<strong>and</strong>ing sector<br />
represents an important <strong>and</strong> an unquestionable added value for tourism industry nowadays.<br />
On the other h<strong>and</strong> we also find some weaknesses. For example the lack of tradition in<br />
wellness or spas in the city, which limits the use of the actual facilities to a small group of<br />
citizens <strong>and</strong> to some <strong>tourists</strong> staying in some specific hotels that are not usually located in the<br />
city centre. Finally the main threats are the typology of city visitors, since at this writing<br />
most of them are are low costs <strong>tourists</strong>. Furthermore, the increasing competition of other cities<br />
that are already positioned internationally.<br />
An important part of the research results are the proposals <strong>and</strong> suggestions addressed to<br />
future <strong>tourists</strong> visiting Barcelona but also to companies willing to meet the needs of these<br />
possible future customers.<br />
New directions for Barcelona?<br />
The following destination concepts will be presented at the TTRA conference:<br />
Mediterranean <strong>Wellness</strong><br />
<strong>Wellness</strong> based on typical <strong>and</strong> traditional values <strong>and</strong> products<br />
<strong>Wellness</strong> de luxe for <strong>business</strong> travelers<br />
Well-being, fitness <strong>and</strong> gastronomy
ATTRIBUTES OF HEALTH AND WELLNESS TOURISM UNITS – AN<br />
IMPORTANCE-PERFORMANCE ANALYSIS<br />
Joana Alegria Quintela<br />
University of Aveiro / Dept. of Economics, Management <strong>and</strong> Industrial Engineering<br />
MA in <strong>Tourism</strong> Management <strong>and</strong> Development<br />
Campus Universitário de Santiago . 3810-193 Aveiro, Portugal<br />
joana.quintela@gmail.com<br />
Anabela Gomes Correia<br />
Polytechnic Institute of Setúbal / College of Business <strong>and</strong> Administration<br />
Campus do IPS, Estefanilha 2914-193 Setúbal, Portugal<br />
Center for Governance <strong>and</strong> Public Policy Research – University of Aveiro<br />
acorreia@esce.pt<br />
Jjoaquim Gonçalves Antunes<br />
Polytechnic Institute of Viseu / School of Technology<br />
Avenida Coronel José Maria Vale de Andrade<br />
Campus Politécnico . 3504 - 510 Viseu, Portugal<br />
jantunes@dgest.estv.ipv.pt<br />
Abstract<br />
The main objective of this study consists of identifying the attributes that please more <strong>and</strong> that<br />
are more emphasized by the users of five thermal units <strong>and</strong> a hotel with Spa situated in a<br />
Portuguese region. The empiric research consisted on the interpretation of surveys<br />
administrated to their users. The model of this study was based on Importance-Performance<br />
Analysis. Through the IPA analysis, we verified that all the attributes are concentrated on the<br />
area of the critical forces, in which the importance <strong>and</strong> performance attained high levels.<br />
Although, must still be emphasized that “Relation quality / price”, “Quality of complementary<br />
services” <strong>and</strong> “Geographic localization” are attributes that belong to the area risk/opportunity<br />
<strong>and</strong> are in its threshold, which means that <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong> units managers<br />
should concentrate efforts to improve the performance of these attributes because they are<br />
very important to their users.<br />
Keywords: <strong>Health</strong>, <strong>Wellness</strong>, <strong>Tourism</strong>, Attributes, Performance, Satisfaction.<br />
Introduction<br />
The growth of <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong> in Europe is clear <strong>and</strong> it is due to a number of<br />
social circumstances, such as the increase of the citizens <strong>and</strong> to the population oldness <strong>and</strong> its<br />
lifestyles.<br />
On recognizing the increase of the number of people interested in having leisure times with<br />
quality, becomes evident <strong>and</strong> necessary that the supply should give special attention to this<br />
question, as an answer to the needs <strong>and</strong> wishes of consumers, as well as the fulfillment of<br />
their satisfaction levels. This perspective is seen as a determinant factor in what concerns to<br />
the competitiveness which allows the regional development of the inner regions of Portugal,<br />
where this kind of touristic offer can mainly be found.
The study investigates the performance of the main attributes in <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> units,<br />
located in Viseu, a region in the center of Portugal, well-known by its thermal <strong>and</strong> touristic<br />
potential.<br />
The purpose of this study is employing the importance-performance analysis (IPA), a<br />
decision-making tool for service management, to assess the performance of the attributes of<br />
<strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> units in Viseu region <strong>and</strong> analyze the importance those attributes have to<br />
their users.<br />
The Importance-Performance Analysis (IPA) is a technique introduced into the field of<br />
marketing by Martilla <strong>and</strong> James (1977). Although this research method has been referred<br />
mainly in marketing literature it was initially applied in the automobile sector. But in a short<br />
time the application of this technique was applied to the health sector, banking (Ennew et al.,<br />
1993), hotel industry (Martin, 1995), education <strong>and</strong> destination tourism (Hudson <strong>and</strong><br />
Shephard, 1998).<br />
This technique identifies strengths <strong>and</strong> weaknesses of br<strong>and</strong>s, products <strong>and</strong> services by<br />
comparing the two criteria that consumers use in making a choice: the relative importance of<br />
attributes <strong>and</strong> consumers’ evaluation of the offering in terms of those attributes.<br />
Once the importance <strong>and</strong> performance of each attribute have been plotted, the resulting IP<br />
space is traditionally divided into four quadrants. The priorities for improving the attributes of<br />
the service are then inferred from the quadrant where each attribute (performance, importance<br />
point) is located.<br />
Unlike SERVQUAL model created by Parasuraman, Zeithaml & Berry, (1994), which is best<br />
described as an absolute performance measure of consumer perceptions of service quality, the<br />
Importance-Performance paradigm also seeks to identify the underlying importance attributed<br />
by consumers to the various quality criteria being assessed (Sampson <strong>and</strong> Showalter 1999),<br />
constituting a tool for managerial decision making in services.<br />
Several different approaches have been used to undertake Importance-Performance Analysis<br />
(IPA), aka quadrant analysis or gap analysis. Martilla <strong>and</strong> James (1977) originally suggested<br />
that the positioning of the grid lines is a matter of judgement, because the value of IPA is in<br />
determining relative, rather than absolute, levels of importance. In some applications, the<br />
point where the quadrant grid lines cross (the cross-point) is placed in the centre of the scale<br />
used.<br />
Slack (1991) presented an IPA model that considered a relationship between importance <strong>and</strong><br />
performance <strong>and</strong> theorized that target levels of performance for particular product attributes<br />
should be proportional to the importance of those attributes. In other words, importance is<br />
seen as viewed as a reflection of the relative value of the various quality attributes’ to<br />
consumers. According to Barsky (1995), lower importance ratings are likely to play a lesser<br />
role in affecting overall perceptions, while higher importance ratings are likely to play a more<br />
critical role in determining customer satisfaction. IPA also helps to identify which attributes,<br />
or combinations of the attributes are more influential in repeat purchase behavior <strong>and</strong> which<br />
have less impact. The information is valuable for the development of marketing strategies in<br />
organizations (Ford et al., 1991). This view is confirmed by Lovelock et al. (1998), who<br />
stated that importance-performance analysis is an especially useful.
The theoretical <strong>and</strong> practical issues relating to the variations in these components, while<br />
quadrant analysis of some sort appears to be the most common method of inferring priorities<br />
for service improvement in IPA, sometimes some type of gap analysis is also used.<br />
Methods<br />
The methodology used in this study consists of the review of the literature <strong>and</strong> in the analysis<br />
of statistic data. The statistical analysis was conducted based on the quantitative data from the<br />
survey used for achieving the research objectives.<br />
A modified IPA model was used for a sample of users of the five therms located in Viseu’s<br />
region <strong>and</strong> a hotel with Spa facilities. These health <strong>and</strong> wellness units were selected to<br />
investigate the importance of service/product attributes for service providers’ <strong>and</strong> users’<br />
evaluation of services.<br />
A survey of users of health <strong>and</strong> wellness units was conducted for measuring <strong>and</strong> comparing<br />
the perception of these clients about health <strong>and</strong> wellness units attributes’. Empiric data were<br />
collected during a period of four months.<br />
The survey was applied r<strong>and</strong>omly to the users of the mentioned units that were asked to<br />
complete the questionnaire in person. In order to qualify for the sample, individuals had to be<br />
over the age of 18 years old.<br />
Respondents were also asked to provide importance <strong>and</strong> performance scores, in two identical<br />
five-point Likert’s scales, for the 15 service attributes identified for health <strong>and</strong> wellness units.<br />
The instrument was applied for measuring the key variables in the framework including the<br />
perception of service quality, overall satisfaction, <strong>and</strong> pride in the university. The health <strong>and</strong><br />
wellness users were asked about their perceptions with a 5-point rating scale ranging from<br />
“Very Low” to “Very High” on 15 items in the questionnaire (Table 1).<br />
Table 1 – Difference between importance <strong>and</strong> performance means’.<br />
1 Very Low 5 Very High Non applicable NA<br />
SERVICE / PRODUCT ATTRIBUTES<br />
Quality of attendance 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Thermal waters’ quality 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Quality of equipment <strong>and</strong> public areas 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Confidence on the received service 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Quality of the medical consultants 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Quality of thermal application techniques 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Variety of treatments 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Hygiene of the public areas 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Comfort of the public areas 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Quality of the complementary services<br />
1 2 3 4 5 NA 1 2 3 4 5 NA<br />
(lodging <strong>and</strong> animation)<br />
Technical competence of therapists 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Efficiency <strong>and</strong> results of the treatments 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Publicity 1 2 3 4 5 NA 1 2 3 4 5 NA<br />
Geographical location (transportation <strong>and</strong><br />
accessibilities)<br />
1 2 3 4 5 NA 1 2 3 4 5 NA
The survey was distributed to 400 users of those units, with a rate of answer in the percentage<br />
of 64,5%, making a total of 268 valid surveys.<br />
´<br />
Results<br />
The gap between importance <strong>and</strong> performance from both perspectives were also evaluated<br />
using the T-test criteria as shown in Table 2.<br />
After the treatment of the obtained data trough the survey that constitutes the main search<br />
instrument of our empiric study, we can interpret e discuss the results.<br />
Table 2 – Difference of means between the importance <strong>and</strong> performance levels.<br />
Attributes of the <strong>Health</strong> <strong>and</strong><br />
<strong>Wellness</strong> Units<br />
Level of<br />
Importance<br />
Mean<br />
Mean<br />
Level of<br />
Performance<br />
Mean<br />
Difference<br />
Imp. –<br />
Perf.<br />
Level of<br />
Significance<br />
(Sig. 2tailed)<br />
Pair 1 Quality of attendance 4,48 4,13 - 0,35 0,000<br />
Pair 2 Thermal waters’<br />
quality<br />
4,54 4,18 - 0,36 0,000<br />
Pair 3 Quality of equipment<br />
<strong>and</strong> public areas<br />
4,47 4,05 - 0,42 0,000<br />
Pair 4 Confidence on the<br />
received service<br />
4,47 4,12 - 0,35 0,000<br />
Pair 5 Quality of the<br />
medical consultants<br />
4,44 4,16 - 0,28 0,000<br />
Pair 6 Quality of thermal<br />
application<br />
techniques<br />
4,45 4,08 - 0,37 0,000<br />
Pair 7 Variety of treatments 4,40 3,99 - 0,41 0,000<br />
Pair 8 Hygiene of the public<br />
areas<br />
4,52 4,20 - 0,32 0,000<br />
Pair 9 Comfort of the public<br />
areas<br />
4,44 4,07 - 0,37 0,000<br />
Pair Quality of the<br />
10 complementary<br />
services (lodging <strong>and</strong><br />
animation)<br />
4,27 3,74 - 0,53 0,000<br />
Pair Technical<br />
11 competence of<br />
therapists<br />
4,45 4,12 - 0,33 0,000<br />
Par 12 Efficiency <strong>and</strong> results<br />
of the treatments<br />
4,39 4,09 - 0,30 0,000<br />
Pair<br />
13<br />
Publicity<br />
4,02 3,88 . 0,14 0,000<br />
Pair Geographical<br />
14 location<br />
(transportation <strong>and</strong><br />
accessibilities)<br />
4,25 3,86 - 0,39 0,000<br />
Pair<br />
15<br />
Quality / price<br />
relation<br />
4,40 3,66 - 0,74 0,000<br />
Test of the<br />
nule (H0)<br />
<strong>and</strong><br />
alternative<br />
hypothesis<br />
(H1)<br />
Rejection<br />
of the H0<br />
because the<br />
significance<br />
level is<br />
inferior to<br />
0,05,<br />
prevailing<br />
the H1.
Note: Total of 15 variables. T-test bilateral with a significance level of 0,05; N=268.<br />
Gap (Sat-Imp) difference between the users´ satisfaction about the service <strong>and</strong> the importance<br />
given to each attribute.<br />
Relatively to IPA analysis, we verify that the 15 attributes considered in the survey are all<br />
concentrated on the area of the critical forces (Figure 1), in which the importance <strong>and</strong> the<br />
performance attain high levels, calling the attention <strong>and</strong> motivating the <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong><br />
units managers’ to profit the competitive advantage. This aspect strengthens what was<br />
previously said about the high level of satisfaction the users have in the conditions <strong>and</strong><br />
services offered by those units.<br />
From this analysis must still be emphasized that the “Relation quality / price”, the “Quality of<br />
complementary services (lodging <strong>and</strong> leisure)” <strong>and</strong> the “Geographic localization (quality of<br />
transports <strong>and</strong> accessibilities)” are attributes that, in spite of being in a comfortable situation,<br />
belong to the area risk/opportunity <strong>and</strong> are in its threshold, which means that the managers of<br />
<strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong> units has to concentrate efforts to improve the performance of<br />
these attributes because they are important to the clients.<br />
Figure 1 – Importance-performance Analysis.<br />
In this sense, the IPA helps to verify that there´s a high evaluation of all the considered<br />
attributes, alerting <strong>and</strong> incentive the managers of the health <strong>and</strong> wellness units to take a<br />
competitive advantage, because the attributes are classified with a high level of importance<br />
<strong>and</strong> performance.
Conclusions <strong>and</strong> Discussion<br />
In this study, the Importance-Performance attributes of a service quality of health <strong>and</strong><br />
wellness units were examined among users. The key results were that users are satisfied with<br />
the attributes of the services <strong>and</strong> equipments of the units they visited.<br />
However, regarding to the Importance attributes users feel some had lower mean data of some<br />
attributes (i.e. “Relation quality / price”, “Quality of complementary services” <strong>and</strong> the<br />
“Geographic localization”). These findings may be concluded that health <strong>and</strong> wellness<br />
managers should give more attention to these attributes that influences the users satisfaction<br />
with the service received during their stay in those units. Moreover, we suggest that these<br />
service attributes would be improved.<br />
This study also was focused on significant factors affecting respondents’ satisfaction with a<br />
service quality in the visited health <strong>and</strong> wellness units.<br />
The findings of this study could be applied to improve service quality, equipments <strong>and</strong><br />
facilities in those private health <strong>and</strong> wellness, well-known for its touristic potential.<br />
Research limitations/implications<br />
The main limitations of this study are that it was based on a single service industry <strong>and</strong> that<br />
convenience sampling was used. However, its methodology <strong>and</strong> results are valid for various<br />
industries in the service sector <strong>and</strong> provide a solid basis for future research.<br />
The contribution <strong>and</strong> the value of this study consist in the fact that service managers can<br />
exploit the approach taken by this study to improve service management <strong>and</strong> attributes of<br />
health <strong>and</strong> wellness units. The managers have to keep considering the needs <strong>and</strong> wants of<br />
their users regarding their satisfaction levels <strong>and</strong> their loyalty, consequently.<br />
Therefore, future research may be needed to examine these proposed variables. From the<br />
findings, solving service problems <strong>and</strong> improving quality of attributes <strong>and</strong> services of health<br />
<strong>and</strong> wellness units are an important task to use all of their potentialities.<br />
References<br />
Barsky, J.D. (1995). World-Class Customer Satisfaction, Chicago, IL: Irwin Publishing.<br />
Ennew, C. & Binks, M. R. (1999). Impact of Participative Service Relationships on Quality,<br />
Satisfaction <strong>and</strong> Retention: An Exploratory Study. Journal of Business Research, 46,<br />
121-132.<br />
Ford, J. B., Joseph, M. & Joseph, B. (1991). Importance – performance analysis as a strategic<br />
tool for service marketers: the case of service quality perceptions of <strong>business</strong> students in<br />
New Zeal<strong>and</strong> <strong>and</strong> the USA. European Journal of Marketing, 27(2), 59- 70.<br />
Hudson, S., Hudson, P. & Miller, G. A. (2004). The Measurement of Service Quality in the<br />
Tour Operating Sector: A Methodological Comparison. Journal of Travel Research,<br />
Vol. 42, February, 305-312.<br />
Lovelock, C., V<strong>and</strong>ermerwe, S. & Lewis, B. (1998). Services Marketing. A European<br />
Perspective. Prentice-Hall Europe.<br />
Martilla, J.A., James, J.C. (1977), "Importance-performance analysis”. Journal of Marketing,<br />
January, 77-9.
Martin, D.W. (1995). An Importance-Performance Analysis of Service Providers´, Perception<br />
of Quality Service in the Hotel Industry. Journal of Hospitality <strong>and</strong> Leisure Marketing,<br />
3 (1), 5-17.<br />
Parasuraman, A., Zeithaml, V.A. & Berry, L. (1994). SERVQUAL: A Multiple-Item Scale for<br />
Measuring Consumer Perceptions of Service Quality. Journal of Retailing. 64:1, 12-40.<br />
Sampson, S. E. <strong>and</strong> Showalter, M. L. (1999). The Performance – Importance Response<br />
Function: Observation <strong>and</strong> Implications. The Service Industries Journal, Vol. 19(3), 1-<br />
25.<br />
Slack, N. (1991). The Importance-Performance Matrix as a Determinant of Improvement<br />
Priority, International Journal of Operations & Pr
A Comparative Analysis of Spa <strong>Tourism</strong> in Japan <strong>and</strong> Hungary<br />
Tamara Rátz<br />
Kodolányi János University of Applied Sciences, Hungary<br />
tratz@uranos.kodolanyi.hu<br />
Abstract<br />
<strong>Health</strong> is an ancient travel <strong>and</strong> leisure motivation that has inspired people all around the world<br />
to leave their permanent residence <strong>and</strong> visit far-away destinations for thous<strong>and</strong> of years.<br />
Although globalisation trends in supply <strong>and</strong> dem<strong>and</strong> also affect spa <strong>and</strong> health tourism which<br />
leads to the introduction of novel <strong>and</strong> exotic treatments <strong>and</strong> services, health-oriented leisure<br />
<strong>and</strong> tourism behaviour is still considerably culture-dependent on the one h<strong>and</strong>, <strong>and</strong><br />
economically <strong>and</strong> environmentally influenced on the other h<strong>and</strong>. As a consequence of its<br />
richness in geothermal resources <strong>and</strong> its unique culture, Japan has been able develop a<br />
distinctive path in spa tourism development <strong>and</strong> wellness. Hungary is also in rich thermal<br />
springs <strong>and</strong> spa culture also developed for centuries, but the leisure <strong>and</strong> tourist supply <strong>and</strong><br />
dem<strong>and</strong> are highly different in the two countries, due to each countries’ unique cultural,<br />
economic <strong>and</strong> natural background.<br />
The paper analyses the similarities <strong>and</strong> differences between health-oriented leisure mobility<br />
<strong>and</strong> the development characteristics of health tourism in Japan <strong>and</strong> Hungary, <strong>and</strong> assesses the<br />
cultural <strong>and</strong> environmental factors that have shaped development in each country. Based on<br />
secondary literature research, personal observation at Japanese hot springs destinations <strong>and</strong><br />
customer attitude analysis based on a mail survey carried out among 150 international visitors<br />
to Japanese spas, questions to be discussed also include health tourism marketing issues, the<br />
range <strong>and</strong> characteristics of facilities, as well as perceptions <strong>and</strong> attitudes of foreign <strong>and</strong><br />
domestic visitors. In addition, the paper aims to identify the specific factors in Japanese <strong>and</strong><br />
Hungarian spa tourism that may prove to be attractive for certain visitor segments in the<br />
respective countries.<br />
Introduction<br />
Japan <strong>and</strong> Hungary are both listed among the world’s five richest countries in terms of<br />
thermal <strong>and</strong> medicinal springs. However, this richness is explained by different natural<br />
factors: in Japan it is the widespread volcanic activity that makes the isl<strong>and</strong>s of the country<br />
one of the world’s greatest hot spring (onsen) destinations (Kojima <strong>and</strong> Kawamura 2006),<br />
while Hungary’s favourable position is due to the Carpathian basin’s particularly high<br />
geothermal gradient (Boldizsár 1973).<br />
This paper is based on field research in Japan in spring 2008 supported by the Japan<br />
Foundation Fellowship for Intellectual Research. The major objective of the research project<br />
was to explore <strong>and</strong> underst<strong>and</strong> the social, economic <strong>and</strong> environmental aspects of healthoriented<br />
leisure mobility in Japan. The project had a theoretical as well as a practical<br />
approach. Despite the growing significance of Japan both as a country of origin <strong>and</strong> a<br />
destination of tourism, relatively little research has been undertaken to explore the sociocultural<br />
<strong>and</strong> economic aspects of Japanese <strong>tourists</strong>’ behaviour, although interest in the subject<br />
has been growing recently (e.g. Graburn 1983, Creighton 1997, Baláz <strong>and</strong> Mitsutake 1998,<br />
Hendry <strong>and</strong> Raveri 2002, Guichard-Anguis <strong>and</strong> Moon 2009).
<strong>Health</strong>-oriented leisure <strong>and</strong> travel mobility in Japan is a relatively under-researched area,<br />
especially in the international literature, so an assessment of the factors affecting Japanese<br />
health-oriented leisure <strong>and</strong> tourism dem<strong>and</strong> – such as the various cultural <strong>and</strong> economic<br />
aspects of dem<strong>and</strong> as well as the constraints <strong>and</strong> the push factors that motivate the Japanese to<br />
choose health-oriented forms of leisure <strong>and</strong> tourism services – can be a valuable contribution<br />
to the existing tourism research literature.<br />
The development of spa <strong>and</strong> health tourism in Japan<br />
Bathing in hot springs has been a quintessentially Japanese form of leisure for centuries: the<br />
country’s arguably oldest hot spring, Dogo Onsen has a history stretching back over 1500<br />
years (JNTO 2010). However, the attraction of onsen is about much more than hot water: the<br />
essential components of the modern onsen experience are nutrition, sightseeing, exercise <strong>and</strong><br />
relaxation in natural surroundings (Seki <strong>and</strong> Heilman Brooke 2005). Throughout the<br />
centuries, the interpretation <strong>and</strong> utilisation of hot springs in Japan has undergone significant<br />
changes. While during the Edo period (1603-1868) travelling to hot springs also represented a<br />
spiritual journey, partly a pilgrimage <strong>and</strong> partly a way to relax one’s mind, in the Meiji era<br />
(1868-1912) onsen visits became institutionalized events for school <strong>and</strong> company groups,<br />
with an emphasis on learning (Raveri 2002). In the second part of the 20 th century, as the<br />
popularity of recreation-oriented tourism increased, many traditional onsen were transformed<br />
into large-scale holiday resorts that are today among the most visited destinations in the<br />
country, offering outdoor <strong>and</strong> indoor communal bathing facilities, hotel spas, as well as<br />
private baths (Chartrungruang <strong>and</strong> Mitsutake 2007), in addition to supplementary services<br />
such as aromatherapy, foot <strong>and</strong> h<strong>and</strong> baths, <strong>and</strong> a wide range of restaurants <strong>and</strong> shopping<br />
facilities (Mansfield 2001, Kobayashi 2004). According to the Japan Spa Association, the<br />
country’s 16,000 onsen get over 140 million visits every year, which is an indication of how<br />
many people, especially the elderly, return repeatedly (Ellis 2004).<br />
In recent years, Japanese hot springs have also become a part of the modern medical system,<br />
although the number of facilities offering long-term therapy is still rather small, since medical<br />
insurance rarely covers onsen stays which tend to be relatively short breaks <strong>and</strong> are typically<br />
regarded as fun trips (Ito 2003). However, the imminent ageing of the country’s population<br />
(Aspalter 2007) is likely to increase the need for enjoyable alternative healthcare solutions<br />
offered by hot springs resorts. Onsen therapy is a type of alternative or complementary<br />
medicine, not directly curing the cause of the disease, but treating the body as a whole, <strong>and</strong><br />
assisting in recuperation, rehabilitation <strong>and</strong> prevention. In addition to the hot springs, the key<br />
elements in Japanese balneotherapy are gases as well as climatic <strong>and</strong> geographical factors (Ito<br />
2003). An onsen's chemical makeup is one of the key elements of balneotherapy. According<br />
to the 1979 revision of the 1948 Onsen Law, Japan’s hot springs are classified into nine<br />
categories based on water properties (Ueda 2006): simple carbon-dioxide springs, hydrogencarbonate<br />
springs, chloride springs, vitriolic springs, ferrous springs, sulphur springs, acidic<br />
springs, radioactive springs, <strong>and</strong> simple thermal springs with water temperature over 25ºC.<br />
The development of spa <strong>and</strong> health tourism in Hungary<br />
Spa tourism based on thermal baths also have a long history in Hungary: the country’s current<br />
supply is built on Roman, Turkish <strong>and</strong> Austro-Hungarian spa heritage, in addition to modern<br />
developments inspired by Western <strong>and</strong> Oriental trends (Puczkó <strong>and</strong> Rátz 2006).<br />
In the territory of Hungary, the first thermal baths were built by the Romans in the 1 st century,<br />
although these ancient spas are only preserved in ruins today as heritage attractions. The<br />
tradition of bathing continued during the 15 th -17 th centuries throughout the country’s 150-
year-long Ottoman occupation: the Turkish baths <strong>and</strong> the culture of spa visits that Hungarians<br />
adopted are among the positive legacies of this historical period. The Turkish-style heritage<br />
baths of Budapest are today equally popular as leisure facilities for local residents <strong>and</strong><br />
heritage attractions for <strong>tourists</strong>. The third golden age of spa-going in Hungary started in the<br />
19 th century when balneology – the study of the art <strong>and</strong> science of bathing – became both<br />
popular <strong>and</strong> scientifically approved. The establishment of the “Balneological Society of the<br />
Countries of the Hungarian Holy Crown” in 1891 (MBE 2004) facilitated scientific cooperation<br />
in balneology, thus resulting in a more effective healing process <strong>and</strong> contributing to<br />
the development of medical spas around the country. The period’s typically science-oriented<br />
focus on the medicinal values of natural waters significantly affected Hungarian spa tourism<br />
development throughout the 20 th century.<br />
However, political <strong>and</strong> economic factors have also played a significant role in shaping the<br />
industry. By 1920, due to the Trianon Peace Treaty ending World War I, Hungary lost more<br />
than two thirds of its territory, <strong>and</strong> the majority of the country’s internationally established<br />
thermal <strong>and</strong> mineral spas were located behind the newly drawn borders. As a consequence,<br />
the focus of spa tourism development shifted to the exploitation of thermal resources of<br />
Budapest <strong>and</strong> other destinations within the country. Unfortunately, the outbreak of World War<br />
2 in 1939 interrupted the progress of Hungarian tourism development, <strong>and</strong> in the newly<br />
established socialist political system spa <strong>and</strong> health tourism development was mostly limited<br />
to state-controlled social tourism (Lengyel, Puczkó <strong>and</strong> Rátz 1996).<br />
Hungary is the fifth richest country in thermal <strong>and</strong> healing waters after Japan, Icel<strong>and</strong>, France<br />
<strong>and</strong> Italy. According to the natural healing assets register, Hungary has 1372 thermal wells, of<br />
which 224 are mineralised <strong>and</strong> 197 medicinal; five medicinal caves, five medicinal mud<br />
sources, one mofetta (a carbon dioxide bath), one natural healing lake (Lake Hévíz), <strong>and</strong><br />
altogether 385 spas, of which 65 are classified health spas (Aquaprofit 2007).<br />
In Hungarian tourism, spa <strong>and</strong> health tourism is a key priority product. The Hungarian<br />
National Tourist Office declared year 2008 the “Year of Waters” including mineral <strong>and</strong><br />
thermal waters, putting the field in the focus of the organisation’s domestic <strong>and</strong> international<br />
marketing efforts. During the last five years, significant capital investment with state support<br />
has been realised in spa <strong>and</strong> health tourism, resulting in the development of new spas <strong>and</strong><br />
wellness centres as well as the necessary tourism suprastructure (hospitality services).<br />
Research methods<br />
During the fellowship period in Japan, both secondary <strong>and</strong> primary research methods were<br />
used to analyse the role of hot springs in Japanese tourism, the characteristics of supply <strong>and</strong><br />
dem<strong>and</strong>, the factors influencing the development of supply <strong>and</strong> dem<strong>and</strong>, <strong>and</strong> to compare the<br />
characteristics of tourism based on thermal resources in Japan <strong>and</strong> in Hungary.<br />
Secondary research methods included the collection <strong>and</strong> analysis of literature sources on<br />
Japanese tourism, hot springs, social <strong>and</strong> economic development, using the Library of the<br />
Japan Foundation in Tokyo, the Library of Sapporo Gakuin University in Sapporo, <strong>and</strong> the<br />
Library of Hokkaido University in Sapporo. This information was later supplemented by<br />
statistical facts <strong>and</strong> other sources on Hungarian spa <strong>and</strong> health tourism.<br />
Primary research, on the one h<strong>and</strong>, included participant observation in the form of visiting<br />
onsen destinations, baths <strong>and</strong> spas, at a variety of locations around Japan (Toyako, Jozankei,<br />
Sapporo, Hakone, Kawaguchiko, Beppu, Osaka, Tokyo). During these visits, data collection
focused on the following topics: information available on the spot <strong>and</strong> beforeh<strong>and</strong> (in printed<br />
promotional materials <strong>and</strong> online), focus <strong>and</strong> style of promotional messages, use of Japanese<br />
<strong>and</strong> foreign language(s) in communication, architectural styles of onsen destinations, range of<br />
services available, type of customers (age, gender, nationality), behaviour of customers.<br />
In addition, a set of qualitative surveys were carried out in order to better underst<strong>and</strong> foreign<br />
spa <strong>tourists</strong>’ experiences <strong>and</strong> attitudes: 30 foreign backpackers were interviewed in the visited<br />
hot springs destinations (between the age of 18 <strong>and</strong> 50, representing 9 countries), <strong>and</strong> a mail<br />
survey was conducted on virtualtourist.com with a sample of 150 members who had visited<br />
Japan (an excellent 80% response rate was achieved which may be explained by the website’s<br />
focus on travel <strong>and</strong> communication as well as the researcher’s active involvement <strong>and</strong><br />
presence on the selected site). Both the interviews <strong>and</strong> the mail survey aimed to investigate<br />
the main motivations of visiting a Japanese bath, the possible differences between the previsit<br />
expectations <strong>and</strong> the actual experiences, the most positive <strong>and</strong> most negative aspects of<br />
the onsen experience, <strong>and</strong> the respondents’ expectations <strong>and</strong> image of the ideal Japanese<br />
onsen. Among the 120 respondents, 38% did not visit any onsen, for a variety of reasons,<br />
while staying in Japan, 45% were willing to describe their actual onsen experience, <strong>and</strong> 17%<br />
described in detail the expected ideal onsen experience.<br />
The Japanese onsen experience<br />
Not surprisingly, the central theme of the Japanese onsen experience, almost irrespectively of<br />
the respondents’ nationality, proved to be the enjoyment of the hot waters. Several<br />
respondents mentioned how “relaxing <strong>and</strong> mind-soothing” bathing was, although some also<br />
pointed out that the high temperatures enjoyed by the Japanese bathers may prove to be<br />
slightly uncomfortable for novice <strong>tourists</strong>. As one American tourist recalled: “we were told<br />
that a gaijin (foreigner) might have to get out after fifteen minutes or so since the body is not<br />
used to such heat.”<br />
The geographical location <strong>and</strong> the architecture of the destination are also important elements<br />
of the onsen experience. Onsen ryokan have always been constructed of natural materials,<br />
including timber, paper, bamboo, grass or cloth, in order to form an environment that<br />
encourages “traditional behaviour”, i.e. the personal, relaxing rituals of the Japanese bath<br />
(Altman 2008). While many onsen have been modernized over the last decades – which, in<br />
many cases, has led to replacing the atmospheric, wooden Japanese buildings with large<br />
concrete structures that are less in harmony with the environment, there are many exceptions<br />
where the onsen have been remade in an elegant, traditional Japanese way, with refined<br />
artwork, elegant flower arrangements, impeccable <strong>and</strong> relatively flexible personal service,<br />
excellent food served in private rooms <strong>and</strong> small capacity.<br />
In addition to the built environment, the natural surroundings also play a key role in affecting<br />
visitors’ satisfaction. For example, when describing the most positive part of his onsen<br />
experience in Hakone, one respondent emphasised that “the onsen was surrounded by lush<br />
vegetation <strong>and</strong> you could see the lake of Hakone from where you were bathing”. The image of<br />
the ideal onsen almost exclusively represented an outdoor experience, e.g. “a naturalistic<br />
mountain setting with a lovely view, or if not this, then a view of a garden”, or “set in a great<br />
natural environment such as in the middle of a forest or beside the crashing sea”.<br />
In Japan, gastronomy – with meals generally being included at onsen ryokans – is a key<br />
component of the overall onsen experience. International visitors – particularly to the smaller,<br />
less mass-oriented hot springs – generally appreciate the typical onsen cuisine which,
although unintentionally, represents the key characteristics of the increasingly popular “slow<br />
food” movement. Japanese cuisine has traditionally been based on the principle of<br />
consciously enjoying both the flavours <strong>and</strong> the presentation of the food, <strong>and</strong> paying particular<br />
attention to details such as matching the colour of the plate with the colour of the food, or the<br />
type <strong>and</strong> timing of each course served, relative to the previous course. However, high quality<br />
food as part of the typical onsen experience was only mentioned by repeat customers who<br />
have already enjoyed the culinary delights available at a traditional onsen ryokan, which<br />
suggests an incomplete pre-visit image of first time bathers.<br />
The main difference between Japanese <strong>and</strong> international visitors’ perceptions of onsen visits<br />
is related to the nature of the experience. While in domestic Japanese tourism hot springs are<br />
mostly seen as relaxation-, pleasure- or health-oriented destinations, most Western <strong>tourists</strong><br />
staying at hot springs were more inspired by culture- <strong>and</strong> heritage-related motivations than by<br />
health reasons, since, in the words of a Canadian tourist: “What is more Japanese than<br />
onsen?” Several respondents emphasised that their main motivation to visit an onsen was to<br />
“experience Japanese life more”, that nobody “can or should go to Japan without visiting an<br />
onsen since it is such a big part of their culture <strong>and</strong> traditions”, <strong>and</strong> that bathing in the hot<br />
springs “is one of the most interesting <strong>and</strong> special experiences of a visit to Japan”. It shall be<br />
noted that Japan has changed significantly in the last fifty years, <strong>and</strong> the socio-economic <strong>and</strong><br />
cultural changes are reflected in many aspects of the reality experienced by visitors, including<br />
architecture (traditional Japanese thatch-roofed wooden buildings have mostly disappeared) or<br />
consumer habits (the ubiquity of shopping facilities is overwhelming). Many international<br />
leisure visitors who come to Japan to see a unique culture that is significantly different from<br />
their own may feel slightly disappointed by the thoroughly modernized <strong>and</strong> Westernized<br />
country, or even by the seemingly harmonious coexistence of Western lifestyle <strong>and</strong> the<br />
widespread manifestations of traditional cultural heritage. Modern Japan is an overdeveloped<br />
country where, to a surprisingly large extent, the tourist milieu (Michalkó <strong>and</strong> Rátz 2008),<br />
particularly in the metropolitan areas, is composed of concrete high-rise buildings, neon signs,<br />
<strong>and</strong> generally nondescript architecture, so the traditional hot springs are among the few places<br />
left in Japan that have retained what Westerners perceive as traditional Japan. Consequently,<br />
visiting an onsen is one opportunity for international travellers to get in touch with the socalled<br />
“real Japan” <strong>and</strong> “authentic Japanese culture”.<br />
However, throughout the country, there are many well-developed onsen towns catering for<br />
large numbers of mostly domestic <strong>tourists</strong> that have already lost their traditional atmosphere.<br />
As one respondent described an onsen in Hakone: “the onsen was more like a very large gym<br />
pool, with a wall to separate the men from the women.” Since most foreign visitors expect the<br />
Japanese onsen to “look as natural as possible rather than like swimming pools, use natural<br />
rock <strong>and</strong> have traditional Japanese style plants around it”, they are more likely to be<br />
attracted by the so-called “hidden” hot springs (Neff 1995), with just one or a few<br />
establishments, catering for a much smaller number <strong>and</strong> generally more discriminative<br />
visitors. Yet, although these “hidden” onsen are able to offer a rural, fairly natural, quiet<br />
atmosphere, both physical <strong>and</strong> cultural access may be a challenge for international visitors.<br />
While mass-oriented resorts are usually easily accessible by the country’s extensive railway<br />
network, most small onsen require guests to have their own transportation. Language<br />
difficulties pose a similar problem: particularly finding information <strong>and</strong> establishing contact<br />
in any other language than Japanese may be difficult, since on the spot, the helpfulness of the<br />
hosts usually overcome language barriers. However, while Japan is generally a touristfriendly<br />
country, the reserved attitude of the Japanese may lead to a deliberate Japanese-only<br />
marketing communication policy in more upmarket onsen ryokan, in order to maintain the
exclusivity of the place by excluding simply curious Westerners with little or no affiliation to<br />
Japanese culture, thus ensuring the satisfaction of their traditional clientele. As one<br />
respondent from Singapore said: “onsen ryokan is Japanese centred. You'd need to speak<br />
Japanese <strong>and</strong> some ryokan will only accept guests introduced through sister hotels”.<br />
The traditional Japanese aesthetics represented by the “hidden” hot springs draws many<br />
foreigners, but also domestic visitors are motivated by the relaxing <strong>and</strong> nostalgic atmosphere<br />
promised by such establishments. In one of the most densely populated countries in the world,<br />
where the majority of the population live in crowded urban areas, hot springs breaks may help<br />
restore the equilibrium between the social <strong>and</strong> the personal. In addition, within the<br />
contradictory framework of the Japanese tourism industry that aims to internationalize its<br />
supply <strong>and</strong> preserve the vanishing cultural traditions, domestic tourism enjoys an increasing<br />
popularity, since travelling to rural areas is perceived by many domestic visitors as a reunion<br />
with Japanese identity (Creighton 1997). Thus, it is also the “real Japan” what many domestic<br />
visitors seek during their holidays, a concept similar to foreign <strong>tourists</strong>’ perceptions in terms<br />
of being pre-Western, pre-industrialised <strong>and</strong> non-urban, but also acknowledged by the<br />
Japanese as a place located in the past.<br />
As indicated by the survey results (<strong>and</strong> confirmed by e.g. Tsukada 2003, Kojima <strong>and</strong><br />
Kawamura 2006), foreigners typically perceive an onsen visit as a pleasurable experience<br />
because of the warm, soothing water, but also some sort of a cultural challenge since there are<br />
strict rules to learn <strong>and</strong> follow. Although a thorough description of the basics of Japanese<br />
bathing etiquette is included in practically any information or promotional material, including<br />
guidebooks, websites, <strong>and</strong> even the onsen changing rooms (all very vigorously emphasising<br />
the correct rules, e.g. not taking soap into the tub, really washing yourself well, taking off<br />
jewellery beforeh<strong>and</strong>, bathing without swimsuit, separate pools for men <strong>and</strong> women, not<br />
taking the little towel into the water), first time visitors may still experience discomfort as one<br />
American respondent described: “Another interesting detail I nearly missed was not knowing<br />
that I had to shower & wash my body with soap before entering the large bath. […] Lastly,<br />
when I was done with my late night bath I thought it was polite to drain all of the water out of<br />
the tub so the person who follows me would not bath in my water. I learned from the ryokan<br />
manager that I should not have drained the tub of its water. She was very polite to me <strong>and</strong><br />
understood that I was not very keen on their bathing etiquette. I felt pretty silly after the whole<br />
experience....like an American idiot.” Consequently, it is easy to develop a preconception of<br />
an onsen visit as some sort of cultural test as opposed to the relaxing physical experience it<br />
actually is. The difference in tone is particularly sharp in comparison with marketing<br />
messages of spas in Hungary (<strong>and</strong> elsewhere outside Japan), which generally focus on the<br />
pleasantness of the experience <strong>and</strong> the variety of services, treatments, not on expected<br />
behaviour.<br />
Obviously, many international visitors to Japan are simply not interested in an onsen<br />
experience. For some, the reason is the separation of men <strong>and</strong> women: “My wife <strong>and</strong> I have<br />
visited Japan three times <strong>and</strong> lived there for more than two years, but we have not gone to<br />
onsen. Since most onsen are for males only or females only, we would not be together. Since<br />
we are not highly fluent in Japanese, we would not be able to socialize with those around us.”<br />
The lack of interest or an unfavourable attitude towards hot springs may also stems from<br />
intimidation: the further out of the tourist areas they get, the less likely they will find Englishspeakers<br />
<strong>and</strong> the more likely they will be confused about what is expected of them (Kojima<br />
<strong>and</strong> Kawamura 2006). As one respondent explained: “I travelled by myself <strong>and</strong> didn't feel<br />
going into such an onsen by myself as I didn't exactly know whether men <strong>and</strong> women would be
separated <strong>and</strong> I don't like being stared at”. Although the bathing rules are not particularly<br />
complex, being naked among strangers make many Western <strong>tourists</strong> uncomfortable,<br />
especially as they tend to st<strong>and</strong> out in a predominantly Japanese crowd. “It can be awkward<br />
when the Japanese stare at a foreigner in an onsen. I know my mother (when she visited as a<br />
tourist for two weeks) was very uncomfortable about this <strong>and</strong> not keen to do this again.”<br />
In addition, there are also many behavioural rules <strong>and</strong> little flexibility in traditional onsen<br />
accommodation; for example, it is rather unusual for Japanese onsen ryokan to accept guests<br />
travelling alone, which, from an international visitor’s point of view, this is slightly in contrast<br />
with the separate bathing principle, <strong>and</strong> again, does not make the overall experience easier for<br />
foreigners. However, recently there has been some gradual change in terms of rules <strong>and</strong><br />
flexibility among ryokan owners, partly as a concession to international visitors, but mostly to<br />
accommodate a younger, well-travelled Japanese clientele (Altman 2008).<br />
Discussion <strong>and</strong> conclusions<br />
Spa <strong>and</strong> health tourism development has a long history both in Japan <strong>and</strong> in Hungary,<br />
although as opposed to the national character of the Japanese development, Hungary’s spa<br />
heritage is based on a multicultural tradition including Roman, Turkish, <strong>and</strong> Austrian customs<br />
<strong>and</strong> practices. Spa towns are among the most popular domestic tourist destinations in both<br />
countries, but spa <strong>and</strong> health resources <strong>and</strong> facilities are also featured in the countries’<br />
international tourism marketing communication, although to a different extent (health <strong>and</strong><br />
wellness tourism is marketed by the Hungarian National Tourist Office as a priority product<br />
of key importance, while the role of hot springs seems to be secondary compared to the<br />
country’s cultural heritage in Japanese international marketing). Although Hungarian <strong>and</strong><br />
Japanese spas are equally able to offer both wellness <strong>and</strong> health benefits, the majority of<br />
customers are motivated by the leisure <strong>and</strong> relaxation aspects of the product (Aquaprofit<br />
2007, IBS 2007).<br />
However, the medical orientation of spas is traditionally much stronger in Hungary than in<br />
Japan, despite the scientific acknowledgement of the medical benefits of the Japanese onsen.<br />
Similarly to other Central European health tourism destinations, Hungarian spas offer a wide<br />
range of therapeutic treatments, although the several weeks long, physician-prescribed cures<br />
that were so typical throughout the 19 th -20 th centuries, <strong>and</strong> particularly in the socialist period,<br />
are slowly disappearing, mainly due to the financial transformation of the healthcare system.<br />
In the last decade, spa <strong>and</strong> health tourism trends in Hungary have included the growing<br />
popularity of wellness facilities <strong>and</strong> treatments, <strong>and</strong> extensive construction of wellness hotels<br />
<strong>and</strong> spa centres around the country, even at locations with spectacular natural attractions (such<br />
as e.g. the natural thermal lake of Hévíz or the travertine mound of Egerszalók). This<br />
construction-oriented development is in contrast with the main Japanese trends where the aim<br />
is to create an onsen experience that is as natural as possible. (Although a parallel type of<br />
development, the creation of so-called “super spas, the best example of which is the Oedo-<br />
Onsen Monogatari hot spring theme park in Tokyo, is also present in Japan as well)<br />
(Talmadge 2006).<br />
The Japanese incoming tourist market is a relatively small segment in Hungarian tourism, but<br />
with exceptionally high potential. Product effectiveness <strong>and</strong> efficiency in Hungarian tourism<br />
targeting the Japanese market depend on underst<strong>and</strong>ing the exact needs <strong>and</strong> wants of the<br />
target customers, <strong>and</strong> satisfying these needs by offering products that are distinctive in nature<br />
(<strong>and</strong>, consequently, are able to stimulate dem<strong>and</strong> to travel to a new destination) <strong>and</strong> familiar<br />
in quality. The socio-cultural background of potential visitors defines both perceptions of
distinctiveness <strong>and</strong> expectations of quality st<strong>and</strong>ards. The physical environment of Japan <strong>and</strong><br />
its richness in geothermal resources determines the local product structure of spa tourism<br />
which is similar in character to Hungary, i.e. spa tourism in both countries is based on thermal<br />
springs). In addition, the actual economic situation of Japan also affects spending power <strong>and</strong><br />
consumer behaviour, so it is necessary to use a complex approach when investigating tourist<br />
dem<strong>and</strong> <strong>and</strong> behaviour.<br />
When considering the potential appeal of Hungarian spas in the Japanese market, it is<br />
important to realise that for Japanese <strong>tourists</strong>, Hungary is usually not a primary destination,<br />
but part of a Central European tour (HNTO 2006). The fact that Japanese spa tourism is also<br />
based on thermal waters may be considered both an advantage <strong>and</strong> a disadvantage: incoming<br />
Japanese visitors are familiar with the practice of bathing in hot waters, but Hungarian spas<br />
need to provide a unique selling point in order to make a spa visit an unmissable Hungarian<br />
tourist experience: e.g. heritage spas with unique history <strong>and</strong> architecture may be attractive for<br />
Japanese customers.<br />
In Japan, young single females have a particularly high travel propensity (IBS 2006), <strong>and</strong> they<br />
might be interested in wellness <strong>and</strong> beauty treatments in Hungary, but, as suggested by the<br />
interviews with Asian young female backpackers during the field study, they may also be shy<br />
to enjoy a mixed bathing environment. Senior Japanese citizens also have an increasing travel<br />
propensity, <strong>and</strong> they may appreciate the health benefits provided by the Hungarian spas,<br />
although the necessary length of stay for medical cures would be much longer than the current<br />
average length of stay of Japanese <strong>tourists</strong> in Hungary (HNTO 2006). Medical onsen<br />
therapies are not particularly well established in Japan at the moment, <strong>and</strong> senior travellers<br />
may be rather concerned about foreign customs <strong>and</strong> behaviour. Consequently, although there<br />
is a positive attitude to <strong>and</strong> interest in Hungarian spas in the Japanese market, Hungary’s most<br />
important attractions are culture- <strong>and</strong> heritage based at the moment, <strong>and</strong> it would require<br />
significant product development <strong>and</strong> marketing efforts to position Hungary as a major spa <strong>and</strong><br />
health tourism destination among Japanese <strong>tourists</strong>.<br />
Acknowledgements<br />
The survey forming the basis of this study was supported by the OTKA (K67573)<br />
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Does tourism really contribute to our quality of life? A tourism<br />
destination residents’ perspective<br />
Renda, Ana<br />
ESGHT, University of Algarve, Portugal<br />
arenda@ualg.pt<br />
Júlio Mendes<br />
Faculty of Economics, University of Algarve, Portugal<br />
Patrícia do Valle<br />
Faculty of Economics, University of Algarve, Portugal<br />
Abstract<br />
The increasing importance <strong>and</strong> complexity of tourism activity confers new dimensions <strong>and</strong><br />
therefore new challenges to places. Thus local governments are even more responsible for a<br />
sustainable development planning that lead to satisfy <strong>tourists</strong>’ expectations <strong>and</strong> to improve the<br />
residents’ quality of life.<br />
However, despite the planning efforts <strong>and</strong> widely recognized importance of residents’<br />
attitudes regarding tourism development, the residents’ perspective is often forgotten or<br />
undervalued.<br />
The present investigation adopts the residents’ point of view by analyzing the importance of<br />
the perceived tourism impacts in the assessment of their own quality of life <strong>and</strong> well-being.<br />
This paper results from the literature review on quality of life <strong>and</strong> tourism areas <strong>and</strong> proposes<br />
a preliminary theoretical model that will be subsequently tested through the study of the<br />
municipality of Loulé, located in the Algarve, one of the most internationally well-known<br />
Portuguese destinations, by applying a structured questionnaire to a sample of residents.<br />
Keywords: Residents; Perception; <strong>Tourism</strong> Impacts; Quality of Life; Well-Being; <strong>Tourism</strong><br />
Development.<br />
Introduction<br />
<strong>Tourism</strong> has become increasing important as an economic activity <strong>and</strong> as a social<br />
phenomenon. It is also an interesting holistic <strong>and</strong> integrated research area. Its importance <strong>and</strong><br />
complexity requires a destination effort to adequate the supply to the <strong>tourists</strong>’ desires <strong>and</strong><br />
motivations especially once <strong>tourists</strong> are increasingly dem<strong>and</strong>ing <strong>and</strong> experienced.<br />
At a time when more <strong>and</strong> more people travel looking for remarkable experiences,<br />
differentiation tends to be the most successful strategy in order to guarantee the competitive<br />
advantage in tourism. Sustainable development planning is one of the key points to achieve<br />
this.<br />
Nowadays there is an increasing awareness of tourism development impact on tourism<br />
destinations. As Jurowski (2004) argues, the quality of life of the residents in a community is<br />
affected by the consequences of tourism. This reinforces the idea of Allen et al. (1988) that
the residents must be willing partners in the process <strong>and</strong> their attitudes toward tourism as the<br />
perceptions of its impact on the community should be continuously evaluated.<br />
Governments have the responsibility to satisfy both the expectations <strong>and</strong> desires of <strong>tourists</strong>,<br />
<strong>and</strong> to improve the quality of life of residents. However, despite the planning efforts, the<br />
widely recognized importance of residents’ attitudes to tourism development <strong>and</strong> the concern<br />
about their quality of life <strong>and</strong> well-being, the residents’ perspective is often forgotten or<br />
undervalued. Only recently, the studies of quality of life <strong>and</strong> happiness within nations have<br />
increased but, in general, these studies have been conduct from the perspective of decisionmakers<br />
<strong>and</strong> not from the community ones.<br />
This study adopts the resident’s point of view by analyzing the importance of the perceived<br />
tourism impacts in the assessment of their own quality of life, a topic insufficiently studied in<br />
the tourism area. The study has the purpose of creating a model to analyze the relationship<br />
between residents’ perception of tourism impacts <strong>and</strong> the perception of their own quality of<br />
life. It is crucial to underst<strong>and</strong> if residents feel tourism as important for their own quality of<br />
life or, on contrary if they value other dimensions related with everyday life even without<br />
tourism. This research will be based on a case study, specifically examining the perceptions of<br />
a sample of residents of the eleven parishes of the municipality of Loulé, located in the<br />
Algarve tourism destination.<br />
For a better underst<strong>and</strong>ing of the study this paper describes the geographic study area <strong>and</strong><br />
characterizes generically his host community in terms of demographic, social, economical <strong>and</strong><br />
cultural aspects. It provides a background to the research by outlining the benefits <strong>and</strong> costs<br />
associated to tourism development, residents’ attitudes towards tourism <strong>and</strong> some of the key<br />
theories <strong>and</strong> concepts associated.<br />
Study area<br />
The Algarve, one of the most internationally well-known Portuguese destinations, is located<br />
in the south of Portugal <strong>and</strong> it is a traditionally sun <strong>and</strong> beach destination since the 60’s <strong>and</strong><br />
more recently it st<strong>and</strong>s out internationally as a very popular golf destination. As stated in the<br />
National Strategic Plan for <strong>Tourism</strong> (ME, 2006:6), the “proposal for the country will focus on<br />
the key factors that differentiate Portugal from other competing destinations – Climate <strong>and</strong><br />
light”, “History, culture <strong>and</strong> tradition”, Hospitality” <strong>and</strong> Concentrated diversity” <strong>and</strong> on<br />
elements that bring value to Portugal in the context of <strong>tourists</strong>’ options – “Modern<br />
authenticity”, Safety <strong>and</strong> Competitive quality”. The Algarve, has also these performance<br />
features which can be important tools to develop the region as an excellence destination.<br />
The municipality of Loulé is centrally located in the Algarve tourism destination. It entails<br />
geographic diversity <strong>and</strong> socio-cultural, economic <strong>and</strong> environmental differences as for<br />
example the very different stages of tourism development in the eleven parishes.<br />
The Litoral, seaside presents plenty of natural resources <strong>and</strong> tourist attractions <strong>and</strong> it is the<br />
region that gives visibility to the Algarve destination. This area has a big human density <strong>and</strong> a<br />
great diversity of accommodation, restaurants <strong>and</strong> all kind of tourist supplies. The population<br />
works mainly in the tertiary sector <strong>and</strong> generally is characterized by particular social cultural<br />
elements, some of them very traditional <strong>and</strong> a marked culture of acceptance <strong>and</strong> integration.<br />
In this area live daily those natives <strong>and</strong> other people of various nationalities <strong>and</strong> cultures,<br />
some of which began as <strong>tourists</strong> <strong>and</strong> after that have become residents due the features of the<br />
region <strong>and</strong> the attractiveness of a quality of life lifestyle. Coexist even immigrants from
Africa (mainly Cape Verde, Angola <strong>and</strong> Mozambique) that have for years voted the Algarve<br />
<strong>and</strong> the municipality of Loulé as their “port of refuge <strong>and</strong> work” <strong>and</strong> immigrants from eastern<br />
<strong>and</strong> Brazil who that also come to this region, attracted by employment opportunities.<br />
The emerging Barrocal, located between the seaside <strong>and</strong> the low mountain range, is gradually<br />
changing its traditional activities to tourism. However, this area still has agriculture <strong>and</strong><br />
livestock practices mainly of subsistence <strong>and</strong> in some cases as an economic complement of<br />
working in the tertiary sector. Many residents work in Loulé <strong>and</strong> Faro cities or on the Algarve<br />
coast (especially in the tourism industry). This area is characterized by a village lifestyle,<br />
marked by traditional practices which coexist in some moments, with new experiences<br />
resulting from the presence of some <strong>tourists</strong> <strong>and</strong> foreign residents <strong>and</strong> from the proximity to<br />
the coast.<br />
Finally Serra, the low mountain range with very few residents <strong>and</strong> almost unexplored tourism<br />
is a territory in desertification due the sparing employment <strong>and</strong> the more adverse physical<br />
conditions to liveability. This is an isolated territory with a more rugged climate. The main<br />
economic activities in Serra are forestry, livestock (goats, sheep <strong>and</strong> pigs), <strong>and</strong> the production<br />
of traditional cheeses, sausages <strong>and</strong> the highly appreciated spirits from arbutus.<br />
Today, the Algarve tourism destination <strong>and</strong> the municipality of Loulé face some problems,<br />
among which are tourism seasonality, dependence on outbound markets <strong>and</strong> consequences of<br />
the initial decades of disorderly developing, without tourism sustainable planning. At this<br />
moment government <strong>and</strong> private sector are trying to consolidate <strong>and</strong> develop strategic<br />
touristic products such as Sun <strong>and</strong> Beach, Meetings <strong>and</strong> Congresses, Nature <strong>Tourism</strong>, Golf<br />
<strong>and</strong> also new tourism areas related to an authentic <strong>and</strong> unique tourist experience.<br />
With this new reality, it becomes essential to underst<strong>and</strong> how tourism development actually<br />
addresses the residents’ perspective, their interests <strong>and</strong> opinions <strong>and</strong> how this development<br />
contributes to the perception of improvements in their quality of life.<br />
Literature review<br />
This paper will discuss some of the main concepts that the literature review so far carried out,<br />
allowing us to identify as the most important to this investigation, among following: tourism<br />
development <strong>and</strong> tourism destination, residents’ attitudes, tourism impact perception, wellbeing<br />
<strong>and</strong> quality of life, happiness <strong>and</strong> life satisfaction.<br />
Therefore the study, in the context of tourism phenomenon <strong>and</strong> concerning the quality of life<br />
<strong>and</strong> the well-being, focuses essentially on Psychology, in relation to the topics of perceptions<br />
<strong>and</strong> attitudes, on tourism, namely on issues like tourism development <strong>and</strong> tourism industry, on<br />
<strong>Tourism</strong> Sociology, discussing issues related to social processes, social relations in the host<br />
community <strong>and</strong> in relation to <strong>tourists</strong> <strong>and</strong> to tourism industry <strong>and</strong> on <strong>Tourism</strong> Anthropology,<br />
namely socio - cultural changes in host community, processes of change in local identity,<br />
processes of acculturation lifestyles <strong>and</strong> local experiences.<br />
The issue of quality of life is arousing interest within the economic <strong>and</strong> political field.<br />
Researchers <strong>and</strong> stakeholders have begun to realise that a community well-being depends on<br />
the development <strong>and</strong> it also impacts this development. Relevant efforts to measure quality of<br />
life <strong>and</strong> well-being have been undertaken. Some focus on the quality of life, while others are<br />
more directly related to happiness. Most of them apply this concept to the national or<br />
international context, as for example The World <strong>Health</strong> Organization Quality of Life
WHOQOL (WHO 2010), initiated in 1991, the Human Development Index – HDI (HDR –<br />
UNDP 2010), introduced in 1991 or the World Database of Happiness (Veenhoven 2010). In<br />
Portugal we can highlight three studies about municipalities, that are, in general, economic<br />
<strong>and</strong> political approaches to tourism planning <strong>and</strong> tourism industry (Ferrão et al. 2004; Manso<br />
et al. 2007).<br />
Since tourism development causes changes in the territories <strong>and</strong> in host community, it brings<br />
increasing concerns among promoters <strong>and</strong> academics about sustainability because it is<br />
important to underst<strong>and</strong> those changes. According to the World <strong>Tourism</strong> Organization (2004),<br />
"Sustainable tourism development entails the environmental, economic <strong>and</strong> socio-cultural<br />
aspects of tourism development, <strong>and</strong> a suitable balance between these three dimensions to<br />
guarantee its long-term sustainability.” The involvement of residents in an impact assessment<br />
can be useful to both forecast <strong>and</strong> appraise its more complex impacts (Dean <strong>and</strong> Wu 1979).<br />
Moreover, most of the studies show that tourism is seen by many communities as a way to<br />
improve residents’ quality of life <strong>and</strong>, for that reason many communities encourage tourism<br />
development (Pizam 1978; Gursoy <strong>and</strong> Rutherford 2004; Andreck et al. 2005; Lindberg et al.<br />
1997; Uriely 2002). However it is also recognized that this activity causes a negative impact<br />
on destinations <strong>and</strong> among residents, particularly in economical, social <strong>and</strong> environmental<br />
areas. As Pizam (1978) concludes there is a strong support for the hypothesis that big tourism<br />
concentration causes negative resident attitudes towards <strong>tourists</strong> <strong>and</strong> tourism in general.<br />
The tourism sustainable development <strong>and</strong> his relationship with residents’ attitudes is a subject<br />
of considerable interest for many authors (Allen et al. 1988; Andreck <strong>and</strong> Vogt 2000;<br />
Carmichael 2000; Gursoy <strong>and</strong> Rutherford 2004; Jurowski et al. 1997; Ko <strong>and</strong> Stewart 2002;<br />
Lindberg <strong>and</strong> Johnson 1997; Perdue et al. 1987). Some of them apply in their studies the<br />
social exchange theory (Homans, 1961) which recognized that people select exchanges after<br />
having assessed the costs <strong>and</strong> benefits. Most of the results pointed out differences in attitudes<br />
depending on the level of tourism development as well as a variety of other factors can<br />
influence residents’ attitudes towards tourism.<br />
Concerning the Social Exchange Theory <strong>and</strong> according to Turner (1986) residents who<br />
perceive the actual or potential tourism value <strong>and</strong> believe that the costs do not exceed the<br />
benefits will favour the exchange <strong>and</strong> will consequently be supportive of development efforts.<br />
Skidmore (1975) also suggests that individuals will engage in exchanges if the resulting<br />
rewards are valued, the exchange is likely to produce appreciated rewards, the perceived costs<br />
do not exceed perceived rewards <strong>and</strong> they will consequently be supportive of development<br />
efforts. Pizam (1978) provides also evidences to sustain this position. The same situation is<br />
expressed in Jurowski model (1994) which demonstrates that attitudes towards tourism are<br />
influenced by residents’ perceptions of economic, social, <strong>and</strong> environmental impacts.<br />
According to the author, these perceptions are influenced by perceived economic gain, by the<br />
level of use of the recreation resource, <strong>and</strong> by attitudes about humankind’s role in the<br />
preservation of the natural environment.<br />
Several theoretical models based on the social exchange theory have proposed explanations<br />
for variations in resident attitudes toward tourism (Ap, 1992; Jurowski, 1994; Lindberg et al.,<br />
1997). To quote Jurowski et. al. (1997: p.3) “the analysis demonstrate that potential for<br />
economic gain, use of the tourism resources, ecocentric attitude, <strong>and</strong> attachment to the<br />
community, affect resident perception of the impacts <strong>and</strong> modify both directly <strong>and</strong> indirectly,<br />
resident support for tourism”.
The theoretical significance of underst<strong>and</strong>ing residents’ attitudes is their connection with<br />
behaviour (Lepp, 2006). Ajzen <strong>and</strong> Fishbein (1980) explain this connection with their Theory<br />
of Reasoned Action (TRA). TRA is a hierarchical model, which asserts that behaviour is<br />
influenced by behavioural intent, which is influenced by attitudes <strong>and</strong> subjective norms<br />
(perceived social pressure for a particular behaviour), <strong>and</strong> both of these are influenced by<br />
beliefs. In a meta-analysis of past research, found widespread support for the validity of TRA.<br />
In the literature there are also frequent references to issues such as tourism development <strong>and</strong><br />
its relationship with residents’ attitudes (Butler 1980; Doxey 1976; Perdue et al. 1990). Butler<br />
(1980) described tourism development as a series of stages through which a destination<br />
evolves: exploration, involvement, development, consolidation <strong>and</strong> stagnation. This idea is<br />
also expressed in Doxey theory (Doxey, 1976) when he said that those residents’ attitudes<br />
varies with the stage of development of the tourist destination. For the author, residents’<br />
attitudes are positive during the initial stages of tourism development but become increasingly<br />
negative as a destination evolves towards stagnation. A possible addendum to this is Lepp’s<br />
(2006) suggestion that, at destinations with no prior knowledge of tourism, initial tourism<br />
development will be met with suspicion, anxiety <strong>and</strong> fear.<br />
Dogan (1989) also referred to the importance of tourism development level when predicted<br />
that residents’ adjustments will be homogenous in communities where tourism is in its initial<br />
stages of development <strong>and</strong>, as a destination matures, various adjustments might emerge, some<br />
in conjunction with tourism <strong>and</strong> some in opposition. The author emphasise that success or<br />
failure of adjustment strategies influences residents’ attitudes.<br />
The residence area proximity in relation to the main tourism area is another important<br />
relationship to underst<strong>and</strong> residents’ attitudes <strong>and</strong> perceptions (Gursoy <strong>and</strong> Rutherford 2004;<br />
Jurowski <strong>and</strong> Gursoy 2004; Lankford 1997; Sheldon <strong>and</strong> Hoy 1980; Sheldon <strong>and</strong> Var 1984;<br />
Sheldon <strong>and</strong> Abenoja 2001). Belisle <strong>and</strong> Hoy (1980) identify the perceived positive <strong>and</strong><br />
negative impacts by residents, considering the hypotheses that perception vary with the<br />
distance a person lives from the tourist zone <strong>and</strong> with socio-economic status. The authors<br />
conclude that, effectively, the distance affects significantly the perception of tourism impact<br />
but there are small variances in expressed opinions which may indicate that all groups find<br />
some direct <strong>and</strong> indirect benefits in tourism. They also note that the incipient stage of tourism<br />
development can contribute to a positive attitude toward tourism.<br />
Gursoy et al (2004) explore also the effects of the distance residents live from attractions on<br />
their attitudes toward tourism by a theoretical model based on the social exchange theory<br />
developed. The model, proposes that support is based on residents’ evaluation of both the<br />
perceived benefits/costs <strong>and</strong> the state of the local economy. The distance between the<br />
residence area <strong>and</strong> the attraction had a significant effect on how the costs <strong>and</strong> benefits were<br />
evaluated. The negative relation between the uses of the resource <strong>and</strong> the perceived benefits<br />
implies that those who live closest to the attraction feel that an increase in the number of<br />
<strong>tourists</strong> might negatively impact their ability to use it. The nearby residents may be concerned<br />
about losing their ability to use the resource as they used to. They may also be worried about<br />
traffic congestion, crime, litter, noise, <strong>and</strong> cost of living increases Lankford (1997).<br />
Residents sensitive to environmental issues who lived closest to the area appear to be more<br />
likely to support tourism than the in-between group residents with similar environmental<br />
attitudes. The Jurowski (1994) study determined that ecocentric attitudes positively impacted<br />
support for the cultural <strong>and</strong> historic tourism but negatively impacted support for other types.<br />
Consequently, close-in residents with stronger ecocentric attitudes may have been more
supportive because of the type of tourism they were evaluating. The results of the Sheldon<br />
<strong>and</strong> Var (1984) study appears to support this theory as it determined that residents living in<br />
higher density areas are more likely to have positive attitudes toward tourism because they<br />
favoured it over other industries.<br />
The contact frequency with <strong>tourists</strong> (Akis et al. 1996; Sheldon & Var 1984) <strong>and</strong> the fact of<br />
working or not in the tourism sector <strong>and</strong> being economically dependent from it are relevant<br />
linkages to better underst<strong>and</strong> residents’ attitudes. Studies, in generally confirms the existence<br />
of a relationship between an individual’s economic dependency on tourism <strong>and</strong> their overall<br />
attitude toward tourism (Brunt <strong>and</strong> Courtney 1999; Pizam 1978), showing that individuals<br />
who are connected to tourism employment are more favourable to his development.<br />
Once the purpose of this study is to determine the effect of tourism impacts perception on<br />
residents’ perceived quality of life it is essential to know how residents most frequently<br />
perceived tourism. The more significant <strong>and</strong> frequent impacts considered in tourism area (Ap<br />
1992; Akis et al. 1996; Belisle <strong>and</strong> Hoy 1980; Jurowski 1994), that will be considered in this<br />
study, are the economic, social, cultural <strong>and</strong> environmental ones, which matches the presented<br />
WTO definition.<br />
The literature review suggests, as main ideas, that tourism is widely perceived as a way to<br />
improve quality of life, such as employment opportunities, however it can have negative<br />
impacts, e.g. by increasing traffic, crime or by changing hosts’ way of life. There is a strong<br />
perception among residents of investments <strong>and</strong> profitable local <strong>business</strong>es but also the<br />
recognition of negative effects such as an increase in the cost of living (Ap <strong>and</strong> Crompton<br />
1992; Andreck <strong>and</strong> Vogt 2000; Andreck et al. 2005; Akis et al. 1996; Belisle <strong>and</strong> Hoy 1980;<br />
Dyer 2007; Gursoy <strong>and</strong> Rutherford 2004; Jurowski et al. 1997; Perdue et al. 1987).<br />
Another important concept in this study is the one of well-being. Diener (1984) suggests that<br />
there are three hallmarks in subjective well-being area. For the author it is subjective because<br />
it resides within the experience of the individual, it is not just the absence of negative factors<br />
<strong>and</strong> it includes a global assessment. However, although these hallmarks serve to delimit the<br />
area of study, they are not complete definitions of subjective well-being.<br />
The literature review points out to the need of distinguishing various dimensions of wellbeing,<br />
taking into account their inherent objective <strong>and</strong> subjective nature. The well-being<br />
domains considered in this study are organized into four groups as Sirgy (2002), Kim(2002)<br />
of various aspects that the residents take into consideration when evaluating their well-being.<br />
First the material well-being including issues like house ownership, stable employment <strong>and</strong><br />
income are explored by authors like Andrew <strong>and</strong> Withey (1976); Campbell et al. (1976);<br />
Cummins (1996). Second the community Well-being that includes aspects related to<br />
community life, integration <strong>and</strong> social participation Davis et al. (1988). Third the emotional<br />
well being witch explore subjects like the affective component of life, namely love <strong>and</strong> family<br />
life (Andrews <strong>and</strong> Withey 1976; Lane 1994) <strong>and</strong> finally health <strong>and</strong> safety well-being that<br />
include items such as the absence of sickness or the feeling of security in the residence area<br />
(Andrew <strong>and</strong> Withey 1976; Brown 1998).<br />
According to the World <strong>Health</strong> Organization (1994:5) "Quality of life is defined as<br />
individuals' perceptions of their position in life in the context of the culture <strong>and</strong> value systems<br />
in which they live <strong>and</strong> in relation to their goals, expectations, st<strong>and</strong>ards <strong>and</strong> concerns.” For
Veenhoven (2005:61) “quality-of-life can be measured by how long <strong>and</strong> happy people live”.<br />
These definitions provide the crucial dimensions to consider in this study.<br />
On quality of life studies some authors have a general approach to the concept (Cumminis<br />
1996; Diener <strong>and</strong> Suh 1997; Jurowski 2004) others, like Veenhoven (2005), highlight more<br />
specifically the construct of Happiness, yet others, like Andrew <strong>and</strong> Withey (1976) focus on<br />
Life Satisfaction. Happiness <strong>and</strong> Life Satisfaction are two constructs from Quality of life that<br />
will be studied in this research to define the residents’ perceived quality of life. As Sirgy<br />
(2001) points out these constructs, related to Quality of Life, should not be used<br />
indiscriminately. As such, Happiness entails an emotional nature <strong>and</strong> Life Satisfaction a<br />
cognitive one. The author refers that Life Satisfaction involves self- evaluation of one’s life or<br />
accomplishments against some st<strong>and</strong>ard while Veenhoven (2005) defines Happiness as the<br />
degree in which an individual judges the overall quality of life favourably. In other words,<br />
subjective well-being is how well the person likes the life he or she leads.<br />
Methodology<br />
Until now a literature review <strong>and</strong> an exploratory study based on interviews <strong>and</strong> participant<br />
observation have been carried out 55 . Since the researcher lives in the study area, it was<br />
possible to use the techniques of participant observation <strong>and</strong> of informal interviews with<br />
residents. These interviews were not recorded, as the residents do not deal well with the<br />
situation. Only field notes were taken. It was asked to residents, for example, how they felt<br />
about tourism <strong>and</strong> how they face tourism in their own space, how they accept <strong>tourists</strong> with<br />
different nationalities <strong>and</strong> how they perceive the touristic activity impact on their residence<br />
area <strong>and</strong> on their own quality of life. Very important topics in these interviews were the ones<br />
distinguishing well-being, happiness <strong>and</strong> life satisfaction <strong>and</strong> their contribution to the overall<br />
quality of life.<br />
Semi-structured interviews to community leaders parishes’ presidents <strong>and</strong> local companies<br />
were carried out in order to collect more detailed information <strong>and</strong> opinions about the parishes<br />
under study <strong>and</strong> about tourism in the area. This work is still being done so that all leaders <strong>and</strong><br />
organizations representing the parishes are interviewed.<br />
A detailed questionnaire design will be made, based on literature review <strong>and</strong> on this<br />
exploratory study. The aim is to apply a structured questionnaire to a sample of residents in<br />
the municipality of Loulé. Like in many other studies a five-point Likert scale will be used.<br />
Residents will therefore be asked to rate the level of importance <strong>and</strong>/or satisfaction related to<br />
given factors.<br />
Discussion <strong>and</strong> conclusions<br />
The exploratory study conducted so far reveals that residents’ tourism impact perceptions <strong>and</strong><br />
attitudes towards tourism are, in general, very positive in the municipality of Loulé. Residents<br />
perceive tourism as a positive way to develop their residence area which, in many cases, faces<br />
economic <strong>and</strong> social problems mainly due to the lack of employment opportunities. This<br />
occurs primarily in rural areas of the municipality where tourism is not present or is in its<br />
early stage of development. The residents’ support of tourism development seems higher as<br />
residents don’t perceive negatively the tourism impact in the residence area. On the contrary<br />
they tend to valorise the economic <strong>and</strong> social benefits of tourism. There are some indicators<br />
that may reveal an increasing attention by the residents, to environmental factors.<br />
55 This study is part of a PhD research in “Residents’ Perceptions of tourism impacts in their own quality of life”.
These preliminary finding suggests that there are differences of perception among residents<br />
who live in parishes with different tourism development levels. The same occurs for variables<br />
such as nearby residence, contact frequency with <strong>tourists</strong>, economic dependence from it, <strong>and</strong><br />
personal factors such as number of years of residence in the area, nationality <strong>and</strong> age or<br />
qualifications. However, only after application of the questionnaire will it will be possible to<br />
draw conclusions.<br />
The exploratory study guides us to verify the importance of including the well-being<br />
dimensions in the study, once the most important in the study is to underst<strong>and</strong> the relation<br />
between tourism perception <strong>and</strong> quality of life perception. Therefore this exploratory research<br />
has proved very important as it allows us to know how residents underst<strong>and</strong> these dimensions<br />
<strong>and</strong> how they are taken into account when assessing globally the quality of life. Indeed, since<br />
residents tend to associate the quality of life components with more affective or emotional<br />
components (related to happiness concept), or with cognitive ones (linked theoretically to life<br />
satisfaction) it seems sometimes that the relation occurs often without considering the<br />
presence <strong>and</strong> influence of tourism <strong>and</strong> its effects but other aspects of daily life.<br />
The literature review so far enabled us to begin the design of a conceptual model including<br />
the four sets of variables that have been mentioned before <strong>and</strong> their relationships. Thus, the<br />
model will offer the possibility of identifying the moderating effect of the various levels of<br />
tourism development in residents’ perception, taking into account the perception of tourism<br />
impacts, the four well-being dimensions <strong>and</strong> also the relevance of the quality of life<br />
constructs.<br />
We believe that this study may contribute to the adoption of the residents’ perspective of<br />
quality of life in the context of tourism studies, concerning the well-being dimensions,<br />
happiness <strong>and</strong> life satisfaction constructs. It may also be a new tool for public sector <strong>and</strong><br />
investors <strong>and</strong> a contribution for a sustainable tourism development.<br />
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Expectations of <strong>Health</strong> Tourists in Germany – Illusions <strong>and</strong> Reality<br />
Monika Rulle<br />
Department of Geography <strong>and</strong> Geology, Ernst-Moritz-Arndt-University Greifswald,<br />
Makarenkostr. 22, 17487 Greifswald, Germany<br />
rulle@uni-greifswald.de<br />
Abstract<br />
<strong>Health</strong> tourism in Germany was once strongly supported by the social security system. Today,<br />
destinations of health tourism have to attract more than ever the privately paying guests. In a<br />
first step, the paper discusses general questions about modern health tourism. A special focus<br />
was taken on the development of Medical <strong>Wellness</strong>. With the help of a nationwide<br />
representative telephone survey, Germans were questioned about their interest in health<br />
holidays. In the second step, preferences to different offers <strong>and</strong> the satisfaction with these<br />
services were researched. In the case study, health <strong>tourists</strong> in destinations in Mecklenburg-<br />
Western Pomerania were questioned. A comparison between the two surveys reveals much<br />
difference between the mere interest in the offers <strong>and</strong> the actual use of them. The additional<br />
cluster analysis defined three main target groups: married middle-aged women, younger<br />
unmarried men <strong>and</strong> persons age 65 plus.<br />
Keywords: health tourism, visitor expectations, customer satisfaction, target groups,<br />
Germany<br />
The situation of health tourism in Germany<br />
The German tradition in health tourism is long <strong>and</strong> well-known. For centuries, spas were the<br />
centre of tourism activity, however mainly for the well-off people. The situation changed<br />
when in 1957 West Germany passed a law, which made spa treatments part of the regular<br />
benefits of the social security system. As a result of this, slowly the structure of the spas<br />
changed: the once romantic outline of the spas transformed into a setting often dominated by<br />
newly built large scale sanatoriums <strong>and</strong> clinics (Brittner, Stehle 2000). Simultaneously, the<br />
number of arrivals to spa destinations exploded: in West Germany figures grew from 5.2<br />
million in 1977 to 9.3 million arrivals in 1998. In the German Democratic Republic, spa<br />
treatments were organized stately <strong>and</strong> the numbers of participants were far lower. After the<br />
reunification much financial support was necessary to develop the infrastructure to be<br />
nationally competitive (Deutscher Bäderverb<strong>and</strong> 1998).<br />
Between 1999 <strong>and</strong> 2008, the number of arrivals in all German spas grew again from 16.6<br />
million to 19.3 million. However, at the same time, the average number of overnight stays<br />
sank from 6.3 to 5.3. In 1999, the fraction of guests in German spa destination having their<br />
treatments funded by the social security system was only 10.6%, lower than ever (Deutscher<br />
Heilbäderverb<strong>and</strong> 2009).<br />
On the consumer side, the demographic transition with a population growing older fast<br />
created new types of customers in recent years: patients with chronic, but stable diseases like<br />
diabetes as well as persons concerned about their health are searching now increasingly for<br />
medically supervised vacations, paid partially by health insurances or in total privately. Since<br />
the social system pays ever less for spa treatments, new ideas for the destinations become<br />
necessary in order to be attractive for the self-paying guest. In addition, many destinations,<br />
especially in the eastern part of Germany, need to revitalize their offers <strong>and</strong> infrastructure, as
they have reached the state of consolidation or even stagnation in the <strong>Tourism</strong> Area Life<br />
Cycle. <strong>Health</strong> destinations try to re-position their product in order to attract new groups of<br />
visitors. However, they are often insecure about the real needs <strong>and</strong> expectations of their guest.<br />
Primarily, the study was supposed to define the real interests <strong>and</strong> needs of the potential health<br />
traveller. In recent years, the broader development of Medical <strong>Wellness</strong> products seemed to<br />
be a promising innovation in the Germany health tourism market. Secondly, the aim of the<br />
survey was to evaluate the real choice of health <strong>tourists</strong> as well as their satisfaction with the<br />
offers in health destinations, using the case study of Mecklenburg-Western Pomerania. Last,<br />
the definition of target groups was supposed to help to develop further specific offers for<br />
health promotion <strong>and</strong> prevention.<br />
Methods<br />
Two methods were combined for this research project to differentiate between the<br />
expectations of the guests <strong>and</strong> the real use of the offers in the health destinations: first, a<br />
German wide telephone survey among the population age fourteen <strong>and</strong> above was carried out.<br />
The results lead to a deeper insight into the wishes <strong>and</strong> expectations of the potential German<br />
health traveller <strong>and</strong> assessed possible target groups. Secondly, a face-to-face survey in<br />
relevant destinations for health tourism in Mecklenburg-Western Pomerania generated data of<br />
actual health travellers <strong>and</strong> their expectations towards the destination <strong>and</strong> their offers. This<br />
combination of similar questionnaires, as far as appropriate, allowed a comparison between<br />
the stated expectations of possible guest groups from the telephone survey <strong>and</strong> the real<br />
situation in the health destinations.<br />
Telephone survey<br />
In a first step of the survey on German health tourism, the underlying reasons when deciding<br />
for a health vacation were studied. With the help of a nationwide representative telephone<br />
survey, Germans were questioned about their interest in health holidays. The focus was taken<br />
on the privately paid visits, leaving out the far developed market of cure treatments paid by<br />
the health insurances.<br />
The questionnaire was developed at the University of Greifswald in cooperation with the<br />
University of Rostock. The scientific group consisted of one specialist in tourism <strong>and</strong> two<br />
medical practitioners, one being specialised in Community Medicine, the other in<br />
Complementary Medicine. The survey was taken out through May <strong>and</strong> June 2008. Chosen<br />
from a r<strong>and</strong>om sample, 6,325 calls were conducted, receiving 1,063 full interviews (response<br />
rate: 17%). The sample was weighted according to the criteria “size of household”, “gender”,<br />
“age” <strong>and</strong> “residence / Bundesl<strong>and</strong>” (German federal state).<br />
At the beginning of the interview, the concept of “health holiday” was defined as a holiday in<br />
which activities <strong>and</strong> services are used in order to influence the personal state of health in a<br />
positive manner. The questionnaire consisted of 40 questions <strong>and</strong> was fully st<strong>and</strong>ardised.<br />
Most of the questions were closed, with a fixed set of possible answers, though six questions<br />
had hybrid possible answers, giving the respondent the possibility of free answers.<br />
Guests questionnaire<br />
In a second step, the customer satisfaction was analyzed. Between June <strong>and</strong> November 2008,<br />
the data was generated by face-to-face interviews in numerous health destinations in<br />
Mecklenburg-Western Pomerania such as hotels, rehabilitation clinics, thermal baths or<br />
therapy centres. 2,222 contacts were made, resulting in 904 full interviews (response rate:
40%). Only those guests were included in the survey, who positively answered to the<br />
screening question about the motivation of their vacation being health.<br />
The guests’ expectations about the destinations were questioned regarding the infrastructure<br />
as well as various types of offers. Where applicable, the same set of questions of the<br />
telephone survey <strong>and</strong> the guest questionnaire was used.<br />
Modern dem<strong>and</strong>s in German health tourism<br />
Generally spoken, Germans were questioned about their interest in health holidays. The focus<br />
was taken exclusively on privately paid visits, in contrast to the traditional market of cure<br />
treatments paid by the health insurances. The results of the multifaceted study can only be<br />
shown showcased.<br />
First of all, the participants were questioned whether they were familiar with the phrase<br />
“medical wellness”. Only 21.8% said to have heard of the term before. The fraction of women<br />
being familiar with the term was slightly higher (24.4%) than the group of men (19.1%). All<br />
participants, regardless whether they knew the term medical wellness or not, were<br />
subsequently questioned about what kind of associations they had with the expression. Most<br />
of the associations stated were “wellbeing”, “health” <strong>and</strong> “medical attendance” (each about<br />
17%). Less often was “cure” (12%), “holiday” (8.4%) <strong>and</strong> “rehabilitation clinic” (7.9%)<br />
mentioned. Only 15.8% of all participants of the survey said not to have any association with<br />
the concept of medical wellness.<br />
<strong>Health</strong> tourism in Germany is often seen as a possibility to prolong the season beyond<br />
summertime. In fact, 35.7% of the persons preferred spring for health tourism. Autumn was<br />
mentioned next (26.6%), followed by summertime (18.9%). More than 10.3% said that the<br />
season is of no importance.<br />
The estimation of guests about the total costs of a health vacation are of great importance in<br />
the process of deciding for a vacation. 44.9% of the Germans would prefer to spend less than<br />
100 Euro per day <strong>and</strong> person including accommodation, meals <strong>and</strong> treatments. There is a<br />
significant difference between the answers of men <strong>and</strong> women. 49.8% of the women stated to<br />
spend preferably less than 100 Euro, whereas only 39.4% of the men answered similarly.<br />
However, men were far more often willing to spend between 100 <strong>and</strong> less than 200 Euro (45.8<br />
%). Only 39.7% of the women wanted to spend this amount. Concerning the expenditures of<br />
200 Euro <strong>and</strong> more per day, men were also stronger represented than women.<br />
The comparative study in the destination showed an even more specific detail: in<br />
rehabilitations clinics, most of the guests (90%) paid privately less than 100 Euro per day <strong>and</strong><br />
person, including accommodation, meals <strong>and</strong> treatments (77.7 % of all guest even less than 25<br />
Euro). This has to do with the fact, that most of the guests have their main costs covered by<br />
the health insurance companies. Thermal bath <strong>and</strong> therapy centres showed almost similar<br />
results. In hotels, however, 27.8% of the guests spend less than 100 Euro per day <strong>and</strong> person,<br />
<strong>and</strong> further 37.7% spend between 100 <strong>and</strong> below 150 Euro.<br />
The three most preferred types of accommodation have reached almost the same figures: the<br />
holiday flat, four star hotel <strong>and</strong> the rehabilitation clinic were stated with 20.7%, 20.3% <strong>and</strong><br />
19% as being the most suitable accommodation for a health vacation.
Almost three quarters of all Germans (71.9%) preferred a health vacation lasting eight nights<br />
or longer. 25% of the questioned persons would favour four to seven nights duration, whereas<br />
short time trips to health destinations were only chosen by 3.1% of the Germans.<br />
When repositioning a destination, the infrastructure <strong>and</strong> set of offers are of great importance.<br />
However, the real expectations of the guests are often unknown <strong>and</strong> the success is based<br />
rather on intuition than knowledge. Therefore it was an important aspect of the study to find<br />
out which of the offers are attractive enough to be paid fully or partially by the guest. The<br />
study revealed that next to classical massage (33.1%), aqua sports / swimming (29.1%) were<br />
of strong interest for German health <strong>tourists</strong>. For dancing (21.8%), relaxation techniques<br />
(20.2%) <strong>and</strong> gymnastic lessons (19.9%) there was also a large readiness stated to pay the offer<br />
completely. However, less than 10% of the respondents wanted to pay for dietary cures. In<br />
general, traditional spa treatments with local remedies or water treatments after Kneipp as<br />
well as modern offers such as Ayurveda <strong>and</strong> Thalasso therapy were stated to be less attractive.<br />
Additionally, it can be stated that with the rising age of the participant the willingness to pay<br />
offers partially or fully private decreased. This was specially the fact for the offers of dancing,<br />
personal trainer, yoga, Thalasso therapy <strong>and</strong> hot stone treatments. For established treatments<br />
such as cardiovascular training, gymnastic lessons or Nordic walking, an equal readiness for<br />
payment was found among younger as well as older Germans.<br />
Corresponding preferences were also found in the destinations: only two of 23 treatments<br />
were used by more than half of the guests: the participation of swimming / aqua sports was<br />
68.7%; classical massage was used by 57.7%. Additionally, 15 of the 23 offers in the<br />
questionnaire had been attended by less than 20% of the visitors. These can be stated as of<br />
less importance when developing health offers in a destination. The results cannot be<br />
explained with the occurrence of the services: e.g. treatments with local remedies were<br />
offered in 87.5% of the destinations, however, they were used only by 9.6% of the guests.<br />
Similar results were found with other treatments.<br />
Important for the destinations was the fact that of all users of the different treatments, the<br />
group of “satisfied” or “very satisfied” customers reached always fractions above 80% of all<br />
responses. This revealed a very positive state of health tourism in Mecklenburg-Western<br />
Pomerania.<br />
Special target groups for health destinations<br />
With the help of a two-step-cluster analysis, specific potential visitor groups with similar<br />
interests in health vacations were identified. Sixteen characteristics representing different<br />
expectations were analysed: thirteen of the most important offers for health vacations, the<br />
preferred duration of stay, the preferred type of accommodation <strong>and</strong> the accepted maximum<br />
cost for a health vacation. Additionally, six socio-demographic factors were taken into<br />
account: gender, age, family status, employment, highest grade of education <strong>and</strong> net<br />
household income.<br />
The analysis resulted in four clusters. One of them was the group of “males with little interest<br />
in health vacation” <strong>and</strong> was for obvious reasons neglected. The largest group was the<br />
“married group of women interested in health vacations”. 65.9% of this group were persons<br />
aged 35 to 54. 40% of this cluster were full-time employed <strong>and</strong> another 32.8% part-time<br />
working. The group correlated highly in their awareness of health. The preferred<br />
accommodation was the four-star-hotel (23.3%) followed by the rehabilitation clinic (20.9%).<br />
The group of people accepting a maximum of below 100 Euro for one day stay including
accommodation, meals <strong>and</strong> health offers was almost as large as the group accepting more than<br />
100 Euro per day. This cluster took more interest in price reductions funded by the health<br />
insurances than other groups.<br />
The second largest cluster was the group of “younger men interested in health holidays”. A<br />
large fraction of this group (69.5%) was younger than 45 years old <strong>and</strong> 69.5% of them fully<br />
employed. More than half of the group (56.9%) are unmarried. The group also preferred the<br />
four star-hotels, however, rehabilitation clinics <strong>and</strong> holiday flats were closely following up. In<br />
relation to the other clusters, this group showed the largest willingness to pay more than 100<br />
Euro per day per accommodation, meals <strong>and</strong> health offers. Additionally, the younger men<br />
stated a strong interest in additional leisure time activities.<br />
The last identified target group for health vacations was the group of “people age 65 <strong>and</strong><br />
above”. About 26% of all respondents were included in this cluster. This group prefers the<br />
rehabilitation clinic as accommodation <strong>and</strong>, with lesser importance, holiday flats <strong>and</strong> fourstar-hotels.<br />
The seniors are much cost-conscious preferring not to spend more than 100 Euro<br />
per day including accommodation, meals <strong>and</strong> treatments. They were lesser interested in<br />
leisure time activities, but emphasized the importance of medical supervision in the<br />
destination as well as at home, after their return from the destination.<br />
Conclusion<br />
After fundamental reductions in the German health tourism market during the mid 1990s, new<br />
strategies for the growing market of self-paying guests needed to be developed. For Germany,<br />
the development in the new market segment of medical wellness appeared to be promising. In<br />
fact, the study validated that the term medical wellness is not yet established in Germany.<br />
However, the survey showed that not having any idea of its meaning does not imply to have<br />
no specific associations. Indeed, the images vary strongly. Using the term for marketing<br />
activities therefore bears many risks. Destinations have to explain their product in advance<br />
very well in order not to invoke associations, which will later not be fulfilled.<br />
The cure <strong>business</strong> was traditionally a reliable factor in the tourism sector as the guests sent by<br />
the social security system generally have little choice, neither where nor when to take spa<br />
treatments. This lead to constant all-year-around guest numbers in the destinations. However,<br />
the modern self-paying guest follows his preferences. Modern health tourism is supposedly<br />
good functioning as an off-season attraction. However, the study revealed very little interest<br />
in health tourism during the winter time. The preferred seasons are spring <strong>and</strong> autumn;<br />
seasons of the year, when other offers compete already with the attention of the guests.<br />
To attract large groups of guests, the cost of the complete offers should not exceed 100 Euro<br />
per day including accommodation, meals <strong>and</strong> treatments. The willingness to pay more private<br />
money is stronger represented among men, however, any offers above 200 Euro in total will<br />
find little acceptance. Additionally, the guests study revealed that a large number of guests in<br />
rehabilitation clinics still spend very little private money. Most of the expenditure is covered<br />
by the social security system. This leaves much room for further development of the privately<br />
paid market in rehabilitation clinics. The guests of the hotels spend far more <strong>and</strong> can be seen<br />
as a role model for the clinics. Modern rehabilitation clinics already do offer the necessary<br />
infrastructure on a high st<strong>and</strong>ard. Additionally, the results of the telephone survey revealed<br />
that the clinics were mentioned next to holiday flats <strong>and</strong> four star hotels as being most suitable<br />
for a health holiday. The preferred duration of stay of eight or more nights is also a positive
sign for the development of further products in rehabilitation clinics, as lasting medical effects<br />
are understood to be reached through a longer duration of treatment.<br />
The comparison between the telephone <strong>and</strong> the guest survey revealed similar results<br />
concerning the acceptance of partial or full private payment. Guests are only willing to invest<br />
private money for traditional offers such as classical massage <strong>and</strong> aqua sports / swimming.<br />
Medical attendance was another offer, both mentioned <strong>and</strong> also often used in the destination.<br />
Surprisingly for health tourism with a medical impact is the fact, that treatments with local<br />
remedies as well as programmes for a <strong>healthy</strong> diet seem to be little attractive.<br />
The study revealed that modern health tourism, especially the market segment of medical<br />
wellness, offers far less opportunities for the destinations than widely assumed.<br />
Although there is a large interest in health tourism among Germans, with the findings of the<br />
study certain target groups were identified: the married group of middle aged women<br />
interested in health vacations, younger, unmarried men interested in health holidays <strong>and</strong> the<br />
people age 65 <strong>and</strong> above. Each of the group has certain preferences concerning the price of<br />
the vacation, the optimal form of accommodation, <strong>and</strong> other specific preferences such as<br />
leisure time activities for the group of younger men. The destinations have to decide for<br />
certain target groups in order to optimize their product.<br />
References<br />
Brittner, A.; Stehle, T. (2000). Kurverkehr. Trierer <strong>Tourism</strong>us Bibliographien (9). Trier.<br />
Deutscher Bäderverb<strong>and</strong> (1998). Jahresbericht. Guetersloh, Floettmann Verlag.<br />
Deutscher Heilbäderverb<strong>and</strong> (2009). Jahresbericht. Guetersloh, Floettmann Verlag.<br />
Rulle, M., Hoffmann, W. & Kraft, K. (2010). Erfolgsstrategien im Gesundheitstourismus.<br />
Analyse zur Erwartung und Zufriedenheit von Gästen. Berlin, Erich Schmidt Verlag.<br />
The author would like to express her thanks to the supporting Ministry of Economics,<br />
Labour <strong>and</strong> <strong>Tourism</strong>, Mecklenburg-Western Pomerania, Germany, which financed the study<br />
with resources from the European Regional Development Fund.
Exploring The Relationship Between Meditation Flow Experience <strong>and</strong> Well-<br />
Being<br />
Tzuhui A. Tseng<br />
Department of Environmental <strong>and</strong> Cultural Resources<br />
National Hsinchu University of Education, Taiwan<br />
thtseng@mail.nhcue.edu.tw<br />
Ching-Cheng Shen<br />
The Graduate School of Travel Management<br />
National Kaohsiung Hospitality College, Taiwan<br />
Abstract<br />
Well-being is a kind of <strong>healthy</strong> or happy feeling one has, <strong>and</strong> is also one’s goal in life.<br />
Through the process of work, leisure activities, exercise, or social interaction, an individual<br />
could bring his potential into use <strong>and</strong> satisfy his needs, <strong>and</strong> further develop a sense of<br />
accomplishment <strong>and</strong> worthiness, <strong>and</strong> the feeling of happiness. Because leisure experience<br />
could satisfy people’s psychological needs such as recreation, relaxation, self-improvement,<br />
<strong>and</strong> self reliance, it is an important source of well-being. When people are immersed in leisure<br />
activities, they would go into a devoting state of mind, <strong>and</strong> enjoy satisfaction of selfrealization<br />
<strong>and</strong> flow experience of abundant thoughts. Therefore, the effect of flow experience<br />
from leisure activities on well-being is an important research topic.<br />
People in this society are experiencing more <strong>and</strong> more stress from life <strong>and</strong> work. Meditation<br />
can provide satisfaction in people’s physical <strong>and</strong> spiritual needs, <strong>and</strong> has gradually become an<br />
important part of leisure activities. This study would explored the relationships between<br />
leisure activity flow experience <strong>and</strong> well-being, use people who participated in meditation<br />
activities as research subject, <strong>and</strong> collect data through survey interview.<br />
The findings were as the following: 1. On the factor dimension aspect of meditation flow<br />
experience, the Flow State Scale proposed by Jackson <strong>and</strong> Marsh (1996) was used as<br />
reference, <strong>and</strong> clarifying goals, instant feedback, balancing skill <strong>and</strong> challenge, concentrating<br />
on the activity, self-control, changes in sense of time, <strong>and</strong> self-forming experience were<br />
chosen as measure foundations. 2. On the factor dimension aspect of well-being, the Oxford<br />
Happiness Inventory (OHI) of World <strong>Health</strong> Organization (WHO) was used as reference, <strong>and</strong><br />
seven dimensions including physical, spiritual, environmental, social, self-growth, joyful <strong>and</strong><br />
optimistic, <strong>and</strong> life satisfaction were chosen as measure foundations. 3. As for the meditation<br />
flow experience, “the meditation experience is great”, “having the ability to face meditation<br />
challenges”, “enjoy the meditation experience”, “meditation feels good”, <strong>and</strong> “clear about<br />
want I want to do” had higher outcomes. 4. On the well-being aspect, “actively to create in<br />
life”, “cherish good fortune” “harvest from everything in life”, “good performance from<br />
work”, <strong>and</strong> “having hope for the future” showed better results. 5. After analyzing the<br />
relationship between meditation flow experience <strong>and</strong> well-being by using linear structural<br />
equation, it was clear that meditation flow experience <strong>and</strong> well-being had significant positive<br />
relations. 6. In leisure flow experience, “concentrating on the activity”, “clarifying goals”,<br />
“instant feedback”, <strong>and</strong> “self-forming experience” were higher factor dimensions. 8. In wellbeing,<br />
“joyful <strong>and</strong> optimistic”, “life satisfaction”, “self-growth”, <strong>and</strong> “environmental” were
higher factor dimensions. From above results, it is clear that meditation flow experience can<br />
provide people with a higher spiritual level of well-being.<br />
Keywords: Meditation, Flow Experience, Well-being<br />
Introduction<br />
After the Industrial Revolution, due to the fast change of science <strong>and</strong> technology, the social<br />
structure, the cultural system <strong>and</strong> economic activity's fast vicissitude, creates the greatest<br />
pressure <strong>and</strong> astatic for human in psychology <strong>and</strong> the physiology aspects. All sorts difficult<br />
living , such as anxious, phenomena <strong>and</strong> losing sleep, causes the damage to the health of<br />
human body <strong>and</strong> mind directly, subsequently produces “the diseases of civilization”, lets the<br />
human live in the pain <strong>and</strong> is unhappy everyday. The Taiwan suicide mortality rate has<br />
become one of the top ten reasons to cause death in these continues eight years. Using 2007 as<br />
the example, the people died from the suicide as high as 3,933 people, <strong>and</strong> the pressure was<br />
the principal factors to cause the death. The pressure has become one of the attribute to<br />
threaten the human body <strong>and</strong> mind <strong>and</strong> the peace of social (Robinson & Godbey, 1997;<br />
Zuzanek & Smale, 1997; McBride-King & Bachmann, 1999). Because the leisure activity<br />
may enhance individual sense of self determination <strong>and</strong> the society supports, can adjust the<br />
life pressure effectively (Coleman & Iso-Ahola,1993). Hull(1990) thought that the leisure<br />
activity may promote the positive mood which influences the health. Pargament(1997) also<br />
pointed out that people's intelligence strength <strong>and</strong> the mind health was the main resource to<br />
relieve the negative effect from the time pressure, included physical <strong>and</strong> psychological<br />
aspects.<br />
In recent years, “the meditation” in Taiwan becomes one of the leisure activities to relieve the<br />
pressure. The imperial sacrifices repair activity promotes the health <strong>and</strong> the psychological<br />
balance by sitting still which includes adjusting the body, breathing <strong>and</strong> heart. Sitting still<br />
may help individual to reduce rigid, make the brain calmer <strong>and</strong> clearer, achieve tranquilly<br />
dedicated intrinsic wholly-attention, then has the wisdom <strong>and</strong> develop individual potential,<br />
<strong>and</strong> truly feel the original main body of individual . Using the self-restraint <strong>and</strong> the selfcontrol<br />
from the meditation, lets the meditation’s “engages in introspection sees the nature”,<br />
enable the society to become a wise <strong>and</strong> the creativity beautiful world.<br />
The Meditation is not only one of the religious activities, also can eliminate the pressure from<br />
the life, promote the health <strong>and</strong> promote the intrinsic virtue of patience, <strong>and</strong> the meditation is<br />
also an important leisure activity which can let people enjoy the happiness from the<br />
meditation. The core value of leisure activity is to provide people the happy experience, <strong>and</strong> at<br />
the same time leisure is also the key activities which the populace regulate their life <strong>and</strong> the<br />
well being is the ultimate objective which the populace always try to achieve. What kind of<br />
experience does the meditation provide to the people? Do those activities experience can<br />
provide people the well-being? The questions above are the key elements whether meditation<br />
can become important health leisure activity to the populace, <strong>and</strong> they are also the important<br />
topic for this research project.<br />
Literature Review<br />
The meditation flow experience<br />
The meditation flow experience is that when people are doing some kind of activities or the<br />
work, they pay the centralized attention, <strong>and</strong> completely invest in the situation, <strong>and</strong> remove<br />
all the other senses which are not related to the activity, is one kind of meditation flow<br />
experience (Csikszentmihalyi, 1990). The meditation flow experience can cause individual to<br />
be immersed in some kind of activity completely, <strong>and</strong> disregard the other conditions, <strong>and</strong> this<br />
kind of experience brings the greatest joy to people. After the meditation flow experience
proposed at 1975 by Cskiszentmihaly, it was widely applied in all kind of areas which<br />
included music, school education, the network, the job, the sport, the volunteer, the leisure,<br />
the Trans-Culture research, the daily life, the computer network (browsing) <strong>and</strong> so on.<br />
In the measurement of meditation flow experience aspect, Jackson & Marsh(1996) proposed<br />
nine construction surfaces which includes clear goal, immediately pay back, the skill <strong>and</strong><br />
challenge balanced, the sense of self-control, the sense of time change, self-forming<br />
experience, the loss of self-awareness, the unite of the body <strong>and</strong> mind, <strong>and</strong> the total<br />
concentration in the activity. In the networking training environment meditation flow<br />
experience research which proposed by Cation(2000), the surface construction of mediation<br />
can be divided into the immediately payback, the clear goal, the unite of knowledge <strong>and</strong><br />
action, the full concentration, the latent control feeling, temporary lost the determination, the<br />
sense of time change, the long distance live feeling, the spontaneous experience <strong>and</strong> the<br />
positive emotion. This research referred to the meditation flow scale which was applied by<br />
Jackson <strong>and</strong> Marsh (1996) <strong>and</strong> Cation(2000), <strong>and</strong> considered the characteristic of meditation,<br />
<strong>and</strong> used the seven construction surfaces which included “the clear goal”, “immediately the<br />
payback”, “the skill <strong>and</strong> challenge balanced”, “the full concentration in the activity”, “the<br />
sense of self-control”, “the sense of time change” <strong>and</strong> “self-forming experience” to be the<br />
measurement foundation for the meditation flow.<br />
Well-being<br />
Well-being is <strong>healthy</strong> or the joyful feeling which generally may divide into quality of Life, is<br />
called QOL, mental health <strong>and</strong> mental development <strong>and</strong> used the factors above to measure the<br />
well-being. The quality of lives is emphasis on invisible spiritual life level to person's<br />
survival <strong>and</strong> the development meaning, <strong>and</strong> defined the subjective welling being as the<br />
cognation <strong>and</strong> value of the individual to their life satisfaction level. (Diener, Suh, Lucas &<br />
Smith,1999), <strong>and</strong> mainly used the overall life satisfaction feeling <strong>and</strong> the specific satisfaction<br />
feeling to be the measurement foundation. The well being in the metal health aspect thought<br />
that a well being person first need to have a <strong>healthy</strong> mind, <strong>and</strong> this kind of health usually was<br />
show in people emotion aspect. The related research thought that people's subjective well<br />
being situation was decided by certain time inner product extremely emotion <strong>and</strong> the passive<br />
emotion balance. If the people experienced more in happy emotion <strong>and</strong> less in unhappy<br />
emotion, this person could be estimated as a well-being person. The mental development<br />
defined the well being as that the well being was not only about the happiness; moreover also<br />
including reached fully personal potential to achieve the perfection (Ryff,1995). The related<br />
research thought that the subjective well being measurement only limited to people's positive<br />
feeling, but the positive feeling was not equal to positive <strong>healthy</strong> life, <strong>and</strong> then proposed that<br />
the psychological well-being, is called PWB.<br />
Method<br />
In order to analyze the influence relation between flow experience <strong>and</strong> well- being, this<br />
research established linear structure equation pattern which showed as follows: The latent<br />
independent variable for the flow experience (ξ1), latent depends variable for the well being<br />
(η1). The latent independent variable for flow experience (ξ1) included the clear goal (X1),<br />
immediately the payback (X2), the skill <strong>and</strong> challenge balanced (X3), the full concentration in<br />
the activity (X4), the sense of self-control (X5), the sense of time change (X6) <strong>and</strong> selfforming<br />
experience (X7) seven items. Latent depends on the variable well being (η1) the<br />
observation variable included the physiology (Y1), the psychology (Y2), the environment<br />
(Y3), the public relations (Y4), the self-growth (Y5), happy optimistic (Y6) <strong>and</strong> life
satisfaction (Y7) <strong>and</strong> seven items. The relational graph of meditation flow experience <strong>and</strong><br />
well being was shown in Figure 1.<br />
X1 Clear Goal<br />
X2 Immediately payback<br />
X3 Skill <strong>and</strong> Challenge<br />
balance<br />
X4 Full concentration in the<br />
activity<br />
X5 Sense of self-control<br />
X6 The sense of time<br />
change<br />
X7 Self forming<br />
experience<br />
λ x11<br />
λ x21<br />
λ<br />
λ<br />
x31<br />
x41<br />
λ x51<br />
λ x71<br />
λ x71<br />
flow<br />
experience<br />
ξ1<br />
Well-being<br />
η1<br />
Y1 physiology<br />
Y2 psychology<br />
Y3: Environment<br />
Y4: Public relation<br />
Y5: Self -grow<br />
Y6: Happy optimistic<br />
Y7: Life -satisfaction<br />
Figure 1 The influence relation model of meditation flow experience <strong>and</strong> well<br />
being<br />
β 11<br />
Results<br />
Participant basic information analysis<br />
Participant basic document analysis result was shown in Table 1. In the gender aspect, the<br />
majority was the female, accounted for 71.6%. The age aspect, the majority was 41~50 year<br />
old, accounted for 30.9%; next was below 20 years old, accounted for 20.0%. The education<br />
level, the majority was the university level, accounted for 51.7%. In the marital status aspect,<br />
single are the most, accounted for 62.0%. The occupation leaves, the most are the students,<br />
accounted for 39.5%; Next was the armed forces Catholicism, accounted for 23.6%.<br />
λ y11<br />
λ y21<br />
λ y31<br />
λ<br />
λ<br />
y41<br />
y51<br />
λ y61<br />
λ<br />
y71
Table 1 Participant information analysis<br />
Variable Sample ( ) Percent (%)<br />
Male 142 28.4<br />
Gender<br />
Age<br />
Education<br />
Marital<br />
Occupation<br />
Female 358 71.6<br />
20 years <strong>and</strong> below 101 20.0<br />
21~30 123 24.3<br />
31~40 64 12.6<br />
41~50 96 19.0<br />
51~60 93 18.4<br />
61 years <strong>and</strong> up 29 5.7<br />
Junior high school <strong>and</strong> below 20 4.0<br />
Senior high school <strong>and</strong> up 69 13.7<br />
2 years College 79 15.6<br />
University 261 51.7<br />
Graduate school <strong>and</strong> up 76 15.0<br />
Single 311 62.0<br />
Married no Kid 8 1.6<br />
Married have kid 170 33.9<br />
Other 13 2.6<br />
Public servant 118 23.6<br />
Business 29 5.8<br />
Self-Employment 16 3.2<br />
Service Industry 41 8.2<br />
Housekeeping 20 4.0<br />
Retire 41 8.2<br />
Student 198 39.5<br />
Other 38 7.6<br />
Flow experience<br />
The flow experience analysis result was shown as Table 2, “ The experience from<br />
participating meditation activity is very good ” was the highest, next was “when you faced the<br />
challenge during participating the meditation activity, believed that you have the ability to<br />
meet the challenge, <strong>and</strong> overcome it”. 3 “Enjoyed the meditation activity experience”. In the<br />
flow experience, the lowest was “Do not need to ponder <strong>and</strong> then you can make the correct<br />
action”, the next was “You can control the activity when you participate the meditation.<br />
Although the meditation activity had its own difficulty, it is very good experience.
Table 2 Meditation flow activity analysis<br />
Flow experience factors Mean SD.<br />
Clear goal<br />
Immediately<br />
payback<br />
Skill <strong>and</strong><br />
Challenge balance<br />
Full<br />
concentration in<br />
the activity<br />
Sense of selfcontrol<br />
The sense of<br />
time change<br />
I know that I want to participate in meditation activity<br />
clearly.<br />
3.6508 0.8744<br />
When I participate in meditation activity, I know what I<br />
suppose to do clearly.<br />
3.7276 0.8322<br />
When I participate in meditation activity, I know I feel very<br />
good.<br />
3.7475 0.7996<br />
When I participate in meditation activity, I know that I have<br />
good performance.<br />
3.1096 0.8441<br />
When I face the challenge when I participate in meditation<br />
activity, I know that I have enough ability to overcome it.<br />
3.8797 0.7540<br />
The challenge which meditation activity brings to me has<br />
same level with my ability.<br />
3.3214 0.8547<br />
I do not need to ponder <strong>and</strong> I can do the right reaction. 2.8968 0.9274<br />
I participate in meditation activity automatically. 3.3849 1.0022<br />
I pay fully attention when I participate in meditation<br />
activity naturally.<br />
3.4870 0.8285<br />
When I participate in meditation activity, I will pay all my<br />
attention.<br />
3.5964 0.8072<br />
I can control all the activity freely when I am participating<br />
in mediation activity.<br />
3.1016 0.8776<br />
When I participate in meditation activity, I have the ability<br />
to control all the sense of situation.<br />
3.2282 0.8035<br />
I do not feel myself when I am participating in meditation<br />
activity.<br />
2.7440 0.9012<br />
The time past fast when I am participating in meditation<br />
activity.<br />
3.5149 0.8913<br />
The time passing is unusual when I am participating in<br />
meditation activity.<br />
3.6178 0.8466<br />
The experience comes from the meditation activity is very<br />
good.<br />
3.9085 0.7906<br />
Well-being analysis<br />
The well-being analysis result of the meditation activity is shown as Table 3, “I always<br />
thought that the life should be aggressive <strong>and</strong> create on own initiative” is the highest, next is<br />
“I cherish good fortune <strong>and</strong> reason”, next is “when I am work, I will pay all the attention on<br />
work”. The lowest well-being item will be “I am a mood stable person”, the next is “my spirit<br />
is healthier <strong>and</strong> energize, is not easy to feel weary”. The meditation activity will bring more<br />
positive feeling for life <strong>and</strong> it will be helpful in the work concentration.
Table 3 Well-being analysis result of the meditation activity is shown<br />
Physiology<br />
Psychology<br />
Environment<br />
Public relation<br />
Self-grow<br />
Happy optimistic<br />
Life satisfaction<br />
Well being factor Mean SD.<br />
My body is healthier <strong>and</strong> less illness. 3.6612 0.7819<br />
I may adjust my mind to improve my immune system. 3.6309 0.8344<br />
I feel more energize <strong>and</strong> less weary. 3.6247 0.8857<br />
I am a mood stable person 3.4342 0.8727<br />
My body <strong>and</strong> mind always maintain at the comfortable<br />
condition.<br />
3.7310 0.7880<br />
I can h<strong>and</strong>le the setback <strong>and</strong> relieve the angry <strong>and</strong> sad<br />
emotion.<br />
3.6454 0.8270<br />
I can keep my emotion calm <strong>and</strong> face the matter which<br />
makes me angry.<br />
3.6598 0.8193<br />
I am satisfying the environment which surrounds me. 3.8417 0.7532<br />
I can make the atmosphere of the working environment<br />
peace <strong>and</strong> harmonious.<br />
3.7146 0.7527<br />
I will not argue with people for little matter. 3.8953 0.7281<br />
I can communicate coordinated with the others, when I<br />
live with others.<br />
3.7556 0.7397<br />
The co-worker <strong>and</strong> I often hangout, beside the working<br />
period.<br />
3.6440 0.7987<br />
I will pay attention at work, when I am working. 4.0802 0.6778<br />
I can pay attention at work <strong>and</strong> activity which are<br />
processing during daily life <strong>and</strong> work.<br />
3.8045 0.7577<br />
I will make all the effort in the work to have good<br />
performance.<br />
3.9539 0.7027<br />
I always thought that the life should be aggressive <strong>and</strong><br />
create on own initiative<br />
4.1900 0.6949<br />
I always keep interest <strong>and</strong> enthusiastic at work <strong>and</strong> case<br />
daily.<br />
3.9120 0.7466<br />
I feel the hope for the future. 3.9382 0.8080<br />
I can still be optimistic mind in the adverse<br />
circumstance <strong>and</strong> keep working hard.<br />
3.7454 0.7623<br />
I can underst<strong>and</strong> life’s meaning. 3.8926 0.8036<br />
I can obtain the harvest from the daily life. 3.9861 0.6603<br />
I cherish good fortune <strong>and</strong> reason 4.1454 0.6811<br />
The relationship between meditation flow <strong>and</strong> well-being<br />
This study established the relational liner construction model for the meditation activity flow<br />
experience <strong>and</strong> well being <strong>and</strong> used the he Lisrel 8.5 software to find the solutions, <strong>and</strong> the<br />
relational scheme path diagram was shown as Figure 3. The number represented path<br />
coefficient, <strong>and</strong> the number in the parenthesis represented the T value of the path coefficient<br />
value. In the basic matching moderation examination aspect, basically in the pattern of the<br />
meditation flow experience <strong>and</strong> well being of factors reached the remarkable st<strong>and</strong>ard, the<br />
coefficients are between 0.66 <strong>and</strong> 0.87, which belonged to good matching moderation scope.<br />
Each construction surface the measurement of T value are all larger than 1.645, <strong>and</strong> there are<br />
not negative error variations, <strong>and</strong> the error variation all achieved the remarkable st<strong>and</strong>ard,<br />
demonstrated that this pattern basic adaptive is good. In the Matching the moderation aspect,<br />
χ2 value ratio was 2.90, GFI was 0.95, RMSEA was 0.062, AGFI was 0.92, NFI was 0.98,<br />
CFI was 0.99, RMR was 0.046, PGFI was 0.60, <strong>and</strong> PNFI was 0.72, was showing that the<br />
mode has very good matching moderation.<br />
From Figure 3, we can know that the meditation flow experience to the well being which<br />
influence coefficient was exactly the 0.76, t value was 12.85, achieves the remarkable<br />
st<strong>and</strong>ard <strong>and</strong> demonstrated that the the meditation flow activity experience has positive<br />
influence to the well being. When the flow experience was higher, the well being was going
to be higher too. In the leisure flow experience aspect, the factors of “ the full concentration in<br />
the activity”, “clear goal”, “immediately payback” <strong>and</strong> “self-forming” have high construction<br />
surface. In the well-being aspect, the factors of “the happy optimistic”, “life satisfaction”, “the<br />
self-growth” <strong>and</strong> “the environment” have high construction surface. From the analysis above,<br />
we can know that the meditation flow experience provided the populace to have higher level<br />
of well-being.<br />
X1 Clear Goal<br />
X2 Immediately payback<br />
X3 Skill <strong>and</strong> Challenge<br />
balance<br />
X4 Full concentration in the<br />
activity<br />
X5 Self-Control<br />
X6 Sense of time change<br />
X7 Self-Forming experience<br />
0.80 *<br />
(20.97)<br />
0.77 *<br />
(20.04)<br />
0.73 *<br />
(18.22)<br />
0.84 *<br />
(22.74)<br />
0.70 *<br />
(17.38)<br />
0.71 *<br />
(17.72)<br />
0.74 *<br />
(18.89)<br />
Flow<br />
experience<br />
ξ1<br />
0.73 *<br />
(12.85)<br />
Well-being<br />
Figure 3 The casual relationship between mediation flow experience <strong>and</strong> wellbeing.<br />
Conclution<br />
People’s living pressure is increasing, so the life well being value is decreasing. Because the<br />
meditation activity can relieve the pressure <strong>and</strong> it also has the strength to increase people’s<br />
life quality from the mental <strong>and</strong> spirit aspect, so meditation activity slowly becomes popular<br />
leisure activity to the people. This research used the influence relation between meditation<br />
flow experience <strong>and</strong> well being to be the research subject, <strong>and</strong> the finding demonstrated that<br />
higher meditation flow experience has higher well being value. The people who engaged in<br />
meditation activity thought that the meditation activity is very good experience activity,<br />
would bring the more positive outlook for people’s life at the spirit aspect <strong>and</strong> the finding<br />
showed that the meditation had the ability to reduce the pressure from the daily life <strong>and</strong><br />
increase people’s health, <strong>and</strong> promote the intrinsic self-control, so people can be able to enjoy<br />
the mediation activity which was important leisure activity.<br />
References<br />
Andrew, F. M., <strong>and</strong> Withey, S. B. (1976). Social Indicators of Well-Being. New York, NY:<br />
Plenum.<br />
Berger , B . C . , & McInman . (1993) . Exercise <strong>and</strong> the quality of life ,In R .N .Singer , M . ,<br />
& Murpuh , L. K, Tennant ( Eds .) ,H<strong>and</strong>book of research on sport psychology , pp.729<br />
- 760.New York: Macmillan Publishing.<br />
Campbell, A., Converse,P.E., & Rodgers,W.L.(1976). The quality of American life :<br />
Perceptions, evaluations, <strong>and</strong> satisfactions. New York: Russell Sage Foundation.<br />
Coleman, D. & Iso-Ahola, S. E. (1993). Leisure <strong>and</strong> health The role of social support <strong>and</strong><br />
self-determination. Journal of Leisure Research, 25(2) , 111-128.<br />
Csikszentmihalyi, M.,(1975), Beyond boredom <strong>and</strong> anxiety. San Francisco, CA: Jossey-Bass.<br />
η1<br />
0.66<br />
0.78 *<br />
(15.04)<br />
0.79 *<br />
(15.18)<br />
0.75 *<br />
(14.46)<br />
0.80 *<br />
(15.18)<br />
0.87 *<br />
(16.26)<br />
0.81 *<br />
(15.28)<br />
Y1 physiology<br />
Y2 psychology<br />
Y3 Environment<br />
Y4 Public relation<br />
Y5 Self-Grow<br />
Y6 Happy optimistic<br />
Y7 Life satisfaction
Csikszentmihalyi, M.,(1990), Flow: The psychology of optimal experience. New York: Harper<br />
<strong>and</strong> Row.<br />
Diener,E.,Suh, E.M.,Lucas,R.E., & Smith,H.L.(1999)Subjective well-being:Three decades of<br />
progress. Psychological Bulletin, 125(2),276-302.<br />
Gilbert, D., & Abdullah, J. (2004).Holiday taking <strong>and</strong> the sense of well-being. Annals of<br />
<strong>Tourism</strong> Research, 31(1), 103-121.<br />
Hull IV, R. B. ,(1990), Mood as a product of leisure. Journal of Leisure Research , 22 , 99–<br />
111.<br />
Jackson, S.A. & Marsh, H.W. ,(1996), Development <strong>and</strong> validation of scale to measure<br />
optimal experience: the flow stats scale. Journal of Sport & Exercise Psychology,vol. 18,<br />
pp. 17-35.<br />
McBride-King, & Bachmann, K.,(1999), Is work-life balance still an issue for Canadians <strong>and</strong><br />
their employers? You bet it is! Ottawa: Conference Board of Canada.<br />
Pargament, K. I.,(1997), The psychology of religion <strong>and</strong> coping: Theory, research, practice.<br />
New York: Guilford.<br />
Robinson, J. P., & Godbey G.,(1997), Time for life: The surprising ways Americans use their<br />
time. University Park, PA: The Pennsylvania State University Press.<br />
Ryff, C. D. (1995). Psychological well-being in adult life. Current Directions in<br />
Psychological Science, 4, 99-104.<br />
Zuzanek, J., Smale, B. J. A.,(1997), More work-less leisure Changing allocations of time in<br />
Canada, 1981 to 1992. Society <strong>and</strong> Leisure , 20(1), pp. 73-106.
Segmenration <strong>and</strong> Positioning Products <strong>and</strong> Destinations in <strong>Health</strong> <strong>and</strong><br />
<strong>Wellness</strong> <strong>Tourism</strong><br />
Gabriela Cecilia Stanciulescu<br />
Academy of Economic Studies, Bucharest, Romania<br />
gabriela_stanciulescu@yahoo.com, gabriela.stanciulescu@com.ase.ro<br />
Elisabeth Molnar<br />
elis@remtours.ro<br />
Abstract<br />
Purpose. The proposed theme represents a new marketing approach of health <strong>and</strong> wellness<br />
tourism from the point of view of <strong>tourists</strong> segments taken into account <strong>and</strong> the products that<br />
are offered. In this particular case 20 distinct market segments emerged. Based on within<br />
cluster sum of squares the most homogeneous segments were identified . The author was<br />
seeking within cluster sum of squares to be as close to zero as possible indicating a tight<br />
spread around the centroid. In addition she was interested in clusters being as dissimilar to<br />
each other as possible in order to achieve heterogeneity across segments. A distinction when<br />
segmenting a market has to be made between the health <strong>and</strong> the wellness aspects. <strong>Health</strong><br />
tourism refers to those clients with medical conditions who would travel to experience healing<br />
therapies. A person who seeks a wellness travel experience, is generally <strong>healthy</strong> to start with,<br />
<strong>and</strong> seeks therapies to maintain his or her well being.<br />
Key words: Segmentation, Spa culture, Benefit based market<br />
Introduction<br />
Increased competition in health <strong>and</strong> spa tourism has rendered the tasks of market<br />
segmentation, market targeting <strong>and</strong> product positioning of paramount importance. Companies<br />
may gain sustainable competitive advantage through innovative segmentation of their<br />
markets. Distinct market segmentation provides a vehicle for directing one’s marketing efforts<br />
toward that narrower base of potential customers. The trick to marketing to a narrower base of<br />
customers is figuring out which narrow portion to market to. A market segmentation<br />
procedure that achieves such precision, yet has received scarce attention from marketing<br />
scholars is the benefit-based market segmentation schema.<br />
Benefit-based market segmentation involves segmenting the market for a product based on<br />
the intrinsic value that customers derive from the product. This intrinsic value (benefit) could<br />
take various forms such as snob appeal, perceived quality, or derived economy. This method<br />
of market segmentation is significantly different from other methods of market segmentation.<br />
It seeks to get "inside" the consumer=s cognitive processes <strong>and</strong> find out what the customer is<br />
feeling about our product, rather than arbitrarily identifying a consumer based on how much<br />
money she makes or where he lives. The underlying principle is that consumers do not seek a<br />
product per se, rather they seek what that product does for them, or the derived benefit. With<br />
benefit-based segmentation, the objective is to identify why the customer is buying the<br />
product, <strong>and</strong> group customers with similar whys together.<br />
European spa culture has its roots in ancient Babylon where the curative <strong>and</strong> purifying effects<br />
of water were already acknowledged <strong>and</strong> early spas developed. Similar developments are also
evident in Ancient Greece <strong>and</strong> Rome. Spa culture was highly appreciated in Rome where spas<br />
were the centres of leisure activities <strong>and</strong> socializing. Spa culture slowly spread to central-<br />
Europe, where spas were mainly used as places to socialise <strong>and</strong> for cleaning purposes. The<br />
use of mineral water, health <strong>and</strong> hot springs were known also in other cultures like the Mayas<br />
in South-America, the natives in North-America as well as in the Asian cultures where also a<br />
philosophical point of view played a big role in the practice. In the late 19th century, seaside<br />
holidays became fashionable again as the curative effects of mineral water were rediscovered.<br />
The spas became yet again places of social interaction. Switzerl<strong>and</strong> <strong>and</strong> the<br />
French Riviera established spas <strong>and</strong> sanatoriums before the world wars. Thalassotherapy<br />
(based on seawater) has become a major investment in France <strong>and</strong> also elsewhere in Europe<br />
<strong>and</strong> the USA the development <strong>and</strong> re-development of spas is noticeable. Since the beginning<br />
of the 21st century, wellness has become a global phenomenon which will most probably<br />
affect the development of tourism markets <strong>and</strong> the diversification of health related service<br />
provision, as well as will attract new customer segments.<br />
As a word “wellness” is still relatively young. In 1961 an American physician Dr Halbert<br />
Dunn, developed the term as a combination of the words “wellbeing” <strong>and</strong> “fitness”. Later the<br />
word was adapted in connection with some health related publications.<br />
<strong>Wellness</strong> concept <strong>and</strong> wellness tourism is an old traditions. In many ways, this is one of the<br />
most ancient forms of tourism if one considers the scrupulous attention paid to well-being by<br />
Romans <strong>and</strong> Ottomans, the quests for spiritual enlightenment of muslim pilgrims, or the<br />
medical seaside <strong>and</strong> spa tourism of the 18th <strong>and</strong> 19th century European élite.<br />
<strong>Health</strong> <strong>and</strong> wellness tourism is now an international trend set by the health conscious<br />
consumers seeking to enhance their well being through their travel experiences. This type of<br />
consumer seeks to look <strong>and</strong> feel better, to lose weight, to slow the effects of aging, to relieve<br />
pain or discomfort, to manage stress, or to partake in the use of natural supplements like<br />
vitamins <strong>and</strong> minerals to improve their health. Resorts <strong>and</strong> hotels are joining the health spa<br />
development craze, although only some resorts are moving into the scope of services<br />
currently offered by destination spas. Likewise, a growing number of day spas are adding<br />
health <strong>and</strong> wellness programming options.<br />
<strong>Wellness</strong> is first <strong>and</strong> foremost a choice to assume responsibility for the quality of your life. It<br />
begins with a conscious decision to shape a <strong>healthy</strong> lifestyle. <strong>Wellness</strong> is a mindset, a<br />
predisposition to adopt a series of key principles in varied life areas that lead to high levels of<br />
well-being <strong>and</strong> life satisfaction. A distinction is made between the health <strong>and</strong> the wellness<br />
aspects.
HEALTH<br />
TOURISM<br />
Provision of health<br />
facilities utilising the<br />
natural resources of<br />
the country, in<br />
particular mineral<br />
water <strong>and</strong> climate.<br />
<strong>Health</strong> tourism<br />
refers to those clients<br />
with medical<br />
conditions who<br />
would travel to<br />
experience<br />
therapies.<br />
healing<br />
SPA TOURISM WELLNESS TOURISM<br />
Spa tourism is widely<br />
acknowledged as a core<br />
element of the health <strong>and</strong><br />
wellness movement which<br />
covers a broad spectrum of<br />
holistic, curative <strong>and</strong><br />
preventative activities.<br />
<strong>Wellness</strong> can be defined as a<br />
balanced state of body, spirit <strong>and</strong> mind,<br />
including such holistic aspects as selfresponsibility,<br />
physical fitness/beauty<br />
care, <strong>healthy</strong> nutrition, relaxation,<br />
mental activity <strong>and</strong> environmental<br />
sensitivity as fundamental elements.<br />
<strong>Wellness</strong> is also viewed as a way of<br />
life, which aims to create a <strong>healthy</strong><br />
body, soul <strong>and</strong> mind though acquired<br />
knowledge <strong>and</strong> positive interventions.<br />
A person who seeks a wellness travel<br />
experience, is generally <strong>healthy</strong> to start<br />
with, <strong>and</strong> seeks therapies to maintain<br />
his or her well being.<br />
Some topics for spa sector:<br />
1. Spa centres are becoming more relevant to today's traveler. More people go to spas to<br />
improve their looks <strong>and</strong> well-being.<br />
2. Medical spas will provide the prescription for health <strong>and</strong> wellness ( health treatments,<br />
nutrition <strong>and</strong> fitness, health <strong>and</strong> wellness education.<br />
3. Spa experience will become more important in the corporate world. Mixing <strong>business</strong> with<br />
‘spa’ pleasure, <strong>business</strong>es will engage the use of spas to build relationships <strong>and</strong> motivate<br />
employees.<br />
4. The 'Hamam Spa Concept ' will become more famous in spa sector. Hamam Spas offer a<br />
holistic mind/body/spirit experience similar to experiences normally associated with<br />
resort/hotel/destination <strong>and</strong> day spas. Treatments will include cultural <strong>and</strong> social activities in<br />
addition to spa/beauty treatments. However, Hamam has unique concept with traditional<br />
treatments <strong>and</strong> its special structure.<br />
5. International spa tours will replace international spa treatments. Rather than seeking<br />
specific treatments from specific facilities, the international traveller will seek to sample a<br />
variety of spa experiences within the same destination.<br />
6. Spas will become the primary consideration for many travellers. In recent years the fastest<br />
growing segment of the hospitality industry was hotels with spas.<br />
Spa <strong>Tourism</strong> encompasses a number of different tourism experiences based on spa facilities<br />
that are specifically set up for clients to use on a daily basis (ie. no accommodation is<br />
provided).<br />
Destination spas – Resorts that offer a specific health program, with a focus on spa<br />
treatments. Clients stay at the facility <strong>and</strong> are provided with full board.
Resort spas – Sometimes called ‘amenity spas’, the spa treatments are part of a wider range of<br />
recreational activities offered by a resort or hotel. Other fitness <strong>and</strong> health programs are<br />
available but are optional – the emphasis is on leisure <strong>and</strong> wellbeing rather than health <strong>and</strong><br />
fitness.<br />
Other spa experiences include Cruise Spas (cruise ships set up with spa facilities), Club Spas<br />
(day spas with an emphasis on fitness), Golf Spas <strong>and</strong> Ski Spas. A very small but growing<br />
segment of the health tourism sector is dental tourism. Obviously this type of health tourism<br />
does carry with it some dangers.<br />
The newest phenomenon is the development of ‘Spa <strong>Tourism</strong>’, where the emphasis is on<br />
relaxation <strong>and</strong> beauty treatments. Spa resorts in fact have a long history – travellers have<br />
been attracted to mineral springs, which are often believed to have many healing properties,<br />
since the Roman era. ‘Taking the waters’ became a popular pastime amongst the middle <strong>and</strong><br />
upper classes in the 18th <strong>and</strong> 19th centuries in Britain <strong>and</strong> Europe. The latest revival in spa<br />
treatments began in the 1980s <strong>and</strong> continues to be a major sector of the health tourism<br />
industry.<br />
The turn of the century has produced concern about the future of the spa industry in its classic<br />
form as a component of a comprehensive health system; on the other h<strong>and</strong>, there is talk of a<br />
renaissance in which the spa industry becomes a fixed component of the hotel trade. Spa<br />
hotels, which up till now shared highly similar operational <strong>and</strong> <strong>business</strong> conditions, are<br />
worried about heretofore lucrative long-term stays, the loss of interest from the health care<br />
sphere, the loss of the possibility to generalize the results of spa treatment, as well as the loss<br />
of motivation by qualified health care providers. This trend concerns all traditional spa<br />
industry leaders. On the other h<strong>and</strong>, the spa industry is becoming a component of hotel<br />
services on a global scale. <strong>Wellness</strong> or spa operations are not missing from any newly opened<br />
“full-service/upscale” hotel, hotel lines are adding spa facilities, <strong>and</strong> “spa br<strong>and</strong>s” are being<br />
franchised. On one h<strong>and</strong> traditional spa hotels fear sophisticated competition, while on the<br />
other they could capitalize on the fact that consumers already consider spa services to be<br />
st<strong>and</strong>ard offerings <strong>and</strong> that these consumers have become accustomed to them <strong>and</strong> are<br />
familiar with individual procedures. The traditional facilities are attempting to set themselves<br />
apart from the competition <strong>and</strong> maintain a hallmark of exclusivity in various manners such as<br />
employing the appellation of “medical wellness,” certificates, <strong>and</strong> so on. Nevertheless, they<br />
need to be careful. Following this unprecedented boom the market appears to be saturated <strong>and</strong><br />
the tide of services <strong>and</strong> new ideas is slowing; many trends in tourism are going in a single or<br />
opposite direction.<br />
<strong>Health</strong> tourism ranges from travel experiences that offer relaxation <strong>and</strong> promote a general<br />
sense of well-being (eg. health farms <strong>and</strong> spa resorts) to travel that is for specific medical<br />
reasons (eg. to obtain cosmetic surgery). Most people participate in health tourism for one or<br />
more of the following reasons:lose weight, quit smoking or conquer some other addiction,<br />
become fitter, become less stressed, gain physical flexibility, improve digestion <strong>and</strong><br />
circulation, gain a more positive outlook on life, improve their appearance.<br />
<strong>Health</strong> tourism tends to appeal to the upper end of the market, with many luxury hotels <strong>and</strong><br />
resorts tapping into this lucrative market. Clients are generally affluent, female <strong>and</strong> middle<br />
aged. Most are private clients, although the corporate market is exp<strong>and</strong>ing in many areas.
<strong>Health</strong> resorts became popular during the 1970 <strong>and</strong> 80s. They were often called ‘health<br />
farms’, because they were located in the countryside (where clients could not be tempted by<br />
nearby shops selling forbidden food). Typically they offered a strict fitness program <strong>and</strong><br />
dietary regime (usually vegetarian <strong>and</strong> no alcohol) so that clients would feel fitter, cleaner <strong>and</strong><br />
thinner after a week or so of the treatment. Nowadays, they are more often called ‘health<br />
resorts’, which reflects the emphasis on having a <strong>healthy</strong> holiday in an attractive setting.<br />
Many facilities <strong>and</strong> services are offered at health resorts – from horse riding <strong>and</strong> meditation,<br />
to massage <strong>and</strong> bushwalking.<br />
Findings, limitations <strong>and</strong> future research. Based on the study, the paper reveals 20 segments<br />
<strong>and</strong> several trends that will highly influence this type of tourism. During the course of<br />
implementing this research, several limitations became apparent. First, my data was obtained<br />
late in the season (in the face of severe winters in the local area) <strong>and</strong> as a result spa tourism<br />
visitation numbers were lower than normal. Sampling errors might have crept in. Second,<br />
there were no past studies available to compare our results across samples or alternate<br />
segmentation models. Use of a cluster analytic model imposes certain limitations on our<br />
findings. First, the data set that is utilized when performing cluster analysis needs to be one of<br />
perfection (Milligan 1980). There is no provision in the cluster analysis procedure for missing<br />
values. Secondly, the need for superior computing power arises when conducting this type of<br />
analysis.<br />
Originality. This study provides an alternative to conjoint analytic models of benefit-based<br />
market segmentation, namely a multivariate cluster analytic model. It will be soon seen that<br />
this model is easy to comprehend, relatively effortless in application, <strong>and</strong> involves the<br />
managers responsible for product strategy formulation in interpretation of results. The<br />
cooperative efforts of managers <strong>and</strong> researchers strengthen the validity of results <strong>and</strong> findings.<br />
Past research has shown that the benefits consumers derive from various product <strong>and</strong> service<br />
attributes are powerful discriminatory variables for market segmentation (Haley 1968; Wind<br />
1978). However, the large numbers of such models merely confuse <strong>and</strong> frustrate both<br />
researchers <strong>and</strong> practitioners.<br />
Prior Research<br />
Past research has shown that the benefits consumers derive from various product <strong>and</strong> service<br />
attributes are powerful discriminatory variables for market segmentation (Haley 1968; Wind<br />
1978). Traditionally marketing scholars have restricted benefit-based market segmentation<br />
schema to conjoint analytic models (DeSarbo, Oliver, <strong>and</strong> Rangaswamy 1989; De Soete <strong>and</strong><br />
DeSarbo 1991; Green <strong>and</strong> Krieger 1991; Kamakura 1988; Wittink, Vriens, <strong>and</strong> Burhenne<br />
1994). There are several two-stage conjoint models in use to facilitate benefit-based market<br />
segmentation. However, the large numbers of such models merely confuse <strong>and</strong> frustrate both<br />
researchers <strong>and</strong> practitioners. Consequently, conjoint analytic segmentation models are<br />
largely chosen based on availability of expertise <strong>and</strong> software, coincidental acquaintance with<br />
scholars or algorithms, or personal preferences. The concern for strengths <strong>and</strong> weaknesses of<br />
models of choice <strong>and</strong> the propriety of use of a specific model for a specific application are<br />
often ignored. One can't help but notice the irony of picking an analytic tool to segment<br />
market by derived benefit based on factors other than product attributes <strong>and</strong> true benefits!<br />
This study provides an alternative to conjoint analytic models of benefit-based market<br />
segmentation, namely a multivariate cluster analytic model. We will soon see that this model<br />
is easy to comprehend, relatively effortless in application, <strong>and</strong> involves the managers<br />
responsible for product strategy formulation in interpretation of results. The cooperative<br />
efforts of managers <strong>and</strong> researchers strengthen the validity of results <strong>and</strong> findings. A cluster
analytic model has several methodological advantages. Firstly, the advantage of not<br />
depending on unreliable individual-level estimates of benefits based on any subjective a<br />
priori segmentation scheme, as often seen in conjoint analytic models founded on Hagerty's<br />
(1985) two-stage procedures. Secondly, conjoint models often suffer from insufficient degrees<br />
of freedom that may lead to incorrect part worth estimates <strong>and</strong> misclassification of subjects<br />
(Kamakura 1988; Umesh <strong>and</strong> Mishra 1990). As we will see, a cluster analytic model allows<br />
for ample degrees of freedom provided the sample size is adequate. Thirdly, cluster analytic<br />
models don't face identification problems often witnessed in alternative models that<br />
overparametrize degenerate solution. A related issue thus involves respondent fatigue<br />
associated with conjoint specific data collection procedures. Often the task of attribute<br />
weighting, attribute-level determination, <strong>and</strong> preference statements <strong>and</strong> ratings can be<br />
foreboding for most respondents. In a cluster analytic model interval level data is obtained<br />
with relatively negligible respondent burden, further strengthening the validity of results<br />
obtained.<br />
Theoretical Rationale<br />
A cluster analytic model of benefit-based segmentation is concerned with devising a<br />
methodology of segmenting a very large <strong>and</strong> diverse potential market, through the use of a<br />
statistical algorithm, with the application of very specific benefit-oriented finite variables. In<br />
the search for narrow <strong>and</strong> specific segments there are three criteria that need to be satisfied,<br />
homogeneity within the segment, <strong>and</strong> heterogeneity across the segments, <strong>and</strong> aggregation<br />
throughout segments. Homogeneity within the segment is critical to defining the target<br />
customer. In the case of a benefit-based segmentation scheme, customers that derive the most<br />
similar benefits would be grouped in one segment. For instance, in the leisure <strong>and</strong> recreation<br />
industry it is a common practice to group customers who have young children <strong>and</strong> those that<br />
are on a tight budget. In this case, the common desired benefit being sought is economy.<br />
Heterogeneity across the segments allows for the differentiation of segments <strong>and</strong> consumers.<br />
If two customers have very different needs, such as economy <strong>and</strong> snob appeal, they would be<br />
grouped in two very heterogeneous segments. By making the segments as heterogeneous as<br />
possible, the company ensures that marketing resources are utilized efficiently. Finally,<br />
aggregation is the process by which customers are grouped together. Segmentation was once<br />
thought of as being a desegregation of customers, on the contrary, the objective is to group<br />
them together for the most effective targeting, not separate them out to be targeted separately.<br />
The process of aggregation is expected to result in market segments that satisfy the<br />
aforementioned twin qualifications of homogeneity within <strong>and</strong> heterogeneity across segments.<br />
Methodological Rationale <strong>and</strong> Case Study<br />
The rationale behind the use of cluster analysis ties in very closely to the rationale for market<br />
segmentation. Cluster analysis seeks to organize information about variables so that relatively<br />
homogeneous groups, or clusters, can be formed (Anderson 1984; Dillon <strong>and</strong> Goldstein 1984;<br />
Lance <strong>and</strong> Williams 1967). Similar to market segmentation, the clusters that are formed<br />
should be highly internally homogeneous as well as externally heterogeneous as the groups<br />
should be as dissimilar as possible. Cluster analysis, like market segmentation, is also a<br />
gathering process, since responses are grouped together based on likeness of variables<br />
(Joreskog 1977). Cluster analysis performs agglomerative hierarchical clustering of data in<br />
order to classify observations into prima fascia unknown groups. Observations are aggregated<br />
in a stepwise fashion. Each successive step reduces the number of clusters by one. Similarity<br />
<strong>and</strong> distances are computed based on the scale on which distances are defined <strong>and</strong> the<br />
methods of linking researchers prescribe (Morrison 1976). In this research, a market in the<br />
leisure <strong>and</strong> recreation industry is segmented via the use of a computer-based segmentation
procedure using multivariate cluster analysis. Data was collected from a local spa tourism in<br />
the Midwest <strong>and</strong> cluster analysis was used to create a multivariate model to achieve a very<br />
precise grouping of responses. Findings indicate that the resultant market segments were<br />
clearly identifiable <strong>and</strong> valid. Results obtained from the study have resulted in strategic<br />
planning initiatives enhancing customer visitation <strong>and</strong> satisfaction.<br />
A preliminary draft of the data collection instrument was pre-tested with undergraduate<br />
students <strong>and</strong> the spa tourism management. The final product turned out to be a rather well<br />
formatted <strong>and</strong> concise questionnaire consisting of 26 items covering a range of topics that<br />
pertained to the spa tourism <strong>and</strong> strategic issues facing the management of premises. The data<br />
was procured from a convenience-based r<strong>and</strong>om sample of <strong>tourists</strong> at the local spa tourism<br />
destination. Personal interviews in a mall-intercept fashion were conducted. A high response<br />
rate was made possible through personal interviews assuring respondents of anonymity,<br />
stating the contribution of the study in improving their future visits to the spa tourism, <strong>and</strong><br />
offering a token incentive for participation in the study. A total of 743 surveys were returned<br />
out of a possible 1100 (response rate 67.55%). Descriptive statistics (the frequencies in our<br />
case) on the sample profile indicate that 56.28% of the people visiting the spa tourism were<br />
female, while 43.44% were male. The largest number (38.16%) of visitors fell between the<br />
ages of 25-39. Twenty-two percent of the visitors make between $100 <strong>and</strong> $1,000 annually.<br />
The majority of <strong>tourists</strong>, 51.98% are married, while 37.71% reported being single. People<br />
with children accounted for 57.69% of all visitors, 36.14% had two children (under 18) in<br />
their home. 62.76% of the visitors reside within the county <strong>and</strong> 45.11% travelled less than 200<br />
km. to get the spa tourism. The typical visitor is a married female, with 2 children, has an<br />
income between $300 <strong>and</strong> $3,000, <strong>and</strong> travels less than 200 km to get to the spa tourism.<br />
Table 1 Number of Observations Within Cluster Sum of Squares<br />
Segments Number of Observations Sum of Squares<br />
Cluster 1 20 200.000<br />
Cluster 2 24 240.000<br />
Cluster 3 38 380.000<br />
Cluster 4 25 250.000<br />
Cluster 5 28 28 0.000<br />
Cluster 6 1 10.000<br />
Cluster 7 22 22 0.000<br />
Cluster 8 25 250.000<br />
Cluster 9 11 110.000<br />
Cluster 10 50 500.000<br />
Cluster 11 10 100.000<br />
Cluster 12 31 310.000<br />
Cluster 13 20 200.000<br />
Cluster 14 35 350.000<br />
Cluster 15 20 200.000<br />
Cluster 16 12 120.000<br />
Cluster 17 8 80.875<br />
Cluster 18 27 270.000<br />
Cluster 19 138 138206.174<br />
Cluster 20 176 176216.875
From this survey, we selected several questions that depicted benefits that the spa tourism<br />
visitors might derive from the spa tourism. These selections ultimately became the variables<br />
that were used in the cluster analysis. One of the issues facing the spa tourism was to ascertain<br />
the profitability <strong>and</strong> feasibility of introducing information programs about environment <strong>and</strong><br />
spa benefits, <strong>and</strong> their coexistence on premises. The concern was to determine if there was a<br />
sizable portion of the market that sought the benefit of viewing the spa tourism as an<br />
interactive opportunity for their general wellbeing. In order to aid the decision making<br />
process, three variables that dealt with income levels, number of persons in the household,<br />
<strong>and</strong> willingness to support an information program at the spa were analyzed using the<br />
multivariate cluster analytic model. After the cluster analysis was run, a graph or Dendrogram<br />
was produced that graphically depicted the clusters that we were seeking. The next step is<br />
often referred to as 'cutting the Dendrogram' (Johnson <strong>and</strong> Wichern 1988; Milligan 1980).<br />
Clusters are identified <strong>and</strong> cut based on a Cut or Amalgamation Statistic provided by the<br />
procedure <strong>and</strong> researcher judgement (Morrison 1976).<br />
In this particular case 20 distinct market segments emerged. Based on within cluster sum of<br />
squares the most homogeneous segments were identified (Table 1). We were seeking within<br />
cluster sum of squares to be as close to zero as possible indicating a tight spread around the<br />
centroid. In addition we were interested in clusters being as dissimilar to each other as<br />
possible in order to achieve heterogeneity across segments. We use the distances between<br />
cluster centroids to ensure heterogeneity. Although we now have very distinct clusters, or<br />
segments, the task of segmenting the market is far from complete. The final steps that need to<br />
be taken involve the application of the initial variables to the clusters <strong>and</strong> the decision making<br />
process about what the clusters actually mean. Labels accorded to each segment are largely<br />
based on inputs obtained from spa tourism management. Eventually, based on management<br />
input two feasible segments emerge which seeks the benefits offered by an information<br />
program at the spa premises.<br />
Limitations <strong>and</strong> Future Research<br />
During the course of implementing this research project several limitations became apparent.<br />
First, our data was obtained late in the season (in the face of severe winters in the local area)<br />
<strong>and</strong> as a result spa tourism visitation numbers were lower than normal. Sampling errors might<br />
have crept in. Second, there were no past studies available to compare our results across<br />
samples or alternate segmentation models. Use of a cluster analytic model imposes certain<br />
limitations on our findings. First, the data set that is utilized when performing cluster analysis<br />
needs to be one of perfection (Milligan 1980). There is no provision in the cluster analysis<br />
procedure for missing values. Secondly, the need for superior computing power arises when<br />
conducting this type of analysis.<br />
The lack of a direct comparison between conjoint <strong>and</strong> cluster analysis is a weakness that was<br />
unavoidable in our study. It was not possible to procure the data necessary to perform a<br />
conjoint analysis <strong>and</strong> the cluster analysis without angering our respondent base. Duplication<br />
of information throughout the sample would have been necessary in order to overcome<br />
validity issues raised by comparing models across two samples. One would always doubt if<br />
results were indeed dissimilar due to differences in models or because of differences in<br />
sample. The need for specialized data to run conjoint - based models further illustrate the ease<br />
with which multivariate cluster analysis can be performed with rather simple data from a<br />
st<strong>and</strong>ardized <strong>and</strong> versatile questionnaire.
In summary, we have presented a statistical model using multivariate cluster analysis as a<br />
possible alternative to the error prone conjoint model of benefit-based market segmentation.<br />
This model, if proven effective, could be applied to other <strong>business</strong>es <strong>and</strong> industries. In the<br />
instance of the case study that was performed several distinctive clusters were obtained. These<br />
clusters exhibited the traits that are desired in market segments B homogeneity within the<br />
segment <strong>and</strong> heterogeneity across the segments. However, given the very infantile nature of<br />
this type of statistical theory, there is much work to be done in getting to the point where<br />
multivariate cluster analysis is a reliable <strong>and</strong> accepted method for producing benefit-based<br />
market segments.<br />
References<br />
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Conjoint Experiments," Journal of Marketing Research, 25 (May), 157-67.<br />
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Strategies, I. Hierarchical Systems," Computer Journal, 9, 373-380.<br />
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Morrison, D. (1976), "Multivariate Statistical Methods," McGraw-Hill. Umesh, U. N. <strong>and</strong><br />
Sanjay Mishra (1990), "A Monte Carlo Investigation of Conjoint Analysis Index-of-Fit:<br />
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<strong>and</strong> Power," Psychometrika, 55 (1), 33-44.<br />
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in Marketing, 11 (1), 41-52.
Gulliver in the l<strong>and</strong> of giants?<br />
The opportunities of the Hungarian initiations in the surgical medical<br />
touristic market<br />
Ivett Sziva<br />
Corvinus University of Budapest, Management <strong>and</strong> Business Administration Doctoral School,<br />
Institute of Business Economics<br />
Fővám tér 8, 1093 Budapest, Hungary<br />
ivett.sziva@uni-corvinus.hu, ivett.sziva@gmail.com<br />
Abstract<br />
Medical tourism seems to be one of the most dynamically growing segments of health<br />
tourism, what is more it is evaluated as “wonder-niche” product by the rest of the destinations<br />
in trouble because of the economic downturn. However lots we hear about the area called<br />
medical or surgical or clinical or health-related tourism, the definitions are not clear, nor the<br />
measurement of the volume. Moreover there are several challenging questions regarding<br />
quality factors of services, management of the seamless process of care, <strong>and</strong> liability issues in<br />
the area. There are two main aims of the paper. Firstly to give an academic perspective, what<br />
might be useful for the practice about the most challenging questions of surgical medical<br />
tourism, like definition, dimensions of competition, <strong>and</strong> service process management.<br />
Secondly to map the Hungarian surgical medical touristic market in the framework of an<br />
exploratory research based on content-analysis <strong>and</strong> experts’ interviews in order to give<br />
recommendations for the development.<br />
Keywords: health tourism, medical tourism, private clinic, public hospital, Hungary<br />
Introduction<br />
The phenomena of traveling abroad for medical treatments is not new, as wealthy patients<br />
from less-developed countries traveled for cure to European <strong>and</strong> American clinics even in the<br />
19. century. Nowadays the flow of medical tourism became more complex. The successstories<br />
of the top Asian destinations show enormous change in the supply-side, <strong>and</strong> raise the<br />
question of the changes affecting the dem<strong>and</strong>-side as well. The picture is more tinged if we<br />
have a look on the crowds traveling from the USA to have different (by not all means<br />
cheaper) treatments to other continents, though USA still seems to be the greatest exporter<br />
regarding health-related services (OECD 2009). Among the driving forces of medical tourism<br />
nowadays we can find the overburdened health-care systems, as well as ‘greying’ societies<br />
<strong>and</strong> celebrity culture or differences in technology <strong>and</strong> prices, <strong>and</strong> last but not least, the<br />
blurring in health touristic services, <strong>and</strong> the need for holistic services. The paper focuses on<br />
the definitional issues, as well as the dimensions of competition in order to map the success<br />
factors of medical touristic services. This kind of summary was essential to give a proper<br />
picture of the Hungarian medical tourism. Hungary has rather strong position in the surgical<br />
medical touristic markets in certain areas, but seems to be a “silent Gulliver” as whole, since<br />
the individual, <strong>and</strong> isolated players put the country to the map of medical tourism h<strong>and</strong>ling<br />
their selling chains successfully, without making great above the line promotions. The aim of<br />
the paper to analyze the definitional issues in the regard of Hungary based on the international<br />
definitions, <strong>and</strong> to look in the success factors of the Hungarian players in order to give<br />
recommendations for further development.
A border-less product?<br />
Defining <strong>and</strong> measuring medical tourism<br />
Medical tourism is a dynamically growing segment of health tourism, which commonly<br />
known as including all the forms of traveling for cure <strong>and</strong> prevention. <strong>Health</strong> tourism can be<br />
divided to two parts, to wellness <strong>and</strong> medical tourism. Medical tourism could be further<br />
decomposed: Puczkó - Smith (2008) has broken medical tourism down into therapeutic<br />
tourism (based on natural healing resources), <strong>and</strong> surgical tourism (mostly traditional Western<br />
medicine is used). The authors point out an important trend of the holistic concept of<br />
wellness, what gains ground in every area of health tourism. The commonly known definition<br />
of medical tourism relates to the surgical tourism defined above, as the point of these overall<br />
definitions is: traveling to abroad to obtain medical services as dental <strong>and</strong> surgical care<br />
(Deloitte 2008, OECD 2009), but complex packages can be made with alternative treatments<br />
based on natural resources (ESKI 2009, Youngman 2009).<br />
Defining surgical tourism in details is important regarding the confusion of statistics: some of<br />
the experts estimate that 10 million travelers seek for cure abroad, other study (McKinsey<br />
2008) restricts this amount to 85 thous<strong>and</strong>s worldwide. One of the official statistics in the area<br />
is that of OECD (2009), which is based on the balance of payments item called “<strong>Health</strong>related<br />
travel”, what includes the medical trips with the first motivation of curing, <strong>and</strong> spatravel<br />
also. According to these official statistics, USA is the largest exporter of health-related<br />
services (2,3 billion USD in 2007), followed by Czech Republic (481 million USD), Turkey<br />
(489 million USD), Belgium, Mexico, Italy <strong>and</strong> Hungary (211 million USD). Among the<br />
greatest importers (source markets) we face Germany, USA, Netherl<strong>and</strong>s, Canada, Belgium<br />
<strong>and</strong> Austria. The main question behind the statistics is who can be considered as medical<br />
<strong>tourists</strong> <strong>and</strong> how to measure their flow. Taking the exact definition of McKinsey (2008) as a<br />
starting point, <strong>and</strong> looking into the criticism of that (Youngman 2009) summarized in Table 1,<br />
the following definition could be given, based on the general definition of tourism (travel<br />
lasting more than 24 hours, but less than one year, including touristic services), <strong>and</strong> taking a<br />
st<strong>and</strong> on the debate:<br />
Table 1. The characteristics <strong>and</strong> the dimensions of medical tourism<br />
Dimensions Statement<br />
(McKinsey)<br />
Evaluation (Youngman)<br />
1. Length of stay in hospital Only inpatients In- <strong>and</strong> outpatients<br />
2. Main motivation Only<br />
travel<br />
for medical Mixed motivations<br />
3. Emergency included No emergency No emergency<br />
4. Expatriates included No expatriates No expatriates<br />
5.Trip to neighboring Excluded Included<br />
countries<br />
6. Type of treatments Western medicine Holistic view, alternative methods<br />
inc.<br />
7. Estimated volume of the 85.000 worldwide 5 millions worldwide (America<br />
market (touristic arrival)<br />
600 ths, Europe 1,75 millions, Asia<br />
2,25 millions)<br />
Medical trips to abroad with the voluntary (main or part) motivation of obtaining medical<br />
health services based on particularly Western medicine, which might include alternative<br />
healing methods as well as outpatient surgeries, but excludes treatments for expatriates <strong>and</strong>
emergency cases. As the commonly known medical tourism definition overlaps or equals to<br />
that of surgical tourism, so the terms will be used as synonyms in the following.<br />
The dimension of the competition<br />
The features of the medical touristic market<br />
Being medical tourism a promising niche-segment of tourism, newer <strong>and</strong> newer destinations<br />
appear in the competition, mainly in the most popular outpatient surgeries area, at dental <strong>and</strong><br />
cosmetic treatments. Among the commonly known medical-hubs (eg. Asian countries, USA,<br />
Spain, Belgium) other rising European destinations (Cyprus, Czech Republic, Pol<strong>and</strong>, Croatia,<br />
Bulgaria, <strong>and</strong> Hungary) should be analyzed to get a total picture. An analysis was carried out<br />
(summary can be seen in Appendix 1.) based on studies (Deloitte 2009, ESKI 2009, Medical<br />
<strong>Tourism</strong> Association 2009), as well as researching the web-appearance of the destinations,<br />
<strong>and</strong> having experts interview.<br />
Four different segments can be created among the analyzed countries, particularly based on<br />
the factors of the prices, the know-how <strong>and</strong> the volume of the market. The below expressed<br />
categories can be named as the development phases of medical tourism as well:<br />
• Premium category based on high level know-how: USA <strong>and</strong> Germany plays in the<br />
first, premium category, where competition is fueled by innovation <strong>and</strong> high-tech,<br />
with high price-level generally or in certain areas.<br />
• Medium category with permanent patient flow, <strong>and</strong> professional market behavior:<br />
Spain, Belgium, Cyprus belongs to the second middle-segment, regarding prices <strong>and</strong><br />
technology, where strong market-ties, as well as accreditation seems to be important.<br />
High volume of patients flow is assured by the professional seamless service.<br />
• Countries with price-advantage <strong>and</strong> industrialized medical tourism: Asian countries<br />
can be featured by “industrialized” medical tourism, which is due to the costadvantage,<br />
as well as the powerful state subsidies (investments, marketing). The Asian<br />
countries use their traditional national healing methods for differentiation, what is an<br />
example to be followed.<br />
• Countries with price advantage <strong>and</strong> bottom-up initiations: The Central European<br />
countries use out their cost-advantage <strong>and</strong> the historic market contacts. It seems that<br />
isolated initiations are the typical in these countries. Differentiation is really rare<br />
mostly in Central-Europe, what can cause price-competition in the future.<br />
Among the main source market of medical tourism USA, Middle-East, Germany <strong>and</strong> UK can<br />
be pointed out based on the estimations (McKinsey 2009, Harryono, M. et al. 2006). In these<br />
countries the main driving force is the overburdened healthcare system, or <strong>business</strong>-type<br />
insurance, excepting Middle-East, where the lack of the highly sophisticated technology is the<br />
main reason. Elective treatments seem to be the most popular products, but orthopedics, as<br />
well as cardiology appears regularly. In addition to price-conditions, the holiday-programs of<br />
the chosen destination is crucial for the British <strong>and</strong> Americans, in Germany the financing<br />
conditions of the insurance institutions seems to be essential, while Islamic patients have<br />
special cultural needs (e.g. alcohol-free medicines, great rooms to receive lot of visitor). The<br />
summary of the features of the most significant source markets can be seen in Appendix 2.
The quality <strong>and</strong> management issues<br />
There are only a few researches regarding how the medical <strong>tourists</strong> make their travel decision,<br />
<strong>and</strong> what quality actually mean for them, but according to them it can be stated that the<br />
touristic resources are almost as important for <strong>tourists</strong> as the quality of medical services<br />
(Crompton 2008, McKinsey 2008).<br />
Table 2. The main factors of medical travel decision<br />
Medical factors Touristic factors<br />
� Reputation <strong>and</strong> skills of the � Reputation as a touristic<br />
doctors<br />
destination<br />
� Results of the medical treatments � Price of the trip<br />
� Price of the treatments<br />
� Developed infrastructure<br />
� Insurance <strong>and</strong> guarantee<br />
� Cultural closeness<br />
� Follow-up <strong>and</strong> supporting services � Safety <strong>and</strong> stability<br />
� Foreign language skills<br />
Responding to the dem<strong>and</strong>s’ requirements, the following steps are (or should be) taken by the<br />
medical service suppliers, based on the results of experts’ researches (McKinsey 2008,<br />
Johnson 2010, Youngman 2008) as well as guidelines of concerned institution (AMA 2009).<br />
• Transparency: proper <strong>and</strong> honest information about the results (number of<br />
complications, unsuccessful cases), policy of guarantees is crucial information<br />
regarding travel decision.<br />
• Quality control - accreditation: A debate lies in the question of accreditation: some<br />
practitioners find it as an unnecessary process, as price <strong>and</strong> reputation are the key<br />
issues, others think, it is really important regarding marketing <strong>and</strong> operation<br />
effectiveness.<br />
• International network - seamless services: The key issue regarding medical trips is to<br />
assure the feeling of permanent safety, care, <strong>and</strong> well-being, so highly personalized<br />
services (transfer, hostess, assistance services, <strong>and</strong> interpreter) are essential. The<br />
greatest challenge is to solve the pre-travel <strong>and</strong> the follow-up services in the mother<br />
country, <strong>and</strong> the opinion of the Hungarian medical facilitator will be expresses in<br />
Chapter 3. It can be seen, that managing the seamless process needs professional<br />
facilitators, though the process of des-intermediation appeared in medical tourism as<br />
well, due to the internet.<br />
• Insurance: Having long-run contacts with the private or public insurance companies<br />
seems to be a driving factor of the success. In the USA several insurance companies<br />
started to introduce mini-mad plans for overseas healthcare. There are governmental<br />
initiations in the UK as well as in Germany to finance publicly those treatments<br />
abroad, which are unsolvable at home. In the EU steps are taken to ease the process of<br />
patients’ mobility, so that the EU-citizens could obtain for publicly financed<br />
treatments in another EU-country. Insurance is an important question regarding<br />
liability issues: there is a shortage in travel insurance including medical services.<br />
The following figure summarizes the factors influencing the success, <strong>and</strong> the players of<br />
medical tourism, highlighting destination management organizations (DMOs) <strong>and</strong> the<br />
institutions for cooperation (IFCs, e.g. chambers, research institutions).
Figure 1. The main factors of quality <strong>and</strong> management of medical tourism<br />
Case study of Hungary<br />
Hungary can be called as the “silent Gulliver” of the medical touristic market, as the country<br />
makes a lot less noise than the others, but the number of the medical touristic arrivals near<br />
those in Asian countries (Youngman 2009). Three main questions arises regarding the<br />
statement: firstly how medical tourism can be defined in the case of Hungary, secondly what<br />
is the structure <strong>and</strong> volume of the medical touristic market of Hungary <strong>and</strong> whether making<br />
less noise helps retaining competitiveness, or other steps are needed. Due to the exploratory<br />
nature of the study the qualitative case study methodology was chosen. To assure<br />
triangulation, the information was gained from the following sources: 1. Secondary sources<br />
(studies, articles); 2. Content analysis of the webpages of the service providers; 3. openstructured<br />
interviews with experts from different areas (Hungarian <strong>Health</strong>care Ministry, <strong>and</strong><br />
Research Institute, leader of international medical touristic facilitators, private clinics).<br />
Defining medical tourism in Hungary<br />
It is particularly important to differentiate surgical tourism from therapeutic tourism in the<br />
pool of medical tourism in Hungary, as the latest is commonly known even in the touristic<br />
industry as medical tourism related to treatments based on healing or thermal water, <strong>and</strong> the<br />
surgical part of the product got less or hardly no common interest until the last year. The main<br />
reason for this is that the culture of thermal-water baths is nearly 2000 years old, <strong>and</strong> the<br />
country is one of the richest areas with medical <strong>and</strong> thermal water in the world. That is why<br />
the commonly known idea of health tourism is nearly equal to thermal tourism, <strong>and</strong> however<br />
we can face dynamic development of wellness tourism, the phenomena usually far away from<br />
the international concept of holistic wellness. Thermal tourism was the main focus of the<br />
governmental subsidies, as well as the national communication during the development of<br />
health tourism in the last 10 years. Nowadays the importance of surgical tourism was realized,<br />
<strong>and</strong> some funds were opened in 2009 (mainly for municipalities) to develop infrastructure,<br />
<strong>and</strong> the issue got into the focus of the Hungarian National Touristic Office (HNTO) in the<br />
latest years, mainly in dental segment, particularly in Germany. In the surgical medical<br />
touristic market of Hungary it is important to divide the market to private clinics <strong>and</strong> state<br />
hospitals, regarding the different significance <strong>and</strong> management issues of the areas.<br />
Summarizing the definitional questions, from the scope of the structure <strong>and</strong> volume, three<br />
different service-segments are significant in Hungary: I. therapeutic medical touristic market,<br />
II. surgical medical touristic market: 1) operated by private sector, 2) operated by public<br />
sector.
The scope of the medical touristic market <strong>and</strong> implications<br />
Regarding the success factors of the overall touristic sector highlighted in Figure 1., the state<br />
of the Hungarian touristic sector seems to be good enough to assure basis for medical tourism.<br />
Considering the latest results of Travel & <strong>Tourism</strong> Competitiveness Index (TTCI, WEF 2009)<br />
Hungary was in the first third part of the ranked 133 countries regarding the rest of the factors<br />
in question. The state of the airport infrastructure should be pointed out, as it got the lowest<br />
score of 3,0 (from7). The bad score can be explained by the fact that there is only one<br />
significant international airport in Hungary, <strong>and</strong> the frequencies of the airlines were reduced<br />
in the latest years (affecting particularly badly the surgical touristic players).<br />
Therapeutic medical touristic market<br />
Hungary can be evaluated as a Great Power regarding the thermal <strong>and</strong> healing water resources<br />
as it possesses nearly 1300 thermal springs, among what 300 are used for bathing. The scope<br />
of the healing waters is uniquely wide, <strong>and</strong> assures cure for orthopedic-, rheumatologic-,<br />
cardiologic-, dermatologic-, <strong>and</strong> gynecological diseases. The therapeutic touristic market<br />
generated a turnover of 147 million EUR in 2008 (ESKI 2009). Though Hungary has a great<br />
tradition in therapeutic tourism, the question is whether the infrastructure of thermal baths <strong>and</strong><br />
spa hotels can keep up with the newest trends dem<strong>and</strong>ing traditional therapies in a more<br />
holistic view of well-being. A shocking result of the research of Techniker Krankenkasse<br />
(German health insurer, Mezősi (2009)), investigating the opinions of German travelers raises<br />
serious questions regarding this issue. The rest of <strong>tourists</strong> (80%) were satisfied with the<br />
amenity services <strong>and</strong> leisure activities in Hungary but only 50% of them were content with the<br />
therapeutic treatments, <strong>and</strong> ca. 35% with the medical supervision.<br />
In order to give a picture of the therapeutic touristic infrastructure a content analysis was<br />
done. The r<strong>and</strong>om sample (every fifth of the sites) was chosen out from the database of the<br />
HNTO (2010) containing 85 thermal baths, 52 spa hotels <strong>and</strong> 10 spa hospitals. The analysis<br />
focuses on the features of the medical <strong>and</strong> wellness facilities of the service providers. All the<br />
analyzed thermal baths possess thermal pool (100%), further on balneo-fiziotherapy are quite<br />
regular (45%) but medical supervision is rare (20%), while complementary wellness services<br />
appear at 45% of the baths, but alternative healing methods are missing. In the spa hotels,<br />
medical services – particularly rehabilitation of orthopedic-, rheumatologic diseases – are<br />
common as well as healing water baths, balneo-fiziotherapeutic treatments, diagnostic<br />
sections, while clinical services appeared at 30% of the hotels. Avarage wellness services (e.g.<br />
sauna, pampering) are regular, while alternative methods (e.g. Ayurveda) are rare. The main<br />
orientation of the analyzed spa hospitals was rehabilitation, angiology, gastroenterology, <strong>and</strong><br />
gynecology. Summarizing the results it can be said, that the Hungarian therapeutic touristic<br />
infrastructure is well-developed to serve the mass medical tourism dem<strong>and</strong>ed by elderly<br />
patients. In order to meet the needs of the 50+ segment, innovation <strong>and</strong> up-to-date services, as<br />
well as well-defined atmosphere are needed, <strong>and</strong> serious specialization should be done to<br />
serve younger people with the need for lifestyle therapies, or cure for special diseases.<br />
Therapeutic tourism is one the key issues of the Hungarian touristic development as well as<br />
promotion with the aim of becoming the “Pannon Healing Power” of Europe according to the<br />
National <strong>Health</strong> Touristic Strategy (OEFS 2007). However we have great comparative<br />
advantages based on natural resources, the location-based special, innovative treatments are<br />
missing, as well as the up-to-date holistic atmosphere of the spas. That is why, the strategy<br />
gives priority to product-development, R+D <strong>and</strong> qualification (OEFS 2007). Unique products<br />
could be developed in the area of thermal <strong>and</strong> healing water, medicinal plants, or the special<br />
area called hypo-therapy. This kind of innovative treatments could mean unique attractiveness<br />
or could be combined with the suitable surgical touristic service to give complex product.
Surgical medical touristic market<br />
There are no exact statistics counting the number <strong>and</strong> the turnover of the players involved in<br />
surgical medical touristic market, but according to the estimations (ESKI 2009), the private<br />
sector does the bulk of the turnover. First of all the basic information <strong>and</strong> characteristics of the<br />
market will be described, followed by the analysis of the private <strong>and</strong> public sector, based on<br />
the success factors of medical services (shown at Figure 1.).<br />
The turnover of the total market (private <strong>and</strong> public together) is estimated to be around 36-56<br />
billion HUF (1 EUR = 265 HUF), 90% of that is assured by private service providers. Nearly<br />
300-400 thous<strong>and</strong>s surgical <strong>tourists</strong> arrive at Hungary yearly, <strong>and</strong> around 50-60% of them is<br />
cured at private clinics. Being Hungary a player in the surgical touristic market can be due to<br />
the hard <strong>and</strong> isolated work of the private service providers, who build the international<br />
reputation of the Hungarian clinics as a bottom-up process, but the public hospitals take a part<br />
in the surgical tourism as well. As having no proper statistics of the surgical touristic players,<br />
summarizing the main characteristics of the surgical market (can be seen in Table 1) is based<br />
on estimation of the Hungarian <strong>Health</strong>care Research Institution (ESKI 2009) <strong>and</strong> experts’<br />
interviews.<br />
Table 3. The main characteristics of the Hungarian surgical touristic market<br />
Main products Main source markets Players<br />
Private dentistry (80%), A, CH, D, IR, Ro, n.d. about 600-800<br />
clinics cosmetic-, eye surgery; DK, N, USA clinics, <strong>and</strong> doctors in<br />
IVF + obesity surgery<br />
border-l<strong>and</strong>, Budapest,<br />
marginal<br />
spa towns.<br />
Public clinics gynecology, cancer-, D, Ro, A, S, UA, n.d. hospitals in<br />
cardio-vascular USA<br />
Budapest, border-l<strong>and</strong>,<br />
treatments, eye surgery.<br />
close to Research<br />
Institutions<br />
Though the public <strong>and</strong> private players should be analyzed separately in the regard of success-,<br />
<strong>and</strong> management factors, there are some mutual sources of comparative advantages, what give<br />
the basis for surgical tourism in Hungary:<br />
• Cost-advantage: The costs of medical treatments are definitely low in Hungary, due to<br />
low wages, comparing to those in the developed countries: rest of the treatments (from<br />
heart bypass to spine surgery) cost the 5-15% of the costs of them in the USA. The<br />
prices of the treatments are significantly (by 50-60%) lower than in the USA, but the<br />
difference is great regarding the expenses in Germany, where eye-surgery costs 2782<br />
USD (in Hungary 846 USD), <strong>and</strong> face-lift costs 9126 USD (in Hungary 4881 EUR)<br />
(ESKI 2009).<br />
• High-skilled staff: “Another thing that many may find surprising is that Hungarian<br />
surgeons are held to much stricter educational st<strong>and</strong>ards than those in the U.K. or<br />
U.S.” (Medical <strong>Tourism</strong> Association 2009). Though the high skills of the doctors<br />
seem to be one of the most important enabling competencies of Hungary,<br />
shortcomings should be pointed out. The Hungarian public hospitals face a great<br />
volume of brain-pipe, because of low wages, <strong>and</strong> the aging of the health professionals<br />
causing an avarage low foreign-language skill-level as well as lack of service-oriented<br />
view among the public professionals. Widening surgical tourism could be a solution,<br />
as the Hungarian doctors working abroad could be attracted back, or unless while<br />
staying abroad, they could mean important market-ties in the pre-travel as well as in
the follow-up process. Education can hold market-ties as well: thous<strong>and</strong>s of<br />
international students learn medicine in Hungary, <strong>and</strong> after returning home they can be<br />
the ambassadors of the Hungarian surgical tourism. These kinds of contacts are used<br />
by the private clinics, where the high-level medicine-, language-, <strong>and</strong> management<br />
skills are given.<br />
• Innovation – R+D: The Hungarian medical science <strong>and</strong> research have world famous<br />
results in the area of orthopedics (backbone surgery), cardiology (invasive surgery),<br />
improvement of disabled people (Pető-method), or IVF (Kaáli-method). However<br />
these results are known in the circles of medicine <strong>and</strong> affected patients, with wider<br />
communication, these areas could serve the improvement of the image of the<br />
Hungarian medical professionals.<br />
Surgical tourism in the private sector<br />
Hungary got to the map of surgical tourism due to the private initiations, started by the<br />
dentists in the border-l<strong>and</strong> towns, close to Austria in 1990’s, <strong>and</strong> dental tourism is still the<br />
most important product as well as trademark of the Hungarian surgical tourism. Since then the<br />
example as well as the market know-how began to spread in the country, <strong>and</strong> hundreds of<br />
players launched isolated <strong>business</strong>es, <strong>and</strong> international marketing in different areas, without<br />
any cooperation or state subsidy. However the individual initiations work well, the threat of<br />
the new competitors (Bulgaria, Rumania), <strong>and</strong> the aggressive market-behavior of the older<br />
ones (Czech Republic, Pol<strong>and</strong>) ask for new solutions, as well as governmental support. In<br />
order to get a picture of the market behavior of the private clinics a content-analysis was<br />
carried out. There are no available statistics about the number of clinics involved in the<br />
surgical tourism, so typing the keyword (private clinic, dental-, cosmetic-, eye surgery,<br />
Hungary) in the Google maps seemed to be a good solution to find the individual service<br />
providers. Though problems arose with this solution, as from the hitting list of some<br />
hundreds, only 200 hits were shown, what should be h<strong>and</strong>led as the basic of the sample, from<br />
what every fifth were analyzed in the dimension of transparency, accreditation <strong>and</strong> seamless<br />
services. The evaluation of success factors in the private sphere based on content-analysis,<br />
<strong>and</strong> experts’ interviews are as follows.<br />
• Transparency: Transparency seems to be an issue to be developed: the statistics of the<br />
successful / unsuccessful cases appeared only at one service providers, the prices were<br />
missing at the 25% of clinics, as well as the own guarantee.<br />
• Image: The Hungarian dental-, cosmetic-, <strong>and</strong> eye surgery have great reputation in the<br />
international market, at which industrialized medical tourism could be built out.<br />
• Accreditation: Neither of the Hungarian clinics possess international accreditation,<br />
according to the list of the accreditation institutions (JCI, Tempos, ACHS), <strong>and</strong> only<br />
15% of the clinics analyzed have TÜV/ISO accreditation, <strong>and</strong> it means a disadvantage.<br />
According to the leader of medical facilitator, as well as the expert of <strong>Health</strong>care<br />
Ministry, the accreditation is essential for simple reasons: firstly it is a marketing tool<br />
serving comparison, secondly accreditation is the basic requirements of public <strong>and</strong> the<br />
rest of the private insurance institutions, thirdly without contracts with these<br />
institutions, the industrialized medical tourism ca not be built out. In the near future a<br />
centralized qualification process will be started in the aim of mapping the market, <strong>and</strong><br />
assuring unified quality by recommendations, <strong>and</strong> researching the satisfaction of the<br />
patients as well as broadcasting information about patients’ mobility (ESKI 2009).<br />
However this kind of process is essential, having the accreditation accepted by the<br />
target-market of the service provider is a crucial factor.
• Seamless services: The professional medical facilitators discovered the country in<br />
2004, when Hungary joined the EU, <strong>and</strong> started to carry out the seamless service in a<br />
great volume (VMFE, 2009). The seamless service is carried out by the rest of the<br />
players in dentistry, what is more, the practice of organizing consulting possibilities in<br />
the mother-country became a best practice in the market (Pollard 2010). Other players<br />
– particularly in the cosmetic surgery – are in difficult situation, as complex diagnosis<br />
are needed, which costs lot in the mother country, so they offer “fam-trips” to assure<br />
the first check-up <strong>and</strong> the personal contact with the doctors <strong>and</strong> the country at an<br />
affordable price. The follow-up process seems to be hard to solve: “It is really<br />
difficult, as the doctors in the mother-country are willing to reject to give help to a<br />
returned medical tourist. The solution is to find a Hungarian doctor in the mothercountry<br />
or to take the patient back to Hungary.” (Medical facilitator). According to the<br />
content-analysis only 35% of the clinics analyzed promote supporting services<br />
(transfer, hostess), the complementary services (hotels, flights) appear at the 52% of<br />
the clinics, while 40% of them have international contact (facilitator, consulting<br />
possibility in the source country), <strong>and</strong> only 10% of them promote their contracts with<br />
international insurances. Regarding these results, it can be said, that the greater or<br />
first-mover players of the market started the seamless process, while the smaller or<br />
newer players in the majority should realize the importance of that.<br />
• Insurance: According to the experts’ interview, there are several clinics in contract<br />
with Italian as well as German insurance institutions. There are good practices of the<br />
private clinics to h<strong>and</strong>le the patients’ mobility. According to the leader of a private<br />
clinic, the process is not easy but can be managed. Firstly they build contacts with the<br />
G.P.-s in the mother country, who make the administration of the authorization<br />
process of the public health insurance company. The patients is cured in Hungary with<br />
the permission of the insurance institutions, the bill is made out for the institutions,<br />
<strong>and</strong> to make the payment sure, the clinic make an insurance for recovering the debt.<br />
This extra way of security work in all cases, when the public insurance company is in<br />
delay with payment.<br />
• Innovation: Working with the up-to-date technology is crucial in the most competitive<br />
areas (dentistry, cosmetic <strong>and</strong> eye surgery), <strong>and</strong> according to the experts’ opinions, the<br />
Hungarian players invest in the newest know-how without sparing pains. Alternative<br />
healing methods are important areas of innovation. Medical herbal treatments have<br />
been already used in the dental surgery, but healing water could serve for plastic<br />
surgery, as well as gynecology, if suitable treatments, with suitable infrastructure<br />
would be assured by the spas. There are good example of cooperation among spa<br />
hotels <strong>and</strong> private clinics: in Budapest as well as in the border-l<strong>and</strong> towns luxurious<br />
hotels with high-quality spas give location for surgeries <strong>and</strong> rehabilitation.<br />
Surgical tourism in the public sector<br />
Some public hospitals (no accurate data) started to be involved in the surgical tourism, though<br />
the rest of the leaders of the public clinics find tourism as a way-out from their generally<br />
difficult financial situations. In Hungary the rest of the hospitals are owned by municipalities<br />
or the state, <strong>and</strong> the Hungarian healthcare systems is financed by centralized public insurance<br />
fees <strong>and</strong> taxes, but the system suffers from deficit at almost every year since. It is important to<br />
highlight, that one of the major problems, beyond the lack of financial resources, is the<br />
ineffective structure <strong>and</strong> operation of the hospitals. In 2007 a major structural reform started,<br />
<strong>and</strong> the overcapacity of the state hospital was partly reduced by cutting the number of acute<br />
beds, <strong>and</strong> increasing the volume of chronic beds. However the reform was needed, the time<br />
pressure of the process did not let enough scope for finding the optimal volume as well as
financing (OECD 2009/a). That is why there is free capacity at different treatments (e.g.<br />
orthopedics, heart surgery) without enough hospital beds. This unutilized capacity could be<br />
used by the medical <strong>tourists</strong>, if proper amenity service is built out, <strong>and</strong> could be the source for<br />
extra turnover for the hospitals, as well as for the staff. It is essential to have a governmental<br />
decision regarding developing surgical tourism in the public-sphere. The healthcare system of<br />
Hungary is under reformation, <strong>and</strong> newer steps could be expected regarding enhancing the<br />
effectiveness, <strong>and</strong> the quality. The question is whether the state – as the main owner –<br />
supports the idea of surgical tourism, <strong>and</strong> starts to pump European Union subsidies to priority<br />
hospitals, with focusing on surgical tourism. The state of the public hospitals regarding the<br />
success-factors of medical tourism is as follows:<br />
• Transparency: There are serious problems regarding transparency, even it is difficult<br />
to define that how many individually financed treatments were made, or how many<br />
doctors made diagnostic analyzes for their own private patients in the hospital. It is<br />
highly significant to make a transparent solution; otherwise there could be a threat for<br />
having waiting lists for the residents, when surgical tourism starts to boom. The issue<br />
of transparency arises in the area of statistics, considering the success of the treatments<br />
as well. The Hungarian public health insurance started to makes statistics about the<br />
failures, to know which points of the healing process should be improved, but they are<br />
not public, neither have we proper information about the amenity services provided by<br />
the hospitals.<br />
• Image: “However there are great results in orthopedics, cardiology the good skills of<br />
our doctors is not communicated widely. That is the reason why Hungarian healthcare<br />
is not on the medical map, it is not the first destination, what came to the mind of an ill<br />
person searching for cure. It is another question that there areas, where prices, <strong>and</strong> the<br />
word of mouth have their effects.” (The leader of a private clinic).<br />
• Accreditation: As well as in the private sector, accreditation seems to be essential (or<br />
even more essential) in the public sector. That could be the starting point to widen the<br />
contracts with foreign public <strong>and</strong> private insurance companies.<br />
• Seamless services + insurance: Though we have little information about the marketties<br />
of the public hospitals, the the experts’ interviews show that the international<br />
facilitators reached the public hospitals as well. The foreign public <strong>and</strong> private<br />
insurance companies also involved in the process. The basic problem is the low<br />
quality of the amenity services, <strong>and</strong> the lack of service-oriented view of the health<br />
professionals. If the government gives vote for surgical tourism in the public sphere,<br />
these problems could be remedied by the partner-hospital model (isolated wing of<br />
hospitals for medical tourism, using the same infrastructure of the public hospital<br />
(ESKI 2009)), or by cooperation with hotels.<br />
• Innovation: The medical infrastructure of the rest of the hospitals is up-to-date enough<br />
to serve surgical tourism, but there are serious shortcomings regarding the amenity<br />
facilities detailed above.<br />
Conclusion<br />
Hungary got to the map of world-wide medical tourism as a “Happy Dent” destination, since<br />
the 80% of the treatments in the framework of surgical tourism refer to dentistry. Other areas<br />
like cosmetic-, <strong>and</strong> eye surgery, as well as gynecology, cancer-, cardio-vascular treatments<br />
provided by the public hospitals are in dem<strong>and</strong>. Even the country has world-famous results in<br />
orthopedics (backbone surgery), cardiology (invasive surgery), improvement of disabled<br />
people (Pető-method), or IVF (Kaáli-method), what is not used out because of the capacity<br />
limits of the affected clinics <strong>and</strong> doctors, <strong>and</strong> the lack of wider communication. Regarding the<br />
development phases of the medical tourism, the Hungarian service providers are at the stage
of price-advantage segment. Due to the permanent innovation of the private clinics, steps are<br />
taken to the next stage, what can be called “Medium category with permanent patient flow,<br />
<strong>and</strong> professional market behavior”, while the world-wide famous results could hold the<br />
possibility of getting to the premium category based on high level know-how. In order to<br />
reach these stages, the following steps are recommended:<br />
Stage of medium category with permanent patient flow, <strong>and</strong> professional market<br />
behavior:<br />
Efforts are made in the area of dental-, surgical-, eye surgery for assuring permanent up-todate<br />
quality, as well as seamless, professional services. In order to have industrialized medical<br />
tourism, <strong>and</strong> permanent patients-flow, the best practice of seamless services, <strong>and</strong> crucial<br />
solutions (e.g. pre-travel, follow-up services, travel insurance) should be spread, as well as<br />
joining the accreditation systems of the target-markets. IFCs got great role in this area, by<br />
raising awareness, <strong>and</strong> controlling the quality. Co-operation with the touristic sector <strong>and</strong><br />
getting the well-deserved attention in the national touristic promotion of health tourism, as<br />
well as in the development fund are essentials. The public sector faces several challenging<br />
questions detailed above, where the decision of the government to support the surgical<br />
tourism or not seems to be vital. Without governmental support, the model of “partner<br />
hospital” cannot be carried out, but the surgical tourism can be increased with the help of<br />
hospitals, <strong>and</strong> assistance services, in the area of outpatient surgery, <strong>and</strong> rehabilitation.<br />
Differentiating strategy is important regarding the sharpening competition <strong>and</strong> using<br />
traditional, national healing methods seems to be good example (e.g. in Asia). The cooperation<br />
with the therapeutic touristic service providers could be a solution, in order to make<br />
specialized, high-quality methods <strong>and</strong> products based on healing water, medicinal plants.<br />
Stage of premium category based on high level know-how<br />
The areas of the distinguished results of the Hungarian medical research assure the possibility<br />
of getting in the circle of the “bests” in the medical touristic market. It is important to<br />
highlight that the rest of the results is reached in international cooperation or thought to<br />
foreign physicians to spread the knowledge of healing. This means that the know-how spreads<br />
quickly, <strong>and</strong> eliminates the source of the competitiveness. In this perspective, the medical <strong>and</strong><br />
pharmaceutical research institutions have a crucial role, to keep moving the wheels of<br />
innovation with new results. Based on the nowadays results, in the area of the unique methods<br />
detailed above, the actual limits of the infrastructural capacity should be lifted. It could<br />
happen even with the help of the private sector, <strong>and</strong> a high-level price, complex niche-product<br />
should be built out. All the areas in question can have rehabilitation, lifestyle treatments based<br />
on the therapeutic touristic services, what could add the extra possibility of differentiation.<br />
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Appendix 1. The characteristics of the main (or selected) medical touristic destinations<br />
Country Main areas Main characteristic Prices Accredit<br />
(USD) ation<br />
Thail<strong>and</strong> General <strong>and</strong> Some first-mover, 1. Dental 1. JCI –<br />
cardiac surgery, prominent hospital with impl. 1600 9 hosp.;<br />
cosmetic surgery, strong communication, USD, 2. 2.<br />
dentistry, strong state subsidies, Facelift Treatme<br />
orthopedics Thai treatments - 2400 USD ntabroad<br />
rehabilitation, low<br />
– 5<br />
prices<br />
hospitals<br />
Singapore General surgery, Strong governmental 1. Dental 1. JCI –<br />
cardiac surgery, support, national impl. 1180 16 hosp.;<br />
ophthalmology, communication, low USD; 2. 2.<br />
orthopedics, prices, Traditional Facelift Treatme<br />
gynecology, Chinese medicine 2700 USD ntabroad<br />
urology<br />
- n.d.<br />
India Cardiac surgery,<br />
orthopedics,<br />
ophthalmology,<br />
alternative<br />
medicine<br />
USA Rare, complex<br />
illnesses,<br />
treatment of<br />
cancer,<br />
cardiology,<br />
neurotic<br />
treatments,<br />
general surgery<br />
Belgium Cardiology,<br />
cosmetic surgery,<br />
transplantation,<br />
dentistry, fertility<br />
treatments<br />
Germany Wide variety for<br />
surgery: from<br />
cosmetic to<br />
spinal,<br />
cardiology,<br />
Spain Gastric bypass,<br />
cosmetic surgery,<br />
dentistry,<br />
orthopedics, IVF<br />
Some prominent<br />
hospital, strong market<br />
contacts <strong>and</strong><br />
governmental support,<br />
differentiation: holistic<br />
concept (alternative<br />
methods), extra low<br />
prices<br />
Famous clinics, the<br />
highest technology, <strong>and</strong><br />
skills, continuous R+D<br />
Close to main markets<br />
(UK, NL) ,strong<br />
market-contacts, high<br />
quality, low(er) prices,<br />
opened society<br />
Prominent hospitals in<br />
famous destinations,<br />
Advanced technology,<br />
R+D, high skills,<br />
rehabilitation:<br />
spas+health resorts<br />
Ranked as 7. for highest<br />
quality healthcare in<br />
EU (WHO), famous<br />
holiday destination,<br />
cheap touristic infra. –<br />
long stay, returning,<br />
close to main markets<br />
(UK, D, I)<br />
1. Dental<br />
impl. 500<br />
USD; 2.<br />
Facelift<br />
2700 USD<br />
1. Dental<br />
impl. 2800<br />
USD; 2.<br />
Facelift<br />
14.500<br />
USD<br />
1. Dental<br />
impl. 1000<br />
USD; 2.<br />
Facelift<br />
3524 USD<br />
1. Dental<br />
impl. 1188<br />
USD; 2.<br />
Facelift<br />
9126 USD<br />
1. Dental<br />
impl. 1288<br />
USD; 2.<br />
Facelift<br />
7,198 USD<br />
1. JCI –<br />
16 hosp.;<br />
2.<br />
Treatme<br />
ntabroad<br />
- 6<br />
1. JCI –<br />
n.d.<br />
hosp.; 2.<br />
Treatme<br />
ntabroad<br />
- 3<br />
1. JCI –<br />
n.d.<br />
hosp.; 2.<br />
Treatme<br />
nta. -12<br />
1. JCI –<br />
5 hosp.;<br />
2.<br />
Treatme<br />
nta. -5<br />
1. JCI –<br />
17 hosp.;<br />
2.<br />
Treatme<br />
nta. –<br />
over 40<br />
Overall message<br />
High quality, low<br />
price, exotic travel,<br />
great experience in<br />
medical travel -<br />
image made by the<br />
service suppliers, <strong>and</strong><br />
facilitator<br />
“Peace of Mind when<br />
<strong>Health</strong> Really<br />
Matters” – high<br />
quality, low prices,<br />
transparent national<br />
facilitator-system +<br />
strong<br />
communication<br />
“The Global<br />
<strong>Health</strong>care<br />
destination” -<br />
holistic view:<br />
Western medicine +<br />
traditional Indian<br />
treatments<br />
(Ayurveda, Yoga),<br />
governmental<br />
support, med. tourism<br />
on the official<br />
national tours. site<br />
Leading surgeons <strong>and</strong><br />
hospitals in the world<br />
with the most up-todate<br />
R+D results –<br />
image built by market<br />
players<br />
Modernity, high<br />
quality, costefficiency<br />
- image<br />
built by market<br />
players<br />
Excellent reputation,<br />
high skills, <strong>and</strong> hightech,<br />
rehabilitation-<br />
image built by market<br />
players<br />
Medical hub of<br />
Europe, high quality,<br />
low cost - image built<br />
by market players
Country Main areas Main characteristic Prices<br />
(USD)<br />
Cyprus Cosmetic, dental High skills, 1. Dental<br />
surgery,<br />
international training impl. 1671<br />
orthopedics, for doctors, high-tech USD; 2.<br />
cardiology, IVF private centers, Facelift<br />
prominent<br />
destination<br />
vacation 5,343 USD<br />
Czech<br />
Republic<br />
Dental, cosmetic<br />
surgery, IVF,<br />
rehabilitation<br />
Pol<strong>and</strong> Dentistry,<br />
cosmetic surgery,<br />
cardiology,<br />
ophthalmology,<br />
neurology<br />
Croatia Dental, cosmetic<br />
surgery<br />
Bulgaria Dental, cosmetic<br />
surgery, lifestyle<br />
treatments, IVF<br />
Hungary Dental, cosmetic<br />
surgery,<br />
orthopedics,<br />
ophthalmology<br />
High quality, low<br />
prices, close to markets<br />
(D, A), famous spas +<br />
towns<br />
Close to markets (D,<br />
RU, North-Europe),<br />
international training<br />
for doctors, high-tech<br />
private centers, success<br />
in innovation<br />
Low prices, high skills,<br />
starting networking,<br />
traditional image in<br />
vacation tourism<br />
Low cost, some high<br />
quality centers, rest is<br />
under construction, spas<br />
for rehabilitation<br />
High quality centers,<br />
highly skilled staff with<br />
international<br />
experience, first-mover<br />
hubs in Western-<br />
Hungary, unexploited<br />
innovation in<br />
cardiology<br />
1. Dental<br />
impl. 1046<br />
USD; 2.<br />
Facelift<br />
4051 USD<br />
1. Dental<br />
impl. 805<br />
USD; 2.<br />
Facelift<br />
3980 USD<br />
1. Dental<br />
impl. 975<br />
USD; 2.<br />
Facelift<br />
4813 USD<br />
1. Dental<br />
impl. 1166<br />
USD; 2.<br />
Facelift<br />
2659 USD<br />
1. Dental<br />
impl. 882<br />
USD; 2.<br />
Facelift<br />
4885 USD<br />
Accredit<br />
ation<br />
1. JCI –<br />
4 hosp.;<br />
2.<br />
Treatme<br />
nta. – 19<br />
1. JCI –<br />
4 hosp.;<br />
2.<br />
Treatme<br />
nta. – 3<br />
1. JCI –<br />
0 hosp.;<br />
2.<br />
Treatme<br />
nta. –8<br />
1. JCI –<br />
0 hosp.;<br />
2.<br />
Treatme<br />
nta. – 15<br />
1. JCI –<br />
0 hosp.;<br />
2.<br />
Treatme<br />
nta. –0<br />
1. JCI –<br />
0 hosp.;<br />
2.<br />
Treatme<br />
nta. –28<br />
Overall message<br />
“Treasure your health<br />
in Cyprus” – complex<br />
health +vacation<br />
experience,<br />
governmental<br />
support, med. tourism<br />
on the official<br />
national tours. site<br />
High st<strong>and</strong>ards, low<br />
prices, <strong>and</strong> great<br />
natural resources -<br />
image built by market<br />
players<br />
High quality with<br />
international<br />
experience,<br />
innovation, but low<br />
prices - image built<br />
by market players<br />
Complex experience,<br />
low prices<br />
Low prices, complex<br />
experience<br />
“Happy dent” – high<br />
quality, low prices,<br />
complex experience -<br />
- image built by<br />
market players,<br />
governmental support<br />
recently started
Appendix 2. The characteristics of the main source markets<br />
Country Main motivations Popular treatments Popular<br />
USA price-sensitiveness,<br />
complex<br />
treatments+holiday<br />
Middle-<br />
East<br />
highest level<br />
technology<br />
Germany motivation of public<br />
insurance, pricesensitiveness<br />
at<br />
elective treatments<br />
UK motivation of public<br />
insurance, pricesensitiv.<br />
at elective<br />
treatments, hospital<br />
infection, complex<br />
holiday<br />
general surg., cancer<br />
treatm., orthopedics,<br />
heart-bypass,<br />
cosmetic surg.<br />
heart surgery, cancer<br />
treatm., orthopedics,<br />
detox programs<br />
dental treatments,<br />
orthopedics,<br />
cosmetic-, eye<br />
surgery<br />
dental, cosmetic,<br />
orthopedic surgery,<br />
<strong>and</strong> fertility<br />
treatments<br />
destinations<br />
Asia, Latin-<br />
America,<br />
Middle-East,<br />
inside USA<br />
growing<br />
North-America,<br />
Asia, Europe<br />
Czech Republic,<br />
Hungary, <strong>and</strong><br />
Pol<strong>and</strong><br />
Belgium, Spain,<br />
India, Hungary,<br />
<strong>and</strong> Cyprus<br />
Nr of outbound<br />
tour. arrivals (2008)<br />
ca. 540 ths.<br />
no overall<br />
estimation: UAE –<br />
100 ths., Saudi<br />
Arabi 200 ths<br />
ca. 272 ths.<br />
ca. 75 ths<br />
(Source: Pollard 2010, Deliotte 2009, McKinsey 2009, Techniker Krankenkasse 2009,<br />
Crompton 2008, Biomedme 2009)
Developing Quality Criteria for Spa <strong>and</strong> <strong>Wellness</strong> Hotels: the Case of<br />
Estonia<br />
Heli Tooman<br />
Pärnu College, University of Tartu, Estonia<br />
heli.tooman@ut.ee<br />
Tiina Viin<br />
Pärnu College, University of Tartu, Estonia<br />
Abstract<br />
The objective of this paper is to give an overview of the process of development of the<br />
categorisation system for Estonian spa <strong>and</strong> wellness hotels. The categorisation system has<br />
been developed on the basis of the experience of several other countries <strong>and</strong> organizations,<br />
also the results of thorough research, mapping <strong>and</strong> analysis of Estonian spa hotels <strong>and</strong> the<br />
services provided. The need for the research arose, on the one h<strong>and</strong>, by the appearance of<br />
several new hotels to the Estonian hotel market who started to market themselves as a spa<br />
<strong>and</strong>/or wellness hotel without having sufficient respective services <strong>and</strong> conditions, <strong>and</strong> on the<br />
other h<strong>and</strong> by the growing need to communicate to visitors clear messages concerning the<br />
specific features <strong>and</strong> quality of spa hotels. There is no common internationally recognised <strong>and</strong><br />
accepted categorisation system for spa hotels all over the world but such systems have been<br />
developed <strong>and</strong> introduced by several countries <strong>and</strong> organisations.<br />
As the terms ”spa” <strong>and</strong> ”wellness” have become undefined <strong>and</strong> unregulated catchwords which<br />
are often misleading, the Estonian Spa Association adopted a decision in 2006 to launch a<br />
project for the development of classification <strong>and</strong> categorisation criteria for Estonian spa<br />
hotels. The initial survey was conducted in 2006 among all fifteen spa hotels which belong to<br />
the Estonian Spa Association, <strong>and</strong> the repeat survey was conducted in 2009 among 10 spas.<br />
The purpose of the surveys was to identify objective information as a basis for the<br />
classification of spa hotels <strong>and</strong> for the development of the respective categorisation system<br />
which follows internationally recognised concepts. The research tasks consisted in thorough<br />
mapping of the services <strong>and</strong> conditions of Estonian spa hotels, analysis of results <strong>and</strong><br />
development of a system for the classification <strong>and</strong> categorisation of spa hotels. The research<br />
method applied was a survey in the form of a questionnaire. The respective questionnaire was<br />
developed by the Pärnu College of the University of Tartu <strong>and</strong> the survey was conducted in<br />
cooperation with the Estonian Spa Association.<br />
As a result of the first survey, classification of spa hotels into three categories was suggested:<br />
medical spa hotels, spa hotels <strong>and</strong> wellness spa hotels. First, the categorisation criteria for<br />
medical spa hotels were developed. By now the system of categories of medical spa hotels has<br />
been implemented. On the basis of the results of the second survey, categorisation criteria will<br />
be developed for spa hotels <strong>and</strong> wellness spa hotels in 2010. Assessment of conformity with<br />
the respective categorisation criteria will hopefully start in the same year, 2010. A spa hotel<br />
applying for a category has to conform to the categorisation criteria applicable to hotels in<br />
Estonia <strong>and</strong> in addition also to requirements established to spa facilities <strong>and</strong> services.<br />
Key words: quality criteria, spa <strong>and</strong> wellness hotels.
Introduction<br />
Arguments for the need for quality criteria for spa <strong>and</strong> wellness hotels<br />
Development of spa industry is founded on the interest people have had since the earliest<br />
times in mineral springs that differed from ordinary springs in their appearance, taste <strong>and</strong><br />
temperature. The essential framework of spa industry is based mainly on the use of natural<br />
resources <strong>and</strong> <strong>healthy</strong> climate with an important contribution from medical care <strong>and</strong> a<br />
comprehensive approach to therapeutic stays. More recently, increasing popularity of the<br />
wellness concept has acted to stimulate leisure-based health concept <strong>and</strong> health tourism. At<br />
the heart of the wellness concept lies the WHO definition of health as “a state of complete<br />
physical, mental <strong>and</strong> social well-being <strong>and</strong> not merely the absence of disease or infirmity”.<br />
The concept of spa <strong>and</strong> wellness hotels <strong>and</strong> notions of health tourism have been in the<br />
forefront of this process, with the development of gyms, saunas, fun pools <strong>and</strong> wellness<br />
centres following. But also contradictionary trends have been highlighted. On the other h<strong>and</strong>,<br />
a growing global leisure-based health orientation has become incorporated into a selfconscious<br />
fitness lifestyle. But at the same time in a number of countries there has been a<br />
reduction of social financial support for rehabilitation <strong>and</strong> treatments in medical spas, as a<br />
result of which traditional European health resorts such as spas <strong>and</strong> sanatoriums faced a crisis<br />
in the later 1990s (Hall, Brown, 2006; Nahrstedt, 2004).<br />
Over the past years the health tourism, spa <strong>and</strong> wellness sector has experienced enormous<br />
growth. More <strong>and</strong> more individuals opt for the unconventional treatments <strong>and</strong> the popularity<br />
of health <strong>and</strong> wellness products promises to increase even further. Theories abound as to the<br />
reasons for this exponential growth, many of which cite the anomie of western, capitalist<br />
societies, the breakdown of traditional religions, <strong>and</strong> the fragmentation of communities.<br />
Concomitant progress in science <strong>and</strong> medicine has led to better preservation of the body <strong>and</strong><br />
increasing absence of disease, yet mental, psychological <strong>and</strong> emotional problems are often left<br />
untreated. The scarce research available suggests that those who avail themselves of the<br />
plethora of experiences available appear to be not only on a touristic journey of physical<br />
movement, but also on a journey towards greater self-awareness <strong>and</strong> contentment (Smith,<br />
Puczko 2009). Thous<strong>and</strong>s of new spa <strong>and</strong> wellness products <strong>and</strong> services have come to<br />
market, <strong>and</strong> Pilzer (2007) calls it The New <strong>Wellness</strong> Revolution, explaining that the majority<br />
of opportunities in wellness still await the individual entrepreneur or health professional.<br />
Today spa visits, health tourism, wellness, beauty <strong>and</strong> fitness programmes, regenerative,<br />
reconditioning <strong>and</strong> relaxation stays, are all dynamically growing products <strong>and</strong> tourist product<br />
packages which, combined with all-inclusive accommodation, catering, entertainment,<br />
sporting <strong>and</strong> other activities, are responding to the most challenging dem<strong>and</strong>s of individual<br />
<strong>tourists</strong>. The type of client at spas ranges from guests in search of a rest all the way to the<br />
truly ill, including all forms of prevention up to rehabilitation <strong>and</strong> the treatment of chronic<br />
diseases. Spas are a frequent tourist destination of young <strong>and</strong> old, singles, families with<br />
children, <strong>and</strong> recently also a favourite venue for putting on congresses <strong>and</strong> conferences<br />
(European Spa Industry…; Spas – a further... 2007). Goebel et al (2007) vividly describe the<br />
current situation as follows: The consequence of this significant increase was <strong>and</strong> still is the<br />
establishment <strong>and</strong> opening of a myriad of <strong>business</strong>es, products <strong>and</strong> services. Unfortunately,<br />
the lack of st<strong>and</strong>ards <strong>and</strong> uniform criteria is not only limited to non-traditional service<br />
suppliers but concerns almost all aspects of health, spa <strong>and</strong> wellness tourism. The<br />
consequence of missing quality schemes coupled with outst<strong>and</strong>ing dem<strong>and</strong> led to a<br />
mushrooming of ‘want-to-be’ <strong>and</strong> ‘try-to-be’ health <strong>and</strong> wellness providers since set up costs<br />
<strong>and</strong> entry barriers are low.
There is a lot of confusion in the use of the terms spa <strong>and</strong> wellness <strong>and</strong> it often misleads<br />
visitors due to the lack of common concepts. There is a similar confusion concerning spa <strong>and</strong><br />
wellness hotels. Addition of the words spa or wellness spa to a hotel name may not always<br />
mean that the hotel really measures up to that. This has made categorisation criteria for spa<br />
hotels very necessary <strong>and</strong> they have also been developed by different organisations of many<br />
countries. The main purpose of categorisation systems is to organise the market <strong>and</strong> define the<br />
quality st<strong>and</strong>ards of services in order to make the service reliable to the client. How can<br />
quality best be communicated?<br />
The more common European quality systems for spa <strong>and</strong> wellness hotels<br />
This paper covers more thoroughly only a few main principles <strong>and</strong> main documents of quality<br />
criteria of European spa <strong>and</strong> wellness hotels, which have also been taken as a basis for the<br />
development of the categorisation system of Estonian spa hotels. There are, however, many<br />
more of such quality systems both in Europe <strong>and</strong> on the global scale.<br />
The award of the EUROPESPA-med seal of approval means that the holder meets the<br />
exacting st<strong>and</strong>ards of ESPA in terms of general therapy infrastructure, hygiene <strong>and</strong> safety<br />
(Certified exclellence…; International seal of approval...). The EUROPESPA seal of approval<br />
is designed for spas <strong>and</strong> health resorts in the classical health care segment as well as centres<br />
specialising in medical wellness whose services include treatment <strong>and</strong> cures. <strong>Health</strong> resorts<br />
certified by the European Spas Association are listed in the EUROPESPA directory, which<br />
lists the leading spas in Europe meeting the criteria of the ESPA (EUROPESPA.<br />
International...).<br />
The EUROPESPA wellness quality seal (EUROPESPA wellness...) is specially developed by<br />
the European Spas Association (ESPA). The award of the EUROPESPA wellness quality seal<br />
means the holder meets the exacting st<strong>and</strong>ards of ESPA in terms of wellness infrastructure,<br />
wellness service, hygiene <strong>and</strong> safety. The customer knows that EUROPESPA wellness<br />
certified hotels are fulfilling the international quality st<strong>and</strong>ards of the European Spa<br />
Association. The set of criteria contains about 350 audit questions checked through an<br />
announced audit on site <strong>and</strong> approx. 600 testing points is an anonymous check (mystery test)<br />
made by a professional test person.<br />
The European Audit Institute <strong>Wellness</strong> & Spa provides certification of wellness hotels in four<br />
categories: for hotels with special wellness <strong>and</strong> spa offers <strong>and</strong> wellness ambience; for hotels<br />
with special medical offers <strong>and</strong> concepts <strong>and</strong> wellness ambience; for golf hotels with special<br />
wellness <strong>and</strong> golf concepts <strong>and</strong> wellness ambience, <strong>and</strong> for hotels with special thalassic <strong>and</strong><br />
spa concepts with wellness. In every category there are 3 grade levels awarded: leading,<br />
premium <strong>and</strong> quality. The quality certificate of the European Audit Institute <strong>Wellness</strong> & SPA<br />
is an award not only for the wellness <strong>and</strong> spa area but for the entire hotel with all its facilities<br />
(<strong>Wellness</strong> Europe Certificates…).<br />
BISA, the British International Spa Association, has become one of the leading representative<br />
bodies for spa accreditation worldwide. Through its British International Spa Accreditation<br />
scheme, BISA seeks to establish consumer confidence through quality st<strong>and</strong>ards in the spa<br />
<strong>and</strong> health resort industries (BISA. International…; BISA. Accreditation…). First established<br />
in 1998, the Waves of Excellence is an accreditation system developed to indicate that a spa is<br />
offering products <strong>and</strong> services that the consumer can enjoy with confidence.
The DOSTWELL <strong>Wellness</strong> Quality Seal is a quality system for wellness-oriented enterprises.<br />
DOSTWELL is an international project co-financed by the European Union – Interreg IIIC<br />
programme. 8 partners from 7 European countries joined together to define wellness on EU<br />
level, to develop a wellness cluster model, set up wellness quality st<strong>and</strong>ards, define a wellness<br />
product <strong>and</strong> promote the concept of wellness water based tourism, as water is the common<br />
element to all regions taking part in this project (DOSTWELL – Quality in <strong>Wellness</strong>). The<br />
wellness quality seal is oriented towards modern management approach, <strong>and</strong> spirit of<br />
sustainability also leaves room for <strong>and</strong> encourages an organisation to keep <strong>and</strong> further develop<br />
their individuality <strong>and</strong> distinctive characteristics.<br />
European <strong>Wellness</strong> & <strong>Health</strong> St<strong>and</strong>ard (EuWHS) was elaborated by international experts <strong>and</strong><br />
specialists of the European Economic Chamber of Trade, Commerce <strong>and</strong> Industry EEIG<br />
(Brussels) to avoid unfair competition, to protect consumer interests <strong>and</strong> to contribute to an<br />
improvement of the quality in this specific field. <strong>Wellness</strong> <strong>and</strong> health centres the quality of<br />
which complies with the quality criteria as stipulated by the European <strong>Wellness</strong> <strong>and</strong> <strong>Health</strong><br />
St<strong>and</strong>ard can be certified as quality enterprises (European <strong>Wellness</strong> <strong>and</strong>…)<br />
The Fáilte Irel<strong>and</strong> Spa <strong>and</strong> <strong>Wellness</strong> Categorisation Programme sets the criteria for the<br />
categorisation of Irel<strong>and</strong>’s spas <strong>and</strong> wellness retreats (The Fáilte Irel<strong>and</strong> Spa…). Speaking at<br />
the awards ceremony, Tony Lenehan, Fáilte Irel<strong>and</strong>‘s Head of Industry St<strong>and</strong>ards & Quality<br />
emphasized: “This new categorisation system creates a win-win situation for both operators<br />
<strong>and</strong> customers. It will help operators to better advertise their services <strong>and</strong> will aid both<br />
existing <strong>and</strong> new customers to better underst<strong>and</strong> the variety of spa <strong>and</strong> wellness offerings<br />
available, make informed choices <strong>and</strong> find the products that best suit their needs. ”<br />
In each Alpine region country today, there are nationally developed wellness criteria <strong>and</strong><br />
initiatives, e.g. Wellfeeling (Switzerl<strong>and</strong>), Well-Vital (Bavaria), Belvita (South Tyrol) <strong>and</strong><br />
Best <strong>Health</strong> Austria (Austria). For a participant of the development <strong>and</strong> marketing initiative<br />
“Alpine <strong>Wellness</strong>”, apart from the general wellness basis quality criteria, the minimum<br />
criteria in the area of “alpine character” are obligatory. Furthermore, every alpine wellness<br />
company can distinguish itself by fulfilling additional criteria in the areas of “alpine<br />
indulgence”, “alpine fitness” <strong>and</strong> “alpine medical wellness”. Alpine <strong>Wellness</strong> International<br />
was in 2003. (Alpine <strong>Wellness</strong>…)<br />
The quality concepts <strong>and</strong> criteria of spa <strong>and</strong> wellness hotels of also other continents were<br />
examined during the preparation of this study. The following is a brief review of such<br />
concepts. In October 2008, the Singapore Ministry of Trade <strong>and</strong> Industry appointed CaseTrust<br />
as the accreditation body for the spa <strong>and</strong> wellness industry (Casetrust for spa <strong>and</strong> ...). In 2004<br />
the Thail<strong>and</strong> Ministry of Public <strong>Health</strong> adopted the Thai spa st<strong>and</strong>ards (Ministerial<br />
Announcement...), which defined health <strong>and</strong> beauty service enterprises, st<strong>and</strong>ards for service,<br />
service providers, <strong>and</strong> principles <strong>and</strong> methods for inspecting <strong>and</strong> certifying st<strong>and</strong>ards for<br />
health <strong>and</strong> beauty service enterprises. The basic principles of the quality systems <strong>and</strong> quality<br />
criteria described in this paper served as an important basis <strong>and</strong> guidance for the development<br />
of the categorisation system of Estonian spa hotels.<br />
Development of <strong>Health</strong>, Spa <strong>and</strong> <strong>Wellness</strong> tourism in Estonia<br />
National tourism policy <strong>and</strong> tourism development activities are implemented by the Estonian<br />
Tourist Board, which is a subunit of the Enterprise Estonia Foundation <strong>and</strong> belongs to the<br />
administrative sphere of the Ministry of Economic Affairs <strong>and</strong> Communication. In 2006, the<br />
Estonian Parliament adopted the National Development Plan for <strong>Tourism</strong> for 2007–2013
(Eesti Riiklik… 2006). In 2009, the marketing concept “Introduce Estonia” was developed on<br />
the initiative of Enterprise Estonia to establish the manner <strong>and</strong> ways in which Estonia is to be<br />
marketed. Presenting Estonia as a travel destination includes four main topics that are most<br />
important to the country: cultural holiday, city holiday, nature holiday <strong>and</strong> wellness holiday<br />
(“Introduce Estonia” br<strong>and</strong> manual 2009). Presenting Estonia as a wellness holiday<br />
destination – if there were a competition for selecting the spa kingdom of the world, Estonia<br />
could easily snatch that title (Instructions for focus topic of wellness holiday 2009). Estonia is<br />
a spa paradise – with an impressive number of spas considering its small territory <strong>and</strong><br />
population.<br />
Estonia has long traditions <strong>and</strong> experience from more than 170 years in the development of<br />
resort, health <strong>and</strong> spa tourism. The relatively favourite geographic position, the sea, beautiful<br />
natural s<strong>and</strong>y beaches <strong>and</strong> local natural resources, particularly curative mud but also mineral<br />
waters have been the main preconditions for the birth <strong>and</strong> development of resorts, particularly<br />
health resorts in Estonia. A number of new spa hotels were built in 2000–2008 in different<br />
regions of Estonia <strong>and</strong> these have been the main <strong>and</strong> significant tourism products outside<br />
Tallinn which have attracted visitors all the year round in Estonia.<br />
In 2009, 1.38 million foreign <strong>tourists</strong> stayed overnight at the accommodation establishments<br />
of Estonia (-3,9% compared to 2008). The number of nights spent was 2.74 million (-6,5%<br />
compared to 2008). Foreign overnights on both holiday <strong>and</strong> <strong>business</strong> trips decreased (by 5%<br />
<strong>and</strong> 4 %) , whereas overnights on other trips (incl. spa <strong>and</strong> health treatment trips) decreased<br />
by 13%. The economic crisis which started in 2008 has had a negative effect on all tourism<br />
sectors, including on spa tourism, <strong>and</strong> the quality of the services offered <strong>and</strong> communication<br />
of appropriate marketing messages to potential visitors have become much more important<br />
than earlier (Estonian <strong>Tourism</strong> Statistics…).<br />
Through different times, the objectives of the Estonian Spa Association have been to develop<br />
<strong>and</strong> provide high-quality health resort <strong>and</strong> rehabilitation treatment <strong>and</strong> spa services. In the<br />
course of that time the competition in the spa hotel market has dramatically increased <strong>and</strong><br />
therefore it has become increasingly important to communicate clear messages concerning the<br />
specific characteristics <strong>and</strong> quality st<strong>and</strong>ards of hotels. In 2006 the Estonian Spa Association<br />
adopted a decision to launch a project for the development of classification <strong>and</strong> categorisation<br />
criteria for Estonian spa hotels, <strong>and</strong> the Pärnu College of the University of Tartu is involved in<br />
the project as a partner.<br />
Research Design<br />
The objectives of the first survey were to obtain an objective overview of the current situation<br />
of the capacities, services, volumes <strong>and</strong> conditions of the spa hotels which are members of the<br />
Estonian Spa Association <strong>and</strong> of the situation in the market. As only medical spas belonged to<br />
the Estonian Spa Association during the planning <strong>and</strong> conduction of the survey, the objective<br />
was to use the results of the survey as a basis for the development of classification <strong>and</strong><br />
categorisation criteria for Estonian spa hotels according to international models bearing in<br />
mind medical spa hotels. A survey in the form of a questionnaire was used as the research<br />
method. The long questionnaire of the survey consisted of four parts: general characterisation<br />
of the organisation, infrastructure, clients <strong>and</strong> staff of spa hotels. Each part in its turn<br />
consisted of related questions <strong>and</strong> detailed subquestions. The sample of the survey consisted<br />
of all 15 spa hotels which belonged to the Estonian Spa Association in 2006. The survey was<br />
conducted in the period from 17 April to 27 May 2006 <strong>and</strong> responses were received from all<br />
spa hotels included in the sample.
The statistics obtained from the survey have been adjusted to make the results unambiguous.<br />
The analysis of information on the volumes of services, rooms <strong>and</strong> the staff was based on the<br />
description „volume per 100 beds“, which made it possible to make the analysis of the<br />
information more underst<strong>and</strong>able than „volume per bed“, in which case the figures would<br />
have been very low <strong>and</strong> difficult to analyse. The statistics were analysed with the MS Excel<br />
spreadsheet <strong>and</strong> the results were presented in the research report in the generalised form, i.e.<br />
no indicators of any spa hotel were presented separately (Eesti Spa Liidu spaahotellide…<br />
2006). The survey gave very detailed information on the rooms <strong>and</strong> the services provided by<br />
spa hotels.<br />
On the basis of the results of the first survey, the respective materials of several countries <strong>and</strong><br />
organisations <strong>and</strong> client surveys conducted earlier in spa hotels, the conception of the<br />
classification of Estonian spa hotels <strong>and</strong> the draft categorisation system of medical spas were<br />
developed by the end of 2006 (Spaahotellide kategooriad... 2006). In the course of 2007 the<br />
categorisation criteria were tested <strong>and</strong> appropriate additions were made. Unlike the hotel<br />
categorisation criteria applied in Estonia, the categorisation criteria for medical spas include<br />
increasingly more so-called soft criteria (criteria related to the staff <strong>and</strong> quality of service).<br />
Medical spas have to ensure an appointment of an attending physician to each client, if<br />
necessary, the number of places for therapeutic procedures per 100 beds is 10 in the case of<br />
one <strong>and</strong> two stars, 13 in the case of three <strong>and</strong> four stars <strong>and</strong> 15 in the case of five stars, i.e. not<br />
less than 13 different clients should be able to receive therapeutic procedures at the same time<br />
in a three-star spa hotel. A three-star hotel should have as a minimum 3 physicians per 100<br />
beds. The opening hours of therapeutic services should be not less than nine hours six hours in<br />
three-star spa hotels.<br />
The Estonian Spa Association, which until 2009 only acted as an umbrella organisation for<br />
medical spas, has extended its membership to other spa <strong>and</strong> wellness spa hotels. Stage 2 of<br />
implementation of the spa hotel categorisation system was started – development of<br />
categorisation criteria for spa <strong>and</strong> wellness spa hotels. A new survey was planned <strong>and</strong><br />
conducted in cooperation with the Pärnu College of the University of Tartu. The objectives of<br />
the second survey were to obtain an objective overview of the current situation of the<br />
capacities, services, volumes <strong>and</strong> conditions of the hotels which market themselves as spa<br />
hotels or wellness spa hotels.<br />
A survey in the form of a questionnaire was used as the research method. The sizeable<br />
questionnaire which was, however, different in many respects from the questionnaire of the<br />
first survey, made it possible to thoroughly map the spa <strong>and</strong> wellness spa hotels. The main<br />
differences from the first survey were the absence of the section on medical services (spa <strong>and</strong><br />
wellness spa hotels have no license for the provision of rehabilitation treatment services <strong>and</strong><br />
no doctors among their staff) <strong>and</strong> a great emphasis on the holistic approach to the provision of<br />
services (incl. the volumes, diversity, size <strong>and</strong> conformity of rooms, personal service, etc.)<br />
<strong>and</strong> formation of the ambience, which are characteristic of the wellness concept.<br />
The sample of the survey consisted of 10 spa hotels which market themselves as spa or<br />
wellness spa hotels. The survey was conducted in the period from 01.12 to 31.12.2009. The<br />
final analysis of the results of the survey will be completed in February 2010 <strong>and</strong> the<br />
preparation of categorisation criteria for spa <strong>and</strong> wellness spa hotels is going on at the same<br />
time <strong>and</strong> will hopefully be completed with their approval <strong>and</strong> implementation by the end of<br />
2010. A common characteristic feature of the spa hotels which responded to the survey was
that more than 60% of the visitors are at the age of 26–45 <strong>and</strong> have come on a holiday <strong>and</strong><br />
relaxation trip. This indicator is considerably different from the visitors of medical spas where<br />
76% of the visitors were older than 45 years.<br />
On the basis of the results of the first survey, the Pärnu College of the University of Tartu<br />
made proposals to the Estonian Spa Association for the classification of spas <strong>and</strong> the draft<br />
categorisation criteria for medical spas. By the end of 2008 the categorisation criteria were<br />
approved with a few additions after testing the categorisation criteria for medical spas, the<br />
quality system was completed <strong>and</strong> the first medical spas were accredited. By the beginning of<br />
2010 the respective categories were awarded to nine Estonian medical spas on the basis of the<br />
medical spa categorisation criteria. Spa hotels use the same rating system as hotels <strong>and</strong> apply<br />
stars for classification purposes. Stars are used in design alongside the logo of the Estonian<br />
Spa Association.<br />
The system was designed to inform clients of the range <strong>and</strong> nature of services available. The<br />
fact that the services meet the criteria of the system – <strong>and</strong> the extent to which they meet them<br />
– is a sign of quality that clients can be guided by in visiting Estonian spas. The quality<br />
criteria (Tabel 1) set out the range of services offered <strong>and</strong> the requirements for premises, staff<br />
<strong>and</strong> quality of service. (Spaahotellide kategooriad… 2006; Categories of Spa hotels <strong>and</strong><br />
classification…).<br />
The Estonian Spa Association has adopted the proposals made on the basis of the research<br />
concerning the categories of spa hotels, which are the following:<br />
• Category 1. Medical spa hotel is a recognised hotel licensed to provide outpatient<br />
medical care that specialises primarily in various rehabilitation, dietary <strong>and</strong> medical<br />
spa services.<br />
• Category 2. Spa / wellness spa hotel is a recognised hotel that specialises in various<br />
care, relaxation <strong>and</strong> other spa services. Such hotels are not required to hold a license<br />
for provision of outpatient medical care. Treatment services are not offered <strong>and</strong> the<br />
spa services have a relaxing <strong>and</strong> invigorating nature. Note: The concept of wellness<br />
spa calls for very high quality <strong>and</strong> level of service, personal service, a varied selection<br />
of spa services <strong>and</strong> focus on relevant target groups, which means that only hotels that<br />
meet four-star requirements can apply to become wellness spas.<br />
• Category 3. Medical wellness spa hotel is a higher ranked hotel that offers both<br />
medical <strong>and</strong> wellness spa services. A combination of different categories of spa hotels<br />
is possible if a hotel wants to develop itself as a higher ranked medical wellness spa.
Table 1 Sample of the Classification Requirements for the Medical Spa Category<br />
Requirement * ** *** **** *****<br />
1.1. The licence to provide X X X X X<br />
specialised outpatient medical care<br />
6.2. Separate reception for treatment<br />
<strong>and</strong> spa services<br />
X X X<br />
7.1. Reception by the attending<br />
doctor is quaranteed for every client<br />
if necessary<br />
X X X X X<br />
7.2. Treatment places per 100 bed 10 10 13 13 15<br />
7.5. Swimming pool (at least 25 m<br />
long)<br />
X X<br />
7.7. Availability of spa services X X X<br />
8.1. Special diet therapy menu X X X X X<br />
11. Number of different types of<br />
saunas<br />
1 1 2 3 3<br />
In all categories, the classification (stars) the hotel is applying for is granted if the<br />
classification requirements for hotels <strong>and</strong> spas of the relevant category have been met. The<br />
following documents were prepared in the process of development of categorisation criteria:<br />
Classification Requirements for the Medical Spa Category, Statutes of the Spa Hotel<br />
Classification Committee, <strong>and</strong> Classification Procedure (Categories of spa hotels <strong>and</strong><br />
classification...). The Spa Hotel Classification Committee is the committee created by the<br />
management board of Estonian Spa Association (ESPAL) whose task is to determine the<br />
categories of spa hotels <strong>and</strong> develop relevant classification requirements <strong>and</strong> their<br />
amendments, to decide on granting <strong>and</strong> removing classifications <strong>and</strong> to organise all other<br />
work required for maintaining a functioning classification system. A committee includes the<br />
representatives of the Estonian Spa Association, Estonian Hotel <strong>and</strong> Restaurant Association<br />
<strong>and</strong> the Estonian Association of Travel Agents. Application for a category is voluntary.<br />
Implementation of the system of categories of Estonian spa hotels contributes to the<br />
organisation of the market <strong>and</strong> to the communication of clear <strong>and</strong> reliable messages to<br />
potential visitors.<br />
Conclusions<br />
Fast development of the spa <strong>and</strong> wellness sector can be regarded as a phenomenon of the<br />
beginning of the 21. century. There are different reasons for this, including increased health<br />
awareness of people which has led to a very fast development of spa <strong>and</strong> wellness products<br />
<strong>and</strong> services. No newly opened full service or upscale hotel is without wellness or spa<br />
services, <strong>and</strong> almost all hotels are adding spa facilities <strong>and</strong> services. On the one h<strong>and</strong>,<br />
traditional spa hotels fear sophisticated competition, while on the other h<strong>and</strong> they could<br />
capitalize on the fact that consumers already consider spa services to be st<strong>and</strong>ard offerings<br />
<strong>and</strong> that these consumers have been accustomed to them <strong>and</strong> are familiar with individual<br />
procedures.<br />
Estonian spas have traditionally been medical spas but numerous new spa hotels have been<br />
opened during the last decade which do not provide medical services but offer various<br />
invigorating <strong>and</strong> relaxing procedures. In some of the hotels which have come to the market<br />
the number of the respective services is very limited, however, <strong>and</strong> the quality st<strong>and</strong>ards are<br />
questionable. As health tourism <strong>and</strong> spa <strong>business</strong> are very important aspects of the Estonian
tourism sector for the state as these are tourism products which attract visitors all the year<br />
round, it was also necessary to take steps to ensure the adequacy <strong>and</strong> reliability of the quality<br />
messages of Estonian spas both in the domestic <strong>and</strong> foreign markets.<br />
One important step in that direction was the process initiated by the Estonian Spa Association<br />
for the creation of a system for the classification <strong>and</strong> categorisation of spas. The<br />
categorisation criteria for medical spas, which have been implemented by now, were<br />
developed based on the experience of several countries <strong>and</strong> organisations, thorough research<br />
conducted in the course of the process, <strong>and</strong> results of several client satisfaction surveys<br />
conducted among earlier spa guests. By the beginning of 2010 the second survey has reached<br />
the final stage; categorisation criteria for spas <strong>and</strong> wellness spas are being prepared on the<br />
basis of its results to hopefully implement them in the course of 2010.<br />
Several shortcomings were found in the course of the surveys <strong>and</strong> pointed out in the report of<br />
the research project <strong>and</strong> also at the training days for spa staffs <strong>and</strong> at team meetings in the<br />
course of the project. Quality is no doubt one of the most important keywords <strong>and</strong><br />
requirements of tourism today, including health tourism. We can state that without quality we<br />
cannot talk about <strong>healthy</strong> <strong>business</strong> <strong>and</strong> <strong>healthy</strong> <strong>tourists</strong> in the context of health, spa <strong>and</strong><br />
wellness tourism. The categorisation system of Estonian medical, spa <strong>and</strong> wellness spa hotels<br />
is an important tool for the self-determination of Estonian spa hotels <strong>and</strong> in their efforts to be<br />
among the best of their category.<br />
References<br />
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EUROPESPA International certifications members` benefits. www.espa-ehv.com;<br />
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HINY PACKAGE
Tourists’ satisfaction, leisure involvement <strong>and</strong> health benefit of special interest<br />
tourism: health <strong>and</strong> well-being tourism<br />
Ching-Cheng Shen<br />
The Graduate School of Travel Management. National Kaohsiung Hospitality College,<br />
Taiwan<br />
sccheng1202@hotmail.com<br />
Tzuhui A. Tseng<br />
Department of Environmental <strong>and</strong> Cultural Resources. National Hsinchu University of<br />
Education, Taiwan<br />
thtseng@mail.nhcue.edu.tw<br />
Abstract<br />
Due to the increasing stress from life <strong>and</strong> work, it has become an important issue for modern<br />
people to release stress <strong>and</strong> pursuit health in everyday life <strong>and</strong> leisure time. This has boosted<br />
the development of health <strong>and</strong> well-being tourism activities. Taitung County is located at the<br />
east side of Taiwan. It neighbors the Pacific Ocean, <strong>and</strong> is a beautiful <strong>and</strong> vigorous<br />
environment with green mountains, rushing water, <strong>and</strong> fresh air. It has been promoted as the<br />
spiritual homel<strong>and</strong> of Taiwan, <strong>and</strong> is a good place to develop health <strong>and</strong> well-being tourism.<br />
To raise its unique attraction in tourism activities, special interest tourism has become more<br />
<strong>and</strong> more favored by the general public. Da-Muo Yijin Kung is a special kung-fu<br />
Bodhidharma (Da-Muo) created to enhance health <strong>and</strong> prevent sickness through a series of<br />
exercises. Therefore, how to integrate health <strong>and</strong> well-being into special interest tourism, in<br />
order to create a unique attraction of health <strong>and</strong> well-being tourism is a subject that is worth<br />
looking into. This study took the relationship among satisfaction, behavior involvement, <strong>and</strong><br />
health effectiveness of special interest health <strong>and</strong> well-being tourism activities as research<br />
topic, <strong>and</strong> chose visitors who were at Jing-Mei Villa in Taitung County to learn Da-Muo Yijin<br />
Kung as research subjects. Through survey interviews <strong>and</strong> empirical analysis, the findings<br />
were as following: 1. On the satisfaction aspect of special interest health <strong>and</strong> well-being<br />
tourism activities, fresh air, <strong>healthy</strong> food, Ganoderma tea, owner’s warm hospitality, dining<br />
procedure <strong>and</strong> moving meditation were the higher scored factors. 2. For health effectiveness,<br />
improve physical health, enhance resistance against disease <strong>and</strong> delay ageing were the higher<br />
scored factors. 3. On the aspect of behavior involvement, learning devotion <strong>and</strong> earnestness,<br />
learning time <strong>and</strong> frequency were the higher scored factors. 4. Through factor analysis, factor<br />
dimensions extracted from satisfaction of special interest health <strong>and</strong> well-being tourism<br />
activities included health tourism, learning activities of Da-Muo Yijin Kung, <strong>healthy</strong> diet,<br />
<strong>healthy</strong> environment, <strong>and</strong> <strong>healthy</strong> product; factor dimensions of health effectiveness included<br />
health <strong>and</strong> self-confidence. 5. To analyze the relationships among satisfaction, behavior<br />
involvement, <strong>and</strong> health effectiveness of special interest health <strong>and</strong> well-being tourism<br />
activities, this study developed a linear structural equation, <strong>and</strong> the result showed: satisfaction<br />
had positive relation to behavior involvement <strong>and</strong> health effectiveness; behavior involvement<br />
had positive relation to health effectiveness; behavior involvement was <strong>and</strong> intervening<br />
variable for satisfaction to influence health effectiveness. 6. On the satisfaction aspect of<br />
tourism activities, the learning activities of Da-Muo Yijin Kung <strong>and</strong> health tourism were<br />
important factor dimensions; on the health effectiveness aspect, health <strong>and</strong> self-confidence<br />
were both important factor dimensions. The above result showed that by integrating special
interest activity <strong>and</strong> health <strong>and</strong> well-being tourism, it truly can form a unique attraction,<br />
deepen visitor’s satisfaction, <strong>and</strong> create a valuable health tourism experience for visitors.<br />
Keywords: Special interest tourism, well-being, heath, Jing-Mei Villa, Da-Muo Yijin Kung<br />
Introduction<br />
The rapid development of urbanization <strong>and</strong> industrialization had increased the stress on<br />
everyday life, <strong>and</strong> as a result, affected people’s health <strong>and</strong> well-being. Therefore, the need in<br />
activities that could release stress <strong>and</strong> enhance health is very urgent. Countryside tourism has<br />
leisure tourism <strong>and</strong> stress relief functions, <strong>and</strong> has become an important leisure activity for<br />
people pursuing a <strong>healthy</strong> life. This boosted the development of health <strong>and</strong> well-being<br />
tourism. In addition, with the arrival of an aging society <strong>and</strong> the awareness of a <strong>healthy</strong> living,<br />
maintaining a <strong>healthy</strong> life has become a trend in the modern world. From <strong>healthy</strong> diet, leisure<br />
activities <strong>and</strong> constant exercise to the establishment of resorts focusing on health <strong>and</strong> wellbeing,<br />
all indicated people’s attention to their welfare. Public’s concept on health has changed<br />
from getting treatments from hospital <strong>and</strong> clinics to the idea of preventive medicine, using a<br />
more natural method to maintain the health of body, mind <strong>and</strong> spirit. It is to not only pursuing<br />
physical health, but further seek environmental <strong>and</strong> mental health, <strong>and</strong> eventually protect <strong>and</strong><br />
maintain the health of both body <strong>and</strong> mind.<br />
Due to the competitiveness in the public tourism market <strong>and</strong> the diverse tourism needs people<br />
have nowadays, tourism <strong>business</strong>es have been gradually focusing on minority markets <strong>and</strong><br />
come up with special interest tourism, or theme tours, that’s made specifically for <strong>tourists</strong>’<br />
special needs. Opaschowski (2001) stated that tourism in the 21 Century is like buying a piece<br />
of paradise. <strong>Tourism</strong> <strong>business</strong> is an experience industry, <strong>and</strong> consumers are willing to spend<br />
money to experience a different kind of happiness. They are looking for a kind of enjoyment,<br />
atmosphere, <strong>and</strong> beauty, finding different sensory stimulation <strong>and</strong> experience. Therefore,<br />
there is a growing population in Special Interest <strong>Tourism</strong> (SIT).<br />
Jing-Mei Villa is located in the eastern park of Taiwan. It is a beautiful <strong>and</strong> vigorous<br />
environment with green mountains, rushing water, <strong>and</strong> fresh air. Nearby scenic attractions<br />
include Yuan-Sen Applied Botanic Garden, Chu-Lu Ranch, Hong-Ye Hot Spring, Little<br />
Huang-Shan, <strong>and</strong> Shan-Yuan Beach. The owner of Jing-Mei Villa felt people’s need of health<br />
<strong>and</strong> well-being. He adopted Da-Muo Yijin Kung into the activities <strong>and</strong> paired it with <strong>healthy</strong><br />
diets <strong>and</strong> beautiful leisure environment, <strong>and</strong> developed a health <strong>and</strong> well-being tourism for<br />
people to maintain their health while in leisure activity. This study has based on the concept<br />
of eat <strong>healthy</strong> <strong>and</strong> play happy to explore the relationship among <strong>tourists</strong>’ satisfaction, leisure<br />
involvement <strong>and</strong> health benefit on the product <strong>and</strong> service of health <strong>and</strong> well-being tourism, in<br />
order to provide associated industry some insight when managing this type of special interest<br />
tourism.<br />
Literature Review<br />
Satisfaction<br />
Leisure satisfaction is the psychological result one has after a leisure experience. Bulltena &<br />
Klessing (1969) thought leisure activity satisfaction was decided by the level of coincidence<br />
of one’s expectation <strong>and</strong> actual experience. Leisure Satisfaction is to what degree an<br />
individual is currently satisfied with their leisure experiences <strong>and</strong> activities (Beard & Ragheb,<br />
1980). Oliver (1981) indicated whether consumer is satisfied or not comes from the<br />
comparison of their expectation <strong>and</strong> actual purchase result. Fonell (1992) stated satisfaction is<br />
a reflection of consumer’s overall feeling of like or dislike after they accepted the service (or
used the product). This study combined Bed <strong>and</strong> Breakfast with specially themed activities,<br />
recreation <strong>and</strong> <strong>healthy</strong> diet, therefore, choose health <strong>and</strong> well-being tourism, health <strong>and</strong> wellbeing<br />
activities, <strong>healthy</strong> diets, <strong>healthy</strong> environment, <strong>and</strong> health products as the five<br />
dimensions to measure satisfaction.<br />
Leisure Involvement<br />
Leisure involvement is when <strong>tourists</strong> are interested in leisure activities, sense their value <strong>and</strong><br />
importance, <strong>and</strong> further willing to involve in them. Rothschild (1984) <strong>and</strong> Havitz & Dimanche<br />
(1999) considered leisure involvement as unobservable state of motivation, arousal or interest<br />
toward a recreational activity, tourist location, or associated recreation facility <strong>and</strong> product. It<br />
is evoked by particular stimulus or situation <strong>and</strong> has drive properties. As for the measurement<br />
of leisure involvement, scholars indicated it should include social psychology <strong>and</strong> behavioral<br />
dimensions (Gunter & Gunter, 1980; Kim et al., 1997). Csikszentmihayi (1975) measured<br />
chess player’s leisure involvement by their competition frequency, time spent on it, <strong>and</strong><br />
number of associated books owned. Stone (1984) defined leisure involvement as the time <strong>and</strong><br />
effort one spent on participating in a leisure activity. Kim, Scott, & Crompton (1997) also<br />
pointed out that participation frequency, money spent, travel mileage, skill, equipment owned,<br />
associated books, <strong>and</strong> number of association participated could all be used to measure leisure<br />
involvement. By integrating above literatures, this study would use time invested <strong>and</strong> level of<br />
seriousness to measure leisure involvement.<br />
<strong>Health</strong> Benefit<br />
<strong>Health</strong>y means there are no signs <strong>and</strong> symptoms of any kinds of illness. The appearance of<br />
signs <strong>and</strong> symptoms represented the decrease of certain physiological function, <strong>and</strong> often<br />
needs applicable treatments to recover to the original <strong>healthy</strong> state. Basic prevention is very<br />
important to maintain <strong>healthy</strong>. This is to practice special protection method to promote one’s<br />
health or prevent certain illness before it happens <strong>and</strong> damages body functions. This often<br />
includes physical <strong>and</strong> psychological, <strong>and</strong> emotional health. Basic prevention can also be<br />
categorized into health promotion <strong>and</strong> disease prevention, also called specific protection.<br />
<strong>Health</strong> promotion is an approach behavior, it uses actualizing tendency as guidance, direct<br />
individual to maintain or enhance health, actualize <strong>and</strong> have positive attitude, <strong>and</strong> indicates<br />
one can actively create new positive behaviors. <strong>Health</strong> associated elements such as education,<br />
environment <strong>and</strong> support are also combined to create activates that help promote a <strong>healthy</strong><br />
life, <strong>and</strong> its purpose is to let people have better control over their own health.<br />
Benefit is achieving a goal, which includes goals achieved by participating in leisure<br />
activities, <strong>and</strong> the participants believe that the leisure activity can help them reach that goal<br />
(Ajzen, 1991). Leisure benefit is the subjective feeling of improvement <strong>and</strong> satisfaction one<br />
has during <strong>and</strong> after participating in leisure activities. Bammel <strong>and</strong> Burrus-Bammel (1982)<br />
proposed six benefits of leisure, which included physiological benefits, social benefits,<br />
relaxation benefits, education benefits, psychological benefits, <strong>and</strong> aesthetic benefits. Because<br />
this study’s theme is health <strong>and</strong> well-being tourism, health <strong>and</strong> leisure benefits need to be<br />
considered. Therefore, survey items including health, relaxation, anti-aging, sense of<br />
accomplishment, <strong>and</strong> body shaping are used to measure health benefit.<br />
Da-Muo Yijin Kung<br />
Yijinjing is a traditional Chinese Kung-Fu Bodhidharma (Da-Muo) created to enhance health<br />
<strong>and</strong> prevent sickness through a series of exercises. There are thirteen movements in this<br />
exercise. The basic purpose of Yijinjing is to turn flaccid <strong>and</strong> frail sinews <strong>and</strong> tendons into<br />
strong <strong>and</strong> sturdy ones. The movements of Yijinjing are at once vigorous <strong>and</strong> gentle. Their
performance calls for a unity of will <strong>and</strong> strength, by using one’s will to direct the exertion of<br />
muscular strength. It is coordinated with breathing. Better muscles <strong>and</strong> tendons mean better<br />
health <strong>and</strong> shape, more resistance, flexibility, <strong>and</strong> endurance. Yijinjing can interact with both<br />
physical <strong>and</strong> psychological levels. It can be enhanced if one can practice with the following<br />
four tips: (1) Practice with perseverance <strong>and</strong> patience; (2) Watch what one eats, be sure to<br />
have a balanced nutrition; (3) Have a regulated everyday schedule; (4) Have a peace of mind,<br />
do not impose, do not have too many desires.<br />
Research Framework<br />
Research Framework<br />
The goal of this study is to explore the relationship among people’s satisfaction, leisure<br />
involvement <strong>and</strong> health benefit of health <strong>and</strong> well-being tourism, analyze whether if the<br />
increase of satisfaction would result in <strong>tourists</strong>’ leisure involvement, <strong>and</strong> whether if leisure<br />
involvement would promote health benefit. The research framework of this study is shown in<br />
Figure 1.<br />
Product<br />
Satisfaction<br />
H1<br />
Leisure<br />
Involvement<br />
H2<br />
<strong>Health</strong><br />
Benefit<br />
H3<br />
Figure 1 - Research Framework<br />
Hypothesis<br />
Iso-Ahola & Weissinger (1984) mentioned leisure experience associated leisure dispositions<br />
would ease the health dimension created by stress. Hull (1990) proposed leisure activities<br />
would promote positive mind set <strong>and</strong> affect health. In addition, in serious leisure activities, the<br />
stronger the leisure commitment, the higher the leisure benefit (Stebbins, 1982). Therefore,<br />
this study’s research hypothesis included the following:<br />
H1: Product satisfaction has positive effect on leisure involvement.<br />
H2: Product satisfaction has positive effect on health benefit.<br />
H3: Leisure involvement has positive effect on health benefit.<br />
Surveying<br />
The variables measured in this study included satisfaction, leisure involvement, <strong>and</strong> health<br />
benefit. The five factor dimensions of satisfaction were health <strong>and</strong> well-being tourism, health<br />
<strong>and</strong> well-being activities, <strong>healthy</strong> diets, <strong>healthy</strong> environment, <strong>and</strong> health products. The<br />
dimensions of leisure involvement were invested time <strong>and</strong> seriousness. <strong>Health</strong> benefits<br />
included health, relaxation, anti-aging, sense of accomplishment, <strong>and</strong> body shaping. The<br />
above items would be measured using Likert’s five-point scale. The subjects of this study<br />
were people staying at Jing-Mei Villa <strong>and</strong> practicing Da-Muo Yijin Kung; r<strong>and</strong>om sampling<br />
were used <strong>and</strong> 78 questionnaire were distributed <strong>and</strong> all 78 of them were collected, effective<br />
return rate was 100%.
Analysis<br />
Product <strong>and</strong> Service Satisfaction Analysis<br />
The analysis of product <strong>and</strong> service satisfaction is shown in Table 1. Results showed the top 6<br />
most satisfaction items were fresh air, <strong>healthy</strong> food, Ganoderma tea, owner’s warm<br />
hospitality, dining procedure, <strong>and</strong> moving meditation. Satisfactions for other leisure activities<br />
were relatively lower.<br />
Factor analysis for product <strong>and</strong> service was done by using KMO statistics <strong>and</strong> its value is<br />
0.560, <strong>and</strong> Sphericity test Chi-Square value is 0.342.97, both reached significant level. Five<br />
factors were extracted from product <strong>and</strong> service dimension through factor analysis, <strong>and</strong> the<br />
accumulated explained variance was 75.818%. Factor one included item such as Eastern<br />
Coastal Trip, <strong>and</strong> was named health <strong>and</strong> well-being tourism, with an explained value of<br />
19.21% <strong>and</strong> reliability analysis Cronbach α value of 0.7399. Factor two included moving<br />
meditation <strong>and</strong> sitting meditation so it was named as heath <strong>and</strong> well-being activity, <strong>and</strong> its<br />
explained value was 17.476% <strong>and</strong> reliability analysis Cronbach α value was 0.8792. Factor<br />
three included <strong>healthy</strong> food <strong>and</strong> dining procedure, therefore, it was named as <strong>healthy</strong> diet. Its<br />
explained value was 15.981% <strong>and</strong> reliability analysis Cronbach α value was 0.8911. Factor<br />
four included fresh air <strong>and</strong> visual l<strong>and</strong>scape, which is related more to the environment,<br />
therefore, it is named as <strong>healthy</strong> environment. Its explained value was 14.117% <strong>and</strong> reliability<br />
analysis Cronbach α value was 0.6611. Factor five was Ganoderma tea which is a health<br />
product, so this factor was named health product, <strong>and</strong> its explained value was 9.033%<br />
Table 1 - Satisfaction analysis of produce <strong>and</strong> service<br />
Dimension Product <strong>and</strong> Mean St<strong>and</strong>ard Factor Eigenvalue Explained<br />
Service Factor<br />
Deviation Loading<br />
Variance<br />
<strong>Health</strong> <strong>and</strong> Eastern Coastal<br />
well-being Trip<br />
4.0972 0.5607 0.815 2.305 19.210<br />
tourism Guan-Shan Water<br />
Park Trip<br />
3.8750 0.6700 0.807<br />
Hong-Ye Hot<br />
Spring Trip<br />
3.9583 0.6377 0.593<br />
Owner’s warm<br />
hospitality<br />
4.5000 0.5566 0.575<br />
Yuan-Sen Botanic<br />
Garden Trip<br />
3.7222 0.8088 0.913<br />
Heath <strong>and</strong> Moving Meditation 4.5000 0.6920 0.914 2.097 17.476<br />
well-being Sitting Meditation<br />
activity<br />
4.4722 0.7501 0.879<br />
<strong>Health</strong>y diet <strong>Health</strong>y Food 4.5556 0.5787 0.924 1.918 15.981<br />
Dining procedure 4.5000 0.6051 0.915<br />
<strong>Health</strong>y Fresh air 4.5972 0.5731 0.792 1.694 14.117<br />
environment Visual L<strong>and</strong>scape 4.2778 0.6548 0.747<br />
<strong>Health</strong><br />
products<br />
Ganoderma tea 4.5278 0.5807 0.85 1.084 9.033<br />
Leisure Involvement<br />
Analysis of student’s leisure involvement is shown in Table 2. The result indicated that their<br />
involvement is above average, with the highest score in seriousness level, followed by<br />
practice time <strong>and</strong> frequency.
Table 2 – Learning Commitment Analysis<br />
Commitment Mean St<strong>and</strong>ard<br />
Deviation<br />
1. Regular practicing time 3.6389 0.6566<br />
2. Practice time <strong>and</strong> frequency 3.7083 0.5919<br />
3. Level of seriousness 3.8750 0.5551<br />
<strong>Health</strong> Benefit Analysis<br />
Student’s health benefit analysis is shown in Table 3. It showed that promote health was the<br />
highest, next were enhance immunity <strong>and</strong> delay aging <strong>and</strong> then release stress. This<br />
demonstrated the importance of preventing aging. From visitors’ health benefit item KMO<br />
analysis, its value was 0.720, <strong>and</strong> Sphericity test Chi-Square value was 148.033, both reached<br />
significant level. Two factors were extracted from health benefit items, <strong>and</strong> the accumulated<br />
explained variance was 65.807%. Factor included enhance immunity, delay aging, promote<br />
health <strong>and</strong> release stress, therefore, it is named as health. Its explained value of 42.767% <strong>and</strong><br />
reliability analysis Cronbach α value is 0.7849. Factor 2 included sense of accomplishment<br />
<strong>and</strong> body shaping, <strong>and</strong> because beauty is related with confidence, this factor was named<br />
confidence, <strong>and</strong> its explained value is 23.040% <strong>and</strong> reliability analysis Cronbach α value is<br />
0.670.<br />
Table 3 – <strong>Health</strong> Benefit Analysis<br />
Dimension <strong>Health</strong> Benefit Mean St<strong>and</strong>ard Factor<br />
Deviation Loading<br />
<strong>Health</strong> Enhance<br />
Immunity<br />
4.4167 0.7268 .875<br />
Delay Aging 4.4028 0.8164 .859<br />
Promote <strong>Health</strong> 4.5278 0.5300 .690<br />
Release Stress 4.3333 0.6500 .597<br />
Confidence Sense of<br />
Accomplishment<br />
3.7639 0.7598 .953<br />
Body Shaping 4.1528 0.8164 .608<br />
Eigenvalue Explained<br />
Variance<br />
2.566 42.767<br />
1.382 23.040<br />
The relationship of satisfaction, leisure involvement, <strong>and</strong> health benefit<br />
The special interest tourism model of this study regarding the relationship of satisfaction,<br />
leisure involvement, <strong>and</strong> health benefit is shown in Figure 2 by using Lisrel 8.5. The numbers<br />
represent path coefficient, <strong>and</strong> the ones in parentheses represent T value of path coefficient.<br />
From figure 2, it is learned that model basic goodness-of-fit test all reached significant level<br />
besides health product of satisfaction dimension, <strong>and</strong> T value of all the dimensions were<br />
larger then 1.645 with no negative deficiency variances <strong>and</strong> all deficiency variances reached<br />
significant level, which showed the basic good goodness-of-fit of this model is good. As for<br />
model goodness-of-fit, χ 2 value is 1.14, RMSEA=0.042, NFI=0.82, NNFI= 0.93, GFI=0.92,<br />
AGFI=0.85, PGFI=0.52, PNFI=0.57, RMR=0.065, CFI=0.95, IFI=0.96, which showed the<br />
good goodness-of-fit of this model is good.<br />
Based on figure 2, the influence coefficient of satisfaction toward leisure involvement is 0.27,<br />
t value is 1.65 <strong>and</strong> both reached significant level, which indicated satisfaction has positive<br />
significant effect over leisure involvement, <strong>and</strong> when satisfaction is higher, leisure<br />
involvement is higher; therefore, hypothesis H1 st<strong>and</strong>s. The influence coefficient of<br />
satisfaction toward health benefit is 0.66, t value is 2.98 <strong>and</strong> both reached significant level,<br />
which indicated satisfaction has positive significant effect over health benefit, <strong>and</strong> when
satisfaction is higher, health benefit is higher; therefore, hypothesis H2 st<strong>and</strong>s. The influence<br />
coefficient of leisure involvement toward health benefit is 0.31, t value is 1.73 <strong>and</strong> both<br />
reached significant level, which indicated leisure involvement has positive significant effect<br />
over health benefit, <strong>and</strong> when leisure involvement is higher, health benefit is higher;<br />
therefore, hypothesis H3 st<strong>and</strong>s. There are two paths for satisfaction to affect health benefit.<br />
One is satisfaction’s direct effect over health benefit of 0.66, <strong>and</strong> the other is satisfaction’s<br />
indirect effect over health benefit through leisure involvement of 0.084; satisfaction’s overall<br />
effect over health benefit is 0.74, which indicated leisure involvement’s mediating effect of<br />
satisfaction over health benefit does exist.<br />
As for the observed variables in tourism activity satisfaction, the learning activity of Da-Muo<br />
Yijin Kung is the most important factor dimension, <strong>and</strong> next is health <strong>and</strong> well-being tourism<br />
<strong>and</strong> <strong>healthy</strong> environment, which showed the combination of health <strong>and</strong> well-being activity<br />
<strong>and</strong> tourism is the core of health <strong>and</strong> well-being tourism. In leisure involvement, practice time<br />
<strong>and</strong> frequency <strong>and</strong> level of seriousness are both important factor dimensions, which showed<br />
Da-Muo Yijin Kung needs devotion <strong>and</strong> practice. In health benefit, health <strong>and</strong> confidence are<br />
both important factor dimensions, which showed having a <strong>healthy</strong> mind <strong>and</strong> body makes<br />
people more confident.<br />
X1: <strong>Health</strong> <strong>and</strong> Wellbeing<br />
<strong>Tourism</strong><br />
X2: <strong>Health</strong> <strong>and</strong> Wellbeing<br />
Activity<br />
X3: <strong>Health</strong>y Diet<br />
X4: <strong>Health</strong>y<br />
Environment<br />
X5: <strong>Health</strong> Products<br />
Y1: Regular<br />
practicing time<br />
Y2: Practice time <strong>and</strong><br />
frequency<br />
Y3: Level of<br />
seriousness<br />
0.40 *<br />
(3.02)<br />
0.67 *<br />
(4.23)<br />
0.34 *<br />
(2.60)<br />
0.37 *<br />
(2.84)<br />
0.14<br />
(1.05)<br />
0.85<br />
0.92 *<br />
(8.45)<br />
0.70 *<br />
(6.76)<br />
Product<br />
Satisfaction<br />
0.27 *<br />
(1.69)<br />
Leisure<br />
Involvement<br />
0.66 *<br />
(2.98)<br />
0.33 *<br />
(1.73)<br />
<strong>Health</strong><br />
Benefit<br />
Y4: <strong>Health</strong><br />
Y5: Confidence<br />
Figure 2 – Satisfaction, leisure involvement <strong>and</strong> health benefit of special interest tourism<br />
model<br />
Conclusion <strong>and</strong> Suggestions<br />
With the increasing stress in life <strong>and</strong> work, <strong>and</strong> the arrival of an aging society, health <strong>and</strong><br />
well-being tourism has gradually become a trend. This study choose health <strong>and</strong> well-being<br />
tourism as research topic, <strong>and</strong> the result showed that health <strong>and</strong> well-being activity is the core<br />
of this special interest tourism, <strong>and</strong> create its uniqueness <strong>and</strong> attraction. As for health benefit,<br />
people are paying more <strong>and</strong> more attention on the concept of prevention medicine, using<br />
natural method to maintain the health of body, mind <strong>and</strong> spirit. For better health, they also<br />
continually put in time to participate in health <strong>and</strong> well-being tourism activities. When the<br />
0.64<br />
0.65 *<br />
(3.27)
higher the <strong>tourists</strong> satisfaction in these activities, the more involved they get, <strong>and</strong> the higher<br />
health benefit they would gain. From the results of this study, by combining special interest<br />
activates <strong>and</strong> health <strong>and</strong> well-being tourism could form a unique attraction, deepen <strong>tourists</strong>’<br />
satisfaction, <strong>and</strong> create the value of health <strong>and</strong> well-being tourism.<br />
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Implementation of a model of a sustainable wellbeing destination – case<br />
Savonlinna town<br />
Anja Tuohino<br />
University of Eastern Finl<strong>and</strong>, Centre for <strong>Tourism</strong> Studies<br />
anja.tuohino@uef.fi<br />
Abstract<br />
A conceptual model of destination competitiveness was presented by Ritchie <strong>and</strong> Crouch in<br />
2003. The model is based on a comparative <strong>and</strong> competitive advantage concept including<br />
several attributes of a destination. These are the global environment, the competitive micro<br />
environment, core resources <strong>and</strong> attractions, supporting factors <strong>and</strong> resources, destination<br />
policy, planning <strong>and</strong> development, destination management, <strong>and</strong> qualifying <strong>and</strong> amplifying<br />
determinants.<br />
The model has been further developed by Sheldon <strong>and</strong> Park (2009) to be more readily<br />
applicable in the wellness tourism context. Sheldon <strong>and</strong> Park note that the model is crucial to<br />
identify the contributing factors <strong>and</strong> resources for wellness tourism because it would not be<br />
possible to develop wellness products if the destination cannot provide basic infrastructure<br />
<strong>and</strong> guarantee access to the area.<br />
In this paper the model of Sheldon <strong>and</strong> Park is tested in the Savonlinna region in Finl<strong>and</strong> in<br />
the context of wellbeing tourism. As early as in the 1860s the region of Savonlinna was a<br />
popular holiday resort on Lake Saimaa, attracting visitors from as far afield as St. Petersburg<br />
to experience its spa facilities. Today the old historical spa image of Savonlinna is more or<br />
less a thing of the past <strong>and</strong> the current tourism image is based on the Opera Festival <strong>and</strong> the<br />
resources of its lakel<strong>and</strong> scenery. The recreational use of spas has replaced the traditional spa<br />
culture.<br />
The data for the paper were gathered by interviewing tourism professionals <strong>and</strong> developers<br />
during autumn 2009. In total 14 people were interviewed. The data are supplemented by a<br />
survey of tourism resources in Savonlinna region. The analysis presented in the paper was<br />
done during the summer 2010 <strong>and</strong> is based on both interviews <strong>and</strong> a survey of resources.<br />
Introduction<br />
Destinations can be viewed from two perspectives; destination attractiveness is evaluated<br />
from the tourist’s perspective <strong>and</strong> destination competitiveness from the perspective of the<br />
destination itself. According to Buhalis (2000, p.97) “destinations are amalgams of tourism<br />
products, offering an integrated experience to consumers, <strong>and</strong> are consumed under the br<strong>and</strong><br />
name of the destination (p.98)”. He continues by citing Hall (2000) <strong>and</strong> Davidson <strong>and</strong><br />
Maitl<strong>and</strong> (1997) that “traditionally, destinations are regarded as well-defined geographical<br />
areas, such as a country, an isl<strong>and</strong> or a town”.<br />
While assessing a destination’s competitiveness it can be evaluated with regard to its<br />
economic, political, socio-cultural, technological <strong>and</strong> environmental competitiveness. (see<br />
Ritchie & Crouch 2003/2005). Ritchie <strong>and</strong> Crouch presented their own refined conceptual<br />
model of destination competitiveness in 2003. This is based on a comparative <strong>and</strong> competitive<br />
advantage concept including several attributes of a destination. These are the global<br />
environment, the competitive micro environment, the core resources <strong>and</strong> attractions,
supporting factors <strong>and</strong> resources, destination policy, planning <strong>and</strong> development, destination<br />
management, <strong>and</strong> qualifying <strong>and</strong> amplifying determinants. Comparative advantages include<br />
human resources, physical, knowledge <strong>and</strong> capital resources, infrastructure <strong>and</strong> cultural <strong>and</strong><br />
historical resources. Competitive advantages on the other h<strong>and</strong> include effectiveness,<br />
efficiency, maintenance <strong>and</strong> auditing. As core resources <strong>and</strong> attractors they listed e.g.<br />
physiography <strong>and</strong> climate, culture <strong>and</strong> history, mix of activities, special events <strong>and</strong><br />
entertainment, while supporting factors <strong>and</strong> resources include infrastructure, hospitality,<br />
enterprises <strong>and</strong> facilitating resources. Destination management includes among others<br />
marketing, quality of services, information <strong>and</strong> research, human resource development <strong>and</strong><br />
visitor management. Destination policy, planning <strong>and</strong> development include visions, br<strong>and</strong>ing,<br />
positioning, monitoring <strong>and</strong> evaluation, while location, safety, cost value, image <strong>and</strong> carrying<br />
capacity are seen as qualifying <strong>and</strong> amplifying determinants.<br />
The model by Ritchie <strong>and</strong> Crouch includes many key elements which are important for<br />
competition between tourist destinations. Cracolici <strong>and</strong> Nijkamp point out that “...achieving a<br />
good performance <strong>and</strong> position in the tourism market depends on the capability of a<br />
destination area to manage <strong>and</strong> organize its resources according to an economic logic driven<br />
by competitiveness strategies”. (Cracolici & Nijkamp 2008, 338.)<br />
The model by Ritchie <strong>and</strong> Crouch has been further developed by Sheldon <strong>and</strong> Park (2009) to<br />
be more readily applicable in the wellness tourism context. Sheldon <strong>and</strong> Park noted that the<br />
model is crucial to identify the supporting factors <strong>and</strong> resources for wellness tourism because<br />
it would not be possible to develop wellness products if the destination cannot provide basic<br />
infrastructure <strong>and</strong> guarantee access to the area. According to them (ibid. p. 100) “destinations<br />
can no longer be passive <strong>and</strong> allow themselves to naturally adapt, but must strategically plan<br />
for this market <strong>and</strong> identify their competitive advantage. Identification of wellness resources<br />
<strong>and</strong> products, <strong>and</strong> strategic positioning in the market are critical to success”<br />
From the resource point of view, the attractions are of vital importance. The built-up <strong>and</strong><br />
natural physical environment of a destination, its local culture <strong>and</strong> community spirit can be<br />
considered as the core resources in tourism. The attractiveness of a destination can be<br />
considered from different angles, among them nature <strong>and</strong> l<strong>and</strong>scape, culture, history, facilities<br />
for engaging in various hobbies, <strong>and</strong> accessibility. However, the resource itself is not a<br />
product. Rather, existing resources are the necessary precondition for the creation of a travel<br />
experience that can be turned into a saleable tourism product (Middleton with Clarke 2001,<br />
Middleton 1997, Järviluoma 1994).<br />
Concepts of wellness <strong>and</strong> wellbeing are quite widely used, for example, in the health,<br />
wellbeing <strong>and</strong> tourism sectors. The concepts are sometimes used synonymously, but there are<br />
differences in content <strong>and</strong> meaning. Especially in the Finnish context, the terms are used<br />
interchangeably <strong>and</strong> this inconsistent use has caused considerable confusion. In this paper, the<br />
term of wellbeing is used instead of wellness. The reason for this is that in Finnish one term<br />
“hyvinvointi” is used render what in English is rendered as wellness <strong>and</strong> wellbeing. (see Konu<br />
et al. 2010.)<br />
A model of a sustainable wellbeing destination<br />
As mentioned earlier, Sheldon <strong>and</strong> Park (2009) developed their model (see Figure 1) to be<br />
more readily applicable in the wellness/wellbeing tourism context. In the model of Crouch<br />
<strong>and</strong> Ritchie (2003/2005) br<strong>and</strong>ing, awareness <strong>and</strong> image are situated among qualifying <strong>and</strong><br />
amplifying determinants. Sheldon <strong>and</strong> Park (2009) argue that these br<strong>and</strong>ing efforts should be
situated at the point at which the core resources of wellness tourism are identified. They<br />
explain this by stating that the wellness resources connected with culture <strong>and</strong> cultural<br />
elements of the host community are a crucial part of the identity/br<strong>and</strong> of a destination.<br />
Sheldon <strong>and</strong> Park (2009) locate wellness destination policy <strong>and</strong> planning in the third stage.<br />
The reason for this is that in their view wellness tourism cannot be sustainable if it has no<br />
clear vision, goals <strong>and</strong> positioning on the market. Further, Conlin <strong>and</strong> Baum (2003) argue that<br />
public policymakers <strong>and</strong> private sector decision-makers need to recognize the human<br />
resources in indispensable component of successful sustainable tourism development.<br />
According to them, human resources have to be part of the overall planning instead of an<br />
operational consideration. Baum’s comprehensive model calls for consideration of the five<br />
areas of tourism - environment, tourism <strong>and</strong> labour markets, tourism <strong>and</strong> education, human<br />
resource practises in the industry <strong>and</strong> tourism <strong>and</strong> the community in a comprehensive,<br />
integrated <strong>and</strong> cohesive manner. (Conlin <strong>and</strong> Baum, 1994, 2003.)<br />
The planning stage is followed by destination development <strong>and</strong> management. In this stage it is<br />
guaranteed that the wellness products offered <strong>and</strong> provided are of high quality. To realize this,<br />
the stage includes elements such as training <strong>and</strong> education of personnel (human resources)<br />
<strong>and</strong> opportunities to join certification programmes. (Sheldon <strong>and</strong> Park, 2009).
Sustainable <strong>Wellness</strong> <strong>Tourism</strong> Destination<br />
<strong>Wellness</strong> Destination Development <strong>and</strong> Management<br />
Human resource, training, education, certification programs, building<br />
associations among <strong>and</strong> between the wellness industry <strong>and</strong> public sector<br />
<strong>Wellness</strong> Destination Policy <strong>and</strong> Planning<br />
Vision, goals, private-public sectors’ collaborated planning <strong>and</strong><br />
development of policy, monitoring/evaluation measures of wellness<br />
experiences <strong>and</strong> sustainability<br />
Core <strong>Wellness</strong> Resources <strong>and</strong> Attractions<br />
Unique wellness destination features: natural <strong>and</strong> cultural resources,<br />
traditional healing/therapeutic/wellness resources<br />
Supporting Factors & Resources for <strong>Wellness</strong> <strong>Tourism</strong><br />
Infrastructure, superstructure, residents’ hospitality, <strong>and</strong> knowledge of<br />
healing practices, destination atmosphere (a sense of place)<br />
Figure 1. A model of sustainable wellness destination (Sheldon & Park, 2009, adapted<br />
from Ritchie <strong>and</strong> Crouch, 2002).<br />
This paper aims to implement the model by Sheldon <strong>and</strong> Park by examining an urban<br />
destination, Savonlinna town, <strong>and</strong> its surroundings from the perspective of competitiveness in<br />
the context of wellbeing tourism. Geographically Savonlinna town is located in the Eastern<br />
part of Finl<strong>and</strong>, in the centre of Lake Saimaa (see Figure 2).<br />
Considering tourism in general, Savonlinna has good basic infrastructure <strong>and</strong> its accessibility<br />
is relatively good. The town is about 340 kilometres from the capital Helsinki by road <strong>and</strong><br />
about four hours away by train (see Figure 2). Savonlinna Airport is located about 20<br />
kilometres outside the city, <strong>and</strong> the journey to Helsinki takes 40–60 minutes by plane.<br />
Savonlinna is built on a chain of isl<strong>and</strong>s located throughout a number of large lakes. The lake<br />
environment is a key asset for Savonlinna town.
Figure 2. The location of Savonlinna town.<br />
By interviewing local developers <strong>and</strong> entrepreneurs the aim is to ascertain how local actors<br />
perceive the current situation <strong>and</strong> positioning of Savonlinna in the wellbeing tourism context.<br />
Do they see any future potential for wellbeing tourism? Given the many discussions at local<br />
level on Savonlinna’s prospects in wellbeing tourism, the meaning of the paper is to find<br />
whether Savonlinna can be seen as a sustainable wellbeing destination in the future.<br />
Methodology <strong>and</strong> data gathering<br />
The data for the paper were gathered by interviewing tourism professionals <strong>and</strong> developers.<br />
The interviews were conducted on between 15 September 2009 <strong>and</strong> 21 December 2009. In<br />
total 14 interviews were conducted. The interviews took from 23 minutes to 78 minutes. All<br />
interviews were taped <strong>and</strong> later transcribed. Interviewees were local wellbeing entrepreneurs,<br />
regional developers <strong>and</strong> project managers in wellbeing-related projects. Regional developers<br />
represented the public sector.<br />
The analysis presented in the paper was done during in summer 2010 <strong>and</strong> is based on both<br />
interviews <strong>and</strong> a survey of resources. The survey of resources is based on both written <strong>and</strong><br />
observational material. The supplementary documentary data also includes material from a<br />
bachelor´s thesis intended to survey the internet availability of wellness products in the<br />
province of South Savo.<br />
The interviews were a part of the Nordic Wellbeing project implemented in Savonlinna<br />
region. The main objective of the project will be the creation of a customer-driven Nordic<br />
wellbeing concept around Nordic resources based on unique values in the Nordic countries,<br />
anchored in nature, outdoor life, cleanliness, health image <strong>and</strong> the values of the northern<br />
hemisphere. The thematic interviews included questions about the unique selling points of the<br />
region, cooperation <strong>and</strong> networking as well as resources used in wellbeing tourism<br />
development.<br />
Savonlinna as a Sustainable Wellbeing <strong>Tourism</strong> Destination in Finnish context<br />
Wellbeing can be connected to a certain extent to supporting factors <strong>and</strong> resources.<br />
Savonlinna’s infrastructure <strong>and</strong> facilities are suitable for the wellbeing sector, as the main<br />
hotels in the town <strong>and</strong> its surroundings have a long history as rehabilitation centres. Because<br />
of this, the knowledge of healing practices is good, likewise the knowledge of the use of<br />
natural resources such as the water element.
In tourism marketing Savonlinna has been described as the liveliest <strong>and</strong> most vibrant<br />
summertime town in Finl<strong>and</strong>. Savonlinna <strong>and</strong> its surroundings are among our country’s most<br />
popular holiday regions. The lake scenery of Saimaa offers a perfect setting for a cultural, spa,<br />
beach, activity or city holiday – or for a combination of these. Various distinctive boutiques,<br />
idyllic cafes <strong>and</strong> high-class restaurants, offering friendly service <strong>and</strong> warm hospitality, add to<br />
the unrivalled charming atmosphere of the Savonlinna region (www.savonlinnatravel.com).<br />
Finnish wellbeing tourism focuses mainly on nature, peace <strong>and</strong> quietness, activities <strong>and</strong> also<br />
some cultural offerings (Kangas & Tuohino 2008, Finnish Tourist Board 2008a). This also<br />
applies to Savonlinna. The natural core resources are unspoiled natural environment including<br />
forests, lakes <strong>and</strong> other waterways, hills <strong>and</strong> extensive areas of wilderness. In Savonlinna<br />
region are is also four distinct seasons to be exploited in different tourism products. Finnish<br />
wellbeing innovations are generally internationally well known. Sauna <strong>and</strong> Nordic walking<br />
have notably raised their profile as generally known Finnish products (Finnish Tourist Board<br />
2008a). Both activities are well represented in Savonlinna region. The town has a long history<br />
as a spa tourism destination.<br />
As early as in the 1860s the region of Savonlinna was a popular holiday resort on Lake<br />
Saimaa, attracting visitors from as far afield as St. Petersburg to experience its spa facilities<br />
(Hirn & Markkanen 1987). The spa <strong>and</strong> casino were built in 1896. In 1898, the casino was<br />
extended. The old spa was destroyed by fire in 1962. Today the Spahotel Casino is in<br />
recreational use <strong>and</strong> offers wide range of summer activities. However, the old historical spa<br />
image of Savonlinna is more or less a thing of the past <strong>and</strong> the current tourism image is based<br />
on the Opera Festival <strong>and</strong> the resources of its lakel<strong>and</strong> scenery. The recreational use of spas<br />
has replaced the traditional spa culture.<br />
In the vicinity of Savonlinna town there are Linnansaari <strong>and</strong> Kolovesi aquatic national parks<br />
in year-round use. The nature experiences are supported by high quality self-catering cottage<br />
<strong>and</strong> hotel accommodation <strong>and</strong> restaurant <strong>and</strong> sauna facilities. The municipalities of Kerimäki<br />
<strong>and</strong> Punkaharju strengthen the image of Savonlinna region as a wellbeing destination due to<br />
two significant rehabilitation centres located in these municipalities.<br />
In surveying the wellbeing companies <strong>and</strong> their offerings in the Internet Mahkonen (2008)<br />
found 19 companies providing wellbeing tourism services in South Savo province. These<br />
companies have altogether only 56 saleable products in the Internet. Only two of the 19<br />
companies were located in Savonlinna town. In Hook’s survey (2008) only four<br />
wellness/wellbeing products were found in Savonlinna.<br />
Wellbeing tourism is one product theme earmarked for development in the Finnish national<br />
tourism strategy published by the Ministry of Trade <strong>and</strong> Industry (Finnish Tourist Board<br />
2008a). This led to the development of ‘Development strategy for Finnish wellbeing tourism<br />
in international markets, 2009-2013’ in 2008. As the Finnish wellbeing tourism strategy is<br />
quite new, its implementation is still ongoing. There are plans to develop more comprehensive<br />
wellbeing tourism products <strong>and</strong> services for foreign markets. The vision for Finnish wellbeing<br />
tourism by the Finnish Tourist Board (2008a) is: “Finl<strong>and</strong> is known as a country that can<br />
offer wellbeing, rest, <strong>and</strong> relaxation. Its wellbeing offering is clearly defined. The offering has<br />
been put together in a manner that is marketable <strong>and</strong> follows sustainable development. It<br />
comprises packages or modules that are easy to purchase <strong>and</strong> internationally known.<br />
Wellbeing tourism is a year-round activity that can extend the tourism season in Finl<strong>and</strong>”.
On the regional level, the tourism development strategy of the Province of South Savo <strong>and</strong> the<br />
strategy of Savonlinna town give the guidelines for wellbeing tourism development. In both<br />
strategies wellbeing is seen as one of the main strategic foci in the region. The lakemilieu <strong>and</strong><br />
cultural heritage are in a strong position in strategy <strong>and</strong> visions. In practice the development<br />
work in the region is just beginning.<br />
In Finl<strong>and</strong> there are so far no official associations in the wellbeing sector or governmental<br />
organizations promoting co-operation between the wellbeing industry <strong>and</strong> the public sector.<br />
However, the government provides support for social holidays that frequently take place in<br />
wellness or wellbeing facilities. In addition, there are rehabilitation programmes for war<br />
veterans (Aho, 2007). As mentioned earlier, Savonlinna <strong>and</strong> its surrounding municipalities are<br />
decidedly competent in the rehabilitation sector.<br />
There are ongoing actions implementing the Finnish Wellbeing Strategy. One of the aims is to<br />
create st<strong>and</strong>ardised products on international wellness markets. In the process new kinds of<br />
cooperation <strong>and</strong> cooperation models between the wellness industry <strong>and</strong> public sector are<br />
likely to take shape. In Savonlinna region there are at present no known activities for the<br />
implementation of wellbeing strategy.<br />
In Finl<strong>and</strong> there is a fairly good education system in place for service personnel in the<br />
wellbeing sector. In addition, a new full-time degree programme in Experience <strong>and</strong> <strong>Wellness</strong><br />
Management has started up (Haaga-Helia 2010). In Turku University of Applied Sciences<br />
there is ongoing a project entitled Innovations <strong>and</strong> Learning in Spa Management (Turku<br />
University of Applied Sciences 2010). In Savonlinna there are several educational options in<br />
the wellbeing sector as all levels of education from vocational school to university are well<br />
represented in the town.<br />
Attributes describing Savonlinna as a wellbeing tourism destination<br />
Figure 3 shows the attributes interviewees associated with Savonlinna town. Above all, Lake<br />
Saimaa, the lake environment, lake scenery or water elements were mentioned by every<br />
interviewee. In addition cultural attractions like the medieval castle of Olavinlinna, the<br />
Retretti Art Centre <strong>and</strong> the Opera Festival were mentioned.<br />
While examining the supporting factors the interviewees mentioned the ideal location of<br />
Savonlinna as a key asset. The accessibility from St. Petersburg <strong>and</strong> the Helsinki metropolitan<br />
region were likewise considered important. The potential for attraction <strong>tourists</strong> from Russia<br />
also emerged. Other supporting factors mentioned were mainly connected to natural resources<br />
<strong>and</strong> infrastructures, e.g. forests, rocks, isl<strong>and</strong>s, steam boats, self-catering cottages <strong>and</strong> chalets.<br />
The Savonlinna spirit was also mentioned by some respondents.<br />
Core resources <strong>and</strong> attractions also included lakes <strong>and</strong> aquatic environment, national parks<br />
<strong>and</strong> cultural attractions. Natural resources were seen as a core resource, while the main<br />
attractions mentioned were Olavinlinna castle, the Retretti Art Centre, the Opera Festival <strong>and</strong>,<br />
of course, lakes. In addition the local people <strong>and</strong> <strong>business</strong>es were seen as unique selling points<br />
of Savonlinna. When asked about added value for the region, the respondents mentioned<br />
attributes like national parks, local services <strong>and</strong> hospitality, genuine people, authentic way of<br />
life, variety <strong>and</strong> attractiveness. On the other h<strong>and</strong>, it was also mentioned that the town is an<br />
underachiever compared to the resources available.
The role <strong>and</strong> actions of Savonlinna town <strong>and</strong> Savonlinna Region Federation of Municipalities<br />
were highly appreciated in connection with wellbeing destination policy <strong>and</strong> planning. The<br />
planning <strong>and</strong> policy in the region are guided by national, regional <strong>and</strong> local tourism strategies.<br />
At present Savonlinna has its own tourism development <strong>and</strong> town planning projects in the city<br />
centre. Projects also include planning activities for new spa <strong>and</strong> wellbeing facilities.<br />
Destination development <strong>and</strong> management received only few comments. The strong role of<br />
town <strong>and</strong> regional policymakers was mentioned as well as the importance of Savonlinna<br />
Travel Ltd. Educational resources were also mentioned by some.<br />
-<br />
Wellbeing Destination Development <strong>and</strong> Management<br />
- competent human resources available, excellent educational <strong>and</strong> training resources<br />
- Savonlinna Travel Ltd.<br />
Wellbeing Destination Policy <strong>and</strong> Planning<br />
- cooperation between municipalities, town <strong>and</strong> Savonlinna Region Federation of Municipalities<br />
- strong role of town in tourism planning <strong>and</strong> policy<br />
- strong actors in the region (Savonlinna Travel ltd, Savonlinna Region, Centre for Expertise, Centre<br />
for <strong>Tourism</strong> Studies in the University of Eastern Finl<strong>and</strong>)<br />
- Locomotive actor is missing at present<br />
Core Wellbeing Resources <strong>and</strong> Attractions<br />
- unique lake environment, Saimaa lake, Saimaa scenery, beautiful lake l<strong>and</strong>scape<br />
- natural <strong>and</strong> cultural resources<br />
- resources connected to lakes<br />
- strong culture <strong>and</strong> history (Opera festivals, Retretti Art Centre, Olavinlinna medieval castle)<br />
- ideal for active nature-based tourism<br />
- unique living environment for both habitants, workers <strong>and</strong> <strong>tourists</strong><br />
- Traditional healing/therapeutic/wellbeing resources<br />
- local people, <strong>business</strong>es, hospitality<br />
- good old history<br />
- certain kind of exoticism<br />
- competent <strong>and</strong> capable <strong>business</strong>es (e.g. SaimaaHoliday)<br />
- Old historical spa <strong>and</strong> casino<br />
Supporting Factors <strong>and</strong> Resources for Wellbeing <strong>Tourism</strong><br />
- geographical location close to Russian border <strong>and</strong> St. Petersburg<br />
- good accessibility by air, road <strong>and</strong> rail from capital area<br />
- ideal location on the shores of Saimaa, on the isl<strong>and</strong><br />
- charming small town<br />
- historical steam boats<br />
- forests, rocks, isl<strong>and</strong>s, aquatic environment<br />
- Kolovesi <strong>and</strong> Linnasaari National parks<br />
- variety of accommodations (hotels, cottages, etc.)<br />
- knowledge of healing <strong>and</strong> rehabilitation practices<br />
- vital lake environment<br />
Figure 3. Savonlinna as a sustainable tourism destination<br />
- interaction between man <strong>and</strong> nature<br />
- Municipality of Kerimäki with a wooden church<br />
- Municipality of Punkaharju with a ridge <strong>and</strong> history related Russian Tsar<br />
Figure 3. Savonlinna as a sustainable tourism destination. Attributes listed by<br />
interviewees.
Conclusion <strong>and</strong> discussion<br />
The aim of the paper is to test the model by Sheldon <strong>and</strong> Park in Savonlinna by examining an<br />
urban destination, Savonlinna town <strong>and</strong> its surroundings from the perspective of<br />
competitiveness in the context of wellbeing tourism. The overall finding of the interviews is<br />
that Savonlinna was perceived as a destination product. In addition there was much discussion<br />
on Savonlinna’s assets for wellbeing tourism. However, the interviewees pointed out that in<br />
practice there is still much to be done to achieve the status for Savonlinna town of a<br />
sustainable wellbeing tourism destination. At the moment, such status is more in the minds of<br />
respondents than on a tangible, practical level. As noted earlier in the case of one<br />
rehabilitation centre (see Tuohino & Kangas 2008) one of the greatest challenges for<br />
wellbeing tourism is opportunity. Currently the wellbeing segment in Savonlinna region is<br />
still limited <strong>and</strong> fragmentary.<br />
Lakes were seen as the town’s main resource. However, the use of lakes in the wellbeing<br />
context was difficult for the interviewees to envisage. Among the interviewees there was a<br />
strong vision of wellbeing tourism development around the lakes but the main question was<br />
how in practice to exploit lakes in tourism product development.<br />
For some reason, none of the interviewees mentioned the strategies while describing the<br />
frameworks of Savonlinna in the wellbeing context in spite of existing national, regional <strong>and</strong><br />
local tourism development strategies giving the guidelines. In general it was apparent in the<br />
interviews that the interviewees analyzed Savonlinna as a tourism destination, not as a<br />
wellbeing tourism destination. As one interviewee said “Savonlinna is an underachiever<br />
compared to resources available”.<br />
However, it emerged that the model by Sheldon <strong>and</strong> Park can indeed be implemented in the<br />
case of Savonlinna <strong>and</strong> used in evaluating the attributes of the town. According to the<br />
findings presented in this paper there is still a lot of work to be done before Savonlinna can<br />
really be seen as a sustainable wellbeing tourism destination. Therefore this paper presents the<br />
first phase of the process.<br />
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Mahkonen, A. (2008). Etelä-Savon alueen hyvinvointimatkailutuotteet Internetissä.<br />
Unpublished bachelor’s work. <strong>Tourism</strong> Studies. Mikkeli University of Applied Sciences.<br />
Ritchie, J.R. & Crouch, G.I. (2003/2005). The Competitive Destination: A Sustainable<br />
<strong>Tourism</strong> Perspective. Wallingford: CABI Publishing.<br />
Sheldon, P. J. & Park, S.-Y. (2009). Development of sustainable wellness destination. In<br />
Bushell, R. & Sheldon, P. J. (Eds.), <strong>Wellness</strong> <strong>and</strong> <strong>Tourism</strong> – Mind, Body, Spirit, Place,<br />
(pp. 99-113). Innovation <strong>and</strong> <strong>Tourism</strong> - Connecting Theory & Practice series. New York:<br />
Cognizant Communication Corporation.<br />
www.savonlinnatravel.com
Polish Spas – in need of a polish?<br />
Eastern <strong>and</strong> Western European perspectives on spa <strong>and</strong> health tourism<br />
Sub-theme: Segmentation <strong>and</strong> positioning products, br<strong>and</strong>s <strong>and</strong> destinations in health<br />
<strong>and</strong> wellness tourism<br />
Dorota Ujma<br />
University of Bedfordshire, UK<br />
dorota.ujma@beds.ac.uk<br />
Research paper<br />
This paper aims to explore the ‘ethnocentrically’ divided – <strong>and</strong> culturally specific<br />
underst<strong>and</strong>ing of spa tourism, health tourism <strong>and</strong> wellness tourism; specifically based on<br />
comparisons between the Central <strong>and</strong> Eastern European (especially Polish) <strong>and</strong> Western<br />
perspective.<br />
Drawing on Dann <strong>and</strong> Liebman Parrinello’s (forthcoming) call to discern, contextualize <strong>and</strong><br />
better appreciate research published beyond English-speaking world, Polish <strong>and</strong> English<br />
literature on health <strong>and</strong> spa tourism is reviewed <strong>and</strong> interpreted in combination. It appears that<br />
Polish approaches view spas <strong>and</strong> health resorts as popular destinations with a number of<br />
protected natural on-site sources (e.g mineral or thermal water), offering contact with nature<br />
resulting in improvements in health <strong>and</strong> well-being. Polish spas tend to be functional,<br />
utilitarian <strong>and</strong> regimented in their delivery; where ‘improving health’ is achieved through<br />
basic, traditional treatments, connected with a specific locale. Moreover there is a belief that<br />
just staying within the spa environment is beneficial; that improvements to health <strong>and</strong> well<br />
being occur simple by “being there”. In contrast to Western facilities both the quality of<br />
facilities together with customer orientated service is not expected to be of a high st<strong>and</strong>ard. In<br />
Western Europe the connection with nature <strong>and</strong> natural resources, along with its perceived<br />
effectiveness of related treatments, is less prevalent <strong>and</strong> so is of less importance. The<br />
philosophy <strong>and</strong> customer approach of Western ‘spas’ are often founded in the gentle<br />
encouragement towards <strong>healthy</strong> living through often exotic <strong>and</strong> luxury treatments which take<br />
place in r<strong>and</strong>om premium settings.<br />
Such differences are not only embedded in the manner in which these types of tourism are<br />
delivered <strong>and</strong> experienced – but also in the very specific definitions adopted by differing<br />
cultures which are in turn influenced by both semantics <strong>and</strong> tradition. Whilst in Western<br />
literature spa tourism is seen as a component of health tourism (for example Hall 2003), the<br />
Polish reviews (such as Rydz 2005, Wolski 1970, 1991) indicate that the overlap between the<br />
two may be only partial; resulting in spa tourism covering more types of tourism, not always<br />
related to health alone (Hadzik 2009).<br />
As a result it is suggested that current health tourism definitions should be more sensitive to<br />
cultural variations, <strong>and</strong> that both Western <strong>and</strong> Eastern European practitioners be more aware<br />
of the opportunities relating to both location <strong>and</strong> customer care.<br />
References<br />
Dann, G. M.S. <strong>and</strong> Liebman Parrinello, G. (Eds.) (Forthcoming) The Sociology of <strong>Tourism</strong>:<br />
European Contributions, Emerald<br />
Hadzik, A. (2009) Turystyka zdrowotna uzdrowisk (Spa tourism in health resorts),<br />
Wydawnictwo Akademii Wychowania Fizycznego, Katowice.
Hall, M. (2003) Spa <strong>and</strong> <strong>Health</strong> <strong>Tourism</strong>, in S. Hudson, Sport <strong>and</strong> Adventure <strong>Tourism</strong>, The<br />
Haworth Hospitality Press, NY, pp. 273- 292<br />
Rydz, E. (Ed.) (2005) Kształtowanie funkcji turystycznych w miejscowościach<br />
uzdrowiskowych (Shaping the role <strong>and</strong> function of tourism in health resorts), Pomorska<br />
Akademia Pedagogiczna, Słupsk.<br />
Wolski, J. (1970) Turystyka zdrowotna a uzdrowiska europejskich krajów socjalistycznych<br />
(<strong>Health</strong> tourism <strong>and</strong> spas in the European socialist countries), Problemy Uzdrowiskowe,<br />
5.<br />
Wolski, J. (1991) Turystyka uzdrowiskowa (Spa tourism), Problemy turystyki (<strong>Tourism</strong><br />
Problems / Issues), 1-2.
A strategy based on the traditional health tourism in Central-Europe<br />
<strong>and</strong> new spa <strong>and</strong> wellness trends<br />
Policy <strong>and</strong> strategy document<br />
Várhelyi Tamás<br />
Regional <strong>Tourism</strong> Knowledge Center, Szolnok, Hungary.<br />
varhelyit@hotmail.com<br />
Torday Judit<br />
Regional <strong>Tourism</strong> Knowledge Center, Szolnok, Hungary.<br />
Key-words: health tourism, medical spa, traditional spa, knowledge center<br />
Abstract<br />
On the basis of the perceptible developments in tourism <strong>and</strong> the domestic conditions, health<br />
tourism is considered the most important sector of tourism in Hungary. Due to the effects on<br />
health, life style <strong>and</strong> on the related products to these, health tourism – in English term: spa<br />
industry- has more significance than just tourism. Underst<strong>and</strong>ing these trends <strong>and</strong> based on<br />
the local traditions, we try to create a spa industry development strategy for Hungary <strong>and</strong><br />
Central-Eastern Europe.<br />
Traditional health tourism is thermal water based activity, including spa, long cures, <strong>and</strong><br />
health treatments evolved in Central Europe in the 19 th century, partly based on the spa<br />
culture of the Roman Empire. Concerning spa cities the Austrian-Hungarian Monarchy was<br />
market leader in many aspects. In those times such treatments were considered as the most<br />
efficient methods for fighting gastrointestinal problems <strong>and</strong> rheuma.<br />
In the last decade health, taking care of our body <strong>and</strong> soul is getting more <strong>and</strong> more valuable.<br />
In the modern world it is also accompanied with the notion of success: we can become more<br />
successful in our work, surroundings <strong>and</strong> private life if we can remain <strong>healthy</strong>, neat <strong>and</strong> fit.<br />
This is the explanation for a growing need for spa <strong>and</strong> wellness tourism within the tourism<br />
sector.<br />
Nowadays on the basis of world trends we can talk about producing goods related to the<br />
tourism industry in addition to the traditional travel service <strong>and</strong> hospitality. Some products<br />
can also be exported, as a matter of fact they can behave similarly as the products of other<br />
export oriented industries. The point here is the export of the innovative services including the<br />
products just like in telecommunication, information technology or health care.<br />
Businesses with billion turnover developed in the spa industry <strong>and</strong> we might think that by<br />
means of our traditions <strong>and</strong> of our thermal springs we belong at the forefront of the world. In<br />
reality according to the return of the industry we only take up a place in the middle field <strong>and</strong><br />
practically we do not take part in the new trends <strong>and</strong> export. The reason for this lies mainly in<br />
the insufficiency of the domestic entrepreneurial culture <strong>and</strong> knowledge. The project carried<br />
out by the <strong>Tourism</strong> Knowledge Center, sponsored by the Ministry of Economy wished to<br />
change this with the available resources.<br />
<strong>Health</strong> tourism is also the most important type of tourism for the regions of the Carpathian<br />
Basin. The reason for this lies in sectoral trends, increasing dem<strong>and</strong>, rich traditions <strong>and</strong>
excellent capabilities. Despite of these, countries of the regions are not among the most<br />
successful countries in Europe. It is obvious that these countries together would be one of the<br />
market leaders, if they can function properly on the market. To support this, we established a<br />
tourism knowledge center, <strong>and</strong> an innovative tourism cluster. According to it the current<br />
situation could be changed via the following:<br />
• Underst<strong>and</strong>ing world trends, benchmarking, development of strategies <strong>and</strong> action<br />
plans<br />
• Identifying traditions <strong>and</strong> capabilities in line with current trends <strong>and</strong> based on the<br />
results, modern product development through organized innovation<br />
• Coordination of innovative, interested, interdisciplinary market players<br />
In order to realistically comprehend the tendencies we have to interpret the circumstances of<br />
the health tourism <strong>and</strong> emphasize its importance in the international field. This is not always<br />
easy, there can be misunderst<strong>and</strong>ings even concerning the name of the industry. In the English<br />
terminology the spa <strong>and</strong> wellness industry is used instead of health tourism. In the near future<br />
for that very reason we have to redefine the term ‘health tourism’ <strong>and</strong> it will be appropriate to<br />
include ‘medical tourism’ into it also.<br />
The transformation of the term ‘spa’, the suppression of water based service can mean a<br />
reshaped <strong>business</strong> model. In the case of the world’s most profitable health resorts not the<br />
admission price but the therapy fee makes up the most considerable amount of return <strong>and</strong> by<br />
all means the most profit comes from the treatments. Apparently this world trend will be<br />
effective in Hungary also, we have to prepare for it or rather this can lead to the extreme<br />
increase in the domestic health tourism return.<br />
The quality <strong>and</strong> diversity of spa waters is a common strength of Centre Europe. Hungary has a<br />
European quality health service in several professions. It has close connections with the<br />
traditional thermal tourism. In health tourism (spa, wellness <strong>and</strong> medical tourism),<br />
professional basis is getting more significant, <strong>and</strong> the most dynamic sector being medical<br />
wellness. So it is obvious to use the traditions – with proper innovation it can be successful<br />
tool on the present spa market.<br />
Relative underdevelopment of these countries can be an advantage in the spa world, as less<br />
industrial environment goes well with naturality, it is more capable <strong>and</strong> attractive for<br />
bioproducts as well. There is more potential for tourism service development requiring large<br />
sites: golf tourism <strong>and</strong> horse tourism are appropriate subjects for strategy developments in<br />
these regions.<br />
According to the numbers Hungary is not in the first ten European countries <strong>and</strong> by all means<br />
it is an illusion that we are a ‘superpower of baths’ or even can be one. In spite of this as a<br />
member of the middle field with our great traditions <strong>and</strong> the possession of considerable<br />
amount of thermal springs we can be more successful than we are now, even double the<br />
present return <strong>and</strong> significantly increase the profitability which is still very moderate<br />
nowadays. This means the health tourism would not only be the pride of our country, but it<br />
could also be the main sector of the Hungarian economy.<br />
For Europe the general spa trends of the last decade were threats. There were coming from the<br />
US, <strong>and</strong> allow developing spas without thermal water. Using our traditions <strong>and</strong> the trends of<br />
medical wellness together, Europe could remain in strong position, <strong>and</strong> Centre Europe can<br />
increase its market share.
References<br />
The International Spa Association <strong>and</strong> the Hartman Group: Consumer Report: Spa-Goer <strong>and</strong><br />
Non-Spa Goer Perspectives, ISPA, Lexington, 2006.<br />
Várhelyi T., Müller A: Spa tourism <strong>and</strong> regional development: it can be more successful with<br />
cross-border cooperation. Neighbors <strong>and</strong> Partners: On the Two Sides of the Border (ed: I.<br />
Süli-Zakar) Debreceni Egyetemi Kossuth Egyetemi Kiadó, 2008. 309-314. p.<br />
SRI International: The Global Spa Economy 2007. Global Spa Summit, New York, 2008.<br />
Cohen, M., Gerard Bodeker: Underst<strong>and</strong>ing the global spa industry. Elsevier, 2008.<br />
Várhelyi T: Hungary & Central-Eastern Europe, Global Spa & <strong>Wellness</strong> Industry Briefing<br />
Papers, p. 23-25, Global Spa Summit, 2009.<br />
Stanton, L.: Research: Global Spa Consumers. Spa <strong>business</strong>, 2009/3, pp. 32-36.
Australian <strong>Wellness</strong> <strong>Tourism</strong> Providers: Definition, Typology <strong>and</strong> Current<br />
Status<br />
Cornelia Voigt<br />
School of Management, University of South Australia<br />
City West Campus, GPO Box 2471, Adelaide, SA 5001, Australia<br />
Cornelia.Voigt@unisa.edu.au<br />
And<br />
Jennifer Laing<br />
<strong>Tourism</strong> Research Unit, Monash University<br />
Berwick Campus, PO Box 1071, Narre Warren, VIC 3805, Australia<br />
Jennifer.Laing@BusEco.monash.edu.au<br />
Abstract<br />
This paper provides insight into the current structure of Australian wellness tourism providers,<br />
which is based on a national scoping study investigating supply <strong>and</strong> dem<strong>and</strong> of Australian<br />
health tourism. A new wellness tourism provider typology consisting of three core categories<br />
is suggested: (1) Beauty Spa Hotel/Resorts, (2) Lifestyle Resorts, <strong>and</strong> (3) Spiritual Retreats. In<br />
order to build a picture of the structure of the industry, the main body of this paper provides<br />
examples of wellness tourism operators that illustrate each of the wellness tourism provider<br />
categories. This is followed by a discussion of the results of a survey sent to all Australian<br />
wellness tourism providers, demonstrating the nature of services offered by the three core<br />
types of wellness tourism operators. This research contributes to the underst<strong>and</strong>ing of<br />
different approaches to developing <strong>and</strong> delivering wellness tourism, not only within one<br />
country but also in comparison to how wellness tourism is supplied in other countries.<br />
Key words: wellness tourism, Australia, typology, spa, retreat, resort<br />
Introduction<br />
Although there is some evidence that Australia’s Indigenous people have used geothermal<br />
waters for spiritual <strong>and</strong> medicinal purposes for thous<strong>and</strong>s of years (Lambert, 2008; White,<br />
2009), the Australian wellness <strong>and</strong> health tourism industry is very young when compared to<br />
its development in Europe <strong>and</strong> some Asian countries. One reason for this might be that – with<br />
the notable exception of the mineral <strong>and</strong> hot springs in the Daylesford/Hepburn Springs<br />
region <strong>and</strong> the Mornington Peninsula in the state of Victoria – Australia does not possess<br />
large deposits of mineral <strong>and</strong> hot springs that have been the central focus for Europe’s healthseeking<br />
travellers for centuries. Researchers have noted that the term ‘spa’ has distinctly<br />
different meanings in English-speaking countries <strong>and</strong> continental Europe (Puczkó &<br />
Bacharov, 2006; Williams et al., 1996). Accordingly, the Australian wellness <strong>and</strong> spa tourism<br />
industry is focused on health promotion <strong>and</strong> prevention rather than on medical cure or<br />
rehabilitation as traditionally found in European countries (Bennett, King, & Milner, 2004;<br />
Puczkó & Bacharov, 2006; Smith & Puczkó, 2008).<br />
Possibly fuelled by broad socio-cultural <strong>and</strong> economic factors such as escalating health costs,<br />
an increasing scepticism of orthodox biomedicine on one h<strong>and</strong> <strong>and</strong> a growing acceptance of<br />
alternative healing practices on the other, <strong>and</strong> a rise in the health consciousness of consumers<br />
(Pollock & Williams, 2000; Weiermair & Mathies, 2004) as well as a need to downsize <strong>and</strong>
simplify one’s life in light of rising stress-levels <strong>and</strong> the fast pace of everyday life (Douglas,<br />
2007; Smith & Puczkó, 2008), the Australian wellness tourism industry has grown<br />
exponentially in the past decade. For example, Australian spa providers have experienced a<br />
growth rate of 129 percent between 2002 <strong>and</strong> 2006 (Intelligent Spas, 2006) while more recent<br />
data shows that the number of Australian spa facilities is still exp<strong>and</strong>ing despite the global<br />
economic downturn (Intelligent Spas, 2009). Until recently, however, there has been a<br />
“distinct lack of published research on health tourism issues in Australia” (Bennett, King, &<br />
Milner, 2004, p. 122). Previous research has tended to focus narrowly on only one type of<br />
wellness tourism provider or one group of wellness tourist without considering that there<br />
might be a broader range of wellness tourism supply <strong>and</strong> dem<strong>and</strong>. Consequently, a recent<br />
Australian national scoping study aimed at defining wellness tourism in the Australian context<br />
<strong>and</strong> investigating supply <strong>and</strong> dem<strong>and</strong>. This paper focuses on the supply-side <strong>and</strong> discusses a<br />
newly developed typology of wellness tourism providers. Based on this typology, a nationwide<br />
survey was conducted to establish a profile of all Australian wellness tourism suppliers.<br />
This paper provides an analysis of the services of three distinct core categories of Australian<br />
wellness tourism providers.<br />
A New Typology of <strong>Wellness</strong> <strong>Tourism</strong><br />
Apart from the apparent agreement that wellness tourism is a form of Special Interest <strong>Tourism</strong><br />
(SIT) (e.g. Hall, 2003; Letho et al., 2006), existing definitions <strong>and</strong> typologies vary<br />
extensively. It seems that there is a tension between finding a broad enough typology that<br />
acknowledges a diversity of wellness tourism supply <strong>and</strong> dem<strong>and</strong>, but that is narrow enough<br />
to enable workable data collection. For instance, very broad wellness tourism typologies such<br />
as the one suggested by Sheldon <strong>and</strong> Bushell (2009) which includes medical tourism,<br />
sport/fitness, adventure tourism <strong>and</strong> volunteer tourism activities may be useful in a heuristic<br />
sense, yet are so inclusive that they limit realistic, practical application.<br />
One area of disagreement between scholars is whether wellness tourism subsumes medical<br />
tourism (e.g. Sheldon <strong>and</strong> Bushell, 2009), or vice-versa (e.g. Bookman & Bookman, 2007), or<br />
alternatively whether wellness <strong>and</strong> medical tourism are two essentially separate tourism<br />
categories. This paper supports the view that there is a theoretical difference between ‘cure’ or<br />
‘illness’ concepts on one side <strong>and</strong> the ‘wellness’ concept on the other (Müller & Lanz<br />
Kaufmann, 2001; Nahrstedt, 2004; Voigt, 2008). Whereas medical <strong>tourists</strong> are illness-oriented<br />
because they primarily travel in order to cure or treat a certain illness or medical condition,<br />
wellness <strong>tourists</strong> go on vacation in order to maintain or improve their health <strong>and</strong> well-being<br />
<strong>and</strong> thus try to reach higher levels of wellness. Consequently, providers catering to those<br />
differing cure- or wellness-driven needs of <strong>tourists</strong> can thus also be conceptualised as two<br />
distinct sub-segments of health tourism suppliers (Figure 1). However, a wellness tourism<br />
definition <strong>and</strong> typology that is purely based on this distinction in dem<strong>and</strong>, is still too vague<br />
<strong>and</strong> difficult to operationalise because <strong>tourists</strong> can improve their health <strong>and</strong> well-being in a<br />
vast range of tourism contexts.<br />
Another basis upon which to develop a wellness tourism typology concerns the deliberate<br />
creation of tourist infrastructure that is specifically <strong>and</strong> primarily designed to enable <strong>and</strong><br />
enhance people’s health <strong>and</strong> well-being. For instance, while the supply of volunteer tourism<br />
might evoke increased well-being of participating <strong>tourists</strong>, this type of travel is primarily<br />
designed to provide aid for communities or assisting in environmental or cultural preservation<br />
(Brown, 2005; Wearing, 2001). One could argue that the emphasis is the well-being of<br />
communities or the environment rather than the well-being of the <strong>tourists</strong>. Similarly,<br />
adventure tourism infrastructure is primarily designed to offer extreme physical challenges,
thrills <strong>and</strong> excitement which sometimes even involves <strong>tourists</strong>’ taking physical risks that are<br />
dangerous rather than health-promoting.<br />
However, there seems to be infrastructure that is specifically designed to facilitate <strong>tourists</strong>’<br />
health <strong>and</strong> well-being. An extensive literature review as well as previous research in the<br />
Australian context (Inside Story, 2007; Voigt, 2009), as well as interviews with key<br />
stakeholders, revealed three distinct core categories of wellness tourism providers. These<br />
three provider groups can be labelled as (1) Beauty Spa Hotels/Resorts; (2) Lifestyle Resorts;<br />
<strong>and</strong> (3) Spiritual Retreats (Figure 1).<br />
Medical tourism providers cater<br />
to <strong>tourists</strong> who travel because<br />
they want to treat/cure a medical<br />
condition.<br />
MEDICAL<br />
<strong>Tourism</strong> Providers<br />
Special Interest<br />
<strong>Tourism</strong><br />
HEALTH<br />
<strong>Tourism</strong><br />
Overlap<br />
‘Medical <strong>Wellness</strong>’<br />
1. Medispas<br />
2. Traditional European Spas<br />
3. Therapeutic Recreation <strong>and</strong><br />
Rehabilitation<br />
3. s<br />
Figure 1: Typology of <strong>Health</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong><br />
<strong>Wellness</strong> tourism providers cater to<br />
<strong>tourists</strong> who travel because they<br />
want to maintain or improve their<br />
health.<br />
WELLNESS<br />
<strong>Tourism</strong> Providers<br />
Beauty Spa<br />
Hotels/Resorts<br />
Lifestyle Resorts<br />
Spiritual Retreats<br />
Before explaining these categories <strong>and</strong> presenting concrete, illustrative examples in section<br />
4.1, it needs to be acknowledged that there is an overlap between medical <strong>and</strong> wellness<br />
tourism, creating three additional types of health or ‘Medical <strong>Wellness</strong>’ tourism suppliers: (1)<br />
So-called ‘Medispas’, where alternative therapies are offered beside medical treatments such<br />
as Botox injections or liposuction <strong>and</strong> the line between true health promotion <strong>and</strong> the<br />
correction of physical ‘problems’ or ailments becomes blurred; (2) Traditional European spas<br />
where spa therapies are perceived as mainstream medicine <strong>and</strong> therefore subsidised by<br />
national health insurance schemes as well as receiving ‘patients’ with physical ailments; (3)<br />
Therapeutic Recreation/Therapeutic Rehabilitation facilities which offer holistic <strong>and</strong><br />
alternative wellness therapies <strong>and</strong> counselling to support people with serious illnesses or to<br />
rehabilitate individuals with addictions or other psychological disorders. The major focus of<br />
this paper, however, lies on the three core categories of wellness tourism providers.<br />
Bringing together the dem<strong>and</strong> as well as the supply side, wellness tourism can be defined as<br />
the sum of all the relationships resulting from a journey by people whose primary motive is to<br />
maintain or promote their health <strong>and</strong> well-being <strong>and</strong> who stay at least one night at a facility<br />
that is specifically designed to enable <strong>and</strong> enhance people’s physical, psychological, spiritual<br />
<strong>and</strong>/or social well-being (Voigt, 2008).
Methods<br />
To underst<strong>and</strong> the Australian supply-side <strong>and</strong> structure of wellness tourism, a range of<br />
methods were employed, including secondary data analyses, stakeholder interviews <strong>and</strong> five<br />
detailed cases studies. The interviews with the stakeholders <strong>and</strong> the interviews conducted for<br />
the cases studies included site visits in all Australian states with the exception of the Northern<br />
Territory, the Australian Capital Territory <strong>and</strong> Tasmania. A final method, most relevant for<br />
this paper, consisted of a mail-out survey which was based on an audit of Australian wellness<br />
tourism providers which produced a database of 590 <strong>business</strong>es.<br />
Sampling Frame. The definition of wellness tourism applied in this research deliberately<br />
incorporates the limitation of “to stay at least one night at a facility”. Therefore, the main<br />
emphasis during the audit was to achieve as complete a census as possible of <strong>business</strong>es that<br />
included or were attached to accommodation facilities. It was assumed that providers with<br />
accommodation would receive a higher proportion of <strong>tourists</strong> than local residents in<br />
comparison to establishments without accommodation. Nevertheless, a number of day spas<br />
(although less than a census) were also included in our sampling frame, based on an<br />
acknowledgment that some <strong>tourists</strong> visit these facilities while on vacation. This was important<br />
to gain a broad snapshot of the Australian wellness tourism industry.<br />
The sampling frame was established on the basis of a database of suppliers provided by the<br />
Australian <strong>Tourism</strong> Data Warehouse (ATDW). The database included all suppliers listed by<br />
the ATDW where the experiences field included ‘health <strong>and</strong> wellbeing’. The database was<br />
subsequently reviewed by two research team members, with out of scope records removed<br />
(e.g. <strong>business</strong>es that provide a spa bath in their rooms but do not offer any other health <strong>and</strong><br />
wellness tourism services, or duplicates), which substantially reduced this database. The<br />
database was then crosschecked against other sources, such as Sensis Yellow <strong>and</strong> White<br />
Pages, online directories (e.g. SpaFinder) <strong>and</strong> private records of the research team, to include<br />
additional providers in the database.<br />
Survey Instrument. A self-completion mail-out questionnaire was developed that included<br />
questions in regard to the nature of the service offerings; the <strong>business</strong> profile including year of<br />
establishment, staffing; <strong>and</strong> promotion strategies <strong>and</strong> distribution.<br />
Data Collection Procedure. Before the survey was mailed out, each of the 590 wellness<br />
providers was contacted by telephone <strong>and</strong> the name of an appropriate manager was identified<br />
<strong>and</strong> recorded in the database. This enabled the research team to produce personalised<br />
introduction letters. These letters, together with a hard copy of the questionnaire <strong>and</strong> a reply<br />
paid envelope were sent to every wellness provider listed in the newly created supply data<br />
base. A tracking serial number was printed on the reply paid envelope <strong>and</strong> responses were<br />
recorded in the supply data base. The envelope was then discarded <strong>and</strong> the serial number was<br />
not attached to individual questionnaire records. Two reminder letters after four <strong>and</strong> after<br />
eight weeks were posted to non-respondents. A total of 156 responses were received by the<br />
closing date of the survey, representing a response rate of 25 percent.<br />
Data Analysis. The survey data was captured electronically <strong>and</strong> set up as an SPSS (Version<br />
17) data file. The data was initially inspected through frequency count <strong>and</strong> cross-tabulation to<br />
check for range validity <strong>and</strong> logical consistency. After deleting four questionnaires due to<br />
missing data, we had responses from managers of 68 Beauty Spa Hotels/Resorts, 37 Day<br />
Spas, 27 Lifestyle Resorts <strong>and</strong> 22 Spiritual Retreats. The data set was then analysed by<br />
frequency count, cross-tabulation <strong>and</strong> the calculation of means.
The actual responses were compared with the data base classifications in regard to location<br />
<strong>and</strong> wellness tourism provider category. The distribution of <strong>business</strong> location of the sample<br />
was consistent with the distribution within the supply data base, suggesting that there was no<br />
significant sample bias on the basis of respondent’s <strong>business</strong> location. A comparison between<br />
the distribution of wellness tourism provider category within the sample <strong>and</strong> the supply data<br />
base revealed an over-presentation of the beauty spa resort/hotel <strong>and</strong> the lifestyle resort<br />
categories <strong>and</strong> an under-representation of the day spa category. The higher non-response rate<br />
among day spa providers might be explained by their major focus on local residents rather<br />
than <strong>tourists</strong>, so that they may have perceived that the study was not applicable to them.<br />
Results<br />
The Three Core <strong>Wellness</strong> <strong>Tourism</strong> Provider Categories<br />
The main focus of Beauty Spa Hotels/Resorts is on body <strong>and</strong> beauty treatments such as<br />
facials, massages <strong>and</strong> body wraps. Of the three provider groups, Beauty Spa Hotels/Resorts<br />
are most likely to offer some form of water-based treatment. In this regard, some beauty spa<br />
facilities have an intrinsic geographic advantage as they are based on or around mineral or<br />
thermal pools. Spas that do not have this advantage also offer water-based treatments, for<br />
instance in the form of steam rooms, saunas, whirlpools, hot tubs <strong>and</strong> wet treatments rooms<br />
(e.g. for baths <strong>and</strong> hydrotherapy massages such as a Vichy shower). Day spas are very similar<br />
to Beauty Spa Hotels/Resorts, however they do not include or are not attached to<br />
accommodation facilities.<br />
Some beauty spas are managed independently but are still physically located on the premises<br />
of hotel or resort accommodation suppliers. In recent years, many beauty spas have been<br />
added to existing tourism resort properties, considerably increasing their marketing<br />
advantage, revenue per occupied room, occupancy <strong>and</strong> perceived value for room rate<br />
(Monteson & Singer, 2002). Indeed, it seems that hotel or resort guests nowadays expect fouror<br />
five-star properties to encompass spa facilities.<br />
Based on the discussion with stakeholders <strong>and</strong> through the audit of wellness tourism provider<br />
service offerings it can be argued that Australian Beauty Spa Hotels/Resorts seem to follow<br />
one out of three different thematic approaches.<br />
In the first approach, spa services, facilities <strong>and</strong> décor are reminiscent of traditional<br />
European-style spas. One example is the Aqua Day Spa located in the Sheraton Noosa Resort<br />
& Spa in Queensl<strong>and</strong>. A central focus of this establishment is the use of water with an ‘Aqua<br />
Therapy Centre’ including indoor pools with a range of resistance pressure treatments,<br />
submerged water-lounges, a Vichy shower, a steam room <strong>and</strong> Roman outdoor spas. The décor<br />
consists of Roman-like statues <strong>and</strong> the tiled floors <strong>and</strong> walls as well as the crisp, white<br />
uniforms of the staff, reminiscent of doctors’ coveralls evoke the image of a luxurious<br />
sanatorium. The Aqua Day Spa also includes eight treatment room, including a couple’s room<br />
in which only European cosmetic br<strong>and</strong>s (the Swiss La Prairie <strong>and</strong> the French Thalgo) are<br />
used for the therapies.<br />
In the second approach, the spa theme is strongly based on Asian healing techniques <strong>and</strong><br />
philosophies. An example is Shangri-La’s signature spa br<strong>and</strong> CHI, which was launched only<br />
this year at the Shangri-La Hotel in Sydney. The concept of CHI spas was developed by<br />
recognised specialists <strong>and</strong> its treatments <strong>and</strong> products are based on Traditional Chinese<br />
medicine with its concept of ‘chi’ or ‘qi’ which represents the life force or energy flow that<br />
sustains health, well-being <strong>and</strong> personal vitality. Guests visiting CHI spas fill out a
questionnaire that determines which one of the Chinese Five Elements (metal, water, wood,<br />
fire <strong>and</strong> earth) they are <strong>and</strong> allowing the spa services to be tailored accordingly. The<br />
treatments in CHI spas focus on removing blockages of ‘chi’ with movement, stretching <strong>and</strong><br />
massages as well as ‘movement of the mind’ through relaxation <strong>and</strong> meditation. Although<br />
CHI spas strive to incorporate local elements in their interior design, Chinese <strong>and</strong> Himalayan<br />
artefacts, warm colours <strong>and</strong> woods, as well as specifically designed, mystical ambient lighting<br />
support the Asian healing concept <strong>and</strong> make reference to the Himalayan Shangri-La legend, a<br />
place of personal peace, well-being <strong>and</strong> enchantment.<br />
In the third approach, some Beauty Spa Hotels/Resorts deliberately seek to create a uniquely<br />
Australian theme, thereby often drawing on Indigenous cultural elements <strong>and</strong> healing<br />
philosophies. The Reef House Day Spa at the Sebel Reef House & Spa in Palm Cove,<br />
Queensl<strong>and</strong> illustrates this approach. In their five treatment rooms, the Reef House Day Spa<br />
offers therapies with Aboriginal names such as ‘Yanko’ (meaning ‘sound of running water’<br />
<strong>and</strong> is a Vichy shower treatment), ‘Kodo’ massage (meaning ‘melody’ which is based on<br />
Torres Strait Isl<strong>and</strong>er massage techniques) or ‘Gapu Yuru’ (meaning ‘water cloud’ which<br />
includes a ritual using hot <strong>and</strong> chilled stones, a facial, body wrap <strong>and</strong> exfoliation). They use<br />
the Australian skin care br<strong>and</strong> Li’Tya (meaning ‘of the earth’) which distributes products that<br />
have been created based on Indigenous knowledge of the therapeutic value of Australian<br />
plants such as lemon myrtle <strong>and</strong> wild rosella flowers. The interior design incorporates the<br />
surrounding rainforest with an open-air reception <strong>and</strong> glimpses on the tropical garden <strong>and</strong> the<br />
use of native timbers, for instance for the h<strong>and</strong>crafted, leaf-shaped signature massage table<br />
from Melaleuca wood. It should be noted that while some Australian wellness tourism<br />
suppliers <strong>and</strong> providers build on the advantage of using Indigenous healing traditions in order<br />
to make their services <strong>and</strong> products more attractive to <strong>tourists</strong>, those <strong>business</strong>es are generally<br />
not owned by Indigenous Australians <strong>and</strong> employment of Indigenous staff is also rare.<br />
Lifestyle resorts typically entail the participation in a comprehensive program which focuses<br />
on health-promoting behaviour changes in areas such as nutrition, exercise <strong>and</strong> fitness,<br />
personal goals <strong>and</strong> counselling <strong>and</strong> stress management. Lifestyle resorts are what Americans<br />
often call a ‘destination spa’ <strong>and</strong> as McNeil <strong>and</strong> Ragin (2004, p. 32) observe: “The sole<br />
purpose of this type of spa is to set guests on a healthier path for life”. Spivack (1998, p. 68),<br />
however, notes that the term ‘spa’ is often avoided by lifestyle resort owners because it is seen<br />
as too closely associated with beauty treatments. Therefore, terms such as ‘health resort’,<br />
‘wellness centre’, ‘fitness retreat’ or ‘health farm’ are more common in this category.<br />
Examples of an Australian lifestyle resort are the two Golden Door lifestyle resort properties.<br />
The original Golden Door resort is located in Willowvale, Queensl<strong>and</strong>’s Gold Coast<br />
hinterl<strong>and</strong>, <strong>and</strong> opened in 1993. The other resort, the Golden Door Elysia, opened 10 years<br />
later in the Hunter Valley, New South Wales. The two Golden Door properties were<br />
developed in different ways, required different levels of capital investment <strong>and</strong> therefore offer<br />
different experiences. Whereas the Golden Door in Queensl<strong>and</strong> has a more rustic, closer to<br />
nature feel, Elysia is more elegantly designed <strong>and</strong> luxurious. The Golden Door became<br />
famous with its 5-14 day health programs that promise long-lasting lifestyle changes. Based<br />
on an extensive health <strong>and</strong> fitness assessment, Golden Door staff establish personalised<br />
programs to meet the individual needs of each guest. Both Golden Door properties possess<br />
extensive indoor gym facilities, tennis courts, <strong>and</strong> swimming-pools, <strong>and</strong> are surrounded by<br />
nature that is the setting for bushwalking activities. An extensive assortment of activities <strong>and</strong><br />
seminars is offered, ranging from T’ai Chi, yoga, aquaerobics, water polo, Kung Fu, boxing,<br />
women’s <strong>and</strong> men’s health, <strong>and</strong> cooking classes, to detoxification, <strong>and</strong> alternative healing
therapies such as Feldenkrais, acupuncture, naturopathy <strong>and</strong> hypnotherapy. Both Golden Door<br />
resorts also include a beauty spa where guests can book beauty treatments at an additional<br />
cost. Program guests have three fixed meal times built into their program structure. The<br />
cuisine offered at the Golden Door consists of low fat, wholesome meals without added salt<br />
<strong>and</strong> sugar. Furthermore, alcohol, non-herbal teas <strong>and</strong> coffee are not allowed on the premises<br />
<strong>and</strong> the resort is a smoking-free zone. Amenities such as television, Internet <strong>and</strong> telephones<br />
are not offered <strong>and</strong> the use of mobile phones is discouraged <strong>and</strong> not permitted outside of the<br />
guest’s room.<br />
The emphasis of Spiritual Retreats is on spiritual development or enlightenment. Spiritual<br />
retreats can be religious or non-religious but always include meditation in various forms.<br />
Many spiritual retreats are based on some specific teachings or philosophy <strong>and</strong>/or focus on the<br />
study of a specific activity such as yoga, T’ai Chi or Reiki or particular meditation techniques.<br />
Like lifestyle resorts, some spiritual retreats also focus on detoxing <strong>and</strong> fasting. Here,<br />
however, this often has a distinct spiritual note in terms of ‘purification’ or ‘cleansing’ <strong>and</strong><br />
not only in regard to weight loss or getting rid of un<strong>healthy</strong> toxins. Additionally, one can also<br />
distinguish ‘non-silent’ <strong>and</strong> ‘silent’ Spiritual Retreats. In ‘silent’ spiritual retreats, participants<br />
are not allowed to talk to each other the entire time; they are supposed to focus entirely on<br />
their personal spiritual journey. Compared to Beauty Spa Hotel/Resorts <strong>and</strong> Lifestyle Resorts,<br />
the interior design <strong>and</strong> facilities of Spiritual Retreats tend to be more basic <strong>and</strong> participants<br />
often have to share austere rooms <strong>and</strong>/or bathroom facilities. Guests are also often expected to<br />
participate in housekeeping activities, such as washing the dishes after meals. The food<br />
offered in Spiritual Retreats is often vegetarian or vegan <strong>and</strong> alcohol is generally not<br />
permitted.<br />
The majority of Australian Spiritual Retreats are based on or influenced by Asian<br />
philosophies <strong>and</strong> meditation techniques. Examples are the week-end or short monastic retreats<br />
that are regularly organised at the Nan Tien Temple in Wollongong, New South Wales. The<br />
Nan Tien Temple is the largest Buddhist Temple in the Southern hemisphere, run by nuns<br />
from the Fo Guang Shan Buddhist order. The temple complex incorporates two prayer halls<br />
including shrines five Big Buddha statues, 100.000 small Buddha statues, a gong <strong>and</strong> a drum,<br />
an eight-storey pagoda, a museum, a tea house, a library <strong>and</strong> a conference centre, all set<br />
amidst l<strong>and</strong>scaped gardens which include a lotus pond. There is also housing for nuns <strong>and</strong><br />
monks as well as the ‘Pilgrim Lodge’, where retreat participants <strong>and</strong> other visitors stay.<br />
Retreat participants, or ‘students’ wear traditional grey, monastic garb during their stay <strong>and</strong><br />
men are required to shave their heads for longer retreats. Students are expected to partake in<br />
the normal temple life which also includes morning chanting sessions at 6 a.m. <strong>and</strong> are also<br />
required to observe ‘Noble Silence’. Vegetarian meals, cooked with food donated to the<br />
temple, are served in the public dining hall. Some Nan Tien Temple retreats provide students<br />
with a theoretical approach to learning <strong>and</strong> underst<strong>and</strong>ing Buddhism whereas others teach<br />
several meditation techniques, including sitting meditation, walking meditation, tea<br />
meditation <strong>and</strong> T’ai Chi.<br />
Database Analysis<br />
The final data base consisted of 590 service providers, categorised into 201 spa hotel/resorts,<br />
262 day spas, 28 lifestyle resorts, 83 spiritual retreats <strong>and</strong> 16 hybrids (<strong>business</strong>es that could<br />
not be definitely classified on the database information alone).<br />
Thus, the majority of <strong>business</strong>es in our database consisted of day spa <strong>business</strong>es, even though<br />
there was no intention to achieve a complete Australian census for this wellness provider
category. Of the three core wellness tourism provider categories that include accommodation,<br />
Spa Hotels/Resorts were clearly the majority (35%), followed by Spiritual Retreats (14%) <strong>and</strong><br />
Lifestyle Resorts (5%).<br />
The supply of wellness service providers in Australia is distributed differently across the<br />
states. The biggest proportion of all wellness service providers is located in New South Wales<br />
(29%), followed by Victoria (24%) <strong>and</strong> Queensl<strong>and</strong> (22%), Western Australia (12%), South<br />
Australia (7%), <strong>and</strong> Tasmania (4%). Only 2% of the <strong>business</strong>es are located in the Australian<br />
Capital Territory <strong>and</strong> 1% in the Northern Territory. Moreover, New South Wales contains the<br />
majority of Spiritual Retreats <strong>and</strong> Lifestyle resorts, whereas Queensl<strong>and</strong> hosts the highest<br />
proportion of Spa Hotels/Resorts.<br />
Survey Analysis<br />
Business Profile. The basic <strong>business</strong> profile revealed the proportions of regional versus<br />
metropolitan wellness providers, how long the <strong>business</strong>es were operating, their average<br />
number of employees <strong>and</strong> their distribution channels.<br />
Based on the survey responses, it is also apparent that the majority of wellness providers in<br />
Australia are located in regional areas (72%) rather than in metropolitan areas (28%).<br />
However, there are differences between the types of wellness providers. As expected, day<br />
spas are more likely to be found in metropolitan areas than Spa Hotels/Resorts, Lifestyle<br />
Resorts or Spiritual Retreats (Table 1).<br />
Table 1: Metropolitan versus Regional Distribution of <strong>Wellness</strong> <strong>Tourism</strong> Providers <strong>and</strong><br />
Day Spas<br />
<strong>Wellness</strong> Provider Category<br />
Day<br />
Spas<br />
Spa<br />
Hotels/Resorts<br />
Lifestyle<br />
Resorts/Retreats<br />
Spiritual<br />
Retreats<br />
TOTAL<br />
Metropolitan<br />
area<br />
41% 24% 32% 18% 28%<br />
Regional area 59% 76% 68% 82% 72%<br />
The respondents of our survey were asked when their <strong>business</strong> was established. Almost half<br />
of all <strong>business</strong>es (48%) providing wellness services are only five years old or less, which<br />
confirms the youthfulness of the wellness tourism industry in Australia. Of all wellness<br />
tourism provider categories, Spiritual Retreats tend to have been established longer than the<br />
other types (59% of spiritual retreats have been in <strong>business</strong> for more than 11 years versus 21%<br />
Spa Hotels/Resorts <strong>and</strong> 16% Lifestyle Resorts).<br />
The size of wellness tourism facilities can differ substantially, which is mirrored by the<br />
number of full-time staff a <strong>business</strong> employs. Fourteen respondents of our survey only<br />
employed one full-time staff, <strong>and</strong> only nine <strong>business</strong>es employed 20 full-time staff or more.<br />
The highest number of full-time staff employed by a Lifestyle Resort was 105. Table 2 shows<br />
the average number of full-time staff across the different wellness provider categories <strong>and</strong><br />
categorised as metropolitan or regional. Lifestyle Resorts tend to employ the highest number<br />
of full-time staff. This is attributed to the fact that they usually provide a range of different<br />
services that require the employment of specialists (e.g. nutritionists, fitness trainers,<br />
beauticians, massage therapists, nurses). Spiritual Retreats tend to employ the lowest number<br />
of full-time staff. In general, wellness service providers employed more staff in regional areas<br />
than in metropolitan areas.
Table 2: Average Number of Employees<br />
<strong>Wellness</strong> Provider Category<br />
Average Number of<br />
Employees<br />
Day Spas<br />
Spa<br />
Resorts/Hotels<br />
Lifestyle<br />
Resorts<br />
Spiritual<br />
Retreats<br />
Metropolitan area 4.9 9.4 4.6 np*<br />
Regional area 7.9 5.6 18.6 3.9<br />
Total (all areas) 6.7 6.5 13.7 4.0<br />
(*)Not published where sample base is less than 5 cases.<br />
Respondents were asked about the proportion of clients using different distribution channels.<br />
The vast majority of wellness providers rely on the direct-to-consumer <strong>business</strong> model (Table<br />
3). Only 2% of all wellness service providers use an Internet intermediary <strong>and</strong> 1% of the<br />
<strong>business</strong> results from recommendations by government travel centres or visitor information<br />
centres. The telephone seems to be the key direct-to-consumer distribution channel for day<br />
spas <strong>and</strong> it is also important for the other wellness provider categories. The Internet appears to<br />
be a significant direct-to consumer distribution channel, particularly for Lifestyle Resorts <strong>and</strong><br />
Spiritual Retreats. Forty-one percent of Lifestyle Resorts <strong>and</strong> 66% of Spiritual Retreats<br />
communicate with their customers either via email or via their own Internet booking facility.<br />
Face-to-face contact tends to be more important for Day Spas <strong>and</strong> Hotel/Resorts Spas than for<br />
Lifestyle Resorts <strong>and</strong> Spiritual Retreats.<br />
Table 3: Average Proportion of Bookings via Different Distribution Channels<br />
<strong>Wellness</strong> Provider Category<br />
Day Spas<br />
Spa<br />
Hotels/Resorts<br />
Lifestyle<br />
Resorts<br />
Spiritual<br />
Retreats<br />
TOTAL<br />
Direct from<br />
consumer via:<br />
Phone 72% 55% 42% 20% 52%<br />
Mail - - 3% 3% 1%<br />
In person 17% 14% 5% 10% 13%<br />
Email 7% 17% 31% 39% 20%<br />
Booking<br />
facility on our<br />
Internet site<br />
2% 5% 10% 27% 8%<br />
Internet<br />
consolidator<br />
- 3% 2% 1% 2%<br />
Retail travel agent - - - - -<br />
Government<br />
travel centre/VIC<br />
1% - 1% 1% 1%<br />
Services offered by <strong>Wellness</strong> Providers. Table 4 shows an overview of the types of services<br />
<strong>and</strong> facilities provided by each wellness provider category. The table shows that Lifestyle<br />
Resorts are most likely to offer a wide range of movement therapies such as gym classes,<br />
yoga <strong>and</strong> guided walking or water activities than the other wellness providers. While no<br />
Spiritual Retreat offers gym classes, by far higher proportions of Spiritual Retreats offer<br />
mind-body activities such as yoga, T’ai Chi or Qi Gong or guided walking activities when<br />
compared to Day Spas <strong>and</strong> Spa Hotels/Resorts.
Table 4: Distribution of <strong>Wellness</strong> Services by <strong>Wellness</strong> Provider Category<br />
<strong>Wellness</strong> Provider Category<br />
Services <strong>and</strong> Facilities<br />
Day<br />
Spas<br />
Spa<br />
Hotels/Resorts<br />
Lifestyle<br />
Resorts<br />
Spiritual<br />
Retreats<br />
Total<br />
Movement Therapies<br />
Gym classes/private instructor 5% 16% 32% - 14%<br />
Yoga 8% 25% 68% 73% 35%<br />
T’ai Chi or Qi Gong 3% 10% 36% 32% 16%<br />
Guided walking/hiking - 12% 56% 36% 20%<br />
Guided water<br />
activities/gymnastics<br />
3% 4% 24% 5% 7%<br />
Body <strong>and</strong> Beauty Treatments<br />
Water-based <strong>and</strong> sweat bathing<br />
treatments<br />
41% 34% 20% - 28%<br />
Swimming Pool(s) 11% 34% 36% 5% 24%<br />
Bath tubs/Jacuzzi/Whirlpool 70% 68% 40% - 54%<br />
Natural geothermal pool(s) - 1% - - 1%<br />
Steam room(s) 22% 28% 24% - 22%<br />
Sauna(s) 22% 35% 40% - 28%<br />
Vichy shower(s) 41% 37% 16% - 29%<br />
Body scrubs & wraps 100% 90% 56% - 74%<br />
Manicure <strong>and</strong> pedicure 95% 79% 32% - 64%<br />
Facials 100% 94% 56% 5% 76%<br />
Manual Pressure<br />
Massage 100% 100% 88% 45% 90%<br />
Reflexology 43% 34% 52% 9% 36%<br />
Manipulative/adjustment-based 8% 4% 20% - 7%<br />
Nutrition-based services<br />
Specific diet 11% 15% 64% 55% 28%<br />
Weight management 16% 1% 56% - 14%<br />
Cooking classes/diet education - 1% 60% 32% 15%<br />
Detoxing/fasting 11% 1% 52% 18% 14%<br />
Alcohol not allowed 11% 13% 48% 55% 24%<br />
Coffee <strong>and</strong> non-herbal tea not<br />
allowed<br />
8% 9% 32% 18% 14%<br />
Medical treatments <strong>and</strong> services<br />
GP or nurse on premise 5% 3% 20% 5% 7%<br />
General health assessment 11% 1% 32% - 9%<br />
Minor cosmetic surgery 14% 3% 4% - 5%<br />
Referral to GP 8% 1% 16% 5% 6%<br />
Meditation 19% 7% 68% 100% 34%<br />
Spiritual or religious studies 5% - 24% 82% 17%<br />
Private Counselling 14% 4% 60% 32% 20%<br />
Group Counselling 5% 0% 28% 18% 9%<br />
Complementary & Alternative<br />
Medicine<br />
24% 9% 60% 18% 22%
As expected, Day Spas <strong>and</strong> Beauty Spa Hotels/Resorts are more likely to provide beauty body<br />
treatments (i.e. body scrubs <strong>and</strong> wraps), facials, manicure <strong>and</strong> pedicure than Lifestyle Resorts<br />
<strong>and</strong> Spiritual Retreats. In fact, Spiritual Retreats almost never provide body <strong>and</strong> beauty<br />
treatments.<br />
Lifestyle Resorts are more likely to offer nutrition-based services, general health assessments,<br />
private <strong>and</strong> group counselling, as well as complementary <strong>and</strong> alternative therapies (CAM)<br />
than the other categories of wellness service providers. Although only a few respondents<br />
specified what kind of CAM therapies they offer, therapies mentioned included Traditional<br />
Chinese Medicine, Ayurveda, kinesiology, iridology, naturopathy, homeopathy, bachflower<br />
consults, Feldenkrais, Bowen therapy, hypnotherapy, <strong>and</strong> psychic or crystal healing.<br />
Unsurprisingly, all Spiritual Retreats offered meditation <strong>and</strong> they were much more likely to<br />
offer meditation <strong>and</strong> spiritual or religious teachings than all the other types of wellness service<br />
providers. The fact that 19% of Day Spas offered meditation is a surprising result, as a<br />
previous assessment of spa menus did not appear to include such a service. Perhaps<br />
respondents sought to offer visitors a personal meditative state rather than a guided<br />
meditation. This suggests a blurriness between some of these categories of providers that is<br />
worthy of exploration in future research. Although only some respondents specified the type<br />
of meditation they used, different meditation techniques ranged from Vipassana or Buddhist<br />
meditation, Dru meditation, Raja yoga, visualisation, breath awareness, mindfulness,<br />
Holosync, transcendental meditation, sound meditation, chanting mantra, Kirtan Kriya, chakra<br />
meditation, walking meditation, ‘calming the minds/opening the heart’, <strong>and</strong> ‘loving kindness’.<br />
It also should be noted that 90% of all providers offered massages, making them overall the<br />
most often provided wellness service. Massage therapies <strong>and</strong> techniques respondents specified<br />
ranged from remedial or deep tissue, relaxation massages, Thai, Swedish,<br />
Balinese/Indonesian, Lomi Lomi, Kodo, Shiatsu, Tibetian energetic massage, sports massage,<br />
hot stone, bamboo, cupping, lymphatic draining, ear c<strong>and</strong>ling, pregnancy/pre-natal massage,<br />
<strong>and</strong> aromatherapy.<br />
Finally, Lifestyle Resorts <strong>and</strong> Spiritual Retreats are also more likely to offer specific diets<br />
(most often mentioned menus were vegetarian, vegan, raw foods, <strong>and</strong>/or organic) than Day<br />
Spas <strong>and</strong> Beauty Spa Hotels/Resorts.<br />
Discussion <strong>and</strong> Conclusions<br />
This paper started with a discussion of a new typology of wellness tourism providers. It was<br />
argued that existing typologies often tended to be too broad to meaningfully enable the<br />
collection of data <strong>and</strong> compare different groups of wellness <strong>tourists</strong> or wellness tourism<br />
providers. However, a too narrow typology would fail to recognise the diversity of<br />
experiences wellness tourism providers offer to <strong>tourists</strong>.<br />
The results from this research show that the three core groups of wellness providers are<br />
distinctly different from each other, specifically in regard to the kinds of services <strong>and</strong> facilities<br />
they offer. Despite these differences in service offerings it is nevertheless argued that the three<br />
different core types of wellness tourism providers should not be perceived as completely<br />
separate categories. Instead they can be better portrayed as distributed along a continuum<br />
where there is a gradual distinction between the three types (Figure 2). For instance, some<br />
Lifestyle Resorts put a heavy emphasis on beauty treatments <strong>and</strong> massages, whereas others<br />
accentuate meditation <strong>and</strong> breathing techniques or ‘new age’ services such as psychic
eadings. Similarly, Spiritual Retreats can lean more towards Lifestyle Resorts by providing a<br />
range of seminars <strong>and</strong> discussions about lifestyle issues <strong>and</strong> a focus on physical movement<br />
such as yoga or meditative walking.<br />
The data reveals that there are many more Beauty Spa Hotels/Resorts in Australia than<br />
Lifestyle Resorts or Spiritual Retreats. The majority of previously existing research has also<br />
focused on beauty spas or on <strong>tourists</strong> visiting spas <strong>and</strong> even national <strong>and</strong> regional destination<br />
advertising materials of Destination Marketing Organisations (DMOs) tend to be dominated<br />
by this hedonic type of wellness provider. Australian DMOs but perhaps also DMOs in other<br />
countries should be aware that wellness tourism includes a broader range of providers than<br />
just Beauty Spa Hotels/Resorts.<br />
Beauty Spa<br />
Hotel/Resort<br />
Services<br />
Lifestyle Resort<br />
Services<br />
Body <strong>and</strong> Facial Beauty Treatments<br />
e.g. facials, body wraps, body scrubs, hair removal, pedicure<br />
Water-based <strong>and</strong> Sweat Bathing Treatments<br />
e.g. steam baths, Vichy showers, whirl pools, saunas, hammam<br />
Manual-pressure based therapies<br />
e.g. massages (remedial, Swedish, Thai, Lomi-Lomi, Hot Stone, Shiatsu, etc), reflexology,<br />
acupressure<br />
Manipulative/adjustment-based therapies<br />
e.g. chiropractic, osteopathic<br />
Spiritual Retreat<br />
Services<br />
Only specific forms such as ‘Sweat<br />
Lodges’ or ‘Rebirthing’<br />
Movement Therapies<br />
e.g. swimming, aerobics, dancing, Yoga, Qigong, T’ai Chi,<br />
walking<br />
Energy Therapies & New Age<br />
e.g. Healing Touch, Reiki, crystals, psychic readings<br />
Meditation<br />
e.g. Transcendental, Vipassana, chanting, prayer<br />
Nutrition-based<br />
e.g. cooking classes, weight management, detoxing,<br />
fasting<br />
Counselling & Group Therapies<br />
e.g. stress management, life coaching<br />
Figure 2: <strong>Wellness</strong> <strong>Tourism</strong> Provider Service Continuum<br />
Studying & Learning<br />
e.g. Buddhism or Bible class<br />
This research disclosed some interesting overlaps <strong>and</strong> dissimilarities of wellness tourism<br />
supply in Australia in comparison to other countries. First, as in other countries <strong>and</strong> regions,<br />
wellness tourism is a phenomenon predominantly relying on domestic <strong>tourists</strong> rather than on<br />
international <strong>tourists</strong> (Cooper et al., 1992; Lanz Kaufmann, 2002; Minghetti & Furlan, 2006;
Snoj & Mumel, 2002). Furthermore, relatively high numbers of local residents also visit<br />
wellness tourism providers. Second, as several writers have previously observed (e.g.<br />
Nahrstedt, 2004; Pollock & Williams, 2000; Smith & Puczkó, 2008), wellness tourism is an<br />
increasingly important <strong>and</strong> growing tourism niche.<br />
Despite the widespread economic crisis, the number of wellness tourism providers has grown.<br />
It could be even argued that the wellness tourism industry may benefit from the financial<br />
crisis as people need an outlet where they can de-stress to be able to cope with their worries.<br />
In addition it can be confirmed that Australian wellness tourism – like its Northern American<br />
counterpart <strong>and</strong> most Asian countries – focuses on health promotion rather than on medical<br />
cure. Only a small percentage of wellness tourism providers in this study offer conventional<br />
medicinal treatments or structures. Third, the majority of Australian wellness tourism<br />
providers are located in regional areas which supports Smith <strong>and</strong> Kelly’s observation that<br />
wellness tourism providers are are typically located in settings that are “aesthetically pleasing<br />
[<strong>and</strong>] environmentally lush” (Smith & Kelly, 2006, p. 15).<br />
Minghetti <strong>and</strong> Furlan (2006) propose that creating links between the wellness tourism product<br />
<strong>and</strong> the cultural <strong>and</strong> natural surrounding area provides a competitive advantage over other<br />
regions offering wellness tourism. In contrast to most European countries or countries such as<br />
Japan, however, the Australian wellness tourism industry does not have the competitive<br />
advantage to draw upon thous<strong>and</strong>s of years-old bathing cultures <strong>and</strong> corresponding<br />
architectural heritage. The Australian wellness tourism industry is really only a few decades<br />
old. However, some Australian wellness tourism providers have started to incorporate<br />
Indigenous culture in their product offerings, perhaps in part due to a perception that this<br />
provides them with a strong competitive advantage (Sheldon & Park, 2009). While this might<br />
be true, there also might be the danger of exploiting Indigenous knowledge. This is very<br />
critical especially in light of the gross disparity between many health measures of Aboriginal<br />
people relative to these of non-Indigenous Australians. Unfortunately, whereas the health gap<br />
between Indigenous <strong>and</strong> non-Indigenous people is narrowing in other countries such as the<br />
United States, Canada <strong>and</strong> New Zeal<strong>and</strong>, it is widening in Australia (Ring & Brown, 2003).<br />
Clearly, there are some unresolved issues that wellness tourism operators need to be aware of<br />
<strong>and</strong> sensitive to when incorporating Indigenous elements in their <strong>business</strong> offerings.<br />
An interesting difference between Australian wellness tourism providers <strong>and</strong> those in other<br />
countries is that not even half of Australian Beauty Spa Hotels/Resorts offer water treatments.<br />
It is often claimed that ‘water’ is the central defining element of spas which clearly does not<br />
seem to be the case in Australia. On the contrary, many spas emphasise that they use water<br />
thoughtfully <strong>and</strong> sparingly which reflects the increasing water scarcity in Australia. Lavish,<br />
extravagant use of water can be perceived as wasteful <strong>and</strong> unsustainable by some Australians,<br />
especially in light of extensive government campaigns that ingrain water-saving behaviour in<br />
its citizens.<br />
There seems to be a further difference between Australian <strong>and</strong> European Spiritual Retreats.<br />
Existing literature tends to focus on European Christian, monastic retreat accommodation<br />
(O'Gorman, 2007; Shackley, 2004) <strong>and</strong> there are even tourist guide books recommending in<br />
which Christian monasteries <strong>and</strong> nunneries <strong>tourists</strong> may stay when travelling through Europe<br />
(Clark, 2008; Wright, 2000). In contrast, Australian Spiritual Retreats are clearly much more<br />
influenced by Eastern religions <strong>and</strong> philosophies – even when they are promoted as nonreligious<br />
places – <strong>and</strong> Christian retreat accommodations appear to be rare. If the unique<br />
Australian Spiritual Retreat sector were to be promoted more strongly <strong>and</strong> embraced by
national <strong>and</strong> state DMOs, it could potentially become highly appealing to international<br />
<strong>tourists</strong>. Some international <strong>tourists</strong> with an interest in Eastern spirituality might feel anxious<br />
or unsafe about travelling to Asian countries, or might be concerned about language barriers.<br />
Therefore, they may perceive Australia as a more appealing destination for visiting Spiritual<br />
Retreats.<br />
In conclusion it can be argued that despite the lack of cultural heritage in wellness tourism<br />
<strong>and</strong> some ethical difficulties inherent in the integration of Indigenous elements into this<br />
offering, Australia offers an extensive range of wellness services catering to <strong>tourists</strong> who feel<br />
the need to maintain or promote their health <strong>and</strong> well-being. Not only are there three distinct<br />
types of wellness tourism providers offering distinctly different clusters of wellness services<br />
<strong>and</strong> facilities, but Australian wellness tourism providers also seem to successfully blend<br />
American, traditional European <strong>and</strong> Asian influences, thus creating a unique fusion of<br />
attractive choices for wellness <strong>tourists</strong>. This, in combination with the general image of<br />
Australians as relaxed, friendly, laid-back <strong>and</strong> outdoorsy as well as pleasant climatic<br />
conditions which foster active, <strong>healthy</strong> lifestyles, provide an opportunity for positioning<br />
Australia as a wellness tourism destination. While it is unlikely that international <strong>tourists</strong><br />
would be solely drawn to Australia because of its wellness tourism industry – with the<br />
possible exception of the distinctive nature of Spiritual Retreats – wellness tourism offerings<br />
may present an appealing add-on that is in keeping with the general br<strong>and</strong>ing of Australia.<br />
Future research is needed that would serve as a validation of the proposed wellness tourism<br />
typology outside the Australian context. More research is also needed to further explore<br />
Lifestyle Resorts <strong>and</strong> Spiritual Retreats as well as the types of <strong>tourists</strong> who visit these places.<br />
As previously mentioned, existing research tended to predominantly focus on spa <strong>tourists</strong> or<br />
spa providers. In addition, this study only included the three core types of wellness tourism<br />
providers without focusing on ‘medical wellness’ providers such as Therapeutic Recreation<br />
Retreats or Medispas in its national census. More research should therefore explore these<br />
‘blends’ of wellness <strong>and</strong> medical tourism.<br />
Acknowledgements<br />
The Sustainable <strong>Tourism</strong> Cooperative Research Centre (STCRC), established <strong>and</strong> supported<br />
under the Australian Government’s Cooperative Research Centres Program, funded this<br />
research. The authors also thank all the participating organisations <strong>and</strong> interviewees for their<br />
contribution as well as the other researchers who contributed to the wider study: Professor<br />
Graham Brown, Dr Gary Howat, Mr Richard Trembath, Professor Betty Weiler, <strong>and</strong> Dr<br />
Meredith Wray.<br />
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The Exploration of the Perceived Travel Benefits <strong>and</strong> the Perceived<br />
Importance <strong>and</strong> Interests of <strong>Wellness</strong> <strong>Tourism</strong><br />
Among the Older Adults in Taiwan Kaohsiung<br />
Ping Yu<br />
The Graduate Institute of Adult Education, National Kaohsiung Normal University, Taiwan<br />
alrr2007@gmail.com<br />
Janet I-Jane Weng<br />
Department of English, Wenzao Ursuline College of Languages; The Graduate Institute of<br />
Adult Education, National Kaohsiung Normal University, Taiwan.<br />
janetweng@mail.wtuc.edu.tw<br />
Abstract<br />
The purposes of this study are to explore <strong>and</strong> analyze the potential elderly market of wellness<br />
tourism. By using a questionnaire survey, 596 adults of age 50 <strong>and</strong> above with various<br />
backgrounds in Kaohsiung, the biggest city in southern Taiwan, are involved in the study. An<br />
effort is made to investigate their perceived travel benefits, their perceived importance of<br />
wellness facilities <strong>and</strong> services in hotels, <strong>and</strong> their interests in participation in related<br />
activities. Data were analyzed using the statistical cluster analysis, discriminant analysis, chisquare<br />
test, <strong>and</strong> the t-test. As a result, the elder travelers were segmented into two relatively<br />
well-defined types in terms of their perceived travel benefits: the active benefits seekers <strong>and</strong><br />
the passive benefits seekers. Each type has its own characteristics <strong>and</strong> interests in<br />
participation on the wellness-related activities. The findings indicate that demographic<br />
background, travel experiences <strong>and</strong> health condition are different significantly between active<br />
<strong>and</strong> passive benefits seekers. The active benefits seekers tend to be more interesting in<br />
participating in hotel extended wellness-related activities compared with the passive seekers.<br />
On the other h<strong>and</strong>, compare to the active benefits seekers, the passive benefits seekers ranked<br />
the hotel health-related services <strong>and</strong> facilities as more important. The study reveals not only a<br />
new perspective to define the wellness market among Taiwan elderly, but also a new market<br />
which can be focused on. Based on the results, discussions <strong>and</strong> suggestions are generated for<br />
practitioners <strong>and</strong> researchers.<br />
Keywords elderly, older adults, travel benefits, wellness tourism, wellness hotel<br />
Introduction<br />
Since the health <strong>and</strong> wellness are the topics concerned most by the older adults, the wellnessrelated<br />
tour package is one of the most attractive leisure selections for the elderly. Research<br />
showed the elders attached a lot importance for health <strong>and</strong> leisure. In addition, they liked to<br />
join in travel activities <strong>and</strong> were interesting in lifelong learning (Smith & Kelly, 2006). Chen<br />
<strong>and</strong> Wu (2005) identified five motives of overseas travel among the Taiwan elders <strong>and</strong> the<br />
motivation of “health promotion” is on the top of the list as “show off the fun” is the lowest<br />
one. However, as little research has so far been done about wellness tourism, the knowledge<br />
of this potential market is very insufficient (Smith & Kelly, 2006). <strong>Wellness</strong> travel is a fairly<br />
new product. To better underst<strong>and</strong> the wellness market for those retired older adults with<br />
more leisure time but limited income resources <strong>and</strong> physical considerations, the authors<br />
believe that their perception of general travel benefits might have great influences on their<br />
trying the new product. Since travel serves multifunctional needs of the <strong>tourists</strong>, their<br />
perceived travel benefits should be examined as a group type which reveals more meaning to
the real market. Little research has looking on the elderly market <strong>and</strong> from this perspective.<br />
The specific goals of the research are to explore the elders’ wellness travel market, to identify<br />
the clusters by perceived travel benefits among the elderly, to analyze the demographic<br />
background, travel experience, <strong>and</strong> their health perception <strong>and</strong> behavior in different clusters,<br />
to explore their perceived importance of wellness hotel services <strong>and</strong> facilities in different<br />
clusters, <strong>and</strong> to compare the participation interests of extended wellness-related activities of<br />
travel in different clusters.<br />
Literature Review<br />
The focus of the study is on the perceived travel benefits of the older adults for wellness<br />
market <strong>and</strong> its correlation with some variables of hotel wellness-related services. Thus, the<br />
concepts of wellness tourism, wellness hotel services <strong>and</strong> facilities, <strong>and</strong> the characteristics of<br />
travelers for wellness tourism will be discussed.<br />
Definition of <strong>Wellness</strong> <strong>and</strong> <strong>Wellness</strong> <strong>Tourism</strong><br />
Halbert Dunn (1959) wrote about a special state of great personal health contentment which<br />
consists of an overall sense of well-being. He used “high-level wellness” to describe the state<br />
which sees human as a harmony of body, spirit <strong>and</strong> mind <strong>and</strong> being dependent on their<br />
environment. The term “wellness” was also mentioned by Ardell (1977, 1986), Travis (1984),<br />
Benson & Suart (1992), Greenbert & Dintiman (1997), <strong>and</strong> Myers, Sweeney & Witner (2005)<br />
in their health-related publications. Hertel (1992) of the German <strong>Wellness</strong> Association<br />
reviewing the definitions of wellness in USA found it shared certain common characteristics:<br />
lifestyle is of critical importance, self-responsibility for health, the multi-factorial roots of<br />
health as well as the exploitation of our potential for a better quality of life.<br />
In a sense, the wellness tourism can be been seen as a part of the health tourism (Mueller &<br />
Kaufmann, 2001; Harahseh, 2002). The authors borrowed the definition of wellness<br />
developed by Mueller <strong>and</strong> Kaufmann (2001) who defined wellness tourism as “the sum of all<br />
the relationships <strong>and</strong> phenomena resulting from a journey <strong>and</strong> residence by people whose<br />
main motive is to preserve or promote their health” to focus on the related wellness services<br />
<strong>and</strong> facilities provided by the hotel in the journey.<br />
Definitions of Benefits <strong>and</strong> Travel Benefits.<br />
The Oxford Dictionary (2003) defines “benefit” as “an advantage or profit gained from<br />
something”. According to Driver, Brown, & Peterson (2001), there are two uses of the word<br />
“benefits”. One is simply the monetary valuation of that gain. The second is referred as “a<br />
change that is viewed to be advantageous—an improvement in condition, or a gain to an<br />
individual, a group, to society, or to another entity”. They also argued “benefits defined as<br />
gains or advantageous changes are thus directly subject to predictive modeling <strong>and</strong> to testing<br />
for cause <strong>and</strong> effect relationship.” Since the study focuses more on the intention <strong>and</strong> attitudes<br />
of elder consumers towards travel <strong>and</strong> what might be considered as beneficial, the authors<br />
adopt the second concept of the definition. As Driver, Brown, & Peterson (2001) said “the<br />
noneconomic measures are useful in recreation resource management.”<br />
Studies on Benefits Segmentation in <strong>Tourism</strong> <strong>Wellness</strong> Market<br />
There are many alternative segmentation criteria suggested in the tourism literature (Forgen,<br />
2005; Kangas & Tuohino, 2007; Smith & Puczkó, 2009), such as demogrphics, geographics,<br />
psychographics, expenditure. <strong>and</strong> perceived benefits.
The key question in market segmentation is what is the most effective segmentation criterion?<br />
According to Haley (1968), the rationale behind this segmentation approach is that the<br />
benefits identified by the consumers were the basis for the existence of true market segment.<br />
The identified benefits determine the consumers’ behavior more accurately than do other<br />
descriptive variables such as demographic <strong>and</strong> geographic characteristics. Discussing the<br />
conceptualization of leisure attitude, Iso-Ahola (1980) argued leisure participation is affected<br />
by the intention toward an object. The intention is determined by a person’s attitude of that<br />
object, which is a result of belief of that object. Also, if a person has reason to believe that<br />
participation in a leisure activity will lead to intrinsic rewards, the attitude toward that activity<br />
is highly positive. <strong>Wellness</strong> pursuit is common among older adults. Thus, it is reasonable to<br />
claim the perception of the travel benefits, comprising of belief <strong>and</strong> attitude might affect in<br />
certain wellness tourism related intention <strong>and</strong> behavior which is crucial to underst<strong>and</strong> the<br />
elder market. In addition, several authors have suggested that benefit segmentation is one of<br />
the best segmentation bases (Loker & Perdue, 1992; Morrison, 1996). Ahmed, Barber, <strong>and</strong><br />
Astous (1998) claimed that because the benefit segmentation identified the travelers’<br />
motivations <strong>and</strong> satisfaction of what they want <strong>and</strong> what they need, it was more appropriate in<br />
defining destination segments <strong>and</strong> developing marketing strategies. After reviewing several of<br />
the academic publications, Frochot <strong>and</strong> Morrison (2000) argued that benefit segmentation is<br />
most helpful in designing <strong>and</strong> modifying facilities <strong>and</strong> attractions, vacation packages, activity<br />
programming, <strong>and</strong> service quality measurement.<br />
Several studies focusing on benefit segmentation in Japan <strong>and</strong> America have revealed<br />
significant differences in some socio-demographic variables (Yannopoulos <strong>and</strong> Rotenberg,<br />
1999; Jang, Morrison, & O’Leary, 2002). Smith & Puczkó (2009) argued when defining the<br />
targets <strong>and</strong> targeting strategies <strong>and</strong> tactics, it is essential to know what benefits exist <strong>and</strong><br />
prospective customers may associate with a health trip.<br />
Only a few studies were reported on Taiwanese travelers using benefit sought among travelers<br />
to analyze the market. Fu (2003) studied the motivation/benefits of older travelers in Taiwan<br />
using factor analysis. She found the travel motivation of rest/relaxation, being with families,<br />
feelings of relaxation, <strong>and</strong> appreciation of the nature were recognized to be the most important<br />
by guests over age of 55. The results were identical with the study by Guinn (1980). Chen &<br />
Wu (2005) studies the motivations of the Taiwanese senior travelers, which is generally<br />
accepted as having a direct relationship with the benefits sought <strong>and</strong> divided the market into<br />
four segments: “the all-directions seniors”, “ the conservative seniors”, “the active <strong>and</strong><br />
optimistic seniors“, <strong>and</strong> “the knowledge <strong>and</strong> health seeking seniors”. A recent empirical study<br />
by Chen, Prebesen, & Huan (2008) identified relaxation, pursuing multiple activities,<br />
recreation, <strong>and</strong> enjoying nature as the top four motivations of wellness travelers<br />
To date, almost no reported research directly using the perception of travel benefits of the<br />
elders to segment the wellness market of the aging population. The study attempts not only to<br />
identify a new market in wellness tourism in terms of the perceived travel benefits of the<br />
elders, but also to underst<strong>and</strong> how the identified clusters are related their ratings of wellness<br />
services <strong>and</strong> facilities <strong>and</strong> their interests in participation of the activities provided by the<br />
wellness hotels on an overseas trip.<br />
Research Method<br />
Research Respondents:<br />
Questionnaire survey <strong>and</strong> purposive sampling method were adopted for the study. 596 elderly<br />
respondents, 227 males <strong>and</strong> 369 females over age 50, from eleven elderly activity centers
located in different administration districts in Kaohsiung who had international travel<br />
experiences were participated to investigate the wellness tourism market.<br />
Research Instruments:<br />
The questionnaire of “the Perceived Travel Benefits Scale for Elderly” consists of 25 travel<br />
benefit-related questions in 5-point Likert scale. The questionnaire is derived from Fu (2003)<br />
who edited the scales of Jang, Morrison, <strong>and</strong> O’Leary (2002) <strong>and</strong> Arimond <strong>and</strong> Elfessi (2001).<br />
Yu <strong>and</strong> Fu (2008) revised it <strong>and</strong> using 596 elder respondents for factor analysis <strong>and</strong> obtained<br />
6 benefit factors: Family gathering <strong>and</strong> relationship enhancement, nature appreciation,<br />
experiencing life, escape <strong>and</strong> relaxation, cultural underst<strong>and</strong>ing, <strong>and</strong> social interaction which<br />
match Fu (2003) factor structure <strong>and</strong> explain 70.1 % of the variance in total. The<br />
Cronbach’sαfor each factor <strong>and</strong> the total score are between .70 to .97 <strong>and</strong> show good<br />
reliability.<br />
After a well review of the definition of wellness, Mueller <strong>and</strong> Kaufmann (2001) revealed<br />
important service categories in wellness tourism in hotel industry. They are: body/physical<br />
fitness/ beauty care, relaxation: rest/mediation, health: nutrition/diet, mind: mental<br />
activity/education, environmental sensitivity, <strong>and</strong> social contacts. In addition, to arouse<br />
participants’ self-responsibility for wellness is essential for the services. In the study, to<br />
investigate the elder market, questionnaires of “ the Perceived Importance of <strong>Wellness</strong><br />
Facilities in the Hotel (PIWFH; 11 questions in 3- point Likert scale)” <strong>and</strong> “Participation<br />
Interests in Extended <strong>Wellness</strong> Activities (PIEWA; a checklist of 16 items) were derived from<br />
the above Mueller <strong>and</strong> Kaufmann’s wellness market analysis framework to measure the<br />
elders’ perceived importance <strong>and</strong> interests in wellness hotel <strong>and</strong> the extended services of<br />
wellness activities. Using 596 elder respondents for reliability analysis obtained Cronbach’s<br />
α= .873 for the PIWFH <strong>and</strong> Cronbach’s α =.743 for PIWAT. In addition, questions of<br />
demographic factors, travel experiences, <strong>and</strong> health related behaviors were also included in<br />
the questionnaire.<br />
Data Processing<br />
Cluster analysis was used to identify the groups of people who had similar travel benefit<br />
perception among the elderly. Then, t-test <strong>and</strong> chi-square were applied to describe the<br />
differences in their demographic backgrounds, travel experiences, health behaviors, their<br />
perceived importance of hotel services, as well as their interests of the wellness activities<br />
between the identified clusters.<br />
Findings <strong>and</strong> Discussions<br />
Two Identified Clusters: Active Benefits Seekers <strong>and</strong> Passive Benefits Seekers<br />
The study used both hierarchical <strong>and</strong> non-hierarchical cluster analysis methods. Since the<br />
hierarchical cluster analysis can only process less than 100 cases, about 10% of the samples<br />
were r<strong>and</strong>omly selected from the 596 cases <strong>and</strong> analyzed using the hierarchical method. The<br />
tree diagrams <strong>and</strong> agglomeration step tables favored a two-cluster group solution. To further<br />
determine the cluster solution, the next step cluster analysis <strong>and</strong> k-means were used which reconfirmed<br />
the two-group solution. Also, a discrimination analysis was used to check the<br />
cluster solutions with all variables (6 perceived travel benefit factors) used to create the<br />
cluster, <strong>and</strong> the two-cluster solution was clearly confirmed. With a success rate of 96.5% <strong>and</strong><br />
above for each cluster <strong>and</strong> 97.3% for total clusters, the allocation was virtually perfect.<br />
The elderly traveler cluster groups were named by comparing the mean values of the 6 major<br />
travel benefit factors in each cluster groups to find out the characteristics that differ
significantly from each other. There were only 2 cluster groups identified, the means of all 6<br />
benefit factors in “cluster 1” were all significantly higher than those in “cluster 2”. Therefore,<br />
the elderly in “cluster 1” were named as “Active Benefits Seekers”; on the other h<strong>and</strong>, those<br />
in “cluster 2” were named as “Passive Benefits Seekers”. The percentage of population in<br />
type of active benefits seekers (n=395; 66.3%) is higher than the passive benefits seekers<br />
(n=201; 33.7%).<br />
Table 1: The perceived travel benefits between active <strong>and</strong> passive benefits seekers<br />
1. Family gathering <strong>and</strong><br />
relationship<br />
enhancement<br />
Cluster<br />
(n=395)<br />
I Cluster II (n=201)<br />
Active<br />
Passive<br />
benefits seeker benefits seeker t-value p<br />
M SD M SD<br />
21.31 (2.27) 17.64 (2.43) 18.37 .000<br />
2. nature appreciation 20.59 (2.17) 16.53 (2.28) 21.54 .000<br />
3. experiencing life 11.96 (1.77) 9.69 (2.06) 13.85 .000<br />
4. escape <strong>and</strong> relaxation 17.27 (3.07) 14.14 (2.73) 12.96 .000<br />
5. cultural underst<strong>and</strong>ing 11.82 (1.68) 9.15 (1.65) 19.05 .000<br />
6. social interaction 15.78 (2.07) 12.53 (2.06) 18.68 .000<br />
Description of the Demographic Background of two Clusters<br />
To underst<strong>and</strong> the background differences of elderly travelers in two clusters, both t-test <strong>and</strong><br />
chi-square were applied. The results show that there are significant differences on the<br />
variables of age, education level, <strong>and</strong> discretionary income between active benefits seekers<br />
<strong>and</strong> passive benefits seekers. However, there is no significant difference on gender <strong>and</strong><br />
occupations before retirement between two groups.<br />
Compared to the passive benefits seekers, the active benefits seekers is younger with higher<br />
educational level <strong>and</strong> have higher discretionary monthly income than the passive benefits<br />
seekers. The passive benefits seekers are comparatively much older with lower educational<br />
level <strong>and</strong> tend to have less discretionary monthly income. The details of demographic<br />
background between active benefits seekers <strong>and</strong> passive benefits seekers are as Table 2.
Table 2. Demographic Background by Clusters<br />
Demographic background<br />
age<br />
education<br />
Discretionary<br />
income<br />
(NT$)<br />
Active<br />
benefits<br />
seekers<br />
(N=395)<br />
Passive<br />
benefits<br />
seekers<br />
(N=201)<br />
50~54 70 17.7% 22 10.9% 92 15.4%<br />
55~59 56 14.2% 23 11.4% 79 13.3%<br />
60~64 65 16.5% 32 15.9% 97 16.3%<br />
65~69 78 19.7% 34 16.9% 112 18.8%<br />
70~74 79 20.0% 49 24.4% 128 21.5%<br />
75 <strong>and</strong> above 47 11.9% 41 20.4% 8 14.8%<br />
Elementary<br />
59 14.9% 46 22.9% 105 17.6%<br />
<strong>and</strong> below<br />
Middle school 70 17.7% 40 19.9% 110 18.5%<br />
High school 104 26.3% 61 30.3% 165 27.7%<br />
Junior college 38 9.6% 15 7.5% 53 8.9%<br />
College <strong>and</strong><br />
university<br />
104 26.3% 38 18.9% 142 23.8%<br />
Graduate<br />
school<br />
20 5.1% 1 0.5% 21 3.5%<br />
20000 <strong>and</strong><br />
174 44.1% 117 58.2% 291 48.8%<br />
below<br />
20,001~40,000 98 24.8% 53 26.4% 151 25.3%<br />
40001~60,000 61 15.4% 16 8.0% 77 12.9%<br />
60,001~80,000 48 12.2% 10 5.0% 58 9.7%<br />
80,001 <strong>and</strong><br />
above<br />
14 3.5% 6 2.5% 19 3.2%<br />
Total (N=596) Chi-<br />
square p<br />
13.012 .023<br />
17.558 .004<br />
18.887 .001<br />
The findings of travel experiences among senior <strong>tourists</strong> between two clusters show that the<br />
differences are significant in almost all related variables including times of overseas travel,<br />
last travel date, <strong>and</strong> travel destination, except their travel companion. Compared to the<br />
passive benefits seekers, the active benefits seekers tend to travel more often <strong>and</strong> the date is<br />
more recent. Northeast Asia, including Japan <strong>and</strong> Korea, is their favorite destination of the<br />
last travel <strong>and</strong> they also travel more to those countries outside of Asia.<br />
On the other h<strong>and</strong>, among the passive benefits seekers, the times of overseas travel are<br />
comparatively fewer. Also, 45.8% of their last travel date is three years ago. The top three<br />
destinations of their last travel are China (37.3%), Southeast Asia (29.4%), <strong>and</strong> Northeast<br />
Asia (25.9%). The details are as Table 3.
Table 3 Cross-table of Background of Travel Experiences by Clusters<br />
Background of travel<br />
experience<br />
No. of<br />
times of<br />
overseas<br />
travel<br />
Last travel<br />
date<br />
Destination<br />
of last<br />
travel<br />
Active benefits<br />
seekers<br />
(N=395)<br />
Passive<br />
benefits<br />
seekers<br />
(N=201)<br />
1 78 19.7% 56 27.9% 134 22.5%<br />
2-3 105 26.6% 65 32.3% 170 28.5%<br />
4-6 74 18.7% 36 17.9% 110 18.5%<br />
7-9 35 8.9% 19 9.5% 54 9.1%<br />
10 <strong>and</strong> above 103 26.1% 25 12.4% 128 21.5%<br />
Within 1 year 147 37.2% 46 22.9% 193 32.4%<br />
1-2 years ago 105 26.6% 42 20.9% 147 24.7%<br />
2-3 years ago 56 14.2% 21 10.4% 77 12.9%<br />
3 years ago 87 22.0% 92 45.8% 179 30.0%<br />
Southeast Asia 99 25.1% 59 29.4% 158 26.5%<br />
Northeast Asia 128 32.4% 52 25.9% 180 30.2%<br />
China 94 23.8% 75 37.3% 169 28.4%<br />
North<br />
America<br />
27 6.8% 9 4.5% 36 6.0%<br />
Europe 33 8.4% 4 2.0% 37 6.2%<br />
New Zeal<strong>and</strong><br />
<strong>and</strong> Australia<br />
14 3.5% 2 1.0% 16 2.7%<br />
Total (N=596) Χ 2 P<br />
17.086 .002<br />
36.638 .000<br />
24.533 .000<br />
Regarding the self report health <strong>and</strong> related behavior between two clusters, the active benefits<br />
seekers are healthier than the passive benefits seekers (Table 4). In general, compare to the<br />
passive benefits seekers, those who perceived higher travel benefits tend to be younger, with<br />
higher education level, <strong>and</strong> more spending power. Also, they travel more often <strong>and</strong> the time<br />
is more recent. They are healthier <strong>and</strong> keep a better health habits. The above findings indicate<br />
the relationships between perception of travel benefits with their travel behavior <strong>and</strong> health.<br />
Table 4 Means <strong>and</strong> t-Value of <strong>Health</strong>-Related Variables between Clusters<br />
<strong>Health</strong> perception <strong>and</strong><br />
behavior<br />
Active<br />
benefits<br />
seekers<br />
(N=395)<br />
Passive<br />
benefits<br />
seekers<br />
(N=201)<br />
t-value P<br />
1. Perception of health<br />
condition<br />
1.94 2.32 5.464 .000<br />
2. Engagement in leisure<br />
activities<br />
1.30 1.52 4.464 .000<br />
3. <strong>Health</strong> check 1.49 1.64 2.904 .005<br />
4. Pay attention to<br />
health-related<br />
knowledge<br />
1.23 1.42 4.161 .000<br />
5. Pay attention to<br />
<strong>healthy</strong> living habits<br />
1.16 1.36 4.628 .000<br />
Perceived Importance of <strong>Wellness</strong>-related Hotel Services <strong>and</strong> Facilities<br />
The elderly <strong>tourists</strong> were asked to assess the importance of the hotel’s wellness services <strong>and</strong><br />
facilities. The hotel services of “sports facilities”, “bath, sauna, steam” <strong>and</strong> “activities of<br />
learning courses” are perceived as the top three items for both groups. To underst<strong>and</strong> the<br />
differences of perceived importance between the active <strong>and</strong> passive benefits seekers, the t-test
was applied. The finding shows only four variables are statistically significant, including<br />
activities of learning courses (mean=1.89, 2.02, t=2.416, p=.0.16), atmosphere of calmness or<br />
relaxation (mean=1.31, 1.45, t=2.720, p=.007), non-smoking area/room (mean=1.30, 1.41,<br />
t=2.018, p=.044), <strong>and</strong> information of health related topics (mean=1.51, 1.63, t=2.384,<br />
p=.018). The passive benefits seekers attach more importance to the above services. It reveals<br />
that among elder travelers, those perceived less travel benefits might be the major target group<br />
for the wellness services <strong>and</strong> facilities provided by the hotels.<br />
Participation Interests in Extended <strong>Wellness</strong>-Related Activities<br />
Among the extended wellness-related activities provided by the hotels, the top three activities<br />
of interests for active benefits seekers are “Cultural programs (e.g. music, arts)”, “Hiking or<br />
bicycling with tour guide”, <strong>and</strong> “Massage” <strong>and</strong> for passive benefits seekers are “Cultural<br />
programs (e.g. music, arts)”, “Hiking or bicycling with tour guide”, <strong>and</strong> “Organic food/living<br />
food diet”. There are five items having a significant difference (p .05) in the count of<br />
participation interest between two groups, which are “hiking or bicycling with tour guide”<br />
(χ 2 =6.577, p=.010), “Yoga, meditation, relaxation activities”(χ 2 =12.979, p=.000), “Massage”<br />
(χ 2 =10.656, p=.001), “Special recipe” χ 2 =9.291, p=.002 , <strong>and</strong> “Low calorie<br />
diet” χ 2 =16.838, p=.000 . As a result, the percentages of these five activities are<br />
significantly higher in active benefits seekers than the passive benefits seekers.<br />
Conclusions <strong>and</strong> Suggestions<br />
1. Two clusters are identified as “active benefits seekers” <strong>and</strong> “passive benefits seekers” by<br />
the elders’ perceived travel benefits. The demographic characteristics, health perception <strong>and</strong><br />
travel behaviors in each type are distinct. It indicates the importance of using “benefits” for<br />
elder’s travel market segmentation. Compare to the passive benefits seekers, those who<br />
perceived higher travel benefits tend to be younger, with higher education level, <strong>and</strong> more<br />
spending power. Also, they travel more often <strong>and</strong> the time is more recent. They are healthier<br />
<strong>and</strong> keep a better health habits. These findings reveal positive relationships between<br />
perception of travel benefits <strong>and</strong> their travel behavior <strong>and</strong> health.<br />
2. As almost all elders perceived the hotel wellness services <strong>and</strong> facilities to be somewhat<br />
important to very important, the passive benefits seekers valued more about learning course<br />
activities, atmosphere of calmness or relaxation, non-smoking area/room, <strong>and</strong> information of<br />
health related topics, in comparison with the active benefits seekers. This may be resulted<br />
from their related demographic background, travel experiences <strong>and</strong> health behavior. It needs<br />
further research. The top three services <strong>and</strong> facilities for all elders are sports facilities,<br />
bath/sauna/steam, <strong>and</strong> activities of learning courses. The findings are similar to the empirical<br />
study by Meuller & Kaufmann (2001) <strong>and</strong> Tsai & Wu (2005). It is recommended the wellness<br />
hotel operators <strong>and</strong> marketers to have these services <strong>and</strong> facilities as the basic requirements in<br />
their infrastructure of the wellness hotels <strong>and</strong> passive benefits seekers should be the major<br />
target group.<br />
3. The wellness tourism providers should also include “Cultural programs (e.g. music, arts)”,<br />
“Hiking or bicycling with tour guide”, <strong>and</strong> “Massage” <strong>and</strong> “Organic food/living food diet”<br />
which are on the top list for elders for their interest of participation. However, compared to<br />
the passive benefits seekers, the active seekers should be the target group for the extended<br />
wellness activities. They have more intentions in joining almost all the wellness activities<br />
provided by the hotels. The differences are especially significant on “Hiking or Bicycling<br />
with Tour Guide”, “Yoga, Meditation, Relaxation Activities”, “Massage”, “Special Recipe”,<br />
<strong>and</strong> “Low Calorie Diet”.
4. Travel benefit perception reflects the expectation <strong>and</strong> intention of travel behavior. The<br />
participation interests in extended wellness activities reflect higher intention in involving in<br />
wellness services than the perceived importance of the hotel services. Iso-Ahola (1980)<br />
mentioned of active <strong>and</strong> passive leisure participation. The active <strong>and</strong> passive travel benefits<br />
seekers maybe the best indicators of the active <strong>and</strong> passive wellness travel participation for<br />
the elders.<br />
The distinct characteristics <strong>and</strong> wellness travel interests of the active <strong>and</strong> passive benefits<br />
seekers suggest that the benefit segmentation of elder travelers is a useful strategy in<br />
developing wellness market; thus, the operators <strong>and</strong> the marketers of wellness tourism have to<br />
underst<strong>and</strong> the characteristics of these two types of benefits seekers <strong>and</strong> their preferred<br />
benefits. When the active benefits seekers are more interested in participation in extended<br />
wellness activities, it is reasonable to infer that to increase the perception or the awareness of<br />
travel benefits of the elders might broaden the market.<br />
5. The hotel operators <strong>and</strong> marketers are recommended to promote different benefits for<br />
different benefits seekers. To the active seekers, the “ nature appreciation ”, “cultural<br />
underst<strong>and</strong>ing”, <strong>and</strong> “escape <strong>and</strong> relaxation” are perceived as the most important benefits. On<br />
the other h<strong>and</strong>, the passive benefits seekers stressed more on the benefits of “family gathering<br />
<strong>and</strong> relationship enhancement”, “appreciation of the nature”, <strong>and</strong> “social interaction”. The<br />
marketers can match their marketing strategies with the mentioned benefits to further<br />
motivate different benefits seekers in participating of more health related activities in the<br />
wellness tourism. Especially, as the potential of active benefits seekers in wellness market is<br />
higher, the hotel operators <strong>and</strong> marketers can promote the market by matching the right<br />
benefits <strong>and</strong> offer more in-depth, diverse, <strong>and</strong> learning activities to satisfy their needs.<br />
Therefore, it is necessary for the professionals in wellness market to underst<strong>and</strong> the intention,<br />
dem<strong>and</strong>s, <strong>and</strong> attitudes of the older people <strong>and</strong> incorporate the wellness knowledge into their<br />
program design <strong>and</strong> implementation, <strong>and</strong> be capable of facilitating the elders’ awareness of<br />
wellness travel benefits.<br />
6. To better prepare the market, more detailed information need to be obtained regarding the<br />
specific needs, preferences, <strong>and</strong> the ways of engaging wellness activities in travel of the<br />
passive <strong>and</strong> active benefits seekers. Furthermore, the stability of the typology of active<br />
benefits seekers vs. passive benefits should be further tested. As the two-types of benefits<br />
seekers are confirmed within the elder travelers in Kaohsiung, Taiwan, more empirical studies<br />
are needed to verify the two types, as well as its relationship with other wellness related<br />
attitudes <strong>and</strong> behavior in the future.<br />
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Unpulished manuscript.
Destination Image in the Context of <strong>Wellness</strong> Travel<br />
Andreas H. Zins<br />
Institute for <strong>Tourism</strong> <strong>and</strong> Leisure Studies<br />
University of Economics <strong>and</strong> Business, Vienna, Austria<br />
<strong>and</strong>reas.zins@wu.ac.at<br />
Abstract<br />
This study tries to give an answer to the question whether the images of destinations differ<br />
across different travel contexts (wellness vs. sun & beach) <strong>and</strong> wellness <strong>and</strong> non-wellness<br />
travelers respectively. This objective is demonstrated by considering two sets of destinations:<br />
European <strong>and</strong> Asian countries which are specializing to a varying degree in wellness tourism.<br />
In addition, the conceptualization of destination image follows the direction of an ‘overall<br />
composite <strong>and</strong> gestalt impression’ summarized by Keaveney <strong>and</strong> Hunt (1992) which requires<br />
also an adequate holistic measurement process. For this purpose the procedure outlined by<br />
Tapachai <strong>and</strong> Waryszak (2000) for developing so-called proxy benefit prototypes for<br />
describing the product category of a destination is replicated. Meaningful practical results<br />
could be elaborated by profiling destination images of ten different countries from the<br />
perspective of the above mentioned traveler segments. Plots from MDS <strong>and</strong> consecutive<br />
property fitting procedures assisted in visualizing the results <strong>and</strong> competitive relations.<br />
Keywords: Category-based processing, MDS, free-elicitation, consumption values<br />
Introduction <strong>and</strong> Background<br />
Repeatedly tourism scholars are reviewing scientific work related to destination image <strong>and</strong> its<br />
measurement (Echtner <strong>and</strong> Ritchie 1993; Jenkins 1999; Gallarza, Saura <strong>and</strong> Garcia 2002; Pike<br />
2002, 2007; Tasci, Gartner <strong>and</strong> Cavusgil 2007). Steve Pike’s review of about 260 articles on<br />
destination image studies of the past 35 years confirms a rapidly increasing field of interest.<br />
However, both of his analyses (Pike 2002, 2007) come to the conclusion that qualitative<br />
methods are scarcely used <strong>and</strong> moreover that most of the studies are lacking a specific travel<br />
context. Echtner <strong>and</strong> Ritchie (1993) strongly recommended using a combination of structured<br />
<strong>and</strong> unstructured methods to completely capture destination images consisting of attributebased,<br />
holistic, functional, psychological, unique <strong>and</strong> common characteristics. Many of the<br />
more recent publications focused on the interrelationship between functional (cognitive) <strong>and</strong><br />
psychological (emotional, affective) aspects of destination images. Moreover, the discrepancy<br />
between the mainstream conceptualization of the image construct <strong>and</strong> a matching<br />
measurement carefully addressed by Keaveney <strong>and</strong> Hunt (1992) is not overcome<br />
automatically. Similarly, the issue of travel context, particularly relevant when conceiving the<br />
market as partitioned into segments, has not been considered appropriately for the<br />
measurement of destination images.<br />
Particular concerns have been raised as to the conceptualization <strong>and</strong> an appropriate<br />
measurement of destination image. Concept definitions for the image construct exist almost as<br />
many scholars deal with this issue. Many of these definitions are quite broad appealing to<br />
ideas <strong>and</strong> impressions, beliefs <strong>and</strong> thoughts <strong>and</strong> emotional reflections about a particular<br />
destination (e.g. Hunt 1975, Lawson <strong>and</strong> Bond-Bovy 1977, Crompton 1979, Dichter 1985,<br />
Reynolds 1985, Tasci <strong>and</strong> Kozak 2006). In contrast, others explicitly narrow the concept to<br />
associations or components (e.g. Hosany, Ekinci <strong>and</strong> Uysal 2007, Gartner 1993). However, in
summary or as a commonly accepted bottom line, image comprises not only facts but also<br />
fantasy, not only objective reality but also subjective inference, truth <strong>and</strong> conjecture,<br />
observation <strong>and</strong> evaluation.<br />
One of the few exceptions for using a qualitative approach which is embedded in a concise<br />
conceptual framework is Tapachai <strong>and</strong> Waryszak’s (2000) work on the role of beneficial<br />
image for destination selection. They base their approach on the category-based image<br />
processing theory discussed by Keaveney <strong>and</strong> Hunt (1992) extensively. Keaveney <strong>and</strong> Hunt<br />
(1992: 167) argue that the “lion’s share of store image research did not capture store image<br />
empirically”. This caveat of mainly attribute-intensive research approaches for supposedly<br />
measuring synergistic <strong>and</strong> gestalt nature images does not seem to be relevant in the domain of<br />
retailing but also in the area of destinations (Echtner <strong>and</strong> Ritchie 1993, Pike 2002, 2007).<br />
The discrepancy between concept definition <strong>and</strong> measurement is fuelled particularly in view<br />
of the rival mid-level theories of piecemeal processing (Fiske 1982) <strong>and</strong> category-based<br />
processing (Fiske <strong>and</strong> Pavelchak 1984, Sujan 1985). Piecemeal processing assumes that<br />
consumers evaluate product attributes each time anew when they are encountered (exposure,<br />
presentation). Evaluations are made independently of the presence of other attributes. And<br />
finally, judgments are formed by combining these isolated elements. This type of processing<br />
<strong>and</strong> information integration is deemed to be effortful, however, ignores prior experience with<br />
other instances of the same category (inferences, conclusions). By contrast, category-based<br />
processing supposes that incoming information is immediately compared with previously<br />
defined categories based on ‘family resemblance’. Categorization of items evolves <strong>and</strong><br />
depends on the degree of match of cues within the category. A successful match invokes the<br />
relevant ‘schema’ in memory. A schema is made of salient attributes, importance of attributes,<br />
relationships among attributes, evaluative conclusions, context, <strong>and</strong> the sequence of events.<br />
Basically, a copying mechanism is triggered where the generic schema is adopted to a specific<br />
instance together with the affect inherent. If a category match fails completely <strong>and</strong> the<br />
involvement level is sufficiently high the consumer will engage in a more effortful processing<br />
style <strong>and</strong> will probably come up with a new category in memory. However, if the incoming<br />
information about a stimulus fits the existing category it is evaluated as ‘typical’ <strong>and</strong> is<br />
deemed to be best remembered. Otherwise, if mildly discrepant information is encountered<br />
modifications to the existing category have to be made. Yet, it is assumed that these deviating<br />
or differential information cues are quickly forgotten. As a consequence, it is strongly<br />
recommended to adapt measurement techniques to these basic assumptions about information<br />
<strong>and</strong> categorization processing routines.<br />
Hence, this study tries to give an answer to the question whether the images of destinations<br />
differ across different travel contexts (wellness vs. sun & beach). In addition, the<br />
conceptualization follows the direction of an ‘overall composite <strong>and</strong> gestalt impression’<br />
summarized by Keaveney <strong>and</strong> Hunt (1992) which requires also an adequate holistic<br />
measurement process. In this respect, the current study is a replication of Tapachai <strong>and</strong><br />
Waryszak’s (2000) attempt with four major extensions: 1. The process for developing the socalled<br />
proxy-prototypes for destinations is based on travelers with <strong>and</strong> without prior<br />
destination visits. 2. The main study is not administered in a class-room situation but with<br />
travelers of various source markets at a destination which has both main offers: sun <strong>and</strong> beach<br />
<strong>and</strong> wellness. 3. The study differentiates between two different travel contexts: sun <strong>and</strong> beach<br />
versus wellness <strong>and</strong> 4. To generate useful results for strategic marketing the study investigates<br />
the destination image of more than one country.
Research methods<br />
First, data on beneficial image components were collected in two different settings: 1. from<br />
about 100 travelers at home (Austria in this case) for the destinations Thail<strong>and</strong> <strong>and</strong> Hungary<br />
splitting the sample into a 2 by 2 roster: travel context <strong>and</strong> previous visits. Travel context was<br />
either a wellness trip or a seaside/lakeside vacation. The task was to elicit reasons why they<br />
would travel to the given destination in a completely open format. To consider contextual<br />
differences half of the sample was told to having decided for a sun & beach (sea or lake) trip;<br />
the other half decided for a wellness travel. 2. from about 60 travelers in Thail<strong>and</strong><br />
differentiating between wellness <strong>and</strong> other types of <strong>tourists</strong>. Applying this kind of item<br />
generating approach it is possible to elaborate on differences in category descriptions about<br />
destinations travelers bear in mind when choosing travel destinations.<br />
Second, to address the focal area of concern – the dominance of piecemeal or attribute based<br />
image measurement – this study followed the line of thought of the middle level theory of<br />
category-based processing. Once, consumers are capable of assigning a new stimulus to an<br />
already known category she or he infers existing knowledge <strong>and</strong> schemata about the category<br />
which is held in memory for an exemplar or prototype (Fiske <strong>and</strong> Pavelchak 1984). Tapachai<br />
<strong>and</strong> Waryszak (1990) developed so-called proxy prototypes for a destination (Thail<strong>and</strong> <strong>and</strong><br />
USA) splitting them along five different value domains initially developed by Sheth, Newman<br />
<strong>and</strong> Gross (1991). Their model assumes that consumers associate benefits of consumption<br />
values with a product or service which can be condensed into a five-dimensional array:<br />
functional, social, emotional, epistemic, <strong>and</strong> conditional. For the current study the following<br />
destination proxy prototypes (see Table 1) have been developed from the Step 1 data<br />
collection <strong>and</strong> grouped along the five consumptions values. Respondents were invited to give<br />
their comments <strong>and</strong> remarks on the category descriptions. Coding of the consent, partial<br />
consent or disagreement with the prototype descriptions followed the procedure outline by<br />
Tapachai <strong>and</strong> Waryszak (2000).<br />
Table 1 Proxy prototypes for destination images split into five dimensions<br />
Dimension Proxy prototype<br />
Functional Thail<strong>and</strong> is generally known as a vacation destination with beautiful<br />
scenery, many attractions <strong>and</strong> a constant warm climate. I associate it<br />
with <strong>healthy</strong> <strong>and</strong> country-specific food, cheap shopping opportunities as<br />
well as with outst<strong>and</strong>ing sea water quality (colours) <strong>and</strong> beach quality. I<br />
immediately combine it with family friendly services <strong>and</strong> authentic spa<br />
<strong>and</strong> wellness services.<br />
Emotional Thail<strong>and</strong> is well-known for exotic, relaxing <strong>and</strong> pampering holidays.<br />
The country offers romantic, calm <strong>and</strong> vacations in a safe environment.<br />
Local people are open-minded <strong>and</strong> share an outst<strong>and</strong>ing friendliness<br />
paired with an exceptional hospitality.<br />
Social Thail<strong>and</strong> is highly recommended by friends <strong>and</strong> relatives. Many visitors<br />
come back again <strong>and</strong> again. It is a destination where you can meet<br />
people of every age <strong>and</strong> have plenty of parties.<br />
Epistemic Thail<strong>and</strong> is a country to go for its very different culture. It is known for<br />
a rich variety of traditions. Holidays in the country can easily be<br />
combined with city visits to learn a lot about its cultural heritage.<br />
Conditional For me, Thail<strong>and</strong> is a destination which is easily accessible <strong>and</strong> offering<br />
good value-for-money. There are always a lot of offers <strong>and</strong> attractive<br />
deals. Holidays there mean low incidental expenses.
Third, these proxy prototypes were embedded in a larger paper-<strong>and</strong>-pencil questionnaire<br />
which was administered among real travellers to Portoroz, Slovenia (527 overnight <strong>tourists</strong><br />
from Slovenia, Croatia, Italy, Germany, Austria, Sc<strong>and</strong>inavia). Tourists were invited to<br />
answer in one of the following language versions: English, German, Italian <strong>and</strong> Slovenian.<br />
The sample was split into two halves: one sub-sample had to reflect on five Asian destinations<br />
(Thail<strong>and</strong>, Malaysia, Indonesia, Vietnam, Maldives); the other sub-sample dealt with five<br />
European destinations with access to the sea (Slovenia, Italy, Croatia, Bulgaria, Montenegro).<br />
The destinations were selected on the basis of current <strong>and</strong>/or near-future competitive<br />
relationships in the wellness market. Even though the terms wellness <strong>and</strong> health tourism do<br />
not share a global <strong>and</strong> unique definition the phenomenon of a widely increasing tourism<br />
dem<strong>and</strong> with a strong emphasis on physical <strong>and</strong> mental balance is generally recognized<br />
(Bushell <strong>and</strong> Sheldon 2009, Smith <strong>and</strong> Puczko 2009). The investigation of destination images<br />
in the context of two very different traditions of spa <strong>and</strong> wellness trends (Europe <strong>and</strong> Asia)<br />
appeared to be challenging <strong>and</strong> insightful.<br />
Although the open-ended task of collecting elements of the destinations’ images revealed a<br />
number of common (congruent) arguments for Hungary <strong>and</strong> Thail<strong>and</strong>, the content analysis<br />
lead to the assumption that two different sub-categories of destination prototypes exist For the<br />
main study (considering only countries with traditional sun <strong>and</strong> beach tourism), though, the<br />
proxy prototypes were held constant for each of the ten countries involved expecting stated<br />
partial or full objection where applicable. However, based on the insights gained from the<br />
preparatory studies it was deemed not meaningful to project <strong>and</strong> visualize all ten destinations<br />
in one common competitive map. Finally, to capture contextual effects (wellness vs. sun <strong>and</strong><br />
beach), travellers interviewed for the main study are segmented by their propensity to engage<br />
in wellness activities for the current trip or in a wellness travel in the future.<br />
Results<br />
The sample generated from overnight <strong>tourists</strong> at the selected beach resort in Slovenia was<br />
stratified by nationalities. The given quotas prioritized the top ranked nations, however the<br />
shares are not meant to be proportional to the official statistics. Consequently, the averages<br />
reported here cannot be taken as a valid picture for the average tourism dem<strong>and</strong> for the region.<br />
In contrast, this convenience sample serves the purpose of contrasting mainly two different<br />
traveller segments. These two segments are defined a priori by their affinity towards wellness<br />
travelling. If the current trip was self-rated as a wellness or beauty stay (out of a list of 15 predefined<br />
main travel purposes) or if the respondent stated that she or he generally prefers<br />
staying at wellness resorts or hotels with spa facilities or at some place where spa activities<br />
are consumed, this traveller was classified into the “high affinity or wellness traveller group”,<br />
otherwise into a “low or no affinity segment”. Hence, 62% of the respondents could be<br />
assigned into the group of wellness travellers.<br />
Since the total sample was split into two questionnaire versions (incorporating different sets<br />
of destinations) the structural differences <strong>and</strong> similarities of the sub-samples are analyzed<br />
first. No significant differences are detected in terms of nationality. Overall, there are 29%<br />
Slovenian <strong>tourists</strong>, 25% from Austria <strong>and</strong> Germany, 22% from Italy <strong>and</strong> 24% other<br />
nationalities. No differences in educational level <strong>and</strong> gender can be reported. On average,<br />
respondents followed 14 years of formal education: 31% up to 12 years; two thirds up to 15<br />
years; <strong>and</strong> one third even more. The Asian sub-sample appears to be slightly older (2.5 years<br />
on average). However, significant differences across nationalities <strong>and</strong> wellness affinity turned<br />
out: Among Slovenian <strong>tourists</strong> only 50% can be identified as highly interested in wellness<br />
travel. Italian respondents rank highest with a share of 72% compared to 62% on average.
Austrian <strong>and</strong> German travellers seem to be interested more than average in wellness trips<br />
(67%). This segment appears to appeal more female travellers with 67% share which is a<br />
regular phenomenon in the wellness travel market. No age differences between these two<br />
segments turned out. On average, 37% are at the age below 30 years, 40% in the bracket of 30<br />
to 49 years <strong>and</strong> 23% belong to the cohort of 50+.<br />
The accommodation chosen for the current trip can be taken as a proxy for preference<br />
differentials in general: 57% of wellness travellers chose hotels whereas the share among nonwellness<br />
travellers is only 39%. The non-wellness segment prefers more private<br />
accommodation, campsites, <strong>and</strong> non-paid forms (secondary homes, stays with friends or<br />
relatives). A good majority (60%) of the wellness inclined segment can be found in 4-star<br />
hotels compared to 53% in the non-wellness group. The following Table 2 visualizes the<br />
different main purposes of travel as stated by the different respondent groups. Overall, there<br />
are not too many differences except for culture, culinary <strong>and</strong> curative stays driving the<br />
wellness segment significantly more. The apparent stronger emphasis on recreational<br />
purposes for the wellness segment is not sufficient to be significant.<br />
After having inspected the socio-demographic background <strong>and</strong> basic travel profile of the two<br />
travel segments the focus changes to investigate the destination experiences <strong>and</strong> near-future<br />
plans together with the association of destinations with wellness trips. Table 3 gives insights<br />
into these three perspectives. Whereas some differences in prior destination experience are<br />
mainly due to the sample structure (Austria, Germany, Italy) the wellness segment appears to<br />
represent the more travel active travel population. This materializes in the higher rate of past<br />
visits to Hungary <strong>and</strong> Slovakia <strong>and</strong> particularly for the Asian destinations: Thail<strong>and</strong>,<br />
Maldives, China, Japan, India, Indonesia, Vietnam, Philippines, Malaysia <strong>and</strong> Singapore.<br />
Another perspective is covered by the travel plans looking 5 years ahead. Similarly, some<br />
destinations are favoured through domestic tourism. Higher intentions are revealed by the<br />
wellness segment for Croatia <strong>and</strong> Hungary <strong>and</strong> for all Asian countries presented in the<br />
questionnaire. Among the countries most preferred in this region are Maldives (43%),<br />
Thail<strong>and</strong> (38%), <strong>and</strong> Malaysia (33%). The differentials between non-wellness <strong>and</strong> wellness<br />
travellers, though, can be seen as a first sign of competitive advantage for the latter market<br />
segment. The relative difference is highest for Thail<strong>and</strong>, Philippines <strong>and</strong> Indonesia (almost<br />
double) followed by Malaysia, India <strong>and</strong> Vietnam.
Table 2 Main travel purpose of the current trip by wellness segments<br />
Main purpose of this trip<br />
Non-<strong>Wellness</strong><br />
traveller<br />
<strong>Wellness</strong><br />
traveller<br />
City break 41% 42% 483<br />
Culture tour 28% 40% 474 a)<br />
Multi-destination trip (organised or individual) 27% 34% 486<br />
Activity-packed holiday with lots of exercise/sports 23% 23% 476<br />
Recreational holiday in the sense of relaxing, with little 57% 64% 491<br />
exercise/sports<br />
Curative stay (recommended or prescribed by doctor) 5% 15% 478 a)<br />
<strong>Wellness</strong>/beauty stay 0% 36% 476<br />
Visit to an event 17% 18% 473<br />
Visiting relatives/friends 27% 20% 483<br />
Private stay in connection with <strong>business</strong>/fair/congress 9% 10% 479<br />
Hiking/mountain climbing holiday 10% 11% 478<br />
Cycling/ mountain biking holiday 13% 11% 475<br />
Seaside holiday 77% 80% 504<br />
Culinary tour 28% 37% 471 a)<br />
Wine tour 15% 20% 474<br />
Note: a) Chi² statistic significant at < .05.<br />
Another, more focused, approach to measure the perceived suitability of a destination for<br />
wellness trips was taken be the related question of which country the respondents would<br />
recommend for a wellness trip (third column of Table 3). Again, domestic countries are<br />
somehow positively biased from the nationalities represented in the sample. However,<br />
Hungary shows the strongest appeal among the remaining European destinations. For the<br />
Asian countries, the relative differences are highest for Thail<strong>and</strong> followed by the Philippines,<br />
Maldives, Malaysia <strong>and</strong> Indonesia. Finally, an open-ended question allowed for suggesting<br />
additional destinations for wellness trips not mentioned in the closed list of countries. Spain,<br />
France <strong>and</strong> USA ranked on top of these additional destinations favoured by the wellness<br />
segment. Turkey was mentioned almost as frequently as France however did not qualify for a<br />
specific segment. In contrast, Greece has the same frequency as Turkey but is more often<br />
recommended as a wellness destination from the perspective of non-wellness travellers.<br />
Before going on to the results of the image measurement itself it is important to check the data<br />
for non-response behaviour. The responses to the destination descriptions (presented along the<br />
5 consumption value dimensions for each the 5 countries) are not as complete as in a typical<br />
“check any given item” response format. Table 4 investigates therefore if some systematic<br />
influences can be detected that help explain the rate of non-response. The first column of<br />
Table 4 shows the average non-response share for each of the 5 countries prescribed (5<br />
European <strong>and</strong> 5 Asian for the two sub-samples in the order of appearance in the<br />
questionnaire). From the Asian sub-sample it can be clearly seen that no sequence or fatigue<br />
effect can be substantiated. For the European sub-sample this is not so obvious.<br />
n =
Table 3 Past, future <strong>and</strong> particular wellness trip destinations by wellness segments<br />
Non-wellness travellers <strong>Wellness</strong> travellers<br />
Past experience<br />
Future 5<br />
years’<br />
plan<br />
Considering<br />
wellness<br />
Past experience<br />
Future 5<br />
years’<br />
plan<br />
Considering<br />
wellness<br />
Austria 70% 44% 18% 86% 56% 42%<br />
Bulgaria 21% 26% 10% 19% 26% 15%<br />
Croatia 79% 49% 18% 77% 56% 30%<br />
Czech Republic 45% 31% 10% 48% 30% 16%<br />
Germany 62% 42% 13% 74% 50% 29%<br />
Hungary 44% 29% 15% 53% 33% 25%<br />
Italy 74% 41% 16% 86% 59% 37%<br />
Montenegro 19% 32% 11% 22% 35% 18%<br />
Slovakia 22% 23% 10% 26% 23% 16%<br />
Slovenia 74% 42% 20% 71% 44% 33%<br />
China 7% 22% 10% 10% 26% 13%<br />
India 6% 22% 11% 10% 31% 17%<br />
Indonesia 3% 17% 11% 8% 31% 19%<br />
Japan 6% 23% 11% 6% 29% 14%<br />
Malaysia 3% 19% 11% 7% 33% 20%<br />
Maldives 5% 29% 15% 11% 43% 28%<br />
Philippines 2% 16% 11% 6% 30% 23%<br />
Singapore 4% 17% 10% 6% 26% 17%<br />
Thail<strong>and</strong> 7% 20% 13% 16% 38% 28%<br />
Vietnam 3% 16% 8% 6% 25% 13%<br />
However, investigating the effect of non-response further by differentiating by prior visits of<br />
this destination (column 2 <strong>and</strong> 3 of Table 4) it becomes evident that for 7 out of 10 countries<br />
the refusal of answering is due to a lack of personal experience. Exceptions that apply for the<br />
Maldives, Slovenia <strong>and</strong> Italy demonstrate that perceptions <strong>and</strong> associations were more easily<br />
accessible even in the event of no prior personal exposure. A final check, though, should<br />
inspect if the problem of non-response spreads equally across the two segments (columns 4<br />
<strong>and</strong> 5 of Table 4). In this respect, the proportions for non-response show only for Italy a<br />
significant difference.<br />
Following the coding procedures for the remarks <strong>and</strong> comments on the presented destination<br />
proxy prototypes documented by Tapachai <strong>and</strong> Waryszak (2000) these descriptions were<br />
broken down into 31 different attributes (see Table 5) for which agreement (“1”) or<br />
disagreement (“0”) was coded. Differences of frequencies along these 31 attributes are<br />
inspected for the two traveller segments: non-wellness <strong>and</strong> wellness. Hence, in total, twenty<br />
destination profiles are available for analysis. Overall, it st<strong>and</strong>s out that wellness travellers<br />
have stronger (more frequent) associations with the destinations compared to the non-wellness<br />
segment. This effect becomes more apparent for more familiar countries <strong>and</strong> applies for<br />
European as well as for Asian destinations. To eliminate this awareness or salience effect the<br />
following analysis refers to deviations from the average difference between non-wellness <strong>and</strong><br />
wellness travellers in descending order of strength.
Table 4 Non-response shares for destination images by prior visits <strong>and</strong> wellness<br />
segments<br />
Non<br />
response:<br />
average<br />
sample<br />
No prior<br />
visit<br />
Prior visit<br />
Non-<br />
wellness<br />
travellers<br />
<strong>Wellness</strong><br />
travellers<br />
Slovenia 17% 18% 17% 22% 13%<br />
Italy 28% 38% 26% 35% 23% a)<br />
Croatia 30% 47% 25% a) 31% 29%<br />
Bulgaria 57% 62% 37% a) 59% 55%<br />
Montenegro 51% 57% 26% a) 55% 48%<br />
Thail<strong>and</strong> 30% 33% 9% a) 37% 26%<br />
Indonesia 44% 46% 22% a) 52% 40%<br />
India 42% 44% 15% a) 47% 38%<br />
Vietnam 52% 54% 27% a) 57% 49%<br />
Maldives 43% 43% 38% 50% 39%<br />
Note: a) Chi² statistic significant at < .05.<br />
Table 5 Image attributes as used by the proxy prototype descriptions <strong>and</strong> for profiling<br />
destinations<br />
Beautiful scenery Relaxing Meet people of different age<br />
Many attractions Pampering Different culture<br />
Warm climate Romantic Variety of traditions<br />
<strong>Health</strong>y food Calm City visits<br />
Country-specific food Safe Cultural heritage<br />
Cheap shopping Open-minded locals Easily accessible<br />
Water quality Friendliness Good value-for-money<br />
Beach quality Hospitality Many offers <strong>and</strong> deals<br />
Family friendly service Recommended by friends Low incidental expenses<br />
Authentic spa <strong>and</strong> wellness Many repeat visitors<br />
Exotic Plenty of parties<br />
Note: items in italic were not used in Tapachai <strong>and</strong> Waryszak’s study (2000)<br />
Slovenia shows a more favourable image within the wellness traveller segment with regard to<br />
“beautiful scenery”, “authentic spa <strong>and</strong> wellness facilities”, “water quality”, “family<br />
friendliness”, “beach quality” <strong>and</strong> “many attractions”. Social value facets such as “meeting<br />
people of different age”, “recommended by friends”, “many repeat visitors” <strong>and</strong> “plenty of<br />
parties” are much less attributed to this destination. Croatia shares stronger associations in<br />
the wellness segment with respect to “relaxing”, “romantic” <strong>and</strong> “safe” <strong>and</strong> weaker ones as to<br />
“city visits”, “variety of traditions” <strong>and</strong> “different cultures”. The wellness travellers see Italy<br />
more linked with “easy access”, “many offers <strong>and</strong> deals” <strong>and</strong> “recommended by friends” but<br />
less with “different cultures” <strong>and</strong> “romantic”. Bulgaria shows a much less pronounced profile<br />
<strong>and</strong> profile differences among the two traveller segments. Stronger associations by the<br />
wellness segment appear for “recommended by friends” <strong>and</strong> “relaxing” whereas as weaker<br />
ones for “different cultures”, “city visits” <strong>and</strong> “variety of traditions”. Similar effects can be<br />
observed for Montenegro. However, different aspects st<strong>and</strong> out: “beach quality” <strong>and</strong> “many<br />
offers <strong>and</strong> deals” are more frequently attached with the destination; “many repeat visitors”<br />
<strong>and</strong> “recommended by friends” less frequently.
The second sub-sample considered five Asian destinations for which the following image<br />
profile differences can be observed. Thail<strong>and</strong> is differentiated positively by the wellness<br />
segment by only a few elements: “meet people of different age”, “warm climate” <strong>and</strong> “many<br />
repeat visitors”, <strong>and</strong> negatively by “city visits”, “romantic”, “open-minded people”, “calm”<br />
<strong>and</strong> “cultural heritage”. Indonesia, in turn, exhibits a more favourable image among wellness<br />
travellers with regard to “relaxing”, “hospitality”, “friendliness”, “romantic”, “calm” <strong>and</strong><br />
“exotic”; it is less favourable as to “low incidental expenses”, “easily accessible”, “meet<br />
people of different age” <strong>and</strong> “water quality”. India’s image among wellness travellers appears<br />
more pronounced with respect to “calm”, “open-minded people” <strong>and</strong> “<strong>healthy</strong> food” whereas<br />
weaker in terms of “easily accessible”, “low incidental expenses”, “many offers <strong>and</strong> deals”<br />
<strong>and</strong> “safe”. Vietnam is seen by the wellness segment more favourable with regard to<br />
“friendliness”, “hospitality”, “romantic” <strong>and</strong> “calm” but less positive as to “plenty of parties”,<br />
“meet people of different age”, “many repeat visitors” <strong>and</strong> “water quality”. Finally, the image<br />
profile for the Maldives is stronger among wellness travellers with respect to “easily<br />
accessible”, “many offers <strong>and</strong> deals” <strong>and</strong> “cultural heritage” whereas weaker as to “<strong>healthy</strong><br />
food”, “country specific food”, “family friendly” <strong>and</strong> “authentic spa <strong>and</strong> wellness”.
Figure 1 Image positions of five Asian destinations by non-wellness <strong>and</strong> wellness<br />
travellers<br />
The final analysis uses the profile data for the selected destinations (2 sets x 5 countries x 2<br />
segments x 31 attributes) to project their associations into a low-dimensional beneficial image<br />
space. This approach was conducted by applying two separate runs of multi-dimensional<br />
scaling procedures (ALSCAL: Young 1987: 32) on the rectangular matrices. A threedimensional<br />
configuration for the Asian data converged with ratios for Kruskal’s Stress at .02<br />
<strong>and</strong> <strong>and</strong> R² of .99. The European data had similarly satisfying convergence conditions: Stress<br />
= .01 <strong>and</strong> R² = .99. The following two Figures 1 <strong>and</strong> 2 use the coordinates of the 3dimensional<br />
space of the destinations <strong>and</strong> add the attribute profiles attached to them through a<br />
routine called property fitting calling the C-Match algorithm developed by Cliff (1966; Rroutine<br />
programmed by C. Buchta). Destination labels without suffix represent images held<br />
by non-wellness travellers whereas labels with the suffix “_W” represent those of wellness<br />
travellers.
These MDS-plots help to visualize competitive relationships among the given destinations<br />
<strong>and</strong> to identify large or small differences among the selected traveller segments. The projected<br />
attribute vectors support finding meaningful shortcut descriptions for the dimensions of the<br />
MDS map. The compound image differentials materialize particularly for Thail<strong>and</strong> <strong>and</strong><br />
Indonesia. Distances along Dimension 1 are relative large compared to the other countries <strong>and</strong><br />
can be traced back to attributions of “warm climate” <strong>and</strong> social benefit aspects. In Dimension<br />
2 only the Maldives are set aside from the other destinations profiling strongly by the<br />
attributes “romantic”, “calm” <strong>and</strong> “pampering”. Dimension 3 separates again the Maldives<br />
particularly from India <strong>and</strong> Thail<strong>and</strong> which is particularly due to the cultural heritage<br />
associated with the latter ones <strong>and</strong> the outst<strong>and</strong>ing beach <strong>and</strong> water quality attached to the<br />
former.
Figure 2 Image positions of five European destinations by non-wellness <strong>and</strong> wellness<br />
travellers<br />
The competitive positions for the European destinations can be summarized as following:<br />
Distances between the two traveller segments are particularly strong along Dimension 1,<br />
however much larger among Slovenia, Croatia <strong>and</strong> Italy compared to Montenegro <strong>and</strong><br />
Bulgaria, both destinations which are rather in an early stage of their tourism life-cycle. Social<br />
aspects (favouring the Bulgarian <strong>and</strong> Italian image) <strong>and</strong> “relaxing”, “many attractions”,<br />
“country-specific food” (favouring the Slovenian image by wellness travellers) are profiling<br />
the second dimension. Cultural diversity together with the flavour of romance determines the<br />
stretch along the third dimension setting Croatia distinctly apart from the four other<br />
destinations.<br />
Conclusions <strong>and</strong> Recommendations<br />
The study aimed at replicating the applicability of the measurement of destination images<br />
through proxy beneficial prototypes in the light of a category-based processing paradigm. The<br />
replication of Tapachai <strong>and</strong> Waryczak’s (2000) study about Thail<strong>and</strong> <strong>and</strong> the USA followed
four lines of extensions. First, the preparation steps of collecting free elicited arguments for<br />
visiting a destination took place with travellers of different age, gender, prior destination<br />
experience <strong>and</strong> situations (at home vs. at the destination). While the individual salience of<br />
arguments was limited to an average of 4 to 5 the content analysis <strong>and</strong> categorization into<br />
more abstract benefits resulted in 48 different aspects out of which 31 have been used to<br />
develop benefit proxy prototypes covering the five consumption value domains outlined by<br />
Sheth et al. (1991). Compared to Tapachai <strong>and</strong> Waryczak’s study using predominantly<br />
students as respondents this study reveals a broader scope in functional, emotional, epistemic<br />
<strong>and</strong> social aspects, however a narrower perspective of conditional benefits (rather limited to<br />
price <strong>and</strong> accessibility arguments) which seems rather due to the geographic location between<br />
generating <strong>and</strong> receiving country. In addition, the preparatory data collection steps did<br />
consider two different contextual views: a) a European – short distance – vs. Asian – long<br />
distance <strong>and</strong> b) a seaside/lakeside vs. wellness trip purpose. Differentiating by two completely<br />
contrasting geographic regions it became quickly evident that travellers developed at least two<br />
different sub-types of destination categories. However, the specific travel purpose did not<br />
seem to be a sufficient condition that respondents elaborated or referred to a different subtype<br />
of a destination category (Zins <strong>and</strong> Prompitak 2009).<br />
The second extension to the initial study aimed at testing the proxy prototype instrument for<br />
measuring destination images with ‘real’ travellers. The sample taken in Slovenia served the<br />
purpose to have easy access to travellers of different national backgrounds with a high<br />
propensity to belong to either a segment with a strong preference for sun <strong>and</strong> beach vacations<br />
or with a strong affinity towards wellness trips. The samples were split into half covering<br />
selected European destinations on the side <strong>and</strong> Asian destinations on the other. Both samples<br />
shared very similar socio-demographic <strong>and</strong> travel characteristics which reduced unintended<br />
impacts on the image measurement results.<br />
The third extension dealt with the influence of a particular travel context. While the<br />
preparatory studies stated the main purpose of the fictitious trip explicitly (sun <strong>and</strong> beach vs.<br />
wellness) the main study investigated the destination images from the perspective of two<br />
different traveller segments (wellness vs. non-wellness). Apart from their general travel<br />
preferences towards wellness <strong>and</strong> spa activities travellers belonging to this segment<br />
demonstrated straight behavioural differences relevant for tourism marketing: gender,<br />
nationality, accommodation types <strong>and</strong> quality levels, past <strong>and</strong> future travel experiences. From<br />
this approach of competitive analysis it can be concluded that Hungary <strong>and</strong> Croatia – apart<br />
from Austria, Germany <strong>and</strong> Slovenia – have positioning advantages as wellness destinations<br />
within the wellness segment; much in contrast to other European destinations like Turkey,<br />
Greece or Spain. Among the Asian countries a similar advantage can be observed for<br />
Thail<strong>and</strong>, the Philippines, <strong>and</strong> Maldives.<br />
By considering not only one destination but a number of current or potential competitors the<br />
current study made a fourth extension. A contrasting analysis for both traveller segments <strong>and</strong><br />
for each of the ten destinations revealed relatively outst<strong>and</strong>ing assets <strong>and</strong> weaknesses which –<br />
of course – can only be assessed finally by comparing positioning goals of an individual<br />
destination. Yet, it is rather intriguing that the much stronger image associations for Indonesia<br />
<strong>and</strong> India create some mental obstacles to position Thail<strong>and</strong> as a wellness destination more<br />
favourably, particularly among wellness travellers.<br />
Assuming that the category-based processing theory holds in the context of destination<br />
competition: what are the consequences for destination marketing managers? Under the
piecemeal hypothesis <strong>and</strong> an undifferentiated strategy for a given destination it would be<br />
sufficient to emphasize on the attributes which are common to similar countries. In contrast,<br />
under the category-based assumption the destination marketing organization would rather<br />
follow the schemas underlying the relevant destination category. This category seems to be<br />
less distorted by a given travel purpose <strong>and</strong> more dependent on the geographic distance <strong>and</strong><br />
nationality. More relevant however appear to be two other main strategies: differentiation <strong>and</strong><br />
niche. While the marketing plans would not differ essentially compared to the undifferentiated<br />
strategy (putting some or relatively strong emphasis on one or several attributes) under the<br />
category-based processing assumption it would have to entail a differentiation on many if not<br />
all aspects to induce the consumer to develop a sub-type. This recommendation is neither<br />
obvious nor apparent from competitive positioning maps commonly generated in marketing<br />
research. Yet, the consequences for developing an appropriate destination marketing strategy<br />
are quite different considering a priori completely different information processes on the<br />
consumer side.<br />
What lessons could be learnt from a methodological point of view? The replication of the<br />
proxy prototype instrument for destination image measurement was successful in general. The<br />
non-response problem was slightly better (average across destinations: 39%) compared to the<br />
students’ sample of Tapachai <strong>and</strong> Waryszak’s study (2000; 45%). Considering, though, the a<br />
priori selection of only destination novice students the non-response phenomenon in the<br />
current study among travellers without prior visits to the various destinations was exactly the<br />
same. Nevertheless, from comments respondents wrote into the questionnaire it became<br />
evident that many respondents refused any response due to a lack of sufficient knowledge.<br />
This cognitive boundary is difficult to break through where appropriate. Relatively openended,<br />
unaided answers are cognitively more effortful to elaborate <strong>and</strong> to reveal (orally or in<br />
written). Aided answer formats – often in the form of attribute lists – ease the job however<br />
may introduce biases between long-term, stable cognitions versus those which are constructed<br />
ad hoc.<br />
The experiences of the content analysis <strong>and</strong> the consecutive coding steps into more abstract<br />
benefit categories which fit into the proposed five consumption value dimensions gave<br />
additional insights into the critical role of the researcher. The split into the functional,<br />
emotional, social, epistemic <strong>and</strong> conditional dimensions is in many instances artificial <strong>and</strong><br />
cuts the rich, contextual <strong>and</strong> schema-based information delivered by respondents into pieces.<br />
Valuable nuances get lost which are against any comprehensive <strong>and</strong> more complex<br />
conceptualizations of destination (or br<strong>and</strong>) images. Measurement instruments slicing the<br />
image concept into lists of attributes where cognitive, affective <strong>and</strong> maybe conative aspects<br />
are treated separately rather move away from a valid mapping effort.<br />
In this respect, the current attempt has probably also limitations <strong>and</strong> avenues for further<br />
improvements <strong>and</strong> refinements. The question of which destinations are competing which each<br />
other: only destinations within a limited geographic distance or only destinations with exactly<br />
the same tourism products? should be addressed by applying different research methods.<br />
Further evidence should be elaborated on how destinations are represented in the consumers’<br />
minds <strong>and</strong> compared which each other. Repertory grid techniques are among meaningful<br />
options. And, of course, in order to deliver more relevant results for marketing purposes, a<br />
study into competitive relationships among destinations would have to be extended to the<br />
most important generating markets for a specific destination
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What is <strong>Tourism</strong> in Dental <strong>Tourism</strong>?<br />
Judit Zoltan <strong>and</strong> Rico Maggi<br />
Faculty of Economics, University of Lugano, Switzerl<strong>and</strong><br />
Istituto di ricerche economiche<br />
Via Maderno 24, CP 4361, CH-6904, Lugano, Switzerl<strong>and</strong><br />
judit.zoltan@usi.ch<br />
Abstract<br />
Dental tourism is an important segment of the growing health tourism industry. Patients<br />
generate relevant tourism revenues for the destination country beyond the direct income of the<br />
dental clinics. This paper illustrates the development of dental tourism in the case of Hungary<br />
based mainly on price competitiveness of treatments. The first part of the paper traces this<br />
development on the base of in-depth interviews with representatives of the sector arriving at<br />
the conclusion that the treatment element still dominates the tourism experience. The question<br />
therefore arises whether a more destination based strategy would allow for a sustainable<br />
future. To respond to this question, the second part of the paper models the experience of the<br />
dental tourist in three phases - get there, stay there <strong>and</strong> live there – focusing on trip duration,<br />
expenditure <strong>and</strong> <strong>tourists</strong>’ activities. Finally, implications for destination marketing strategies<br />
to overcome prospected future decline are discussed.<br />
Introduction<br />
The research is focusing on the tourism components of a specific medical treatment abroad.<br />
Medical tourism captured worldwide attention only in 2006, when medical journals started to<br />
publish papers on the topic, as awareness of the phenomenon in both developing <strong>and</strong><br />
industrial countries was increasing (Horowitz, 2007). It became a growing trend, <strong>and</strong> its<br />
organization, volume <strong>and</strong> economic impact changed. According to Connell (2006), a medical<br />
tourist is someone who in order to minimize his costs of health care decides to travel abroad,<br />
<strong>and</strong> becomes a tourist. Statistically speaking this may be true but it is not very useful<br />
analytically as it mixes dental migrants (or commuters) with dental <strong>tourists</strong> in a strict sense (as<br />
we want to define them in this study) i.e. dental patients who combine the consumption of a<br />
treatment with tourism experience.<br />
The dental tourist’s decision starts with a health problem which creates a more or less urgent<br />
need for an intervention by a dentist. If the price differences among services “at home” <strong>and</strong><br />
“abroad” at some perceived quality level are important enough to incite the patient to travel<br />
abroad for the intervention, the dental patient becomes a potential dental tourist who is<br />
choosing a dentist, <strong>and</strong> – seemingly – in a simultaneous way a destination. However, if the<br />
destination has no touristic value as such for the patient other than being the location of the<br />
more convenient offer for a dental service, we cannot usefully consider this as being dental<br />
tourism. Medical services are dominant in the experience, while tourism spending is not<br />
significant.<br />
Travelers who buy health care abroad usually get a package deal including the treatment, air<br />
transport, transfers <strong>and</strong> accommodation. <strong>Tourism</strong> is thus rather a byproduct of packaging, but<br />
creates substantial benefits to the travel industry. Although as will be argued below, the<br />
tourism part is not necessarily sustainable as it depends completely on the price differences of<br />
medical treatment. We will therefore discuss the potential for increasing the tourism value of<br />
dental tourism to the patient <strong>and</strong> to the destination.
Among the economic factors determining the dem<strong>and</strong> for medical tourism, several<br />
components can be identified; the most important being differences in treatment price, in<br />
national health systems <strong>and</strong> in conditions of private health insurance. The reduced prices can<br />
compensate for the absence of insurance overall or for some treatments (e.g. cosmetic<br />
surgery). These push factors are well known from UK <strong>and</strong> USA who are important source<br />
countries of medical tourism in general. Concerning dental treatments, the British national<br />
health system, scarcely funded by tax revenue, results in long, up to half year stays on the<br />
waiting lists, while some treatments are hardly available in some regions. At the same time<br />
UK`s private clinics are offering their treatments at unaffordable prices for many. As far as<br />
the US is concerned, an estimated 50 million of citizens are without health insurance <strong>and</strong> 120<br />
million without dental coverage which creates <strong>and</strong> important potential for medical <strong>and</strong> dental<br />
tourism. To what extent this translates into effective dem<strong>and</strong> depends on the type of<br />
treatment. Bookman <strong>and</strong> Bookman (2007) claim, that the price elasticity of dem<strong>and</strong> depends<br />
on the importance of the operation less complicated <strong>and</strong> more available treatments being more<br />
price sensitive. The implication for destinations is that they have to closely observe the<br />
development of relative, all inclusive prices to the patient between the source country <strong>and</strong><br />
their own for different kinds of treatments before they ponder about additional tourism<br />
services. Apart from price differences, the necessary elements for the development of medical<br />
tourism (Bookman <strong>and</strong> Bookman, 2007) are: skilled local human capital, domestic research<br />
<strong>and</strong> development, developed infrastructure, stable political <strong>and</strong> regulated legal institutions,<br />
liberalized market economy, available tourist attractions.<br />
Finally, as in general in tourism, good <strong>and</strong> cheap accessibility (i.e. mostly air transport<br />
services) will enhance the competitiveness of a dental tourism destination. Improved mobility<br />
gives better access to health services for the patients, <strong>and</strong> allows for a more efficient use of<br />
existing medical capacities. (Österle, 2007)<br />
The Case of Dental <strong>Tourism</strong> in Hungary<br />
Most of the medical tourism destinations offer dental treatments, but there are some countries,<br />
which are specialized in it. Only estimations are existing, how many people are undertaking<br />
dental tourism worldwide? RevaHelath, an Internet-based database of healthcare providers for<br />
the medical <strong>and</strong> tourism sector, is estimating the market through online advertising<br />
campaigns, impressions of web searches in the sector. Their numbers are still useful as<br />
indicators, looking at the World <strong>and</strong> Hungary’s dental market. The leading dental tourism<br />
destination is Mexico, which comes from its closeness to the United States, from where 25%<br />
of the worldwide dental tourist are coming. The second place is shared between India <strong>and</strong><br />
Hungary. Hungary is serving more European patients, while India attends Asian patients, <strong>and</strong><br />
they share some of the US citizens.
In Table 1. the average prices of each dental treatment at each dental tourism destination are<br />
presented. The last two columns of the table show the prices of the dental treatments in UK<br />
<strong>and</strong> USA, which are the main sender countries regarding dental tourism. The difference is<br />
considerable in most cases.<br />
Dental migration dates back to the late 1980’s, when border-crossing Austrians have been<br />
visiting Hungarian dentists, because their prices were much cheaper than in Austria <strong>and</strong> their<br />
work was known to be of high quality. In the 1990`s German <strong>and</strong> Swiss patients followed this<br />
health migration movement. Around 2003 some dental clinics started to supply incoming<br />
dental <strong>tourists</strong> with travel arrangements <strong>and</strong> accommodation, information about the<br />
destination, basing the marketing on price savings <strong>and</strong> tourism. This became possible with the<br />
presence of the budget airlines, the entry to the European Union in 2004, significantly cheaper<br />
dental prices than in Western countries <strong>and</strong> the well-known expertise of Hungarian dentists,<br />
which will be discussed later on.<br />
Dem<strong>and</strong> side analysis already exists on the topic, however no study has been conducted on<br />
the supply side; on the organization of dental tourism, the actors involved, their strategies,<br />
how they are structured <strong>and</strong> co-operate with different partners. How can the two different<br />
sector, tourism <strong>and</strong> dentistry combine their products?<br />
Through questionnaires the market has been examined by Bünten (2006) <strong>and</strong> Österle, Balazs,<br />
Delgado (2009). Bünten (2006) was questioning foreign <strong>tourists</strong> about dental treatments in<br />
three regions of Hungary; a spa destination, a city at the Austrian border <strong>and</strong> Budapest. Form<br />
the answers of the respondents Bünten (2006) describes three type of dental tourist <strong>and</strong> their<br />
characteristics at the different destination. Österle, Balazs <strong>and</strong> Delgado (2009) sent their<br />
questionnaires via the Hungarian Medical Chamber to all registered dentists in the border<br />
regions with Austria <strong>and</strong> in the capital, Budapest, receiving a 25,34% <strong>and</strong> 20,65% response<br />
rate from the regions. In their results patients from neighboring countries are more attracted to<br />
the regions in Western Hungary, while patients coming by airplane are preferring the capital,<br />
Budapest, for dental treatment. Both studies found the price-performance ratio the main<br />
reason of the dental trips.<br />
For our study the methodology of in-depth interviews has been chosen, in order to get an<br />
overview of this market from the suppliers involved. Eight experts have been interviewed,<br />
public authorities from the tourism <strong>and</strong> the dental side <strong>and</strong> private players (Table 2.).<br />
Additionally two cases of direct evidence have been collected via interview <strong>and</strong> an<br />
experiment to get a deeper insight on actual price differences <strong>and</strong> organizational issues.
The demographic profile of the dental tourist coming to Hungary has been built in accordance<br />
with the interviews done. The average age group, country of origin, income status <strong>and</strong> party<br />
composition are shown in Table 3. For further analysis, it is important to highlight that the<br />
patients are mainly from the lower part of the middle class, with a growth toward the higher<br />
middle income classes. People from low income classes in case of Great-Britain are rather<br />
waiting for the free national health treatments, or do not repair their teeth at all. Patients with<br />
high income tend to do less dental travel, as for them the time is more precious, <strong>and</strong> they can<br />
afford private dental treatment in their own country.
Dental trips are not penalized by seasonality; patients have teeth problems all year around.<br />
Dental tourism is less likely in the Christmas-New year’s break <strong>and</strong> in the month of August,<br />
in the seasons of traditional family holidays, both for doctors <strong>and</strong> patients. Some dental clinics<br />
are also closing for those periods. Most of the arrivals are on Sunday nights, <strong>and</strong> the first visit<br />
of the dentist on Monday, differently from leisure travelers arriving for weekends. Hence a<br />
partnership with a dental clinic represents a perfect complement to the leisure <strong>business</strong> with<br />
respect to seasonality <strong>and</strong> weekly variations. The type of accommodation, where dental tourist<br />
usually stay are 3-star partner hotels, most of the agencies <strong>and</strong> clinics have agreements with<br />
them in Budapest. Some agencies offer wider scale of accommodation from bed&breakfasts<br />
till 5 star hotels. This is a mutually beneficial partnership, the clinics can provide discounted<br />
rooms to the patients nearby, while the hotels have very high occupancy rate all year around,<br />
saving costs for the marketing <strong>and</strong> sales department.<br />
The duration of the trip depends on the nature of the dental treatment. In Table 3. the three<br />
most usual durations of dental trips are introduced. All of these require more than the average<br />
stay of a normal tourist in Hungary, which is 2,6 days (Hungarian Central Statistical Office).<br />
The mode of transportation is airplane for 90% of the dental <strong>tourists</strong>. Hungary <strong>and</strong> its close<br />
neighbor countries are well-served with budget-airlines, which can keep the price of the<br />
overall experience low.
The main part of the <strong>tourists</strong>’ expenditure is coming from the dental treatment itself. As an<br />
example, an Italian patient’s cost calculation about his dental trip is presented in Table 4. The<br />
price in his case depended on how many implants it was necessary to install. There are two<br />
solutions, comprehending a different number of implantations from 8 to 16. In Italy the<br />
dentist always suggested “the 16-solution”, the most expensive <strong>and</strong> also the “easiest” in<br />
technical terms, but also very “destructive” for the patient. The estimated cost was 100.000 €.<br />
In Hungary the dentist offered him the solution with 8 installations <strong>and</strong> significant savings.<br />
As compared to this extreme example, the average saving is around 50-70% of the price in the<br />
sender country, according to our interviews. Private insurance companies are also saving on<br />
the reimbursement; therefore they encourage their customers for treatments in cheaper<br />
countries. The most required treatments are the implants, bridges, <strong>and</strong> crowns, because those<br />
are the most expensive <strong>and</strong> allow bigger savings on the treatments. On average 3-4.000 €<br />
spent on a treatment.<br />
For further evidence, an experiment was conducted using a test person with cosmetic dentistry<br />
problems. An estimate was requested with an x-ray for her treatment in Lugano, Switzerl<strong>and</strong>.<br />
Using the online contact form of dental clinics <strong>and</strong> agencies in Hungary, the same request was<br />
sent to 15 of them. Treatment type <strong>and</strong> price, accommodation offers <strong>and</strong> trip duration were the<br />
main curiosities. 12 answers were returned <strong>and</strong> the results are presented <strong>and</strong> compared in<br />
Table 5. There are four possible solutions for the patients’ problem; treatment I refers to a<br />
cheap composite filling, while treatment II, III <strong>and</strong> IV require a dental laboratory. The<br />
difference in the last three options is the material <strong>and</strong> the technology used; III <strong>and</strong> IV are more<br />
expensive, higher quality solutions. Responses showed higher prices from agencies, due to<br />
their commission fee. Packages include the treatment price <strong>and</strong> the hotel price multiplied with<br />
the number of nights suggested by the clinics. The table confirms that for small scale<br />
treatments it is not worth travelling, while more labor-intensive procedures shows significant<br />
savings even combined with the travel costs. The graph (Figure 1) represents a hypothetical<br />
dem<strong>and</strong> curve for a specific dental treatment <strong>and</strong> illustrates the potential welfare gain realized<br />
at destination which creates a potential for dem<strong>and</strong> for additional tourism services <strong>and</strong><br />
products.
Figure 1 Dem<strong>and</strong> curve using the data from the experiment<br />
In order to analyze the tourism effects of a dental treatment in Hungary, Interview I has been<br />
conducted with the representative of one of the main sender countries. The tourism<br />
representative noted, that in 2007 55.000 Irish tourist visited Hungary, among them almost<br />
10% went for dental treatment. 40% of all Irish dental patients going abroad have chosen a<br />
Hungarian clinic for their treatment. Approximately 5.000 patients spent at least 5 nights in<br />
Hungary.<br />
In line with the Interview I, the tourism factor has not got a significant role in the decision for<br />
having a dental treatment abroad. The clinics can sell their product easier if it is in Budapest,<br />
even if it is a bit more expensive. 80% of the dental <strong>tourists</strong> are going to Hungary only for the<br />
dental treatment. The other 20% are interested in visiting Budapest in the first place, <strong>and</strong><br />
decide after to undertake a treatment during the holiday. So far the <strong>Tourism</strong> Office of<br />
Hungary did not deal with the dental tourism topic. They are promoting heavily the Spa<br />
culture of Hungary, the curing thermal water, as health tourism. Dental tourism is mainly<br />
motivated by the price advantage not the country itself that is why, the tourism industry is less<br />
interested in it. Even though the opportunity is high to convert patients to normal <strong>tourists</strong>.
Interview II was with the Chief Dental Officer of Hungary responsible for quality control <strong>and</strong><br />
head of dental staff <strong>and</strong> dental profession in the country. According to him, Hungary’s leading<br />
position is based on its cheaper prices <strong>and</strong> high quality dental education. The proof of this<br />
high quality education is coming from Israel, which is the only country where dental<br />
education is measured. Israel has one of the highest proportions of dentists to the general<br />
population in the world, with some 7,500 dentists currently practicing <strong>and</strong> about 300 new<br />
ones joining the profession each year. That is reason, why they have introduced a dental<br />
licensing examination, which is m<strong>and</strong>atory to complete successfully in order to obtain<br />
recognition as a dentist. Apparently students having obtained their degree in the Semmelweis<br />
University of Hungary, pass this exam with the highest results. In fact each year<br />
approximately 120 international students are enrolled at one of the English language medical<br />
programs at the university. The result of the EU/EEA Dental Complement Authorities Survey<br />
from 2006 can be seen in Figure 2. Hungary has the highest ratio of dentists with the<br />
specialist degree in the European Union. It is due to the fact, that before the political <strong>and</strong><br />
economic changes of 1989-1990 it was compulsory to study an additional 3 years in a<br />
specialized filed of dentistry for being allowed to practice.<br />
The remaining interviews confirmed the findings cited. Turning to the tourism related aspects<br />
of the findings we discuss the way of organizing the trip, which will lead to the identification<br />
of a destination based strategy in the next part of the paper.<br />
Patients can organise their dental trips in three different ways. Contacting directly the dental<br />
clinic, using a dental agent abroad, or booking via a dental travel agency.<br />
In the most simple case, the patient contacts the dental clinic directly via internet or phone, in<br />
order to get a quote for his treatment. In this model the patient does not pay the commission to<br />
the agent for organizing the trip. Most of the dental clinics have agreements with partner<br />
hotels, if the patient is asking for help in booking accommodation. The hotel can help them in<br />
spending their free time. Clinics following this model are the least successful in the<br />
international competition, as they have only the presence on the Internet abroad. However<br />
those, which are located in well known spa destinations are receiving many incidental tourist
from Austria <strong>and</strong> Germany. Especially elderly repeaters, who are spending 2-3 weeks of<br />
holiday there, <strong>and</strong> during their stay seek out the dental treatment. In this case the dental visit is<br />
the secondary motivation of the patient.<br />
The second possibility is to contact a Dental Travel Agent. In this case the dentistry is<br />
working with several dental travel agents located in the sender countries <strong>and</strong> mainly expatients<br />
of the clinic. They are representing the tangible aspect before the experience, the<br />
person with whom a patient can talk to <strong>and</strong> build up trust. The agents are intermediates<br />
between the clinic <strong>and</strong> the patients, everything is communicated through them, they ask for<br />
the quote <strong>and</strong> book an appointment for the patients. The accommodation is booked by the<br />
clinics at the destination. In terms of number of dental patients per months, this model proved<br />
to be the most successful one. Though success can be influenced by many other factors, such<br />
as how long they have been treating foreign patients, how big the clinic’s capacity, how many<br />
articles have been written on them in foreign media, not to mention customer satisfaction,<br />
which is the key element of word of mouth marketing.<br />
The third <strong>and</strong> most advanced way to book a dental holiday is via a Dental Travel Agency. In<br />
sender countries based agencies are responsible for the marketing, providing information,<br />
finding the right dentist for the patients, arranging appointments, communicating between the<br />
two parties, booking hotel, transfer, entertainment, keeping customer service. Some agencies<br />
are also advertising packages, which are containing a specific treatment the hotel for the<br />
number of nights required by the treatment.<br />
It is common, that agencies have contracts with more than one clinic. Smaller dental clinics<br />
can enter into the dental tourism market only by cooperating with travel agencies, which can<br />
take over the organizational tasks acting as an outgoing tour operator.<br />
As the above findings shows, in dental tourism the treatment part dominates the whole<br />
experience of the <strong>tourists</strong>. Price differences are still significant between sender <strong>and</strong> receiver<br />
countries, which ensure the continuation of the <strong>business</strong> as long as prices are not getting<br />
equalized. The tourism part has not yet been exploited enough, which gives scope for<br />
enhancing the experience with more tourism activities. While current strategies focus only on<br />
treatment <strong>and</strong> hotel elements, the <strong>business</strong> should develop, as the following part of the study<br />
argues, towards destination based strategies, inspired by integrated tourism experience<br />
models.<br />
Strategy for Dental <strong>Tourism</strong><br />
In order to describe a strategy for dental tourism that would take dental tourism closer to<br />
tourism, we apply the “Get there – stay there - live there” model (Croce, Maggi, 2005) which<br />
distinguish these three phases of the tourism experience. The GET THERE phase covers<br />
holiday start-up activities as information gathering ("Virtual Get There") <strong>and</strong> mobility ("Real<br />
Get There"). STAY THERE regards the satisfaction of basic holiday needs, i.e.<br />
accommodation <strong>and</strong> food, <strong>and</strong> LIVE THERE is about the satisfaction of secondary holiday<br />
needs <strong>and</strong> including all the activities of <strong>tourists</strong> at destination. The overall experience of a<br />
tourist is integrated among the three phases, but the degree of integration can vary in the<br />
different organizational models.<br />
Dental treatments are the primary motivation of the dental trips. For obvious reasons the<br />
treatment is placed in Stay there phase (see Table 6). Visiting dental clinics constitutes a basic<br />
need of the patients; dental tourism would not be possible without them. The clinic is the
anchor point of the dental tourism experience, much like the <strong>business</strong> meeting of the<br />
conference is for <strong>business</strong> tourism.<br />
The challenge for the development of dental tourism lies in the currently dominating focus of<br />
the tour organization on the stay there phase, hence the dental treatment complemented by the<br />
accommodation. Figure 3 shows the three actual dominating organizational models of dental<br />
tourism. While in the first of the three cases illustrated the organizational anchor point (i.e. the<br />
TO) is the clinic, in the other two cases the organization of the experience is in the h<strong>and</strong> of a<br />
specialized tour operator. When the first model applies, the tourism experience at destination<br />
represents just an accessory, organized eventually by the hotel or the clinic upon request from<br />
the patient. As there is no integration with the destination, the scope of a DMO to target the<br />
market via the TO is very limited <strong>and</strong> the <strong>business</strong> will never become more touristic. The<br />
intermediation between the clinic <strong>and</strong> the patient by a TO, as in the second case in Figure 3,<br />
makes the organization of the experience more efficient <strong>and</strong> consequently will enlarge the<br />
market. However neither this model includes the tourism experience at the destination in the<br />
dental tourism market. Only the third model where the anchor is again the TO but with direct<br />
access to the destination, i.e. packaging, arranging, offering the whole experience will give<br />
scope for a development of a real dental tourism market. Dental Travel Agencies have the<br />
potential to link effectively DMO-s with the dental industry.
Figure 3 Dental tourism organizational models in the Get there - Stay there - Live there<br />
frame<br />
International competition is growing in Europe, especially in Pol<strong>and</strong>, Turkey, Croatia,<br />
Slovenia, Slovakia, Czech Republic, <strong>and</strong> for British <strong>and</strong> Irish patients with lower willingness<br />
to travel, the prices are already a bit lower in Northern Irel<strong>and</strong>.<br />
So how can Hungary keep its leading position with respect to the eastern competitors which<br />
are sometimes cheaper, but less experienced in this sector? Hungary can beat them at the<br />
moment by guaranteeing its high-quality dental tourism, emphasis on high professional<br />
st<strong>and</strong>ards with more agencies, bigger clinics, more doctors, state of the art technology <strong>and</strong><br />
language skills. A successful strategy has to contain at least two elements: quality control,<br />
cure of the core product <strong>and</strong> extension of the tourism experience to the live there phase.<br />
Hungarian dentists need to cooperate in filtering out lower quality clinics <strong>and</strong> keeping their<br />
good fame facing the foreign competition. Labeling on quality control of dental tourism could<br />
be a strategy in this situation, in which to enter would be a free decision of each clinic. Under<br />
that label all clinics <strong>and</strong> agencies should satisfy dental requirements for foreign patients.<br />
Besides the usual control of a flawless clinic, ensuring fluent communication towards patients<br />
<strong>and</strong> help during their stay in Hungary. This could represent their competitive advantage to win<br />
<strong>and</strong> retain more customers. A recent initiative in this direction is the one of five clinics,<br />
claimed to be the biggest in Hungary, who has decided to form an association of Leading<br />
Hungarian Dental Clinics in 2009. Their efforts concentrate on common marketing <strong>and</strong><br />
lobbying for stronger image building in the European Union. Together those clinics generated<br />
20.000 overnight stays in 2007 <strong>and</strong> 22.000 in 2008.
The country itself could profit much more from the existing dental <strong>business</strong> with higher<br />
involvement of the tourism offices (DMO’s). Patients could be motivated to extend their stay,<br />
or plan a new trip in the future to visit the country, get in touch with the culture or just simply<br />
spend their time more enjoyably, <strong>and</strong> when they return talk not just about the treatment but<br />
also about the destination. Possible cooperation with the <strong>Tourism</strong> Office also in small level,<br />
such as brochures in the waiting room of the dental clinic, would work as a tourist information<br />
point. On higher level, dental tourism should get an important role in thematic marketing of<br />
the county abroad, as it has been decided to dedicate 2011 to the year of <strong>Health</strong> tourism.<br />
Special dental holiday packages should be created for that occasion, using the dental<br />
professionalism in Hungary to attract more tourism.<br />
The Hungarian competitive advantage will shrink within 2 to 3 years, <strong>and</strong> possibly, only the<br />
few big players will continue, those which will take part in dental travel association, have<br />
consultancy service in foreign countries, <strong>and</strong> advertising the most (Interview I).<br />
Making the example of the positioning of dental clinics in Great-Britain <strong>and</strong> in Hungary, the<br />
National <strong>Health</strong> System (NHS) today offers free dental services to the British patients, but at<br />
low quality, concerning availability <strong>and</strong> waiting lists. The British dental clinics offer good<br />
quality services, at high prices. Hungarian dental clinics provide high-quality services for low<br />
prices to Western patients. When the overhead costs will increase in Hungary, the price of the<br />
treatment together with the airplane <strong>and</strong> accommodation might cost as much as the treatment<br />
in Great-Britain. Hungary will be repositioned into high-quality high price dental tourism<br />
segment. At that point the competitive potential of an integration of the dental service with the<br />
improved tourism product comes into play. While today the primary motivation is the medical<br />
treatment, in the future it would be the tourism experience with the dental treatment as a<br />
byproduct.<br />
According to Pucko <strong>and</strong> Ràtz (2006) Hungary’s competitiveness is in wellness <strong>and</strong> city<br />
tourism, while its unique selling proposition is the healing water. Therefore health tourism has<br />
been <strong>and</strong> can be the product, which makes Hungary a favorite destination for the European<br />
visitors. It is based on several elements, such as the unique thermal bath history in the<br />
country, Budapest is the only spa capital in the World, <strong>and</strong> the lake of Heviz is the largest<br />
thermal lake in the World. <strong>Tourism</strong> <strong>and</strong> bathing organizations are trying to ensure that health<br />
tourism becomes the core product of the country. A combination with dental tourism could<br />
develop Hungary to a medical destination, where tourist come to get healthier, relaxed <strong>and</strong><br />
better looking in every sense.<br />
Conclusion<br />
This paper investigates a special type of medical tourism, analyzed from tourism perspectives.<br />
Both the tourism <strong>and</strong> the medical sector get more involved in the phenomenon, deeper<br />
integration is continuously emerging between them. The case study of Hungary’s dental<br />
tourism has been chosen due to its high specialization <strong>and</strong> success in this market. The<br />
country’s competitiveness based on its low prices, high quality, modern technology, central<br />
location, <strong>and</strong> being primer starting with dental tourism, brought the idea to discover its<br />
relevance in terms of tourism, not only in the revenues of the dental clinics.<br />
The findings of the research contains 3 organizational models of Hungary’s dental tourism<br />
supply in the framework of the Get there - Stay there - Live there approach. The 3 models<br />
differ with respect to the intermediaries involved, the degree of integration of the product <strong>and</strong><br />
the anchor point of the experience.
Dental tourism in Hungary is still in the growth phase of its lifecycle. It has still few years of<br />
significant presence on the market, before the overhead costs will increase, <strong>and</strong> the price of<br />
the whole trip will be equal with a treatment in the Western countries.<br />
This study claims, that higher cooperation with tourism, <strong>and</strong> changing target market gives the<br />
possibility to overcome the decline. To consider repositioning into high price-high quality<br />
dental tourism, would imply the dental treatment to become the by-product of visiting<br />
Hungary for those patients, who are also seeking high quality treatment. This new product<br />
will be developed from the old one using its suppliers, such as the clinics <strong>and</strong> the agencies,<br />
which will have a higher degree of cooperation with other tourism suppliers.<br />
Whether dental tourism in Hungary repositions <strong>and</strong> stays still successful or completely<br />
vanishes, would be the scope of a new research, when the phenomenon reaches its maturity<br />
phase. Thinking more globally, further studies could investigate how medical tourism will<br />
react to price increases at different destinations. The changes on the World’s medical supply<br />
map in 10-20 years would be an interesting continuation of the research. Not just in the<br />
supply, also in the dem<strong>and</strong> major changes could occur. Government health reforms <strong>and</strong><br />
country developments can originate new targets within new source countries. However people<br />
will always seek high quality deals, especially when their health <strong>and</strong> beauty are on the stake.
Appendix
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