Health, Wellness and Tourism: healthy tourists, healthy business?
Proceedings of the Travel and Tourism Research Association Europe 2010
Annual Conference 1-3 September, Budapest, Hungary
Puczkó, L. (Ed) (2010).
Health, Wellness and Tourism: healthy tourists, healthy business?
Proceedings of the Travel and Tourism Research Association Europe 2010 Annual
Dalarna, Sweden: Travel and Tourism Research Association Europe.
The Travel and Tourism Research Association (www.ttra.com) is an international network
of travel and tourism research and marketing professionals from a wide variety of
backgrounds. The Association provides a forum where you may benefit from meeting other
people with similar interests. It was founded in 1970 in the USA. Since 1997, the European
Chapter of the TTRA (www.ttra-europe.org) has been active in extending its activities in
Europe and beyond, especially with its annual conference (www.ttra-europeconference.com).
The Chair of the Conference and the Organising Commitee: László Puczkó (PhD CMC MA MSc)
is a managing director and head of tourism section at 2q Tourist Research Partnership and Xellum
management consulting company; and Acting Head of the Tourism Competence Centre at Corvinus
University Budapest (Hungary). He has been a lecturer at several colleges and universities. He is a coauthor
of professional books on health and wellness tourism, the impacts of tourism, visitor
management and tourism management in historic cities. He is member of the TTRA European Chapter
Board and President of the Hungarian Association of Tourism Consultants.
Short Introduction to the Conference
Although travel has always contributed to health and wellbeing, it has often been in indirect
or passive ways (e.g. relaxation and escapism). However, many tourists are increasingly
choosing to go on trips which have the direct aim of improving their sense of wellness. On the
other hand, some destinations are now positioning themselves as market leaders in
health/medical tourism. The effects can even be long-lasting for tourists (and destinations)
and not just confined to the duration of the holiday. This can include spa tourism, which can
be medical or leisure-based; social tourism, where medical treatments are state-funded; sports
and adventure tourism, which increase physical health and fitness; occupational wellness
trips, which address work-related issues such as stress-management; and holistic or spiritual
retreats, which can balance body, mind and soul.
Many of these forms of tourism are based on changing leisure and lifestyle trends, such as
healthier nutrition, fitness regimes, or the quest for alternative spirituality. There are also
shifts in many societies from curative to preventative healthcare, which requires greater
knowledge and self-responsibility. The mainstream tourism industry is also investing heavily
in wellness products – for example the cruise industry – possibly to give a healthy ‘feel’ to a
product traditionally associated with eating too much. How can these contrasting aims be
integrated? The tourism industry is consequently responding to society’s need for holidays,
which enhance quality of life and fulfil all domains of wellness (e.g. physical, emotional,
spiritual, psychological and intellectual).
Furthermore, the link between leisure and tourism seems to be getting stronger, since wellness
and healthy/healthier lifestyle oriented customers tend to go on health(ier) trips, too.
The conference explored the relationship between health, wellness and tourism:
• Changing activities in leisure, lifestyle and travel which improve wellness and quality
• Developments in medical tourism and the shift from traditional curative towards
complementary and preventative activities, or even hedonistic aspirations
• The role of well-established forms of tourism (e.g. spa, sports, social, cruise) and
newer forms of tourism (e.g. holistic, occupational, adventure) in the development of
health and wellness
• The special characteristics of investment and return in health and wellness tourism
• The special characteristics of planning, management and marketing of health and
TTRA Europe would like to extend their sincere appreciation to the conference organizers,
conference chairs and keynote speakers, the dinner speaker, and the panel members and their
László Puczkó, 2q Tourist Research Partnership
Conference Secretariat Weco Travel Ltd- Chemol Travel
László Puczkó, 2q Tourist Research Partnership
Dee Ann McKinney
TTRA Europe gratefully acknowledges the support of the conference:
TTRA Europe is also indebted to the members of the Scientific Committee, who reviewed
121 contributions that were submitted for participation at the conference:
Anja Touhino, Project manager, ITÄHYVÄ, Finland
Aurkene Arzua, Director, CIC tourGune, Spain
Babu George, Assistant Professor of Tourism, University of Southern Mississippi, USA
C Michael Hall, Professor, Department of Management, College of Business & Economics,
University of Canterbury, New Zealand
Edward Huijbens, Docent, Icelandic Tourism Research Centre, Iceland
Frederic Dimanche, Director, Center for Tourism Management, SKEMA, Business School
Nice - Sophia Antipolis, France
Ian Henderson, Managing Partner, TTC International Ltd, U K
Isabelle Frochot, Lecturer, CEMAGREF Grenoble & Université de Savoie
Jana Kucerova, Department of Tourism and Hospitality, Matej Bel University in Banska
Jennifer Laing, Lecturer, Tourism Research Unit, Monash University, Australia
Joseph Sirgy, Professor, Virginia Politechnic Institute &State University, USA
Kai Illing, Professor, Joanneum, Austria
Kaija Lindroth, Degree Program Manager, HAAGA-HELIA, Finland
László Puczkó, Managing director, Xellum Ltd, Hungary
Melanie Smith, Senior Lecturer, Corvinus University of Budapest, Hungary
Pauline Sheldon, Professor, University of Hawaii, USA
Rob Davidson, Senior Lecturer in Business Travel & Tourism, University of Westminster,
Roos Gerritsma, Docent, InHolland, The Netherlands
Sheila Flanagan, Director, DIT, Dublin, Ireland
Sonia Ferrari, Professor of Place, Tourism and Museum Marketing, Università della Calabria,
Tamara Rátz, Head of Institute, Institute of Tourism, Kodolányi János College, Hungary
Economist, sociologist. He has been a teacher of Budapest Business School for 15 years. He
has been a colleague of GfK Hungária Market Research Institute for 20 years, and managing
director of the company since 1993.
He earned his degrees at the College of Commerce & Catering and then at the Eötvös Lóránd
University of Budapest where he majored in Media Studies and Journalism and Sociology.
His special fields are trade, consumer panel research and the research of media use habits.
He is the president of the Hungarian Marketing Association; a member of the Board of the
Hungarian Advertising Association; a member of the Association of Professional Market
Researchers; a member of the Advisory Body of the Marketing and Media Institute of the
Corvinus University of Budapest; a member of the Advisory Body of the Budapest Business
School; a member of the Communication Sub-Committee of the National Euro Coordination
Committee; a member of National Round Table on Pensioners and the Elderly; a member of
ESOMAR’s European Marketing and Sociology Organisation. Klauzál Gábor prize winner,
He is an author and co-author of several college and university lecture notes and course books
on market research. Email: email@example.com
Roger is COO of Thermarium Spa Financial Consulting based in Tyrol, Austria. Roger has
worked in spa development, operations and management for over 15-years during which time
he has built a chain of day spas and premium health clubs, worked extensively throughout
Asia and headed spa recruitment and spa operations for Steiner Leisure. Roger has been
involved in all types of spas and worked with both venture capital and angel investors for
various spa projects.
Roger is now providing experienced client dedicated financial spa planning, conceptual and
operational development to some of the most exciting spa projects in the world.
Email: firstname.lastname@example.org, www.thermarium.com
Dr. MELANIE SMITH
Melanie Smith is a Senior Lecturer and Researcher in Tourism at Corvinus University,
Budapest. Before this, she was Director of BA Tourism and MA Cultural Tourism
Programmes at the University of Greenwich in London. She is also Chair of ATLAS
(Association for Tourism and Leisure Education). She is co-author of Health and Wellness
Tourism (Butterworth-Heinemann, 2008) with László Puczkó and has written several journal
articles about holistic and wellness tourism. She has also recently been involved in teaching
and curriculum development in health and wellness tourism in Hungary, Estonia, and Iceland.
Kevin Turnbull is the Chief Executive of SpaFinder Europe, Middle-East & Africa, a division
of the largest spa marketing and spa gifting company in the world.
Kevin’s insight into the luxury spa market comes partly from his prior role as Director of
Mercedes Benz Luxury Car division in the UK, where he managed the ultra-luxurious
Maybach and the SLR McLaren super sports car business.
His career also saw him as CEO of the internet company Autobytel UK, a subsidiary of
Inchcape plc where he was also Global Group Director responsible for e-Commerce. Before
that he was Chief Executive of Toad plc, a technology business start-up, and played a pivotal
role in raising multi million City funding for the company and successfully floating Toad on
the London Stock Exchange. Kevin spent his early years at Ford and Nissan in sales and
Kevin received a BA (Hons) in History/Politics from Warwick University and holds an MBA
from Durham University. He is a Fellow of the Chartered Institute of Marketing, a Fellow of
the Institute of the Motor Industry and a member of the Institute of Personnel and
Development. He is a frequent speaker at industry events throughout Europe.
… started her professional career by working for a radio station and as a journalist.
Up to now 26 years experience in managing positions in tourism and hotel management.
From 2001 till June 2009 she was responsible at the State Tourist Board of Baden-
Württemberg (Southwest Germany) for marketing and advertising, for the cooperation with
tour operators and travel agencies in Germany and Switzerland.
Especially she participated in the establishment of the quality-certificate and the brand
WELLNESS STARS, which is standing for certified quality in hotels, spas and medical
Since July 2009 she’s consulting in destination-management, auditing and consulting hotels
and spas, offers spa- and marketing concepts as well as public relations. Since 2008 she is the
coordinator of the German Medical Wellness-Group.
GERARD BODEKER, Ph.D.
Dr. Gerry Bodeker researches and advises on international public policy on
traditional,complementary & alternative medicine (TCAM). An Australian, he is senior
clinical lecturer in public health in the University of Oxford Medical School and research
associate at the Oxford Centre for International Development. Dr. Bodeker has been chair of
the Commonwealth Working Group on Traditional & Complementary Medicine and done
work on medicinal plant conservation for the World Bank, the Global Environment Facility
and the UN Food & Agriculture Organization. He has written extensively on traditional
medicine and is co-founder of the WHO-affiliated Research Initiative on Traditional
Antimalarial Methods (RITAM).
Elisabeth Ixmeier is co-founder of Healing Hotels of the World, an exclusive global
partnership of hotels, resorts and retreats offering holistic health and wellbeing in luxury
surroundings. The quality brand Healing Hotels of the World is based on a comprehensive set
of criteria securing holistic health and wellbeing in all areas of a hotel or resort.
Elisabeth has a PhD in philosophy and art history and is practising holistic philosophies such
as Yoga since 30 years. Being a world traveller she became familiar with the leading wellness
resorts and the development towards health travel worldwide. As the co-founder of Healing
Hotels of the World she combines her experience in tourism marketing with her enthusiasm
for personal development and healing.
E-mail: E.Ixmeier@healing-hotels.com, www.healinghotelsoftheworld.com
DEE ANN MCKINNEY
Dee Ann McKinney brings 30+ years of marketing, research and advertising experience to her
current professional position of overseeing Strategic Planning and Research for the Division
of Tourism for the state of Missouri (MDT). She gained her marketing expertise with such
organizations as Southwestern Bell (AT&T), Bell South, the Cincinnati Symphony Orchestra,
regional cable networks and the Missouri Division of Tourism. She has also held media
positions in magazine, newspaper and television advertising sales.
McKinney has served on the Research Committee for the US Travel Association, the regional
(Central States) Board of the Travel & Tourism Research Association (TTRA) and the Direct
Marketing Association of St. Louis Board of Directors. Currently, as liaison to all of MDT's
research vendors as well as other state tourism offices and local, community or tourism
business organizations and other tourism research interested groups. She supervises all
research information releases and competitive analyses. For several years, she has also Cochaired
the state research directors group for the United States-- coordinating, organizing and
moderating meetings of State tourism offices twice each year.
Presently, McKinney is President of TTRA's international Board of Directors. Prior to
becoming the President, she served on the board for four years including as first and second
Vice-President. In June of 2010 she became the Chairman of the Board for TTRA.
Table of Contents
ANTUNES Joaquim Gonçalves 282
AZMAN Inoormaziah 9
BARTH Isabelle 56
BEETON Sue 26
BROOKER Ed 31
BROWN Anthony 248
BROWN Graham 164
CHAN Jennifer Kim Lian 9
CHOI Hwan-Suk Chris 102
CLEEVELY Olivia 248
COLE Shu 37
CORREIA Anabela Gomes 282
DE GRANDPRÉ François 175
DEERY Margaret 38
DIMANCHE Frederic 40
DIMANCHE Christine 40
DO VALLE Patrícia 299
FORMÁDI Katalin 270
FUKUTOMI Akira 248
GERRITSMA Roos 43, 280
GICZI Johanna 203
GUSTAVO Nuno Silva 45
HALLEM Yousra 56
HANAN Katharine 248
HENDERSON Ian 66
HJALAGER Anne-Mette 67
HONGNAPHADOL Wanvipha 76
HOWAT Gary 164
HSIEH Mei-ting (Jessica) 85
HUIJBENS Edward H. 92
İÇÖZ Onur 261
IRIMIÁS Anna 93
JAGO Leo 38
JOPPE Marion 31, 102
JOUKES Veronika 109
JUDIT Torday 376
KIRÁĽOVÁ Alžbeta 121
KOMPPULA Raija 144
KONU Henna 154
KONU Henna 67
LAING Jennifer 164, 378
(Quick search: Ctrl+F)
LAUKKANEN Tommi 154
LEBLANC Marc 175
LUND-DURLACHER Dagmar 184
MAGGI Rico 408
MARCUSSEN Carl 194
MAYER Peter 270
MENDES Júlio 299
MICHALKÓ Gábor 203
MOLNAR Elisabeth 315
MUNDRUCZÓ Margit 227
NEMES Andrea 238
PARMAR Rina 248
PESONEN Juho 144
PIRNAR İge 261
PONOCNY Ivo 184
PRISZINGER Krisztina 270
PUERTAS Xavier 280
QUINTELA Joana Alegria 282
RÁTZ Tamara 189, 203
RENDA Ana 299
ROWLAND Eleanor 248
RULLE Monika 309
SEBASTIAN Filep 42
SHEN Ching-Cheng 309, 358
STANCIULESCU Gabriela Cecilia 324
SZIVA Ivett 333
TAMÁS Várhelyi 378
TOOMAN Heli 348
TREMBATH Richard 164
TRIKI Abdelfattah 56
TSENG Tzuhui A. 315, 348
TUOHINO Anja 366
UJMA Dorota 376
VIIN Tiina 333
VOIGT Cornelia 164,
WEILER Betty 164
WENG Janet I-Jane 381
YU Ping 397
ZINS Andreas H. 408
ZOLTAN Judit 424
Health and Spa Tourism Business: Tourists’ Profiles and Motivational
Jennifer Kim Lian Chan
School of Business and Economics,
University Malaysia Sabah (UMS),
88450, Kota Kinabalu,
E-mail: email@example.com; firstname.lastname@example.org
Health and spa tourism has increasingly become an important economic and marketing
strategy for hoteliers, resorts and tourist destinations to attract tourist visitations. Despite the
fast expansion and popular demand of health and spa services/activities by both local and
international tourists, there is little understanding of the spa and wellness consumers in the
Malaysian context. It argues that a deep understanding of consumer profiles and their key
motivations within this context is vital in order to sustain the growth of health and spa tourism
business. The paper presents a preliminary pioneering exploratory qualitative study that seeks
to understand the spa and wellness tourists’ motivation that are grounded in their own words
during their visits to spa and wellness service centers in Sabah, Malaysia. It reports the
empirical findings of spa and wellness tourists’ motivation by extending the push-pull
motivation theory that focuses on the individual’s psychological factors (motivation,
perception and attitude towards spa and wellness) and the destination’s (Sabah’s) spa and
wellness attributes. Data collection was conducted using in-depth interviews with 15 foreign
tourists in various health and spa service centres in Sabah, Malaysia. It reveals that the retired
aged group is the main category of tourists who go for health and spa services followed by the
professionals who are very health conscious and practice healthy lifestyle. The findings
revealed that health and spa tourist motivation is largely attributed to personal needs and
lifestyles, the price and the functionality/performance of health and spa service providers in
Sabah. The paper provides the broad understanding of health and spa tourists’ profiles in
Sabah, Malaysia and the key motivation factors. The finding benefits the health and spa
service providers in term of developing appropriate marketing strategies and enhanced tourist
satisfaction. The nature of the exploratory study and the type of respondent (foreign tourists)
limit the generalizability of the research findings.
Key words: health and spa, tourist profiles, motivation factors, tourist lifestyle, marketing
strategies for health and spa business
Over the past centuries, health and wellness-oriented activities have been recognized around
the world, with existing of different health practices of the people in different regions for
staying healthy, and for healing/curing remedies as well. The development of health tourism
can be resonated with the echoes of the great economic growth and major demographic shift,
occurring in most countries across the globe. Consequently, the society is aligned between the
consumer’s strong interest in health and the rising affluence, resulting in plethora of consumer
products, whether anti-aging creams or medical procedures, as everyone is in search for health
and well-being (Yeoman, 2008). Additionally, people are practicing a healthy lifestyle to keep
them fit and healthy. This lifestyle, Ryan and Travis (1981); in Kammermann et. al. (1983); in
Nahrstedt (2004), had termed “wellness” which can be described as a way of life, that an
individual create to achieve his/her highest potential for well-being, consists of actions that
the individual able to control, such as how they exercise, eat, manage stress, and perceive the
environment, and achieving a high-level wellness involves continual striving for a more
healthful way of living.
Benner, King and Milner (2004) suggested that health tourism is any pleasure-oriented
tourism which involves an element of stress relief could be considered to be a form of health
tourism. They highlighted the importance of distinguishing between health tourism and the
wide phenomenon of tourism because product perceptions on the part of both suppliers and
consumers will influence the extent to which more specialized travel experiences such as
medical treatment are promoted to mainstream market. Likewise, subsuming spa as a sub
sector of the health and wellness tourism, the spa sector is concomitantly mushrooming in the
past decades as one of the destination’s tourism offerings, especially in the hotel sector. It has
increasingly become an important economic and marketing strategy for hoteliers, resort and
tourist destinations to attract tourist visitations. McNeil and Ragins (2004) suggested that spa
participation is currently showing incredible growth, as more consumers turn to spa facilities
as venues to improve their health and well-being. Although it is luxury, it is seen as much
more necessity, and factors like, personal space, time out, escapism, retreats contribute to spa
visitation. Additionally, Smith and Puczkó (2009) stated that, in historical terms, health and
wellness practices have been very much embedded in regional and local traditions and
cultures, with available natural resources also determining the forms of wellness that were
developed. Therefore, it is arguable that there are extended key motivation factors of tourists’
visitation to health/spa facilities at a particular holiday destination. Despite the expansion and
popular demand of health and spa services/activities by both local and international tourists,
there is a little understanding of the health and spa consumers in Malaysian context.
Therefore, this exploratory qualitative study attempted to understand the health and spa
tourists’ motivation that are grounded in their own words during their visits to health and spa
service centers in Sabah, Malaysia by extending the push-pull motivation theory, to provide
some insights of this popular business. The purpose of this paper is to provide a deep
understanding of tourists’ profiles and their key motivations in health and spa tourism context
which is vital in order to sustain the growth of this tourism business.
Having brief on the issue, the research is aimed at providing a starting point for understanding
Sabah’s health and spa tourism market, particularly from demand perspective, by establishing
a preliminary profile of the health and spa tourists, and identify the key motivators of these
tourists in the health and spa tourism products and services in Sabah, Malaysia. The research
objectives were undertaken in an effort to answer the following questions:
• Who are the health and spa tourists in Sabah, Malaysia?
• Why the tourists utilized any of health and spa products and services while they travel in
Health and Spa Tourism
In recent years, many researches have been undertaken in addressing the issues related to
population health and health tourism. Smith and Puczko (2009) suggested that health tourism
can be viewed from two different perspectives, which are medical and wellness. Spa is one of
the sub sectors of health tourism which positioned in between medical and wellness,
depending on the purposes and types of treatments received when visiting spas. There are
many studies related to health tourism, especially in the field of medical tourism, but very
limited on health, spa and wellness that can be found in tourism literature. Nonetheless, the
studies focused on the development, marketing and positioning the spa establishments – the
supply side, rather than the demand side of health and spa goers/tourists.
According to Mcneil and Ragins (2004), spa participation in the United Stated of America is
showing an incredible growth in the early 1990s when the participation in gyms and health
clubs for fitness slowed down. The researchers stated that many consumers turn to spa
facilities as venues to improve their health and well-being, and the industry continues to grow
at amazing rates and marketing opportunities abound. They highlighted the current issues and
trends in the US spa industry, which the major challenges would be; (i) to meet the
consumers’ needs effectively as a shift in paradigm in spa concept – from indulgence to
wellness, (ii) to stay abreast of the changes in the spa consumer profile; as spa facilities
nowadays are not only cater to women, but also to men, and cater to all age-group of people,
(iii) to provide a more comprehensive array of treatments, services, and activities combined in
a highly conceptualized setting, and (iv) to stay up to date with technological advances in
provision of spa information to prospective consumers. The researchers suggested the uses of
strategies and techniques that respond to consumers’ demands, in the context of target
markets and the four Ps – product, place, promotion and price. They concluded that the spa
marketers must remain flexible and adapt to changes of spa users’ wants and needs, and
continue to improve communications about the spa experience and its benefits.
In line with aforementioned, Chon and Singh (1995) provided a review of trends in marketing
the resorts in USA. One of the product development trends they highlighted was the one that
evolved health awareness – concerns about personal health and fitness which increased the
demand for health-related holidays. Consequently the resorts are adjusting their amenities and
services to accommodate the health demands on vacationer, such as fitness facilities and
health spas have been added to release stress and improve nutrition and physical conditioning.
Moreover, they also stated that the presence of spa at a resort was cited as a primary reason
for drawing them. The trend is expected to continue as more and more people travel for health
reasons to resorts and spas which provides fully monitored and individualized beauty
treatments, and health programs.
Motivation has long been a central subject of study in psychology from varieties of ways,
including from the physiological, psychological or philosophical approaches (Petri and
Govern, 2004: 3-14). The study of motivation is widely being used in understanding human
behaviour and can be found in the literature of many disciplines. Likewise in tourism, the
concept of motivation has been used in understanding tourist behaviours and their travel
decision-making which can be indicative to tourism providers as to attract tourists and fulfil
their needs during their travel at a particular destination.
Page and Connell (2006: 63) stated that motivation as a subject is an integral part of the study
of consumer behaviour in tourism. Mountinho (1987), as cited in Page (2009), defined
motivation as a “state of need, a condition that exerts a push on the individual towards certain
types of action that are seen as likely to bring satisfaction”. It indicates the intrinsic reasons
why the individual is embarking on a particular trip (Weaver and Lawton, 2002: 189). This
psychological concept refers to tourists and the reasons why they embark on a particular trip.
It is too, directly linked to the demand for tourism, which can affected by a range of factors,
and to consumer/tourist behaviour, which does not only affect the initial purchase but also the
tourist experience as well as future decisions (Lomine and Edmunds, 2007: 125).
Consequently, motivation models and studies are seen in a variety in understanding tourist
behaviour in relation to many aspects of tourism, for example, the destination choice (e.g.
Chan and Baum, 2007; Park and Yoon, 2009), tourists’ purchase decision/spending pattern
(e.g. tourists’ souvenir purchase decision by Swanson and Horridge, 2006), and tourism
business marketing and planning strategies (e.g. Oh et. al., 1995; Bansal and Eiselt, 2004).
The results lead to a greater understanding of tourists’ behaviours and thus contributing to
effective marketing strategy in targeting the right tourist market. One of the concepts that are
considered in tourist’s motivation and purchasing process is in term of push-pull factors
which has been widely adopted in researches mostly associated with tourists’ behaviours and
segmentation, from general holiday-takings to special interest tourism, but rather in different
contexts and countries.
Push-Pull Factors of Tourist Motivation
Among the most well-known tourist motivation theory is the push-pull concept (Dann’s,
1977; Crompton’s, 1979; Iso-Ahola’s, 1982), in which activity is seen as a product of a pullpush
relationship. Dann (1981, as cited in Cooper et. al. 1993: 34) pointed out that the
destination pull in response to motivational push, which distinguishes between the motivation
of the individual tourist in terms of the level of desire (push) and the pull of the destination or
attraction. Similarly, Page and Connell (2006: 68) stated that push factors are those that
propel a desire to travel; pull factors are those that influence which destination is selected,
given the initial push, and arise from on a desire to travel. Crompton’s (1979) identified seven
psychological (push) motives: (i) escape from a perceived mundane environment, (ii)
exploration and evaluation of self, (iii) relaxation, (iv) prestige, (v) regression, (vi)
enhancement of kinship relationships, (vii) facilitation of social interaction, and two cultural
(pull) motives: (viii) novelty and (xi) education. This concept has been extensively studied
and widely accepted in tourism literature (e.g., Chan & Baum, 2007; Yoon & Uysal, 2005;
Jang & Wu, 2006; Kim, Lee & Klenosky, 2003; Oh et. al., 1995; Swanson & Horridge, 2006).
It is suggested that push-pull motivation concept is a useful approach for examining the
motivations underlying tourist and visitation behaviour. Gilbert (1991) acknowledged the
push and pull factors influencing the tourism consumer decision-making process (as cited in
Page and Connell, 2006: 68).
The idea of the push-pull model is the decomposition of a tourist’s choice of destination into
two forces, which are push and pull factors (Bansal & Eiselt, 2004). The push factors are
considered to be socio-psychological motivations that predispose the individual to travel,
while the pull factors are those that attract the individual to a destination once the decision to
travel has been made (Oh et al., 1995; Kim and Lee, 2002). This motivation concept
encompasses the push motivation factors, which are related to the tourists’ desire, and pull
motivation factors which are associated with the attributes of the destination choices (Yoon &
Uysal, 2005; Oh, Uysal & Weaver, 1995; Kim and Lee, 2002; Kim, Lee and Klenosky, 2003;
Jang and Wu, 2006).
Yoon & Uysal (2005) stated that push motivations are more related to internal emotional
aspects, while pull motivations are connected to external, situational, or cognitive aspects. On
the other hand, the push factors are origin-related, intangible or intrinsic desires of the
individual travellers, such as the desire for escape, rest and relaxation, health and fitness,
adventure, prestige, and social interaction. Meanwhile, pull factors are those that emerge as a
result of the attractiveness of a destination as it is perceived by the traveller. They include
tangible resources such as beaches, recreation facilities and historic resources as well as
travellers’ perception and expectation such as novelty, benefit expectation and marketing
image of the destination.
Chan and Baum (2007) investigated the motivation factors of ecotourists in ecolodge
accommodation by adopting the push and pull motivation factors. The findings revealed that
the eco-tourists are primarily attracted by the destination attributes (natural attractions,
wildlife, local lifestyle and eco-activities), where ecolodges are located (pull factors), and they
are also pushed by their social psychological desire to escape from their routine of normal life
(push factor). The identification of motivational factors in this study provides a clearer
account of what attracts the ecotourists to stay at ecolodges and suggested that the marketing
strategies for ecolodges should focus more on the destination attractions around the ecolodge
accommodation by positioning the ecolodges based on the unique destination attributes.
Nonetheless, conservation and protection the surrounding natural resources are important too
as these are the main motivational factors for tourists to patronize ecolodges. In contrast, Kim,
Lee and Klenosky (2003) examined the influence of push and pull factors on visitors to the
national parks in Korea. The results of a factor analysis identified four push factor domains
and three pull factor domains underlying respondents’ push and pull factor ratings. The push
factor domains suggested that the visitors to national parks in Korea considered the park to be
valuable recreational resources that provide important opportunity to appreciate natural
resources or enhance health or building friendship (consistent with results of 1999 Report of
Korean National Travel). Meanwhile the pull factor domains reflected the fact that the
national parks in Korea are relatively accessible and located close to most residential and
work areas. The study also provided the additional analyses investigated differences in push
and pull factor domains for different socio-demographic sub-groups and examined the
interrelationships among the push and pull factor domains. The study provided valuable
information in understanding Koreans’ motivation to visit national parks and the results hold
useful implication for park managers and researchers in studying how push-pull factors
impact tourists and visitors behaviour.
In line with aforementioned, it argues that the push and pull theory of tourist motivation can
be applied into health and spa tourism context. Similarly, there must be underlying factors
that motivate tourists for health and spa services while travel to a holiday destination, and
there must be certain health and spa attributes that attract the tourists to health and spa
facilities at the destination countries. Therefore, this research attempted to adopt push and pull
theory motivation concept in identifying the health and spa tourists’ motivation factors and
profiling these tourists.
The push-pull concept was utilized, with modifications being made to focus into health and
spa tourism, which is likely to be more central on the healthy lifestyles of the health and spa
goers and the holiday destination’s health and spa attributes. Accordingly, the push factors are
considered to be socio-psychological motivations that predispose the individual to travel (Oh
et. al., 1995), which evolves tourist’s personal attributes, or a demand-side approach which is
to understand tourist’s decision-making process, such as attitudes, perceptions, and learning
and motivation factors – the four major psychological factors of the individual’s purchase
behaviour (Knowles, Diamantis and El-Mourhabi, 2004: 57). Meanwhile the pull factors are
those that attract the individual to a specific destination once the decision to travel has been
made (Oh et. al., 1995). This may include tangible resources such as beaches, recreation
facilities and historic resources, as well as travellers’ perception and expectation such as
novelty, benefit expectation and marketing image of the destination (Yoon and Uysal, 2005).
Petri and Govern (2004: 20-21) suggested that some behaviour can be understood as
motivated by internal states that activate the individual to respond in genetically determined
ways. Other behaviours seem clearly the result of external information that is acted upon in
light of acquired experiences. This approach of motivation provides a dimension at which
motivation can be studied concerning the source of motivation, that is, the internal motives
versus external motives. The researchers stated that needs are commonly viewed as internal
sources of motivation that activate and direct behaviour to items in the environment that
alleviate some state of deprivation. It implies of physiological terms, and may also include
social and psychological needs. Meanwhile, the external sources of motivation are
emphasized on the motivating effects of either various goal objects or social relationship.
From this point of view, it is suggested that the motivation can be activated by changes in the
Similarly in tourism, (Page, 2009: 90) stated that the intrinsic motivation approach recognized
that individuals have unique personal needs that stimulate or arouse them to pursue tourism
(the desires to satisfy individual or internal needs – self-improvement, self-realization, or
achieve state of happiness, and ego-enhancement). In contrast, the extrinsic motivation
approach examines the broader conditioning factors that shape individuals’ attitudes,
preferences and perceptions, but are more externally determined (the society and the culture
one lives in). Goeldner and Ritchie (2006: 254) suggested that the extrinsic and intrinsic
motivation must be able to consider that travellers are variously motivated by intrinsic, selfsatisfying
goals and at other times are motivated by extrinsic socially controlled rewards (e.g.
other’s opinions). The framework in this research integrated the individual’s psychological
factors and the destination’s health and spa attributes adopting push-pull factors motivation
concept, in order to explain tourist’s motivations in utilizing health and spa services when
they travel to Sabah, Malaysia and the key attractiveness of local health and spa to the tourists
on the other hand, by moderating the demographic variables with the push-pull dimension in
explaining the tourist motivation on health and spa services. This contributes to a better
understanding of health and spa tourists in Sabah, Malaysia and also to the development of
the sector in the coming future, as it benefits the health and spa operators in term of
developing appropriate marketing strategies and thus enhances tourist satisfaction.
Internal motives – physiological, social and
(Needs that activate and direct behaviour)
Petri and Govern (2004)
(Unique personal needs that stimulate or arouse
them to pursue tourism)
Push Factors – Psychological Factors
(Oh et. al., 1995; Yoon and Uysal, 2005; Cooper
et al. 1993: 36; Knowles, Diamantis and El-
Health, spa and wellness perceptions & learning
External motives – the motivating effects of
either various goal objects or social relationship
(Motivation can be activated by changes in the
Petri and Govern (2004)
(The broader conditioning factors that shape
individuals’ attitudes, preferences and
perceptions, but are more externally determined)
Pull Factors – Destination Attributes
(Oh et. al., 1995; Yoon and Uysal, 2005)
Spa as a tangible resource
Unique spa treatments and experiences
Health and Spa Tourists
Figure 1: The Framework for Health and Spa Tourist Motivation Factors
Health-related Tourist Motivation
Though health tourism has longevity in historical terms, health and spa tourism can be
considered at its infant stage, at which health and spa tourists’ motivation remains a
substantive interest for researches. There is generally lack of empirical studies on health and
spa tourism motivation in understanding the fundamental needs of the health and spa goers
during holiday, as there is a growing concern on health among the population at present. It is
suggested that research investigating health, spa and wellness from demand perspective is
needed as many of the available literatures (as presented above) are basically focusing on the
development, marketing and positioning studies of the health, spa and wellness
One of the available researches that directly linked to health and spa goers is of Mak and
Wong (2007), who examined the underlying factors that motivate Hong Kong travelers to
search for spa experiences while travelling away from Hong Kong. The structured
questionnaires were employed to conduct the survey and received a total of 302 responses.
The findings revealed that the Hong Kong spa goers perceived spa as a place for relaxation,
pampering, beautifying treatments, and enhancement of overall health. The motivation
factors; ‘relaxation and relief’, ‘escape’, ‘self-reward and indulgence’, and ‘health and beauty’
are the most important factors that motivate Hong Kong travelers to visit spas. The result was
found to be an integration of European spa goers health perspective and American spa goers
self rewarding perspective. The findings of their study provide researchers and practitioners in
the spa industry with useful insights into understanding the present nature of the demand of
spa in the Asian market.
On the contrary, there are studies integrating healthy lifestyle into consumer/tourists
behaviours by Gonzalez and Bello (2002) show that a strong dependency relationship
between tourists’ behaviours and lifestyle, and the segmentation of the market that emerged
makes a division into five clusters: home-loving, idealistic, independent, hedonistic and
conservative. The labels give a general idea of the lifestyle of each segment. Similarly, the
study by Hallab (2004) on healthy-living oriented lifestyle in the field of travel and tourism
show that the connection between healthy-living habits of US citizens and their travel
characteristics with respect to travel push and pull motivational factors and sociodemographics.
It revealed significant findings in regard to individuals who have a healthyliving
lifestyle and their travel behaviour and shed a light on their socio-demographic
characteristic. The researcher also suggested future researches to use more variables in
seeking to understand further the mentioned segment’s travel behaviour.
Page (2009: 88) stated that there is no all embracing theory of tourist motivation due to the
problem of simplifying complex psychological factors and behaviour into a universally
acceptable theory that can be tested and proved in various tourism contexts. In this study, the
concept of push and pull motivations is used to refer to the perceived importance of health
and spa services for international tourists during their holiday in Sabah, Malaysia. This
implies that certain reasons for health and spa services during travel may correspond to
certain benefits to the tourists that are to be valued and obtained at the destination site.
Therefore, the tourism providers, health and spa providers must understand the tourists with
regards to their health and spa perceptions, expectations and decisions; and so, matching the
destination’s health and spa attributes to the tourists’ diverse needs.
Research Method and Study Site
The qualitative approach was used in this research to provide an insightful understanding of
the underlying motivation factors and perceptions that encourage the utilization of health and
spa services/facilities. Collis and Hussey (2003: 53) stated that the qualitative approach is
more subjective in nature and involved examining and reflecting on perceptions in order to
gain an understanding of social and human activities, which this research dealt with – the
tourists’ ideas, perceptions and involvement in health and spa during holiday. Moreover,
Weaver and Lawton (2002: 388) stated that the qualitative research is suited for situations
where little is known about the subject matter.
Respondents were the international tourists who stayed at four respective resorts in Kota
Kinabalu, Sabah (Shangri-La Tanjung Aru, Shangri-La Rasa Ria, Sutera Harbour, and Nexus
Karambunai) and had used the spa facilities/services provided during their stays at the resort.
The mentioned resort hotels were chosen as the study sites due to reasons; (i) they provide spa
services as part of the hotel services, (ii) they are in the same ranking – can be considered as
five-stars resort hotels, and (iii) they provide similar leisure and recreational activities and
facilities. However, due to the policy of the resort, in protecting the guests’ privacy, which is
not allowed the guests to be interviewed, the interviews were conducted at the Kota Kinabalu
International Airport (KKIA) before they depart back to their home countries or to their next
destinations. The semi-structured interview questions for in-depth interview with the tourists.
It comprised of five sections: questions related to the destination (Sabah) selection;
accommodation selection; spa and wellness experiences in Sabah; the individual’s healthrelated
perceptions and attitudes; and demographic questions. Besides that, the Englishspeaking
international tourists were specifically chose to alleviate the interview conversation
in order to maintain the genuineness of the data, and avoiding translation into other languages,
since nuances may be lost in this process possibly resulting in bias and loss of meaning.
In-depth interviews were conducted with 21 health and spa tourists at the Kota Kinabalu
International Airport (KKIA) from January to February 2010. Approximately 150
international tourists were approached, about 80 were staying at the respective resorts, less
than 40 of them had spa experiences at the resorts, 21 accepted to be interviewed but only 15
in-depth interviews completed (notably tourists from America, Europe and Australasia
regions) due to time constraint.
In-depth interview were conducted using recordings and lasted an average of 40 minutes.
They were conducted with the consent of the health and spa tourists on the day they were
leaving the city (Kota Kinabalu). The in-depth interviews were conducted using the interview
guide approach with a semi-structured format to enable the researcher to identify the topic and
issues in advance and therefore sequence and words the questions during the course of the
interview. The interview started with an introductory note and followed up with demographics
characteristics of the informants. The informants were first asked with questions pertaining to
their destination and accommodation selection, the purposes for coming to Sabah and reasons
to stay at the particular resort, as well as the key attracting factors of the destination and
accommodation selected. Then they were asked about their views on health-related activities
during holiday, and also their spa experience in Sabah (particularly at the resort). The final
section of the interview sought on their perceptions and attitude on health especially
pertaining to spa services and treatments during holiday in Sabah. The informants were asked
and probed for detail explanation wherever required throughout the interviews.
The recorded interviews were transcribed into a written format for data analysis. The data was
revised and analyzed in three stages to identify and develop appropriate themes. First, the
sample will be profiled by socio-demographic characteristics. This is because the relative
importance of the motivational forces has been found to vary as a function of tourists’ sociodemographic
characteristics (Kim, Lee and Klenosky, 2003). Second, push and pull
motivation items will be identified by drawing out the key themes and variables relating to the
descriptive themes – push-pull motivation and push and pull forces (Oh et. al., 1995; Yoon
and Uysal 2005). It was then linked to the tourist motivation factors from the previous studies
based on push-pull motivation factors that relate to health and spa tourism. The final data
analysis was based on health, spa and wellness concept suggested in the literature (Mak and
Wong, 2009; Smith and Puczkó, 2009), at which health and spas are seen as promoting the
individuals’ health and well-being rather than cure (medically), and also the main motivations
of having health-related and spa services during travel associated with the individuals’
awareness of health and well-being. In addition, as push-pull concept was adopted in this
research, therefore, the main health and spa’s attributes were recognized. This provides an
interpretation of health and spa tourism in Sabah, Malaysia.
Findings and Discussions
Profiling Health and Spa Tourists
Table 1 summarizes the demographic profile of the study informants, who are mainly from
the America, Europe and Australasia regions. Majority of the informants were female (75%),
aged more than 30 years old (80%), worked as professionals (80%), had university degree
(73%), and annual income more than 50,000 USD (67%).
Table 1 Profiles of Health and Spa Tourists in Sabah
No Demographic variables % No. Demographic Variables %
1 Nationality (regionally) 4 Occupation
America 20 Professional 80
Europe 80 Non professional 7
Australasia 80 Housewife 13
2 Gender 5 Annual income
Male 25 50000 – 70000 USD 20
Female 75 Above than 70000 USD 47
Not given answer 33
Less than 30 20 6 Educational Level
30 – 49 47 Self-taught 7
More than 50 33 College/University 73
Not given answer 20
By looking at the results of the demographic analysis, it can be said that informants reflected
general demographic information of health and spa tourists, who are mostly female in
professional and executive jobs; baby boomers dominate this market, which fall into the 30-
49 age group, and also the finding of younger spa goers who are less than 30 years old. These
findings indicate an encouraging interest in healthy lifestyle, health and spa tourism among
the tourists. Therefore, it can be said that tourists would likely to go to spa during holiday.
There is an absent of data from a few of informants regarding their annual incomes and
education levels including the housewives. But generally it reveals that the informants have
an annual income of more than 50,000 USD and are university graduates.
Health and Spa: Perceptions and Attitudes
Perceptions, learning and attitudes may be influential to ones’ motivation factors and thus
influence the consumer/tourist behaviours. Accordingly, the informants think that it is
important to participate in activities that contribute to ones’ health and well-being. They seek
to find balance or moderation in their lifestyles which is believed to makes ones healthy or
healthier thus ones may live longer and able to lead more enjoyable lives. The informants
seem to be health conscious, most of them claimed to have being part of the health regimes,
for examples, they do regular exercises, walking or running, Pilates and Yoga, practice
healthy eating, involve in sport activities and occasionally go to spas, have massages,
pedicure and manicure. Few informants confessed that they do not have much time to involve
in any health activities due to the nature of their works (physical jobs, a demanding work): “I
don’t do daily activities in England. No time, because of my work. My work is long, so after
work I have no time to the gym, swimming, or… (Interview informant 14)”, “I don’t do them
but I would like to do them. I don’t have time to do them. (Interview informant 15)” This
indicates that the informants are health conscious but they do not have much time for health
According to the findings, holiday seems as the best time and opportunity for the informants
to do things that they do not normally do at home to improve their health and well-being –
relaxation being part of their holiday as majority of the informants came to Sabah for holiday
and relaxation. They travelled mainly to see the wildlife (Orang Utan, Proboscis monkey, and
turtles) and natural environment (rainforest, mountain, beaches and islands) in Sabah. Other
than that, they also came because of the resorts, weather, culture, proximity to Hong Kong
(transit flights to home countries) and the range of activities like trekking up Mount Kinabalu,
golfing and water activities (snorkelling and diving). Previous travel experiences, the travel
agents’ and friends’ recommendations also influenced tourists’ decisions to come to Sabah,
especially for the first-time tourists. The travel agents and the internet were the main sources
of information for the tourists when selecting a travel destination.
In line with aforementioned, spa is not at all considered to be one of the reasons in selecting
Sabah as a holiday destination. However, when selecting an accommodation, the informants
generally consider spa as part of the resort/hotel’s facilities provided to the guests and would
have expected it if the accommodation is a 5-star resort/hotel. According to the responses, the
informants perceive spa as a place that has the ideas of relaxation, pampering, luxury, the idea
of massage and varieties of treatments, regeneration, clean and calm, tranquillity, enjoyment,
and expensive. Interestingly, there were informants associated spas with hot tubs or hot
springs. This suggests that the spa is associated with water and hot springs are the common
sources for building spas, which can be evidenced from the following quotes: “Luxury,
expensive… I think tranquil… hot tub… (Interview informant 13)” and “Different, because I
lived in Japan, so now I know the spa there was different, kinds of hot springs. So, that’s what
I initially thought about spa. (Interview informant 14)” Therefore, it is suggested that the
informants generally go on holiday for relaxation; spa is not the main reason to select a
holiday destination, but rather as part of the relaxation options/remedies during holiday.
Besides of being relaxed during holiday, the spa experience is regarded as part of the
enjoyment of holiday experience. This is reflected in the response “It is part of the enjoyment
of my holiday and it also adds to the relaxation of my holiday and the experience of my
holiday” (Interview informant 7)
Moreover, majority of the informants thought that it is important to involve in health-related
activities during holiday. They suggested that ones need healthy activities all around and not
just during holiday, or to keep moving and keep doing things even if during holiday, but it is
not the most important, the most important is relaxation; as evidenced from the following
quotes: “We try to incorporate relaxation, walking and tourism” (interview informant 12), “I
think you’ll feel better. (Health activities) It’s important but it’s not the most important. You
generally feel better” (interview informant 14), “The one thing that we try to do each day is
to go for a walk every morning, for at least it makes me energetic” (interview informant 15),
and “Relaxation is the most important, not exercise” (interview informant 18). Interestingly,
the lifestyle factor also motivates the health and spa tourists to visit spa during holiday. This is
evidenced from the quote: “When you’re away from home, and even if you’re relaxing on
holiday, where you have been, you still have to take care of your body. You still need to take
care of your face, of your nails…” (Interview informant 6). The informants thought that spa
experiences during holiday are very nice, enjoyable and relaxing as part of the holiday. To
some informants, it is one of the things that they always do on holiday which gives them the
opportunity to relax and a nice excuse for pamper, and mainly because they have time to do it
Health and Spa Tourists Motivational Factors
The following main themes emerged; (a) Self-satisfying/push factors: rewards after working
hard. (b) Self-fulfilment/push factors: Distress and time-out (relieve from work-stress and
take a break), unwind and rejuvenate and regeneration (busy and stressful life, distant travel
and activities involvement). (c) Spa attributes/pull factors, which consists of two sub-themes:
physical look – tangible resource (environment, atmosphere, decoration) and marketing image
of the spa (affordability, availability and accessibility, range of treatments and
professionalism). The findings are presented in Table 2.
Responses from the interviews show that the individual tourist’s wants/needs-related factors
are the main motivations for the informants to visit health-related and spa facilities during
their holiday in Sabah, Malaysia. When asked why the informants used spa and health
services at the resorts, majority of them answered for relaxation, pampering, distress, unwind,
rejuvenate and enjoyment; all that related to ones’ health and well-being in a more goaldirected
way (self-satisfying goals and self-fulfilment). Very less of mentioning the attributes
that attracts them to the spas – accessibility, affordability and the physical look of the
establishments. The informants simply answered their reasons for having spa experiences
were to relax and pamper themselves during holiday; for example: “We wanted some time-out
just to relax” (Interview informant 4), or “To relax and to get pampered” (Interview
informant 5) and “I wanted to be pampered” (Interview informant 6), “Just to relax and have
the opportunity that we don’t normally have” (Interview informant 8).
Table 2 Themes of Motivation Factors and Push/Pull Factors
Themes / Push and Pull Factors
Push factor :
Self-satisfying goal Escape - relax and pamper
Reward after working hard
Self-fulfilment Distress / Time-out
Relieve from work-stress
Take a break
Unwind / Rejuvenate / Regeneration
Recovery from tension in busy life
Distant travel / long flights
Pull factors :
Spa attributes Physical looks – tangible resource
Environment / Atmosphere
Spa attributes Marketing image
Availability and accessibility
Range of treatments
In addition, the reasons of having spa treatments were also related to the tiredness of being
involved in activities during holiday and the travelling itself (e.g. had long flight). This is
evidenced from the following quotes: “To distress, to relax and after playing physical sports,
it helps my muscles rejuvenate” (Interview informant 10) and “Because I come from the Sri
Lanka, from the Safari and needed to… had a long flight, and it’s good to unwind” (Interview
informant 14). Interestingly, it is discovered that notion of “escape” from daily life, which
commonly as one of the main motivators for holiday exists and related to motivation of
having health and spa experiences at the holiday destination selected. This can be reflected
from the responses: “To relax, that’s the biggest thing. When you go on holiday because you
want to get away 8-10 hours a day working high pressure, come home cook and clean. So you
want to have that spa experience, as I said, to just relax before you go back and face it again”
(Interview informant 9), and “Just to recharge my battery while I am here. So, when I go
home, I’ll feel refresh and back to routine and work” (Interview informant 15)
Clearly, the motivating factors that emerged from the responses, as shown in Table 2,
suggested that health and spa tourists were generally motivated from the individual’s
psychological aspects including variety of reasons related to relaxation during holiday (needs
and wants). From the themes and sub-themes of informants’ motivational factors, it also
suggests that informants are mainly attracted by the spa attributes such as the tangibility of the
spa itself and the marketing image it conveys which have considerate influences on the
informants’ main motivations to visit spas/have spa treatments. These factors include the
environment and decoration of the spa establishment, the affordability, availability and
accessibility of the spa, the varieties of treatments and the professionalism of the staffs.
Interestingly, the motivation factor of “culture/learning” seems exists with relation to health
and spa motivations. However, it is not at the “core” of the motivation to go to spa or to have
spa treatments on the first place, but in influencing the decisions/preferences in choosing
types of spa treatments – traditional/local types of massages.
Push and Pull Factors
It is discovered that the notion of understanding the consumer/tourists behaviours is to study
their travel/holiday motivations. These motivations often related to tourists’ behaviours and
decisions during travel and holiday. It is interesting to note that there is an existence of pushpull
motivational dimension; push factors – the real goal-satisfying and self-fulfilment in
relation to informants’ needs and wants for relaxation and pamper, either as a reward for
oneself after working hard in their careers/jobs or a relieve of stress and tension of their daily
life and works; and pull factors – the spa attributes itself that play an important role in
activating the needs and wants for spa treatments during holiday and resulting health and spa
demands at the destination country. In many circumstances, the initial needs and wants are the
unconscious motivators that are activated upon the actions (spa visitation) by the tangibility
sources of the spa itself.
Although the two different motivating factors emerged in motivating spa visitation among the
tourists, it is the push factors that have a comparative greater effect in influencing the health
and spa tourists’ behaviours to visit spas when they go on holiday. These tourists are the
people who practice generally a healthy lifestyle – involve regular exercises, healthy eating
and perhaps occasional visits to spas or health-related facilities. This indicates that the tourists
are health conscious and well-educated pertaining to their health and well-being, which
increased the demand for health-related holidays (Chon and Singh, 2005). Although some
tourists might not be a regular spa goers at their home countries (generally due to time
constraint and their nature of works), but most of the tourists would have spa treatments
during holiday which commonly related to relaxation purposes, and/or other sociopsychological
factors, which reflected the findings of Mak and Wong (2007); Smith and
Puczkó (2009). It signals the importance of viewing the tourists’ needs and wants in
developing range of products and treatments that fulfilling these needs and wants.
However, it is discovered that health and spa tourists may be conscious on their needs and
wants before their actual travel, but these sub-conscious needs and wants may be evolved or
become significant within the actual travel period. Therefore, it suggests the primary focus
and attention for health and spa providers should be on the aspects of fulfilling the tourists’
health-related needs and wants – that push the individuals to go to spas during holiday. As
concluded by Mc Neil and Ragins (2004), the spa marketers must remain flexible and adapt to
changes of spa users’ wants and needs, and continue to improve communications about the
spa experience and its benefits. Apart from that, the push factors of health and spa tourists in
Sabah also reflected the wellness dimension of health tourism (Smith and Puczko, 2009).
Nevertheless, in some circumstances, the spa attributes equally play a significant role in
motivating spa visitations at the holiday destination, particularly in stimulating the “subconscious”
needs and wants. Meanwhile, to occasional or regular spa goers, there certainly
perceptions and expectation established prior to their visitation to spas at a particular holiday
destination. As spa is perceived to be a place for relaxation, with parallel to health and spa
tourists’ needs and wants, the spa establishment should be designed in a way that promote
elaxation as this is generally the main motivator for the tourists to visit spas. The spa
attributes include the physical environment and decoration of the spa itself, the reasonable
price and accessibility of the spa, the wide range of treatments or signature treatments that
blend with different/local cultures, and the professionalism of staffs. Apart from the actual spa
presentation, significantly the marketing image of the spa through media advertisement such
as brochures and resort’s websites has attracted the tourists to decide for spa visitation during
their holiday in Sabah, Malaysia. Within the framework of push and pull factors, it suggests
that these are the important elements that promote the overall spa experiences from the very
beginning of the spa visitation; at which it is perceived as an experience rather than just a
treatment, and also as part of the holiday relaxation.
Conclusion and Implications
Health and spa tourism in Sabah, Malaysia is still at an infant stage, and there is no
established definition of this growing niche tourism business which indicates an importance to
study within this tourism context. As Pearce (1989:113) stated that motivation is set of needs
and attitudes which predispose a person to act in a specific touristic goal-directed way, it is
discovered that the informants’ motivation to spas are associated with tourists’ motivation to
travel for holiday – relaxation, which this paper has explored and presented the motivational
factors of health and spa tourists in Sabah, Malaysia thus provides an insightful understanding
of what motivates health and spa tourists to visit spas during holiday in Sabah. It is clear that
both self-satisfying and self-fulfilment (push factors) and the spa attributes (pull factors) serve
as the motivational factors to spa visitation.
Moreover, the profiles of the tourists have reflected the findings of previous researches (e.g.
Mak and Wong, 2007; Smith and Puczkó, 2009). The growth of health and spa tourism indeed
affected by the major demographic shift of the world population. As previously stated,
majority of the spa goers are from the retired age group, but current findings show that there
are emerging groups of younger spa goers, within less than 30 years old. The health and spa
market also evolved among the professionals who perceive spas as a way to rest and relieve
from their work stresses, besides having the affordability for holiday and spa treatments as
indicated from their level of income. In addition, health and spa seemingly begin to be
acceptable among the male spa goers. These have directly indicated the needs for products
development to cater different groups of health and spa tourist market.
Particularly, the findings presented in this paper may indeed be significant on an international
scale, as it certainly possible that the tourists (notably from the America, Europe and
Australasia regions) to be indirectly attracted to spa attributes at the holiday destination (in
this case, Sabah, Malaysia) because their main travel motivators are mostly associated with
relaxation when holiday. This paper suggests that marketing strategies for health and spa
should focus on the individual tourist health-related needs and wants. As relaxation and
pamper are the significant motivational factors for health and spa tourists, the health-spa
providers should position their spas based on the relaxation attributes that may stimulate a
relaxing mood throughout the spa experiences – the atmosphere, the layout and decoration,
the staffs, and the spa treatments.
A major limitation of this study is due to the nature of the exploratory study and the type of
respondent (foreign tourists) which limit the generalizability of the research findings. It
suggests a comparative work in a similar context in different locations and countries would
prove beneficial for the possible validation of the findings. Additionally, the generalization of
the research findings can be extended through further research such as the use of these
motivational factors as variables in the quantitative approach in other context of health and
spa tourism – health and spa tourists’ satisfaction, spa treatment preferences, or perceptions
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Holidays as Health: The No Leave, No Life Campaign
La Trobe University, Australia
The current interest in health, wellness and tourism tends to focus on travel for medical reasons
(Connell, 2006; Henderson, 2003; Herrick, 2007), travel for mental and physical rejuvenation
(Mueller and Kaufmann, 2001; Smith and Puczkó, 2009) and travel connected to physical activities
that require and/or encourage certain levels of fitness. It may be a primary, secondary or even
tertiary motivator. However, taking a vacation is in itself a removal from everyday, stressful living,
and recreation leave is considered in many nations as a necessary enabler of one making a
productive and healthy contribution to society.
Furthermore, the potential financial, social and community health costs of workers not taking their
allocated annual recreation leave has been recognised for some time, with researchers and tourism
professionals calling for programs to encourage holiday taking. For example, during 2002, just
under a third of Australians did not take any holidays, and of those who did, only 30 percent took
their maximum allowance of four weeks (Woolcott Research, 2002). Close to a quarter of those
studied stated that the primary reason for not taking any leave was a sense of being too busy at work
(Woolcott Research, 2002). According to Beeton and Pinge (2003: 309), “The very conditions that
taking a break are held to ameliorate have become the reasons for not taking a break”.
Tourist commissions and other government organisations have developed programs over the years
to encourage people to take holidays, especially domestic short breaks. However, the problem of
people stockpiling their leave remains, with 123 million days of annual leave by Australian full time
employees accrued in 2009, equating to AUD$33 billion in wages (Tourism Australia, 2009a).
Consequently, the liability for companies with high levels of accrued leave on their books is
substantial, presenting two major issues in addition to the need to develop what has become a flat
domestic tourism industry: that of community health and business viability.
It is clear that workers need to be persuaded to take their recreation leave, and employers to
encourage the development of a supportive corporate culture. In 2009, the Australian government,
under the auspices of Tourism Australia, developed an innovative program to encourage workers to
take their leave and at the same time holiday in Australia. The No Leave, No Life campaign has two
1. To work with employers to encourage the creation of a positive leave culture in their
2. To remind employees of the personal and professional benefits of taking annual leave (and
taking it in Australia). (Tourism Australia, 2009a: 2)
This paper examines the process that Tourism Australia has adopted to achieve its desired
outcomes, with a focus on the primary employer initiatives, arguing that this model may be applied
In any case where a change in people’s behaviour is required, it is important to understand the
barriers to participating in the desired activity. Persuasive communication theory can assist in
analysing the process and frames this particular Case Study.
According to Ajzen, “persuasive communication can produce a profound and lasting change, a goal
not easily attained by other means” (Ajzen, 1992: 6). Some years prior to that statement, Ajzen
(1988) argued that behaviour is a function of behavioural beliefs that influence a person’s attitudes
towards the behaviour, normative beliefs that determine the subjective norms (perceived social
pressures), and control beliefs that underpin perceptions of behavioural control, advancing
advanced the Theory of Planned Behaviour, outlined in Figure 1.
Figure 1. Ajzen’s Theory of Planned Behaviour
Source: Ajzen (1988: 133)
According to the theory, the intention to act precedes the actual behaviour, with intentions based on
three elements, or salient beliefs: personal attitudes towards the behaviour, one’s perception of
social pressures to undertake the behaviour (or subjective norm), and the perception of how much
personal control one has over that action (perceived behavioural control). In relation to visitor
behaviour, Fishbein and Manfredo (1992) present some strong cases supporting the role of
persuasive communication theory in affecting national park visitor beliefs, attitudes and intentions
and,, ultimately their behaviour.
The perceived control one has over one’s behaviour is significnat as it relates to a sense of personal
choice and the power to do so. This is similar to locus of control theory, which consists of two loci,
namely internal and external (McCool and Braithwaite, 1992) - where a person believes that their
future is controlled by others, they reflect a belief in an external locus of control, which is similar to
a low level of perceived behavioural control in Ajzen’s model.
While the model has three areas of salient beliefs, they are not necessarily evenly weighted, with
some being so weak at times that they are over-ridden by the most dominant belief. For example,
there are times when there may be little or no influence from attitudes and subjective norms, so
consequently a person my move directly from ‘perceived behavioural control’ to an intention to act
(Ajzen, 1988). Such differences are also reflected in the model, presenting a flexible and effective
model that has been applied many times in relation to persuading others (for some tourism and
recreation examples, see Lackey et. al., 2002, Beeton et; al., 2005).
The Case of No Leave, No Life
As noted earlier, the Australian No Leave, No Life campaign commenced in 2009, with the longterm
aim to reduce the amount of accrued recreation leave by Australians and to increase domestic
tourism. Previous attempts in the late 1980s and early 2000s to encourage local holidays by
Australians was only partially successful, with accrued leave continuing to rise and domestic
tourism growth remaining flat. In order to address this, Tourism Australia shifted from the
traditional supply focus of a Destination Marketing Organisation (DMO) to attempting to influence
demand by enlisting the employers along with the tourism industry.
Tourism Australia employed research consultants, Jones Donald Strategy Partners to undertake the
research, using Focus Groups, In Depth Interviews and Online Surveys in 2005 and 2009, along
with Single Source Surveys from 2006 to March 2009 in order to gather the required data (Tourism
Australia. 2009b). They divided their findings regarding barriers to taking leave into two groups
using ‘workplace and personal barriers’ as the differentiators.
The industry provides the domestic holiday options, while Tourism Australia developed tactical
promotions aimed at company employees through a dedicated TV travel show (No Leave, No Life)
and other collateral. The target employees are full time staff deemed to have ‘stockpiled’ over 25
days (or five weeks) of annual leave, as one in four full-time employees in Australia have that
amount of leave owing, pointing to a significant issue. Unsurprisingly, this group tend to be older
males, longer serving employees who typically manage staff, as well as parents of school aged or
older children and empty nesters (Tourism Australia, 2009b). The younger, single, child-free and
women workers did not feature, underlining the broadly accepted fact that the Australian workforce
remains dominated by men at the higher levels of organisations, and as longer-serving employees
due to the continued over-representation of women as family carers. Due to this unusual step for a
DMO to focus on changing the domestic tourism demand environment (or ‘push’ factors as
described by Dann, 1977) via employers, this paper focuses on that aspect of the campaign.
Tourism Australia has taken a three-stepped approach to working with employers, with the first
providing background data on leave stockpiling, the second suggesting some workplace strategies
to address the issue, with the third focusing on enabling employers to change the culture and
attitudes towards taking leave within the organisation through engaging with the No Leave, No Life
program. All of this material was made available via the internet as training modules and videos
In line with the Theory of Planned Behaviour, these results can be framed in the three beliefs that
Ajzen claims informs our intentions, namely attitude (towards the behaviour), (perceived)
behavioural control and subjective norms. This is outlined in Figure 2.
Figure 2. Stated Reasons for not Taking Leave
Move up corporate ladder
Prefer to work
Saving (for emergencies)
Saving (for big trip)
Hard to find things to do
Taking leave is a sign of weakness
Cause work for others
Internal work culture
Source: Tourism Australia, 2009b
Will not meet targets
Hard to fit around projects
Unable to take when it suits
Lack of money
Time taken planning
As can be seen, most of the salient beliefs regarding the barriers are in the ‘behavioural
control’ area, which responds directly with organisational culture. If these outweigh the
reasons for taking leave, the intention NOT to act is formed, consequently there is no action
taken. In order to shift this, Tourism Australia has adopted a strategy aimed at the demand
side of the tourism system (ie the ‘push’ factors). Their stated strategy is to ‘raise the
awareness’ of employers and employees, but they are doing more than this – they are working
to change the salient beliefs of those not taking holidays.
However, Tourism Australia has not looked at those who DO take leave, which would
provide a more holistic perspective and provide data that can be used in the Theory of
Planned Behaviour. By getting both sides and then ascertaining the strength of these beliefs in
the targe group (leave stockpilers) and range of consistent messages can be developed.
‘Strength’ does not relate to how many people believe something, but how much that belief
influence’s one’s decision to act. By ascertaining what are the strongest drivers and inhibitors,
much of the subjectivity of such research can be removed. While this may still produce a
similar outcome to what has been done, this approach would provide a more rigorous result.
The following comment from Beeton and Pinge some years ago remains true: “We need to
take holidays in order to refresh and recharge, otherwise our governments may well face
expensive community health issues in the future” (Beeton and Pinge, 2003: 320).
Tourism Australia’s strategy in relation to employers is to raise awareness of the issue, recruit
employers to the project and then assist them to create a positive leave culture. In terms of
employees, Tourism Australia aims to raise their awareness and communicate the benefits of
taking leave while encouraging them to book a domestic holiday. By analysing Tourism
Australia’s approach via the Theory of Planned Behaviour, we can see its potential for
success, as well as identify some areas that need to be watched carefully, such as the actual
influence the persuasive communications generate. Data is yet to be analysed and published
by Tourism Australia regarding this outcome.
This case demonstrates an innovative, integrated and inclusive approach to the issue of
accrued leave from the business, community and tourism perspectives that could be further
enhanced using the Theory of Planned Behaviour.
Ajzen, I. (1988) Attitudes, Personality and Behaviour, The Dorsey Press, Chicago
Ajzen, I. (1992) Persuasive Communication Theory in Social Psychology: A Historical
Perspective, in Michael M. Manfredo (editor), Influencing Human Behaviour: Theory
and Applications in Recreation, Tourism and Natural Resources Management,
Sagamore Publishing, Inc., Champaign IL, pp.1-28
Beeton, S. & Pinge, I. (2003) ‘Casting the Holiday Dice: Demarketing Gambling to Encourage
Local Tourism’. Current Issues in Tourism, 6(4): 309-322
Beeton, S., Weiler, B. and Ham, S. (2005) Contextual Analysis for Applying persuasive
Communication Theory to Managing Visitor Behaviour. A Scoping Study and Port
Campbell National Park, CRC for Sustainable Tourism, Griffith
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Fishbein, M. and Manfredo, M.M. (1992) A Theory of Behaviour Change, in Michael M.
Manfredo (editor), Influencing Human Behaviour: Theory and Applications in
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safety signs in Yosemite National Park’, Final Research Report to Yosemite National
Park, Wildlife Conservation Society, New York
McCool, S.F. and Braithwaite, A.M. (1992) Persuasive Messages and Safety Hazards in
Dispersed and Natural Recreation Settings, in Michael M. Manfredo (editor),
Influencing Human Behaviour: Theory and Applications in Recreation, Tourism and
Natural Resources Management, Sagamore Publishing, Inc., Champaign IL, pp.292-326
Mueller, H. and Kaufmann, E.L. (2001) ‘Wellness Tourism: Market analysis of a special
health tourism segment and implications for the hotel industry’. Journal of Vacation
Smith, Melanie K. and Puczkó, László (2009) Health and Wellness Tourism, Butterworth
Tourism Australia (2009a) No Leave, No Life, Industry Prospectus, Tourism Australia, Sydney
Tourism Australia (2009b) No Leave, No Life: Employer Module 1. Analysing the Issues for
Employers, Tourism Australia, Sydney
Woolcott Research (2002) Annual Leave Evaluation. Conducted for See Australia. Woolcott
Research job no 5435-M. Sydney
A Case Study of Innovative Wellness Tourism: The Case of RP Vacations,
Griffith University, Australia
University of Guelph, Canada
According to Peter Drucker (1985), innovation is the specific tool of entrepreneurs, the means
by which they exploit change as an opportunity for a different business or a different service.
Entrepreneurs need to purposely search for sources for innovative opportunities, and they
need to apply the principles of successful innovation. Roompot Parks in the Netherlands
represents an example of classic entrepreneurship in that the owner sensed an opportunity to
capitalize on the renewed interest in health and wellbeing, and over time, developed an
innovative program which pulls tourists to Roompot Parks for the primary purpose of
wellness facilities and programs.
This paper highlights the findings of this single case study, which includes a semi-structured
interview with the current manager of RP Care and RP Wellness, along with previous
research undertaken by the lead author four years ago when the concepts were developing. In
so doing, the study explores the relationship between health, wellness and tourism perspective
through an entrepreneurial perspective.
Background – Roompot Parks
The Dutch are keen campers (Klemm & Rawel, 2001), and as a result, there are between 400
and 450 recreational home parks in the Netherlands. Roompot is the third largest holiday park
operator in the Netherlands and considered to be the market leader in ‘sea park’ holidays
along the Dutch North Sea coast, known for its variety of offerings that range from holiday
bungalow parks to traditional camping grounds.. The two larger companies include Pierre &
Vacances and Landal Greenparks. Pierre & Vacances, a French company, is the largest actor
in the Netherlands holiday park market, offering brands that include Center Parcs, Free Life
and Sea Spirit. Landal Greenparks have a strong emphasis on nature and space. Competition
is not limited to just the other holiday park operators. It also comes from external sources, as
new long haul and exotic destinations, often in less developed countries, attract travelers who
may be seeking alternatives (Buhalis, 2000). Roompot is keeping a close eye on the trend
towards the growth in low-cost air travel to foreign markets, realizing that these vacations
may be more affordable than a week spent at a Roompot Park. This scenario, i.e. competing
with ‘more glamorous’ international travel is also a challenge for other holiday parks, as
shown in ongoing research into innovation in Australian holiday parks.
Roompot Parks began has grown over a 45 year period from an initial local family camping
business to an enterprise that now operates 46 parks, 40 of which are in the Netherlands, and
six in Germany. Combined, the parks offer a total of 3,450 holiday bungalows, 1,800 mobile
homes, 5,950 campsites, and 400 marina slots. All the parks are positioned in the mid to
higher end of the market, attracting families and mature couples seeking quality facilities and
While the supply of accommodation had been the company’s core activity, the company had a
change in direction in 2002, focusing on being a full-service provider of all-inclusive
holidays. The strategy was designed to enable Roompot to capitalize and expand on its
existing customer base. Enlarging its product portfolio and service offering enabled Roompot
to clearly distinguish itself from its competitors. In 2010, Roompot Parks sells vacation
accommodations in over 100 resorts and campgrounds, across Europe, including 55 resorts in
the Netherlands, 50 resorts in France, 16 resorts in Germany, 5 resorts in Belgium, 3 resorts in
Denmark, and 1 resort in Poland. Locations in Italy and Spain are under current negotiation.
Roompot’s second area of expertise lies with tour operating. Roompot has developed the
capability of selling its holiday offerings through its own direct distribution channel called
Roompot Vakanties. Perspective customers can book a vacation through three channels,
1. Direct sales via Roompot’s booking centre – remains the most popular method
2. Direct sales via the Internet – increasing in popularity
3. Indirect sales channels through various intermediaries including international travel
agencies (for resale).
Innovation is not new to the company. It has been the first to develop a new product or service on
many fronts including being the first in the Dutch industry to introduce on-line reservations for a
holiday bungalow or campsite. The company is now in the unique position of being able to act as a
consultant, offering its expertise to other operators in the industry.
Introducing a new product or line of services will only benefit Roompot if it can propel the new
offerings into economic and competitive advantages (Walder, 2006). The company however
understands the lag time and effort required prior to seeing any results from its efforts. The firm
has experience with diversification, growing from its initial campground to the point where it now
offers a range of services including holiday reservations, real estate development, construction,
retail and insurance. The net financial result has seen sales almost double from EUR 68.4 million
in 2002 to EUR 118.4 million in 2004 (Bencis, 2005). Very few SMTEs can boost such growth
within such a short period of time. In 2009, Roompot Parks turned over EUR 225 million. Its
parks attracted 1.3 million guests, who stayed approximately 7 million nights.
In order to gain insights, it was essential for Roompot personnel to speak to the concept of
wellness tourism within their parks in their own words and from their individual perspectives.
This study therefore employed qualitative methodology where the research tool comprised of
a single case study based on semi-structured interviews with two individuals with specific
connections to the program. The first interview was conducted in 2006 with the visionary
staff person who was instrumental in developing the concept and a follow up interview in
2010 with the current manager overseeing RP Care and RP Wellness.
Johannsson (2004) suggests the best chance to innovate is found in the ‘intersection’ – a
connection between two different fields. Roompot has clearly found the intersection, by merging
health care and vacations, within its existing operation. The result is known as RP Care, yet
another extension of the Roompot offering.
RP Care is an innovative modular extension of Roompot Vacations, providing guests (both
domestic and European Union) to obtain a variety of quality health and wellness services while
also enjoying a Dutch sea and sand vacation. RP Care has been established in part in response to
the international focus of health care tourism, in particular, the number of Dutch, German and
English who travel abroad in response to long waiting lines and/or electing to undertake elective
medical procedures while on vacation. Roompot felt that it could expand on its initial entry into the
health care, started five years ago with the offering of kidney dialysis at the Banjaard, a five-star
holiday bungalow park, located 10 kms from the first established Roompot Park.
The kidney dialysis service stemmed from the local hospital’s inability to service the needs of an
expanded vacation market and local knowledge, as the founder of Roompot was a member of the
local hospital board, was therefore aware of both the need for additional dialysis service and the
hospital’s desire to establish an off-site clinic. Thus in true entrepreneurial spirit, a separate
building was constructed within the park to house the dialysis service. Patients no longer had to
travel to and remain in a hospital for the procedure. Rather they have the option of visiting the
clinic three times a week, for 2 weeks, enjoying a non-sterile, relaxed but professional
environment. Appointments can be made on line through the Roompot Vacations website, with the
knowledge that the onsite medical staff are all associated with the local hospital.
The dialysis service is a radical innovation amongst holiday parks that traditionally offer
recreational opportunities to a variety of markets. However, previously, the mature market has
been viewed simply as a market opportunity based on their numbers only, as no serious efforts
have been made to alter the product mix in order to attract and retain a larger percentage of this
market. Roompot/RP Care has.
The success of the kidney dialysis service has led Roompot to extend its modular service offerings
into care and cure, augmenting the existing recreation facilities. Thus RP Care was created.
However, the creation of the service has not come without any difficulties. At first, it was a
difficult sell getting medical professionals to partner with RP Care. But Roompot’s founder
understood the value of networks, both in and outside of the business (Grulke, 2005). Based on his
relationships with external organizations, including the local hospital board, he managed to create
the necessary interest in the offering. In 2010, professional personnel from the local hospital staff
the dialysis center, but a local doctor also spends a day now visiting the park booking appointments
with park guests. Other doctors are inquiring about participating in the program.
Table 1 outlines the modular services and amenities planned for various Roompot locations within
Zeeland in partnership with local health providers. A clinic specializing in plastic surgery is
intended to be located in Goes, centrally positioned close to other Roompot parks and the regional
hospital. The location is of benefit to both doctors and patients, who will be able to convalesce in a
quality holiday setting, with family and/or friends.
The strategy to focus initially on the province of Zeeland is based in part on local knowledge of
health care providers, networks and also represents the location of Roompot’s base of operations.
The strategy can be expanded into other provinces within Holland based on local success and
Recreation Care Cure
• Fun stuff
• Care facilities
• Conference facilities
Table 1 - RP Care building blocks
• Plastic surgery
• Pain reduction
The strength of the concept is based on various factors. First, Roompot has essentially created a
win win situation for a variety of players, including local hospitals, health insurance companies,
individuals and for its own corporate opportunity. Local hospitals can now partner with a reputable
private sector business to continue to offer its services but within a decentralized framework.
Health insurance companies benefit from the preventative nature of the services, and the solid
reputation of Roompot to deliver quality care. It eliminates the uncertainty attached with travel to
Asia or other areas of Europe. The individual benefits from the opportunity to avoid lengthy
waiting lists, select the necessary service from the extensive offering, and to recuperate in a
comfortable location, where family and friends can visit, recreate, and remain in the Netherlands.
Roompot is the other winner in this situation, using a radical approach to capitalize on disruptive
social trends. The development of RP Care capitalizes on the aging population in a manner far
removed from what the competition has considered. This competitive advantage can also be
sustained as Roompot has first mover advantages with government health care providers. In
addition, the addition of RP Care addresses the issue of seasonality head on through the
introduction of a new service line and market that may otherwise not frequent a Roompot Park.
Facilities and amenities designed for use during the busy summer months now will be occupied
and used during the spring and fall, raising occupancy rates, and creating new opportunities for
programs and events. Current estimates suggest that two to three percent of Roompot patrons
utilize RP Care services. That number is expected to grow to ten percent as a result of promotion
efforts and the demographic changes noted earlier – older population will seek out care at Holiday
Parks The addition of RP care sends a clear message to the loyal customers who have frequented a
Roompot park over several summers – we’re not abandoning you as you age. In fact, we want to
keep you as a customer, so we’ve developed new programs designed with your needs in mind.
The modularity of the three cornerstones – recreation, cure and care provide the flexibility for
application to a diverse set of circumstances. Health services can be added to a vacation or
conference. Convalescents can recover in a comfortable setting, knowing their needs are looked
after, and the care is available locally.
Roompot’s decision to capitalize on disruptive social trends, focusing on collaboration – aligning,
exchanging, and leveraging opportunities (Dvir et al, 2004) builds on a modular business model.
Such a modular approach gives the company the capability to couple and decouple service delivery
on demand, based particularly on three building blocks – recreation, cure, and care. On demand
business enables a customer to connect in a flexible manner – for instance health services to a
holiday or vice versa, contingent on his/her circumstances or personal preferences. It offers
convalescents a sense of security that they can recover in a comfortable setting, in the knowledge
that their needs are looked after in a professional manner.
The introduction of its modular business model enabled its subsidiary RP care to thrive in an
intensely competitive tourism environment. It also demonstrates Roompot’s leadership in the trade
and beyond, particularly that a radical innovation approach can bring rewards well worth the risk.
In 2010, RP Care facilitates care, cure and wellness opportunities through partnerships with
various health oriented organizations. For example, it provides facilities for disabled guests,
kidney dialysis, accommodations for people with allergies, and automated external
defibrillators at certain properties. It provides arrangements for home care, medical
equipment, and health checks for those vacationing at a Roompot Park, thereby leveraging its
strengths as a Holiday Park chain, with the wide range of health service partners.
The number of requests to capitalize on these facilities and services is growing, as noted in the
increased bookings from 2007 to 2009, illustrated in Table 2.
Bookings for home care and medical
Bookings from foundations and
Table 2 – Increased RP Care Bookings
2007 2008 2009
3,500 4,800 6,000
279 597 799
833 1,081 1,387
The results showcase a growth in patron response to capitalizing on the opportunities for care
and wellness facilities and services, a trend which is expected to grow as awareness of the
program is extended. The actual number of bookings may appear to be low, but the program
itself is quite unique, given that care, cure and wellness are not automatically associated with
a caravan or holiday park experience. The bookings provide opportunities for increased
business for the parks during the shoulder periods, a time when “holiday” patronage has
As with many innovations, there is a test and measure component to the implementation of
the program. Currently, five resorts within the Roompot Parks ‘chain’ have wellness centres,
two which are directly managed. The other three are parks within the RP Parks vacation
umbrella, i.e. vacation bookings. The overall success of the existing wellness programs will
impact future extension of facilities, services and partnerships. Broadly speaking, however, it
is anticipated that the program will continue to grow, given the needs of an aging population,
the opportunities to provide an enhanced visitor experience, and additional business
opportunities for the parks themselves.
RP Care represents a classic example of radical innovation in the sense that the concepts are
very unique – i.e. spending your vacation at holiday park for various care, cure and wellness
programs. The vast majority of holiday park operations shy away from introducing radical
innovation. They are aware of changes in demographics, economics, and environmental
factors, but remain hesitant to initiate new ideas. The concepts generally require a substantial
cash investment up front which, by itself, is a limiting factor for many. Initial returns are
limited, as illustrated previously with the relatively small, although increasing, number of RP
Care bookings. Radical innovation is a risky undertaking, given the longer term payback, and
non availability of benchmarks to assist with concept development.
To that end, the concepts discussed in this paper must be taken into context. The overall idea
is very novel to the industry, and time is needed for the program to expand to fulfill its
potential. Risk has been mitigated to a degree through limiting the number of parks that offer
the facilities, and through partnering with a variety of wellness associations.
Nonetheless, the concept has attracted academic interest in the areas of innovation and
entrepreneurship (Go and Israels, 2010) and practioners. A group of Australian holiday park
operators are scheduled to tour the wellness facilities in mid-September as part of their study
tour of European parks who offer health and wellness activities. Thus in keeping with Rogers
(1962) model of innovation diffusion, the concepts of RP Care may inspire strategic
innovation to take hold in other geographic regions, where it may become a norm to have
health and wellness facilities and activities in holiday parks in the future.
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UNDERSTANDING THE IMPACT OF LEISURE TRAVEL ON THE QUALITY OF
LIVES OF PEOPLE WITH MOBILITY IMPAIRMENS
To date, most research on understanding travel of people with disabilities has been focused on
accessibility issues. Much of this research was a response to policies and regulations set forth
to protect the rights of people with disabilities, such as ADA in 1990. Recently, there is a call
for research looking beyond accessibility when understanding the consumer market of people
with disabilities (Yau, McKercher, & Packer , 2004; Baker, 2006). One of the reasons for this
call is because 2000 Census data show that there are approximately 50 million people with
disabilities in the U.S. Of these, about 36 million people are mobility-challenged (Ray, &
Ryder, 2003). Limited literature on travel for people with disabilities demonstrates that they
have the same desires for travel (Baker, 2005). In addition, some suggest that travel has
special meanings to travelers with disabilities. For example, Yau et al. (2004) concluded that
“being able to travel is a meaningful task through which a person with a disability can
demonstrate to others that they have recovered or started to regain their control over destiny
and to assert their future quality of life” (p.958). Findings from their study imply the potential
impact of being able to travel on the quality of lives of people with disabilities. However, the
impact of travel on the lives of people with disabilities has not been further examined and
determined in the literature. The purpose of this study was to explore the role of travel in the
quality of lives of people with mobility impairments.
Two focus group discussions were held among avid travelers with mobility impairments at the
13 th Congress of Society for Accessible Travel and Hospitality (SATH) in 2009. A total of 12
people participated in the focus groups. Two questions were asked: 1) What was the role of
travel in your life before you became mobility impaired (or “What is the role of travel in your
life?”, if the impairment is a congenital condition)? and 2)Based on your past travel
experience, has travel in general impacted your quality of life? How?
Results & Implications
Focus group discussions revealed the essential role of travel in the lives of people with
mobility impairments. Many considered travel as a basic need in life, such as food and air.
Participants confirmed the positive impact of leisure travel on their quality of lives. They
believed that leisure travel had helped them to 1) regain control of life; 2) overcome the fear
of leaving their mundane environment; 3) complete the rehabilitation successfully; 4) enhance
their relationship with family members; 5) continue learning and exploring of different
culture; and 6) keep the adventurous spirit in their lives. Findings of this study suggested the
psychological, mental, and health benefits for people with mobility impairments. Policy
makers should protect the rights of this population to travel, and business owners/managers
should make sure their facilities and services are accessible.
The Impact of Tourism on Community Wellbeing and Quality of Life: A
Centre for Tourism and Services Research Faculty of Business and Law, Victoria University
and PO Box 14428, Melbourne City, Victoria, Australia 8001
Tel: (613) 9919 4626
Centre for Tourism and Services Research, Victoria University, Faculty of Business and Law
PO Box 14428, Melbourne City, Victoria, Australia 8001
Tel: (613) 9919 1541
The Impact of Tourism on Community Wellbeing and Quality of Life: A Longitudinal
Over the last few decades, substantial research has been undertaken examining the social
impacts of tourism on communities (see for example Sharma, Dyer, Carter and Gursoy, 2008;
Easterling, 2004) with the focus, often, on the level of support residents have for tourism
development. While these studies are extremely useful for tourism planners and policy
makers, they provide less information for those concerned about the wellbeing of the
community and the individuals that comprise communities. Some studies have, in fact,
examined the impact of tourism on the community and residents’ quality of life (QOL),
beginning with the early work by Milman and Pizam (1988) and Perdue, Long and Allen
(1990). More recent work by Tovar and Lockwood (2008), Andereck, Valentine, Knopf and
Vogt (2005) and Jago, Fredline and Deery (2006) have focussed on the specific tourism
impacts that either enhance or detract from the quality of residents’ lives. Much of this
research, however, is a ‘point in time’ examination of the social impacts with little or no
understanding of how perceptions of these impacts change over time. Although studies such
as that by Huh and Vogt (2007) and Getz’s (1994) study of residents’ perceptions in the Spey
Valley of Scotland have provided some insights into the changes that may occur over time,
few other studies have added to this area. This current study aims to address the paucity of
studies on the impacts of tourism on residents’ quality of life over time.
This paper examines the impact of tourism on the QOL of residents and the community as a
whole and it does so at two points in time, 2005 and 2008, using the same 3 questionnaire and
in the same location. Data were collected from host residents using a survey method based on
the instrument developed by Fredline (2002) and Fredline, Deery and Jago (2005). The
sample sizes were 420 in 2005 and 317 in 2008.
The findings show that, at the personal level, perceptions of the impacts of the benefits of
tourism had deteriorated over time and it is through the examination of the specific impacts
that a partial answer as to why this would occur can be found. Between 2005 and 2008,
respondents were statistically less positive about having more interesting things to do, that
tourism provided economic benefits and that tourism enhances pride in the town and an
opportunity to showcase the region. When examining the comments from respondents, there
were comments in 2008, not elicited in 2005, that tourism was spoiling the area and that it
was bringing unwanted activities to the region. In 2005, the comments focused on rampant
development but, three years later, there were substantial comments regarding the need for
sustainable tourism, that ‘Tourism growth should stop’. The study examines the ramifications
of these findings on the community’s QoL and provides recommendations for enhancing and
managing the wellbeing of the community.
Andereck, K.L., Valentine, K.M., Knopf, R.C. & Vogt, C.A. (2005). Residents’ perceptions
of community tourism impacts. Annals of Tourism Research, 32(4), 1056–1076.
Easterling, D. (2004). The Residents’ Perspective in Tourism Research: A Review and
Synthesis. Journal of Travel & Tourism Marketing, 17(4), 45-62.
Fredline L. (2002). Host Community Perceptions of the Impacts of Tourism on the Gold
Coast. CRC for Sustainable Tourism: Gold Coast. 4
Fredline, L. Deery, M. & Jago, L. (2005). Social Impacts of Tourism on Communities. CRC
for Sustainable Tourism: Gold Coast
Getz, D. (1994). “Residents’ Attitudes towards Tourism: A Longitudinal Study in Spey
Valley, Scotland.” Tourism Management, 15 (4): 247–58
Huh, C. & Vogt, C.A. (2008). Changes in Residents' Attitudes toward Tourism over Time: A
Cohort Analytical Approach. Journal of Travel Research, 46 (4), 446-455.
Jago, L., Fredline, L. & Deery, M. (2006). Tourism in small communities: Risk and benefits.
Tourism Review International, 10(1-2), 91-101.
Milman, A. & Pizam, A. (1988). Social impacts of tourism on Central Florida. Annals of
Tourism Research, 15, 191-204.
Perdue, R.R., Long, P.T., & Allen, L. (1990). Resident Support for Tourism Development,
Annals of Tourism Research, 17(4), 586-599.
Sharma, B., Dyer, P., Carter , J. & Gursoy, D. (2008). Exploring residents' perceptions of the
social impacts of tourism on the Sunshine Coast, Australia. International Journal of
Hospitality and Tourism Administration, 9(3), 288-311
Tovar, C. & Lockwood, M. (2008). Social Impacts of Tourism: An Australian Regional Case
Study. International Journal of Tourism Research, 10, 365-378.
Air travel and your health: Is it safe up there?
Frederic Dimanche and Christine Dimanche
Center for Tourism Management at SKEMA Business School
Frederic.DIMANCHE@cote-azur.cci.fr ; email@example.com
When considering the literature about tourists’ health, one finds three main threads: First, the
tourism literature has been mostly concerned with the benefits of travel and tourism on
visitors’ health and wellness. Discussions of medical tourism, spa tourism, wellness tourism
have particularly focused on health tourism as a market and product (e.g., García-Altés, 2005;
Henderson, 2003; Heung, Kucukusta, & Song, 2010). Second, there has been a line of
publications dedicated to managing tourist health and safety (e.g., Keystone et al., 2008;
Wilks & Page, 2003). Finally, a comparatively larger body of the literature considers
perceptions and management of risks, but not necessarily as they relate exclusively to health
(e.g., Lepp & Gibson, 2003, Sonmez & Graefe, 1998). To find specific research about the
effects of travel on travelers’ health, one has to search the medical literature. Among favorite
topics are the effects of traveling to tropical destinations, the risk of infectious diseases,
travelers and sexually transmitted diseases, and digestive disorders. The medical literature
also examines the effects of air travel on the human body.
Of particular interest to us is the impact of travel on tourists’ health and well-being. Traveling
and flying both lead to increased stress and increased risks for the traveler’s health. The
medical literature documents, for example, that business travelers experience significant stress
and file more health insurance claims than their non-traveling colleagues (DeFrank,
Konopaske, & Ivancevich, 2000; Liese, Mundt, Dell, Nagy, & Demure, 1997). It has also
been reported that there was a two- to three-fold increase in psychological claims for travelers
over non-travelers. More specifically, this paper will focus on an aspect of traveling that is
rarely considered in the literature: the impact of air travel and health and well being. Indeed,
in their edited book on managing tourist health in the new millenium (Wilks & Page, 2003),
no author examines the particular case of air travel and health, except to discuss the risk of
transportation accidents. The purpose of this paper is (1) to document through a literature
review the major risk factors and health issues, both psychological and physical, that travelers
face when flying and traveling, and (2) to suggest recommendations to help manage risk and
reduce traveler stress. Indeed, previous research has shown that travel counselors, travel
agents, or human resource departments in business firms do not properly inform and educate
travelers about the risks of flying and traveling (e.g., Lawlor et al., 2000; Lawton & Page,
1997; Welch, Welch, & Worm, 2007) and that experienced travelers had low knowledge of
travel health-related issues (Hamer & Connor, 2004). Those recommendations should be
taken into consideration by individual travelers, human resource management departments in
firms with a traveling workforce, and by travel companies, travel agents, or tour operators.
DeFrank, R. S., Konopaske, R., & Ivancevich, J. M. (2000). Executive travel stress: Perils of
the road warrior. The Academy of Management Executive, 14(2), 58-71.
García-Altés, A. (2005). The development of health tourism services. Annals of Tourism
Research, 32(1), 262-266.
Hamer, D., & Connor, B. (2004).Travel health knowledge, attitudes and practices among
United States travelers. Journal of Travel Medicine, 11, 23-26.
Henderson, J. (2003). Health care tourism in Southeast Asia, Tourism Review International,
Heung, V., Kucukusta, D., & Song, H. (2010). A conceptual model of medical tourism:
Implications for future research. Journal of Travel & Tourism Marketing, 27(3), 236-
Keystone, J., Kozarsky, P., Freedman, D., Nothdurft, H., & Connor, B. (Eds.). (2008). Travel
Medicine (2 nd ed.). New York: Mosby Elsevier.
Lawlor, D., Burke, J., Bouskill, E., Conn, G., Edwards, P., & Gillespie, D. (2000). Do British
travel agents provide adequate health advice for travellers? British Journal of General
Practice, 50(456), 567-568
Lawton, G., & Page, S. (1997). Evaluating travel agents' provision of health advice to
travelers. Tourism Management, 18(2), 89-104.
Lepp, A, & Gibson, H. (2003). Tourist roles, perceived risk and international tourism. Annals
of Tourism Research, 30(3), 606-624.
Liese, B., Mundt, K. A., Dell, L. D., Nagy, L. & Demure, B. (1997). Medical claims
associated with international business travel. Occupational and Environmental
Medicine, 54, 499-503.
Sonmez, S. & Graefe, A. (1998). Influence of terrorism risk on foreign tourism decisions.
Annals of Tourism Research, 25(1), 112-144.
Striker, J., Luippold, R., Nagy, L., Liese, B., Bigelow, C., & Mundt, K. (1999). Risk factors
for psychological stress among international business travelers. Occupational
Environmental Medicine, 56, 245-252.
Welch, D., Welch, L., & Worm, V. (2007).The international business traveller: A neglected
but strategic human resource. The International Journal of Human Resource
Management, 18(2), 173-183.
Wilks, J., & Page, S. (2003). Managing tourist health and safety in the new millennium.
“A Happy Tourist Experience”
Happiness is a concept that has fascinated thinkers for centuries because it is central to
understanding the meaning of human life. Research on happiness has flourished in recent
years in many social sciences. The concept can be defined from multiple perspectives. In
positive psychology (a research field that studies wellbeing in psychology), happiness is
typically defined in terms of three main dimensions: engagement, meaning and positive
emotions. A happy person would therefore be actively involved (engaged) in his or her daily
activities, would lead a personally meaningful life (eg believe in God or contribute to a cause
that he or she believes in) and would regularly experience positive emotions of interest, joy,
contentment and love. Each of the three dimensions of happiness is measurable. Happiness is
therefore a concept that is worthy of scientific research - it can be defined and scientifically
assessed and it is a conscious state of mind.
A qualitative doctoral thesis on tourist experience and happiness was recently finalised and
awarded. In this PhD project, a study of a tourist experience of a group of study abroad
university students was conducted. The study assessed travel motivation and travel
satisfaction of the group in three phases of the students’ travel experience (anticipatory, on
site and reflective phases). Travel motivation themes were identified in the anticipatory phase;
immediate and post hoc satisfaction themes were identified in the on site and reflective phases
of the tourist experience. The students’ motivation and satisfaction themes were identified
through qualitative positive psychology approaches. An exploratory picture of a happy tourist
experience has emerged from this psychological investigation. In this picture, the three
dimensions of happiness from positive psychology – meaning, engagement and positive
emotions – are linked to the students’ travel motivation and satisfaction themes in their three
A series of future quantitative and qualitative studies of tourists’ positive emotions, meaning
and engagement has emerged from this micro analysis of the students’ tourist experience. The
suggested studies are important agendas for future research as the three happiness dimensions
have been linked to a range of health benefits by other happiness researchers. An example of
these health benefits is the improvement in cardiovascular health as a result of experiencing
positive emotions. Investigations of happy tourist experiences from positive psychology and
other social science perspectives therefore need to continue in tourism studies.
URBAN ZEN – AND HOW TO EXPLORE THIS PHENOMENON?
University of InHolland, Amsterdam/Diemen
The presentation will mainly focus on describing the concept of urban zen and what
theoretical framework and methods of research will be applied during this PhD research.
Urban Zen – the appearance of a new cultural landscape
“The complexity and speed of modern life urgently requires counterbalancing experiences for
human beings to feel well. A health and wellness revolution is under way as individuals
attempt to redesign their lives – sometimes in superficial and sometimes in profound ways –
to achieve higher levels of physical, emotional, mental and spiritual wellness”, (Bushell and
Sheldon 2009) i .
In some western cities we can see a reflection of this revolution when we look at the increase
of a holistic ii and healthy offer, such as yoga/meditation centers, health food shops or vegan
restaurants, urban spas or hammans. We can perceive a new urban cultural landscape in which
holistic leisure activities give an extra quality or dimension to public and semi-public space.
In this research this phenomenon has been named: urban zen.
The wellness industry is rapidly growing worldwide. The first results of research amongst
wellness tourists have been documented, but not much, or hardly anything, is known about the
wellness needs and expectations of city dwellers who would like to fulfill their aim of striving
for a holistic lifestyle in their own urban environment. The following three questions are
leading during this research: What lifestyle characteristics do these citizens share and what
does this lifestyle contribute to the quality of their lives? What Western cities iii and specific
areas within these cities are playing a key role in urban zen, both economically and
symbolically? And finally, to what extent are cities marketed as places where you can find
such an cultural landscape?
Theories and methods
Several theories and methods will be applied in order to gain a clearer picture of urban zen
adepts and places. Next to structuring lifestyles characteristics, the results will be connected
with the ideas Pine and Gilmore (1999) on the transformation economy. In their study on the
experience economy, the next step after experiences is said to be the economy of
transformations. Based upon earlier research and own observations, the idea of “selling”
transformations to consumers seems to be an essential part in starting and maintaining an
urban zen lifestyle. Practicing Yoga for example, does not stop after having experienced the
weekly Wednesday evening class; it generally is just a minor marker of a long internal
process of transforming one’s attitude in life and lifestyle manifestations. The choice of
Western cities will be based upon making an inventory and a comparison of the extent of the
urban zen offer. Apart from desk research and participatory observations, in-depth interviews
with participants, practitioners, entrepreneurs and city marketeers will also be carried out.
Key words: holistic and healthy lifestyle, city dwellers/cities, methods of research, leisure
“I expect that in our hasty society there will be a rise of city spas. A place in a metropolis
where people can enjoy a moment of rest”.
(Floris Wyers, owner of Wellness.nl)
i Bushell and Sheldon, (2009). Wellness and Tourism - Body, Mind, Spirit and Place, New
York, Cognizant. Communication Books
ii There are many definitions about the term holistic. The following description seems to be the
most appropriate for this research: “According to AHHA (2007) holistic health as an
approach to creating wellness encourages you to: 1) Balance and integrate your physical,
mental, emotional, and spiritual aspects. 2)Establish respectful, cooperative relationshops
with others and the environment.3)Make wellness-oriented lifestyle choices. 4)Actively
participate in your health decisions and healing process.” – Smith and Puczko (2009).
Health and Wellness Tourism, Butterworth-Heinemann
iii Focus lies on cities in: Europe, the USA, Canada, Australia and New Zealand.
Health Tourism – The SPA Goers in Portugal
Nuno Silva Gustavo
Rua do Campo da Bola, Quinta da Raposeira, Mosqueiros
2460-203 Alfeizerão, Portugal
This paper is part of a work-in-progress PhD dissertation entitled “Tourism, Leisure and
Health – discovering the new SPAs”, the first national study in this particular field.
Having Portugal as a case study, a country in which Health Tourism was recently pointed out
as one of the ten strategic segments for tourism development, this paper aims at presenting
and discussing the new SPAs customers' profiles, as well as helping to understand how
relevant leisure and tourism moments are and how they are used in health management. The
motivations of these new SPA customers, their concerns with spa consumption and health
management in general, and the meanings of SPA consumption in global health management
are other issues focused on in this paper.
This investigation has a national spectrum and it includes about twenty-one cases studies,
including SPAs in different locations (in metropolises, cities, countryside, in and out of the
Portuguese tourism regions, day SPAs, thermal SPAs, and marine SPAs), different concepts
(e.g.: holistic), services (hydrotherapies, balneoteraphies, massages, aesthetics and natural
treatments) infrastructures, and main natural resources (tap water, sea water, spring hot water,
In the twenty-one case studies mentioned, and as the main investigation resource, a survey
was developed. This survey focused on SPA customers' consumption and on their health
management practices (the data was collected during three months with support from the SPA
Staffs). The data collected (824 surveys) was analyzed with SPSS (Statistical Package for
Social Sciences). It was map out the average profile of SPA Goers in Portugal. Different
consumer clusters were outlined with a scalable cluster analysis algorithm - The SPSS Twostep
Keywords: Health and Body management, Leisure, Health Tourism, SPAs
With the pace of globalisation, urbanisation, state-of-the-art technologies and on-line
consumerism in 21 st century western societies, people now live out the illusion of a new
paradigm – the myth of eternal life. In the euphoria of longevity, the adoption of healthy life
styles takes on a singular importance to postmodern daily life. Founded on biomedicalisation
and promoted by neoliberal philosophies of government, health has been reinvented as a
capital to be valued and optimized, taking on a unique centrality within the lifestyle concept
In the light of a new social centrality of health, that is, the growing medicalisation of western
habits, the universe of health services proliferates, a reality which manifests itself in a
growing allocation of leisure and tourism time to body care. This reality is particularly
reflected in the discovery of leisure and tourism periods as privileged opportunities for body
care and management. In accordance with the new concepts and dimensions which
circumscribe the scope of health at the outset of the 21 st century, this niche market has
witnessed a significant diversification in supply. Alongside the pathogenic view of health and
associated services, this market also currently incorporates a new range of services, now
focused on a holistic approach to the body, congregating highly disparate and different
motivations and services within the same market niches thereby expressing this new vision of
the health concept (Yeoman, 2008).
Founded on the wellness ideal (an integrated and holistic view of health), SPAs have imposed
themselves as a leading players in this new health universe as a result of the appropriateness
of their concepts and services to meeting the new challenges emerging from the globalised,
agitated and eminently urban consumer of the 21 st century. “SPAs and wellness resorts may
therefore be conceptualised in cultural/sociological terms as modern day temples where
people can experience rituals, learn to deepen their personal wellness practices, raise their
consciousness, become open to enhanced ways of being and deepen their experience of being
alive” (Cohen, 2008: 8).
The growing centrality of these spaces, expressed through the growth in supply and demand
in postmodern western societies, is the departure point for this article in which we aim to
contribute towards a greater understanding of the demand profile using Portuguese SPAs as
the case study following a nationwide data collection survey.
The significance and meanderings of health in the 21 st century
Today, the meaning and the universe of health find expression in a private, lucrative and wide
ranging market of products and services where slogans and sound bites abound, such as
eternal youth, the most beautiful, the strongest or the healthiest. This is a new notion of public
health which goes beyond the paradigm of disease-free and establishes a holistic and positive
vision of health supported by a specific, socio-political environment which permeates
postmodern 21 st century societies (Minkler, 1989). In the face of growing levels of economic
prosperity, in no way comparable to those prevailing in the post World War Two boom ("The
Glorious Thirty Years”) inaugurating the model of Welfare States when the nationalisation of
the services and the social responsibility of health was taken on by national health services.
Subsequently, the development of new and contemporary, neoliberal governing principles and
policies, were complemented and articulated with the fostering of a vast private market of
health services leading to a new alternative health management model in which the individual
now plays an active and self-responsible role (Rose, 2001). In a society which is profoundly
marked by globalisation, by information technology and communication as well as by the
liberalization of markets, new “health brokers” are affirming themselves in health
management in competition with the traditional “experts”. These offer new, more
“autonomous” and more “accessible” health management products and solutions, which
circulate freely in a new and vast private health market where the laws of marketing rule.
This transfer of responsibility in the health care field, as presented in the new model, is from
the outset a reflection of a scenario marked by the growing disappointment as to the limits of
medicine and its capacity to overcome the new challenges, such as chronic illness or the
unrelenting quest (the myth) for eternal life. “A 2005 report by the WHO (…) estimates that of
all the 58 million deaths in the world in 2005, 35 million (60%) will be caused by chronic
diseases such as heart disease, stroke, cancer, chronic respiratory disease and diabetes”
Whether we opt for more realistic scenarios, or those more visionary as regards the current
issues (EFILWC, 2004), it is clear that health faces a set of new paradigms at the outset of the
21 st century. These require ongoing analysis and reflection, conditioned by a unique scenario
of uncertainty expressed in the paradoxical perception of loss of “power” over the body in no
way consensual with human ambitions and within the scope of new self-management
practices, a hybrid and universal approach to the body and its control have been presented as
Simultaneously and in response, a new private health market has emerged rendering new
services, many of which represent genuine technological revivalisms of health practices from
a ‘golden’ pre-scientific era, expressing a new ideological promotion of health, sold under the
holistic sign of wellness, in which the individual is morally responsible for demanding the
best physical and psychological setup able to play a determinant role in day-to-day
From Natural Hot Spring Treatments to Health Tourism
In a postmodern society, increasingly organised around globalisation vectors, as shown by the
profound political, economic and social changes which mark the beginning of this 21 st
century, “Health Tourism” and the associated practices of health, leisure and tourism have
reinvented themselves and are gaining ever greater popularity as a result of new imperatives
and the greater significance attached to them. This reality is manifested in the reaffirmation of
a new leisure and tourism market, which now emerges dominated by new dimensions,
concepts, spaces and services. “In the 21 st century, wellness travel has become a global
phenomenon. (...) In response to increasing demand, traditional SPA towns around the world
are upgrading or constructing modern SPA facilities. The growth in supply is expected to
foster continuing market expansion, attract new types of customers and diversify product
offerings.” (Messerli, H. and Oyama, Y, 2004: 6)
Sustained by new holistic and wholesome offerings, the new leisure and tourism facilities and
products are today different from those of post-war Europe, then confined to the dominating
logic of classical thermal hot springs, dependent on the existence of medicinal mineral water
(a natural resource) and limited to an eminently hospitalcentric philosophy of service. Today,
supply within the scope of Health Tourism has tended to define itself as wide-ranging and
heterogenic, structuring itself according to global, holistic and health promoting parameters,
resorting to a panoply of knowledge, resources and techniques and not confining itself to mere
usage of hot spring thermal water in evasive leisure facilities (Tabbachi, 2008).
This is a distinct market, of facilities and products of a hybrid nature, where appeals are made
to unique and sometimes paradoxical fusions and interchanges such as those of the natural
and the technological, the scientific and the profane, the western and the eastern, the rural and
the urban. Despite leisure and water continuing to occupy a place of excellence in the
imaginaries of health and leisure, today this is materialised in a variety of services which
range from medical surgery in India (Medicinal Tourism) to recourse to therapeutic
techniques in a thermal facility in Europe (Therapeutic Tourism) to the simple search for
wellness by means of relaxation techniques (Wellness Tourism), thus concentrating such
distinct motivations under the umbrella of the same aims.
By associating these hydrotherapeutic techniques, irrespective of their properties or the nature
of the water used – medicinal mineral, tap or sea water, the new technologies and a service
guided by nature, the natural and ancestral (where technique, decoration and the surrounding
soundscape are examples of the essential variables of service and inherently meticulously
controlled), the rejuvenated SPA label adapts and expresses itself through this new vision of
health which is increasingly defined as healthy, vitalising, positivist, global, holistic and
symbolic. These are new ideals and imaginaries which have in the thermal facilities both their
origin and their antithesis in that, with due exceptions, a new concept of pathogenic and
functional health prevails within them. “The modern SPA is a unique combination of both
ancient traditions and up-to-date technology. The modern-day SPA is centred on holistic
healing as well as wellness philosophies, just as in ancient times. SPAs now offer a myriad of
techniques and services inspired by both Eastern and Western traditions, catering to a broad
array of individuals, each possessing different expectations and needs” (Haden, L. 2007: 9).
Faced with the expansion and privatisation of the healthcare scope, we witness the
proliferation and diversification of services and facilities where leisure and health cross paths
and which, in view of their growing relevance, have been entitled “Health Tourism” or
“Health and Wellness Tourism”. This new conceptual designation not only reflects the
growing emphasis on the wellness perspective of health but also significant growth in this
niche market and its consequent specialisation. “In fact, health tourism and wellness tourism
are frequently used interchangeably. However, as this industry and its consumers become
increasingly sophisticated, discriminate use of these terms is expected” (Messerli, H. and
Oyama, Y, 2004: 10).
Today, “Health Tourism” has assumed the brand image of the original and classic
“Thermalism”, englobing an endless variety of services, which have health and leisure in
common, and where water, due to its natural relationship with the essence of the human
being, remains one of the main elements, albeit used in different ways, with different
objectives and alongside new techniques.
The SPA service supply
The new health concepts, increasingly wider in scope and resulting from the
biomedicalization trends of modern western societies, have, among other aspects, definitively
contributed to the growth of this market, as well as to its specialisation and resulting
segmentation. According to the International SPA Association (ISPA) we can currently
systematise the SPA offer into seven different types: Club SPA, Cruise Ship SPA, Day SPA,
Destination SPA, Medical SPA, Mineral Springs SPA and Resort/Hotel SPA. Nevertheless the
diversity of services in this area allows us to identify other essential variables in the
conceptualisation of this service: the philosophy of service (Holistic SPAs, Zen SPAs,
Spirituality SPAs, Romantic/Honeymoon SPAs, Luxury SPAs), or the type of therapy where in
addition to hydrotherapies (medicinal mineral water for human consumption, sea water)
therapies based on balneotherapy, vinotherapy, chocolate therapy, algotherapy, cromotherapy,
aromatherapy, to name just a few, remain common, as well as the universe of associated
services, (Mountain SPAs, Ski SPAs, Golf SPAs).
From the outset, this service range has grown both qualitatively and quantitatively. Today, the
sector tends to be dispersed worldwide, even though it continues to be closely associated with
the US health market where it developed and consolidated its current conceptual state. On the
international level, Europe also currently ranks as a preferred and growing destination for
When combining the underlying physical dimension with an integrated and holistic view,
these facilities transform themselves into veritable temples for the worship of the body
focused on the paradigm of wellness, SPAs are today a meeting point between western and
eastern views of health “The initial pioneers of the modern-day SPA concept concentrated
upon the physical aspects of wellness by providing their guest with visible results to nagging
physiological problems. (…) Over the years more and more players in the industry have
adopted holistic philosophies, and integrated Eastern and Western wellness systems into their
menus” (Haden, 2007: 1).
In the image of 21 st consumer societies, these spaces have today adopted an eminently
commercial philosophy dedicated to a clientele valuing health, the body, the environment,
social justice, personal development and sustainability. In these facilities, health continues to
be a business of an essentially liberal nature, predominantly out of medical reach and where
branding laws are sovereign. In our days, SPAs emerge as places of greater affirmation of the
ideals of self-health and of self-responsibility where individuals learn to control and monitor
their bodies by resorting to a set of specified techniques which lead precisely into a dialogue
and rediscovery of their own bodies.
It is currently impossible to quantify the universe of the SPA sector in Portugal given the
absence of a legal framework regulating SPA activities: there is only a legal framework for
hot spring thermalism, and within that, for Thermal SPAs. Thus, we must begin by
establishing minimum selection criteria. Only those SPA infrastructures which significantly
render the following services were selected: health care involving recourse to water,
specifically as regards thermal bath treatments and hydrotherapy techniques and the provision
of alternative therapies. Most of the aforementioned infrastructures are integrated into hotels.
In partnership with an expert (invited) from the National Tourism Authority (Turismo de
Portugal) so as to identify the establishments which could be classified as SPAs,
approximately 60 infrastructures were identified. In addition to the aforementioned criteria,
this selection additionally considered geographical location so as to guarantee full coverage
both geographically and the actual SPA concept thus safeguarding the representation of as
many different SPA types as possible.
29 SPAs from the resulting universe agreed to participate in this study with 20 later being
validated. Taking into consideration that a significant part of the questionnaire contemplated
variables of a clinical nature, a minimum of 30 questionnaires was established as the base
requirement for the autonomous validation of an entity. The participant Day Spas, Resort
Hotel SPAs, Destinations SPAs, Medical SPAs ensured the completion of a total of 824
questionnaires by their SPA Goers between May and August of 2009.
Procedure and questionnaire design
The questionnaire was produced within the scope of a PhD project which in its first phase
carried out a review of the available literature on themes such as health, body, leisure and
tourism. The second part of this research, of an empirical nature, first contemplated analysis
of articles and messages conveyed by the major woman’s and men’s magazines in circulation
in Portugal and later, the application of the aforementioned questionnaire. The questionnaire
was produced after analysis by experts in SPA management and involved a pre-test period of
one month. The final version of the questionnaires consisted of four parts: a first section on
SPA consumption (regularity, services used, motivations, satisfaction level and factors of
choice), a second part focused on the representation and meaning of wellness and health, and
a third on health care (practices and routines) and finally a fourth aiming to define the social
and cultural and socio-economic profile of the respondent. The questionnaire was essentially
composed of closed questions, except in the second part where open questions were preferred.
The validation of the applied questionnaire was based on a panel of experts (SPA Managers)
and on a pre-test carried out over one month in March 2009. The final version of the
questionnaire was produced in five languages (Portuguese, English, Castilian Spanish, Italian
and French). The questionnaires were applied in the form of a survey with the cooperation of
the managers and receptionists of the SPAs. Clients would be invited to participate in the
survey after their SPA session.
The statistical processing of the information was carried out using the SPSS -Statistical
Package for Social Sciences- software version 1.7. Based on a descriptive statistical analysis,
the typical profile of the SPA consumer was obtained. So as to identify possible segments in
this demand universe, grouping analysis was later applied with recourse to a TwoStep
algorithm – log-likelihood (considering the nature of the variables in question and the
Based on the sample gathered through the aforementioned questionnaire, one can immediately
present a social and cultural profile of the client who currently frequents Portuguese SPAs. As
regards age, the average SPA client is 38.5, with individuals aged between 30 and 39
representing the client age range with greatest weighting (38.7%). As for gender, women
dominate, accounting for approximately 69.8%. In the case of family structures, those without
dependents (49.5%) emerge as the main users, that is, couples (married or in common law
relationships) (24.4%) and single people without dependents (25.1%). However, the
married/common law relationship with children prevails as the single most important family
structure category with 34.6%.
The Portuguese SPA client is mostly permanently resident in Portugal (73%), despite some
being of other nationalities. Clients permanently residing in other countries represent 27% of
demand with United Kingdom residents (30%) significant in this sample. The typical area of
residence of the SPA client is also classified as being eminently urban (71.7%), be it in a city
(49.5%) or in a metropolis (22.2%).
In terms of educational levels, there is a clear domination of individuals with higher education
(73.9%), particularly honours degrees (56.1%). In line with the social and cultural profile is
also the socio-economic profile with particular emphasis on individuals engaged in
employment (91.7%) and mainly of employee status (73.2%). These individuals mostly work
in the tertiary sector (89.1%), essentially holding executive responsibilities, at corporate
management level (28.0%) or in specialised intellectual and scientific professions (37.0%).
The average monthly net salary of the family aggregate immediately reflects the sociocultural
and socio-economic level of the current population, with the vast majority earning
more than €2,000 monthly. It must also be mentioned that 48.9% of the households of
individuals attending SPAs report average monthly earnings in excess of €3,000.
The study shows that the range and frequency of SPA use is an emerging practice, despite
already being an integral part of the monthly routines of 31.2% respondents. Despite it not
being a regular practice for 40.7% of SPA service clients, it is nevertheless engaged in with a
certain regularity. This scenario is reinforced by the fact that SPA service consumers apply
their daily leisure time as preferential moments for use of these facilities (44.4%),
immediately followed by specific holiday periods (41.3%). The choice of SPAs located in
their own residential areas (28%) or an intentional journey to outside the regular area of
residence to frequent a SPA (36.5%) reinforces the routine and preferential consumption of
these types of services/facilities. In fact, 75% of the clients from our sample mentioned that
when selecting their holiday accommodation they took into consideration whether or not there
was a SPA, with 25% of clients declaring that this is a determinant factor in their final choice.
The main motive of these individuals in visiting a SPA is connected to relieving stress and/or
relaxation. Across the 824 questionnaire respondents, 74.3% mentioned this reason as very
important in their visiting a SPA. It must also be noted that improving mental and physical
health was the determinant reason given for visiting a SPA by over 50%.
From the universe of the most relevant services available at SPAs, clients clearly mention
massages (90.9%) and body treatments (including thermal water therapy – 70%) as the most
sought after. As regards the most relevant services used at SPAs, it must also be noted that
50% of the clients, did not use hydrotherapy services (vichy shower, simple immersion bath,
hydro massage, etc.) during their last visit to a SPA.
Overall and still in terms of services consumed, SPA clients classified their experiences as
positive with 64.7% saying that the services met all their expectations and 31.1% declaring
their expectations were exceeded. Only 4.2% of clients declare that their SPA experiences
globally fell short of their expectations. When deciding which SPA to visit, clients from our
sample identified the quality of treatment, service, hygiene and cleanliness, the service cost as
well as the SPA location as the most relevant factors. 78.6% declared they personally paid for
their last visit to a SPA. Worthy of note is the fact that 14.4% of SPA experiences were gifted,
namely in the form of vouchers.
In addition to the variables described thus far, the current questionnaire also focused on a set
of behaviours and health care attitudes which the SPA clients adopt in their daily lives. When
questioned globally on their lifestyles, 87.3% declared that on a merely personal assessment
they had a healthy lifestyle. The majority of SPA clients questioned declared that a healthy
life depends essentially on their personal care (53.5%), while 45.4% declared that in addition
to taking care of their health, there are also external factors which can condition that healthy
life. Only 1.1% of the sample declared that a having a healthy life does not depend on them
but solely on external factors over which they have no control, such as work, stress imposed
by the pace of daily routines, environmental quality, economic conditions or interpersonal
relationships, specifically with family members and close friends.
As for necessary personal care for a healthy life, the clients questioned transversely referred to
“food and diet” (89.4%) and “physical exercise” (82.9%) as fundamental care. “Alternative
medicine and techniques” were also mentioned as an important recourse in the universe of
personal care” (for example: meditation and pilates, tai-chi, yoga, the SPA, etc.). Other
aspects mentioned, while not as unanimous, were “relaxation” (for example: sleeping duration
patterns, searching for calm environments) “deviating behaviours” (alcohol and tobacco
consumption) “hygiene” and “recourse to monitoring by conventional medicine” (visiting the
doctor) and “associated techniques” (regular check-ups). Only in passing was a direct
reference made to (considered in the category of “others”) external factors (beyond the control
of the individual) which have implications for a healthy life. Although not as consensual in
comparison with the main personal health care factors already described, these are related to
“work” (such as the number of working hours, the workplace and conditions, relations with
colleagues, satisfactory payment conditions), with “everyday stress” (resulting from the
various timetables and obligations to comply with, traffic and the urban rhythm of life in
general) – 36.9% of those questioned mentioned they had a very stressful daily life, the
“environment” (pollution, area of residence) “interpersonal and economic constraints” (family
wellness, resources/economic limitations) are major issues. Among the “other” factors
referred, are “genetic/hereditary”, “epidemics” and “frequenting places which are also
frequented by smokers”.
When confronting those questioned with their wellness practices, on the one hand we see the
prevalence of the aforementioned set of personal care initiatives with the objective of
achieving a healthy life, such as “physical activity” (67.1%), “food and diet”, recourse to
alternative medicine and techniques and visits to SPAs – 33.7% – here, this is a systematically
mentioned and autonomous category in contrast with that initially observed, and on the other
hand, a set of practices diverse in nature. This new universe encompasses sociability practices
– 24.6% – (for example: dinner with friends, going on family outings, going out in the
evening with friends) and hobbies – 21.0% – (for example: travelling, going to the cinema or
theatre, listening to music, reading, painting, gardening, etc.). Recognition of the importance
of physical exercise and an appropriate diet for a healthy life is reinforced by the general
incorporation of these practices in lifestyles. Among those questioned 71.2% regularly
exercise or include exercise in their lifestyle, with only 28.7% of individuals never having
practised regular exercise or only now not involved in regular exercise.
As regards, special care with food and diet (for example: purchasing diet or organic products
etc.) and as mentioned, the scenario is very identical in that 70.2% of individuals regularly
watch what they eat and actually consider it an integral part of their lifestyle. Additionally,
70.1% of those questioned take or have taken food supplements, while 34.1% take or have
taken weight control products (natural or synthetic) These two care initiatives are reflected
namely in the body mass index (BMI) of those questioned (23.2 Kg/m 2 ). Overall, the sample
shows that 69.5% of SPA goers present a normal or below average BMI.
There is yet another set of practices and habits complimentary to those mentioned, for
example, the non-consumption of alcoholic drinks and/or no smoking. Among those
questioned, 51.3% do not drink alcoholic beverages outside mealtimes or do so very rarely
while 41.9% of individuals limit consumption to the weekends and special occasions. In this
sample, 69.4% of individuals are non-smokers and only 18.1% smoke. The remainder are
occasional smokers (particularly at parties or commemorative events). This series of care
initiatives is complemented by a set of monitoring practices such as simple weight watching.
This habit is common to 59.5% of those questioned, with the vast majority routinely watching
their weight at home. In addition to weight watching, 80.4% of the SPA goers who make up
our sample regularly have medical check-ups and in this particular universe 56.7% do so on
their own initiative with 43.3% acting based upon medical recommendation. This scenario
inverts only in the case of illness, upon which 66.3% resort primarily to a doctor and 33.7%
initially seek out the chemist (12.2%), self-medicate, (11.9%) or turn to alternative medicine
The use of health management equipment in the home is another common practice. Overall,
52.9% of those questioned have equipment at home, with 28.5% having medical equipment
(such as blood pressure, glycaemia or cholesterol measurement devices etc.) and 38% have
physical fitness equipment (for example: bicycle, exercise machines, etc.). These practices
incorporate yet another formative/informative dimension on health, sustained by women and
men’s magazines, which are assiduously read by 52.6% of SPA goer respondents. Here,
particular reference must be made of the women’s magazine Happy Woman (17.9%) and the
men’s magazine Men’s Health (7.8%). The internet complements this information source,
with the specific objective of obtaining information necessary to health management by
63.5% of questioned SPA goers, as well as regular reading of specialized magazines and
books on health (40.4%). Despite the overwhelming majority of those questioned being
beneficiaries of their respective national health systems (84.2%), 65.7% have also taken out
additional health insurance coverage.
Finally, and as regards specific beauty care, 78.1% of the sample regularly consume typical
beauty products and 21.0% use or have used the latest technologies to carry out plastic
surgery treatments (for example: lifting, liposuction etc.), slimming or cellulite treatments,
laser hair removal or skin rejuvenation.
When applying the TwoStep agglomeration technique, with a view to identifying clusters
within the universe of SPA consumers, we identify three clusters: Fans SPA Goers, First
Experience SPA Goers, Men SPA Goers
Figure 1 – SPA Goers by cluster in relation to the use of SPAs and other health care
- MEN SPA GOERS
The figure presented allows us to verify how the differences between the respective clusters
can be systemized by the regularity in SPA practices and by the responsibility as to health,
expressed in frequency and health practice categories. The Fans SPA Goers (19.8%)
demonstrate a high level of SPA practice and regularity with the frequency of SPA use and
consumption being as significant as other habits and regularities as regards health care. This
cluster has a positioning in terms of body and health management which is singular within
this universe, which is in itself already particular. In the case of the First Experience SPA
Goers (40.6%) and the Men SPA Goers (32.9%) there is a distinct positioning. In this case
health habits and care are also greater than that of the general population, although just as in
frequency of visits, lesser than that of Fans SPA Goers.
The first limitation of this study is the fact that it focuses on the reality of one single country
in matters which tend to be global in nature. It is important to stress that Portugal is integrated
in Europe, a region where the SPA sector and social significance are not as expressive as in
other parts of the world and so the phase of development of this market cannot be
underestimated. The second limitation of this study pertains to its period of application, which
for technical and financial reasons was limited to a few months when a full year of application
would have been preferable.
The development of the SPA market and the consumers associated seem to a great extent to
reflect a set of new ideals and a new vision associated to health and its management. Centred
on a positivist acceptation of health, where well-being is the dominating theme, SPAs have
reinvented themselves and have reinvented the whole ideal of health. In the SPA image,
health has also tended to diversify and conquer new domains thus transforming the universe
and the imaginary of health tourism, now sustained by a vaster range of services. This is an
evident reality in the consumer universe of -Salut per Aqua-, which goes much further than
the traditional concept associated to water in favour of new holistic techniques and services
founded on principals of relaxation and massage. This is the affirmation of a new, responsible
and proactive philosophy which is the antithesis of that which had previously prevailed.
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Customer perceived value of medical tourism: an exploratory study
The case of cosmetic surgery in Tunisia
Ecole de Management de Strasbourg/Institut Supérieur de Gestion de Tunis
Ecole de Management de Strasbourg
Institut Supérieur de Gestion de Tunis
The present study is an attempt to investigate the dimensions of customer-perceived value in
the context of a medical tourism experience. The value dimensions of the use of the Internet
will also be explored owing to the role of the Internet in the worldwide growth of medical
tourism. On the basis of the theory of consumption value developed by Sheth, Newman and
Gross (1991), the netnographic study shows that the functional dimension has a great
influence on the value perception of the medical tourism experience. The use of the Internet
essentially has functional, social and epistemic values.
Keywords: medical tourism, perceived value, netnography, Internet
Customer perceived value of medical tourism: an exploratory study
The case of cosmetic surgery in Tunisia
Medical tourism is not a modern trend. “Health tourism is a concept as ancient as prehistory
and as up-to-date as tomorrow” (Ross, 2005). What is different in the 21 st century is that
tourists are travelling farther away, to poorer countries, and for medical care that is invasive
and high-tech. (Bookman and Bookman, 2007). In recent years, medical tourism has
experienced an explosive growth; it thus seems obvious that patients moving from developed
to developing countries for care perceive value.
Researchers believe that the growth of medical tourism has been facilitated by the rise of the
Internet (Connell, 2006). Bookman and Bookman (2007) think that the Internet has opened
the doors to medical tourism in developing countries. The Internet is a huge source of
information for medical tourists, enabling them to know more about destinations, facilities,
service suppliers and procedures. It is also a primary medium for suppliers to promote their
service offers and an increasing number of informative medical tourism websites can be
We can then suppose that medical tourism is a profitable activity for developing and
developed countries. On one hand, developed countries can resolve the problem of long
waiting lists and patients can take advantage of attractive costs. On the other hand, medical
tourism is a lucrative activity for developing countries, and several of them are now tapping
into this niche. Countries are thus searching for new ways to promote their infrastructures and
skills, attract medical tourists, increase their numbers and, most importantly, improve their
satisfaction. Therefore, customer value is now a strategic weapon in attracting and retaining
customers (Woodruff, 1997; Zeithaml, 1988). As perceived value is considered as a key
component of consumers’ decision-making and behaviour (Zeithaml, 1988), countries
receiving medical tourists and practitioners should understand what is the value sought by the
customers and where they should focus their attention to achieve the market positioning
required and to best satisfy the customer. From a marketing perspective, it thus appears
interesting to look at medical tourism experiences through the concept of customer-perceived
Our research deals with medical tourism in Tunisia and more specifically with cosmetic
surgery in Tunisia. Through a qualitative study, we will investigate some research questions:
What are the dimensions of customer-perceived value in the context of medical tourism? Is
customer-perceived value only limited to cost consideration? What are the dimensions of
customer-perceived value related to the use of the Internet in the context of medical tourism?
Medical tourism: a booming business
Medical tourism is a growing market catering to patients who travel to foreign countries to
obtain medical care (Deloitte report, 2008). The Tourism Research and Marketing Report
(2006) indicates that the market included approximately 19 million trips in 2005 with a
business volume of around $ 20 billion. This report estimates that the number of trips will
have reached 40 million by 2010, with a growth of 4% for the overall market volume.
Other statistics report that, in 2005, countries like Singapore (www.udel.edu) and Thailand
respectively received between 250,000 and 1 million foreign patients. Similarly, the number
of foreign patients who took a medical tourism journey in Tunisia has more than doubled
between 2003 and 2007. Their number reached 102,000 (Tourismag, 2008) in 2007, as
opposed to 42,000 in 2003 (Lautier, 2005).
Connel (2006) states that “the biggest hurdle that medical tourism has had to face and
continues to face, is the challenge of convincing distant potential visitors that medical care in
relatively poor countries is comparable to what is available at home in terms of results and
safety”. Despite this, we can observe that a growing number of patients from developed
countries are travelling for medical treatment to regions once characterized as ‘third world’
Therefore, with the increasing number of medical travellers, we can suppose that elements of
value other than financial ones may motivate their decision.
The concept of customer-perceived value
Day (1990) stated that the perceived customer value represents the difference between
“customers’ perceived benefits” and “customers’ perceived costs”. The first
conceptualizations of customer-perceived value begin with the works of Zeithaml (1988),
who defined customer-perceived value as “the consumer’s overall assessment of the utility of
a product based on the perception of what is received and what is given”.
The pioneering ideas about perceived value were based on economic theory and the concept
of utility. Despite the relevance of this one-dimensional conceptualization of customerperceived
value, it remains too simplistic and does not make it possible to grasp all of the
explanatory attributes of a purchase. In a marketing context, it has been acknowledged that
value is not restricted to aspects related to price and quality but that it also combines other
functional, emotional and social aspects (Sweeney and Soutar, 2001). Sheth, Newmann and
Gross (1991) identified five consumption values that influence consumer choices, which are
functional, social, emotional, epistemic and conditional values. Sweeney and Soutar (2001)
developed a multiple-item scale for measuring consumer-perceived value (PERVAL). Four
dimensions of perceived value emerged, which are emotional, social, quality/performance and
price/value for money.
The perceived value of the Internet
The use of IT and especially the Internet in healthcare has the potential to change the
healthcare industry worldwide in terms of infrastructure, costs and quality of services
(Wickramasinghe and Goldberg, 2004; Wickramasinghe and Mirsa, 2004). The Internet has
especially become an important medium for marketers and healthcare providers to provide
information and market a wide variety of health care services and products (Bodkin and
Miaoulis, 2007). It has been confirmed that perceived value has a big impact on the use of the
Internet as a medium for the search and procurement of goods. In general, people seeking
information related to health care may act on several motives (Williams et al. 2003). They
may be searching for information as a health care professional, as a consumer looking for a
self-diagnosis or other diagnosis, as a patient to complement information from a doctor, as a
consumer to exchange information with peers or for general interest browsing. Consumers
access online health information in three primary ways: searching directly for health
information, consulting with health professionals and participating in online support groups
(Clines and Haynes, 2001)
Through a qualitative study, we explore the concept of customer-perceived value in a medical
tourism context. We choose netnography as a research methodology because it has been
acknowledged that consumers making product and brand choices are increasingly turning to
computer-mediated communication for information on which to base their purchasing
decisions (Kozinets, 2002). Medical tourists are using forums, chat rooms and blogs to
exchange large amounts of information, share ideas, look for advice, and make contact with
other patients who have experienced a medical tourism adventure. Netnography is a research
method that taps into this huge amount of information by analyzing the exchanges of
members of online virtual communities. On the basis of the criteria developed by Kozinets
(2002), such as the high traffic of posts and the relevance and richness of the data exchanged
among members, we decided to work on the virtual community of Doctissimo. We used nonparticipant
observation, only reading the posts of members with no intervention, and
participant observation by participating in conversations and inducing new discussions.
A thematic analysis was conducted. The choice of categories to be studied was made
according to the method developed by Miles and Huberman (1991). Based on the
consumption value theory of Sheth, Newman and Gross (1991), a thematic analysis of posts 1
has allowed us to highlight different dimensions of perceived value related, on one hand, to
the medical tourism service and, on the other hand, to the use of the Internet in the same
1 We decided to keep the spelling and grammar mistakes to give more credence to the talk of participants.
Functional value is defined as the perceived utility based on the functional, utilitarian, and
physical performance of a product (Sheth, Newmann and Gross, 1991). A study has shown
that the main functional value attributes, in the context of the purchase of a tourism product,
are the quality of the travel agency’s installations, the staff’s professionalism at the travel
agency, the quality of the tourism package purchased and the price. (Sanchez et al. 2006).
Concerning the medical tourism service, several attributes have emerged, such as the cost
differential, the skills of the surgeon and nursing staff, the quality of the equipment, the
quality of care and the importance of the recovery period.
It may seem obvious that cost is a major incentive in the medical tourism industry. In fact,
some figures show that operations in India cost 80% less than in the United States (Walker,
2006). We can observe the same relation between France and Tunisia. “This difference of
price between Tunisia and France is hallucinating, until now I could hardly believe it!!!!”
“Who said it was cheap-rate surgery?? Life over there is cheaper than here and that’s why
prices are lower than here!!”
Before deciding to get an operation, future patients spend a lot of time searching for
information about the skills of surgeons.
“Someone who listens, is attentive, calm, thoughtful and is most importantly licensed, belongs
to a medical association and is very competent!” “My motivations were a competence similar
to what is available in France for a price sharply lower than in France, following the
principle of value for money! Because if surgeons were not worth the trip, I wouldn’t go
there, even if it’s cheaper!”
Concerning the modernity of foreign hospitals, it appears that in many developing countries,
public and particularly private hospitals are well-equipped and meet international standards.
“I leave for the operating room, it’s large, I recognize the respirator… it’s the same brand we
have at home, everything is exactly the same, which goes to show that some received ideas
Regarding the care, many patients appreciate the reactivity and efficiency of the medical staff.
« …I wasn’t feeling very good…, immediately the anaesthetist took care of me,
electrocardiogram, drip, regular blood tests, I felt reassured in this health care
environment.” “As someone who has gone through several operations, I can EASILY SAY
that I had never got or even seen such care at this price.”
The travelling patient aims to purchase a particular service and to achieve a defined health
goal (Bookman and Bookman, 2007). Despite the importance of the medical aspect, it appears
that non-medical services are not insignificant to the medical tourism experience. Medical
tourists especially appreciate the recovery period.
«In my opinion, the advantage of being operated in Tunisia is the rest afterward, they keep
you in the clinic for as long as it takes, after that you end your stay in a hotel, where there are
no concerns such as going shopping or doing housework or what’s for dinner tonight, or the
postman ringing and so on!!”
Bookman and Bookman (2007) asked the question of why a medical tourist picks one
destination over another. They believe that factors such as cultural similarities, distance from
home, medical specialties and reputation influence an individual to favour one country.
Travelling patients think that Tunisia is well reputed in the field of cosmetic surgery. Tunisia
also has strong cultural similarities with France and it is a country where the people speak
fluent French. Finally the geographical proximity between France and Tunisia seems to play
an important role in the choice of medical tourists.
“My first criterion was the fact that the first country to have done surgery for tourists was
Tunisia, so they are more experienced than the others, the second criterion was the proximity:
a two-hour flight is very manageable, and finally the third criterion, the language. In Tunisia,
unlike in Eastern Europe, Thailand or Brazil, all the doctors speak French! It’s important to
be able to easily discuss operating techniques, etc., without asking myself whether I was
As regards the use of the Internet, the functional value of the tool lies in its ability to ensure
remote contact between medical tourists and service providers (surgeon and/or tour operator).
Novak and al (2000) considered the ease of contact as a component of a “compelling online
experience”. Through an empirical study, Heinonen (2008) highlighted how well companies
respond to customers’ inquiries using technology such as e-mails. E-mails have the potential
to improve patients’ perception of the accessibility of their managed care organization and
healthcare providers (Moyer, 1999). Therefore, several medical tourists think that the Internet
and particularly e-mails are an efficient tool to communicate with their surgeon or tour
“Doubts, questions, I immediately send an e-mail to my surgeon who replies to me within the
day, he reassures me, tells me not to hesitate to ask any questions that pop into my head and
that it's normal to be anxious. I appreciate this permanent contact.”
Several studies have also shown the usefulness of electronic mail as a medium for patientphysician
communication, as they make it possible to gain time, and improve convenience
and access to medical care for purposes such as renewing prescriptions, communicating
laboratory results and making appointments (Sciamanna et al. 2007).
In our case, it was found that administrative issues inherent to the medical tourism package
are easily and well handled by electronic communication.
“Did you send him the pictures directly by e-mail or through the website? The surgeon has to
see your pictures to make a diagnosis and assess the cost!
Then his assistant will send an e-mail or call you, anyway, the written estimate will surely be
sent by e-mail and then to show you agree, you will need to send him the confirmation of your
plane ticket reservation!”
Other studies have found that follow-up care is among the main reasons why patients use emails
(Nelson and Stewart, 1993, Houston and al, 2004).
The same finding is observed in a medical tourism context, where the follow-up is performed
remotely. The patient sends photos of the evolution following the operation to the doctor, who
examines them and then gives advice and/or renews prescriptions to the patient.
“He remained available after I got back, by e-mail and by phone and even on live chat…!
Regarding the e-mails, it’s useful to send him photos showing the progress of healing for
example!” “I just had my surgeon on the phone a moment ago, and after observing the
photos, he thinks all the same that I have a stitch that went off under the nipple…”
In the context of our study, the Internet is not only a means used to ensure remote contact, it’s
also the main source of information for medical tourists. The Internet is a wide source of
information that allows customers to access more customized information with minimal effort
and cost (Alba et al. 1997). Through forums, travelling patients can easily get information
with minimal effort.
“Before my operation, I did extensive research on the Internet…” “So I started, I began my
search! I typed “facelift in Tunisia” on my friend Google. It gave me the names of clinics and
forums. The breaking point, but yes, the forums, what an idiot not to have thought about it
before, these things are full of information, lol…. So I signed up on 2 forums, and I visit both
of them daily, I don’t post but I read.”
Social value is defined as the perceived utility based on the association of a product with one
or more specific social groups (Sheth, Newmann and Gross, 1991).
As regards social value, the attributes most often mentioned in literature are obtaining social
approval (Cengiz and Kirkbir, 2007), improving self-image, feeling accepted and making a
good impression (Sweeney and Soutar, 2001), and finally turning to a service provider known
by many other customers (Sanchez et al. 2006). The aspects which stand out the most from
the discussions of medical tourists are related to improving self-image and to turning to a
well-known service provider.
We were able to observe that a large majority of medical tourists turn to cosmetic surgery in
order to improve their self-image and physical appearance in the aim of improving their selfesteem.
“That’s it, I’ve made my decision, after having 6 children, being “obese”, having lost 50 kilos
and reached my forties, I am going to have an abdominoplasty in Tunisia!”
Moreover, medical tourists are looking for the most famous and particularly the most skilled
service provider (surgeon and/or tour operator). We can also observe the formation of groups
supporting for example a surgeon who became famous on the forum.
“It’s true that our surgeon is very attentive to details and very thoughtful. He knows how to
reassure us…” “Our surgeon will soon need a new set of arms to operate all of us!” “What a
successful man he is!”
As regards the Internet tool, the two aspects which stand out the most are related to the
sharing of experience and the formation of groups and social connections.
In addition to seeking health information, individuals can also use the Internet to
communicate with one other in support groups (Houston and al, 2004). In fact, the advent of
the Internet has given rise to many forms of online socialization.
“Thank you for your testimony on your surgical experience in Tunisia: this will be a great
contribution for forum users… so being able to have information on your experience will
provide valuable elements to forum users…” “This forum is an important tool when one
embarks on the adventure of “cosmetic surgery” and I’ve met many people on the forum
ready to help the others.”
Forums dedicated to medical tourism foster the creation of social connections among
members sharing the same opinions and interests. In the forum under study, we can observe
the formation of groups of medical tourists, such as the group of the “lololandaises” and the
“Tunis girls”. The “Tunis girls” group is formed by women who have been operated in Tunis.
The “lololandaises” group is formed by women who have undergone breast surgery.
“Congratulations! You will become a Tunisgirl!!!” “THANK YOU all for your
encouragement!!! And for the lololandaises-to-be: GO THERE stress-free, it’s wonderful to
feel so feminine!!”
Emotional value is defined as the perceived utility based on the ability of a product to arouse
feelings or affective states (Sheth, Newmann and Gross, 1991). Emotional value is related to
the development of positive emotions, such as happiness, interest, and pleasant surprise, and
negative emotions, such as sadness, fear, anger, disgust, and unpleasant surprise (Borod et al.
Previous studies focused on a range of positive and negative feelings arising from a tourism
experience (William and Soutar, 2000; Sanchez et al. 2006; Petrick, 2002) and from a medical
experience (Cengiz and Kirkbir, 2007), such as fear, excitement, pleasure and happiness. In
our case, members made for example comments about being “afraid” and “excited”.
“I keep jumping around because I can’t wait! In 8 days, I’ll be on the plane at this hour!” “A
small tablet before I went to bed to feel relaxed even though I was pretty wired. Not stressed
but excited at the thought of fulfilling my dream.”
“I am supposed to go there on March 2 nd for a breast operation, and now I am really afraid
because there is no way of checking the surgeon’s skills…, I am just afraid of failure.”
Epistemic value is defined as the perceived utility based on the ability of a product to arouse
curiosity, provide novelty, and/or satisfy a desire for knowledge (Sheth, Newmann and Gross,
1991). Goetzinger et al. (2007) stated that the Internet has revolutionized the way consumers
search for information and has completely changed consumers’ decision-making process,
particularly in the health care industry. In the same vein, it has been acknowledged that the
Internet provides some level of epistemic value to those who use it as a resource for health
care information (Wilkins, 1999). Medical tourists conduct several searches on:
The service providers (surgeon and/or tour operators):
“Before my operation, I had done extensive research on the Internet and I had consulted
several surgeons to be sure to have a good surgeon.”
The cost of stays:
"Are rates really more interesting than in France????”
And the postoperative care:
“Otherwise, as regards post-operation care, I clean the scar using Bétadine, by tapping
gently, without rubbing, then you put a good coat of IALUSET healing cream, all over, and
use IALUSET PLUS where it weeps, because it is a healing and disinfecting cream at the
Conditional value is defined as the perceived utility based on the specific context or set of
circumstances faced by the patient. An alternative acquires conditional value in the presence
of previous physical or social contingencies that enhance its functional or social value (Sheth,
Newman and Gross, 1991).
The conditional value of the medical tourism experience finds its essence in the presence of
several contingencies which tend to improve its functional value. These contingencies are
related to the high prices applied in France, the long waiting lists at teaching hospitals and the
absence of coverage for cosmetic surgery.
“It is true that in France, it can be twice as expensive as in Tunisia! Otherwise, there are
some teaching hospitals where prices are around 2,300 euros, but for some, the waiting
periods are too long”
“Concerning coverage, it’s not the lost weight that matters, it is whether or not you have a
"deck", and I have no deck and therefore no coverage…so I’m not interested in being
operated in France”
The table below recapitulates the main findings.
Value Medical tourism service Internet
Functional -cost differential
-abilities of surgeon and nursing
-quality of care
-importance of the recovery period
-assets of the Tunisian offer
(cultural similarity, geographical
Social -turning to a well-known service
-Maintaining remote communication
through e-mails (making the steps
prior to the service contract easier,
and facilitating post-operative
-easy and quick information
-formation of groups and social
Emotional -positive and/or negative feelings
resulting from the experience
Epistemic -information search tool regarding
service providers, costs, treatment
(before and after the operation)
Conditional -high costs in France
-long waiting lists in teaching
-no coverage for cosmetic surgery
Summary of the dimensions of perceived value in the context of medical tourism
This research shows that the medical tourism experience and the use of the Internet in this
context include a set of value dimensions. Knowing the contribution of each value dimension
to consumers’ choice, and in our case to the choice of medical tourists, gives valuable
information to managers (Williams and Soutar, 2000), enabling them to better understand the
concerns and expectations of medical tourists. Like in other studies, it thus seems obvious that
the contribution of functional value is highly significant in the perceived value (Cengiz and
Kirkbir, 2007), especially as regards costs. It is also interesting to note that despite the
importance of costs, medical tourists would not be able to overcome their apprehension if
services were of poor quality; which explains the importance of other aspects of functional
value, such as the surgeon’s skills, the quality of care and the modernity of the equipment. It
is therefore essential that health establishments undergo certification and accreditation to
enhance their reputation.
The functional value of the Internet tool lies in its ability to guarantee a permanent contact. It
is thus essential to optimize the potentialities of the tool. However, and in conjunction with
other studies (Williams and Soutar, 2000, Sanchez et al. 2006), the importance of the
functional dimension in the perception of value should not make us forget the contribution of
Medical tourists see in the Internet tool, and particularly in forums, an effective means of
sharing experience, finding positive stimulation, and especially of finding information on the
different aspects of the Tunisian medical tourism offer. The components listed are
respectively related to social, emotional and epistemic values.
Health care professionals can get more out of these value dimensions, for example by creating
their own blogs or forums, around which they will be able to rally real virtual communities,
thus improving access to information and creating positive word-of-mouth.
The conditional value of the Tunisian medical tourism offer is based on certain aspects of
Western health care systems, such as long waiting lists and the lack of coverage for certain
operations. It would be interesting to communicate more about these issues.
From a managerial viewpoint, the results obtained are a first attempt to enlighten managers on
the major dimensions of the value perceived by medical tourists and on the relative
contribution of each dimension to the perception of value. The goal is to better understand the
needs of medical tourists and thus to better guide their choices and marketing decisions.
From a theoretical viewpoint, these results are a first step in developing a synthetic theoretical
model incorporating the dimensions of both the perceived value in the context of a medical
tourism experience and the usefulness of the Internet in the same context. It is also a first step
towards understanding the key dimensions of perceived value and their impact on behavioural
consequences in a medical tourism context. The ultimate goal is to operationalize the
dimensions of perceived value and test their impact on satisfaction and behavioural
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www.toursimag.com/ui/business/tourisme de sante/
Cruise Tourism - Changing Products – Improving Wellness?
“This presentation examines the rapidly changing cruise tourism industry across the world but
notably in Europe where growth has exceeded all expectations. (NB It will not cover river
cruising). Not only is the market receiving brand new cruise ships but it is seeing a much
greater spread of products on board. One theme being promoted is that of life, health and
wellness – which may seem to conflict with the image of constant eating and drinking on
board such ships!
The image presented and the products offered may not appear to be consistent in ensuring a
total ‘wellness’ regime.
Additionally the rapid growth in cruise tourism and the need to fill ever larger ships may drive
new customers on board whose desired ‘experience’ may not always be compatible with that
of their fellow cruisers. Mixing market segments creates tensions between groups of
passengers where those who are lured by price may have a totally different lifestyle and set of
ambitions and values to those who are focusing on a more ethereal experience.
The presentation will consider the proposition that ‘wellness’ takes on many meanings to
cruise passengers and that visiting the spa and gymnasium may not be an essential part of the
Thankfully my own cruise experience 5 cruises on 3 different cruise lines has not faced that
problem because we fly to USA and avoid Southampton (where I did the highly successful
cruise tourism strategy in 2004/5).
We prefer Celebrity which is said to be four star and promotes wellness and ‘life enrichment’
and does to some extent. Good gyms and exorbitantly prices spas – plus new products that
suggest healthier eating and living on board.
Cruise Tourism Work undertaken:
Port of Southampton Cruise Tourism Strategy
Scottish Cruise Tourism Review
Economic Impact of Cruise Tourism Dover
Antigua Tourism Masterplan
St Maarten Tourism Masterplan
Limassol Cruise Terminal Feasibility
Mombassa Cruise tourism Feasibility
Dublin Cruise Tourism Feasibility
Cosmeceuticals in wellness tourism – Cases of co-branding and co-creation
Associate professor, University of Southern Denmark, Centre for Tourism, Innovation and
Niels Bohrsvej 9, DK 6700 Esbjerg
Researcher, University of Eastern Finland. Centre for Tourism Studies
Puistokatu 5,, FI-57101 Savonlinna
“Cosmeceuticals” is a combination of the terms “cosmetics” and “pharmaceuticals”.
Cosmeceuticals are supplied to the wellness facilities, and they materialize for the tourists
during treatments. Tourism research has not to any significant degree addressed the role of
cosmeceuticals in the wellness industry.
The paper provides examples of strategic alliances from the Nordic countries of co-branding.
Additionally, the producers/distributors of cosmeceuticals may become crucial partners in the
creation of the experience offered in the wellness facilities. With examples from the Nordic
countries, it is demonstrated that alliances can lead to innovation and development in
cosmeceutical enterprises, and that the collaboration can also assist the wellness industry in its
attempts to obtain inimitability. Based on innovation literature, the paper discusses models for
co-creation and factors that facilitate or hamper collaborative processes. Co-creation and cobranding
constitute strategic alleys for the wellness industry. The Nordic evidence suggests
that the opportunities are not fully exploited.
Keywords: Spa and wellness tourism; cosmeceuticals; innovation; co-branding; co-creation;
the Nordic countries.
“Cosmetics” and “pharmaceuticals” together form the term cosmeceuticals, which embrace
anti-aging creams, moisturizers, bathing salts, lip balms and many other products. When
extending the use of cosmeceuticals and applying the rhetoric of health improvements, the spa
and wellness industry is increasingly marching into domains formerly exclusively occupied
by “serious” medical professionals. Similar movements and invasions can be observed in for
example electronics where GPS-technologies have moved from restricted military use to
become an instrument for play and enjoyment, and in the clothing sector waterproof clothes
previously used mainly for military purposes or as working clothes have also disseminated
into outdoor activities for recreation and tourism (Logue 2005, Smedstad 1995).
Wellness tourism integrates body, mind and spirit. A satisfactory tourism experience depends
on the intentions, mood and adaptability of the tourist, but also on the competencies and
professionalism of the wellness staff to interpret and meet the needs of the visitor. Relations
between human beings are found to be crucial in wellness tourism (Kelly & Smith 2009).
However, wellness experiences are not only a matter of intangible procedures and services.
The delivery process is assisted by a large number of auxiliary remedies. Thus,
cosmeceuticals are supplied to the wellness facilities, and they materialize for the tourists
during treatments. As it will be further developed and explained in this article, the image and
the commercial success of cosmeceutical products depend on the interaction between the staff
and the customers in the wellness facilities. Accordingly, it assumed that there is a mutuality
of the two industries, which may or may not be fully envisaged and exploited. It is part of a
collaborative picture that cosmeceuticals are also merchandised on the premises and often part
of the décor. Thus, the role of the cosmeceuticals is, potentially, even more far-reaching in
terms of development and branding.
Although wellness tourism is a topic that attracts many tourism researchers, the role of
cosmeceuticals in the wellness industry has not been addressed too any significant degree.
Generally, it is remarkable how few research reports are generated from the “engine room” of
the wellness industry.
The geographical framework for this study is the Nordic countries, where spa tourism has
existed for a long period of time (Aho 2007, Hemmi & Vuoristo 2004, Kangas & Tuohino
2008, Konu et al. forthcoming 2010, Smith & Puczkó 2009, Suontausta & Tyni 2005). There
are many strategically sound ways for spa and wellness tourism enterprises to move in
developing their competitiveness and brands, and developing their cosmeceutical alliances
might be one of them. One assumption here is that the producers/distributors of
cosmeceuticals are crucial partners in the creation of the experience offered in the wellness
facilities. Cosmeceutical producers play a role both in terms of innovation of new products
and services and in the marketing and branding process. The terms co-creation and cobranding
are applied in the investigation of the nature of such collaborative structures.
Wellness tourism has its roots in the long history of spa resorts, and in that sense is not a new
phenomenon. During more recent decades it has modernized and diversified into a large
variety of categories. As demonstrated by Smith and Puczkó (2009) wellness tourism includes
a high focus in facilities for medical treatments, as well as pure leisure and relaxation sites.
There are also great variations in profiles when it comes to expectations of the tourists’
involvement and activity, either mentally or physically. The rapidly upcoming research
interest covers many issues, but there seems to be an overwhelming interest, for instance in
users’ profiles and in motivations, behaviours and experience. Generally, the rationale is that
there are significant growth prospects due to ageing and changed lifestyles (Bushell &
Sheldon 2009). In parallel, destination studies contribute to the wider perspectives with
evidence about local resources, sustainability fit and economic viability (Pechlaner & Fischer
In the pharmaceutical literature, the development of cosmeceuticals is given quite noteworthy
attention. There is a science based focus on the ingredients that influence the skin's biological
function and the discovery of new active agents (Draelos 2008, Tsai & Hantash 2008).
Spa and wellness facilities provide a long range of treatments. Not all of them imply the use
of cosmeceuticals. There is an ongoing development in the treatments, such as cooling and
hot stones, and vitaminized massages, as well as treatments of the extended body, and
combined mental and physical treatments. Simultaneously, there is a tandem process of
ongoing development with cosmeceuticals that can be applied in those treatments.
Manufacturers are enthusiastic to explore the uses of traditional and new raw materials in
their products. Trends for the near future are claimed to be that natural products and extracts
will replace chemical materials; additionally, plants and fermentation will replace animals as
The use of cosmeceuticals in wellness tourism is only fragmentarily covered in the research
literature, and then only in conjunction with the descriptions of the treatments provided. Smith
and Puczkó (2009) reviewed the many categories of wellness tourism, from medical to
recreational, relaxationally passive to sportily active, physical to spiritual, and focused to
holistic. Treatments where cosmeceuticals are prevalent occur in some of the categories and
not in others. The experiential cosmeceuticals do receive some anecdotal attention in the
literature, for example massages and body wraps based on chocolate. The general trend seems
to be that the inclusion of spa elements in for example hotels and sports centres increases the
profits, and that the growth rate of goods and merchandise is particularly impressive
(Mandelbaum & Lerner, 2008). In terms of treatments, Behrens (2007) points to the strong
diversification and internationalization trends, where large corporations with huge marketing
budgets tend to be the main driving forces. Those players in the wellness and spa market may
have alliances with suppliers of cosmeceuticals in the same league.
On a more general level co-branding with the tourism business and their suppliers is an upcoming,
but still novel research theme (Pechlaner et al. 2006). Co-branding is when two
companies form an alliance to work together, creating marketing synergy. In this situation, a
tourism enterprise will enhance its image by using respected and, preferably, already wellbranded
products, while the suppliers can achieve an extra marketing platform for its
products. Any wellness provider will apply scrubs, lotions, muds etc. during the treatments
and the brands of these can be made very visible and their merits included in verbal
appraisals. The spa-goers are expected to take the first step towards a loyalty to the particular
product. They can also find the same products in the shop to bring back for home treatments
and gifts. Additionally co-branding can include club memberships offers. The co-branding
can also take place on the websites of the enterprises, sometimes even including e-shopping
opportunities (Lee et al. 2006). The research literature is fairly tacit about strategic cobranding
alliances between the wellness industry and its suppliers in this field (Gibson, 2008;
Weiermair & Steinhauser, 2003). Smith and Puczkó (2009) talk about “signature products”, a
term that embraces the development of new spa products and treatments special to the place
and destination. Signature products might involve an active and mutually beneficial a cobranding
of the spa-facilities with the producer and the local community, from where an
element of the signature derives.
Co-creativity moves the issue further. In this case a wellness operator will collaborate
intensively with suppliers of cosmeceuticals in order to develop new products. The open
processes lead to cross-fertilization of knowledge. During the process of co-creation the
purpose for the supplier is also to gain new ideas and insights, which may eventually lead to
product introductions to a wider market (Möller & Törrönen, 2003). Accordingly, tourism
service providers and their suppliers are partners in an innovation process, and leading
tourism enterprises are responsive test benches for new supplies with a higher quality and
better market potential. Such innovation processes are not well illuminated in tourism
innovation literature (Hjalager, 2010).
This study combines literature reviews with brief and targeted case studies. As the research is
part of a larger project on “Nordic Wellbeing” the geographical focus is the Nordic countries,
in particular Denmark and Finland. Persons selected for interviews are managers of spa and
wellness facilities and cosmeceutical manufacturers and distributors. As tourism research is
only marginally addressing issues about co-branding and co-creation, the Internet and the
trade press has been an important supplementary source of knowledge on specific practices in
the global spa and wellness industry.
Spa Industries and their Suppliers – Cases from Denmark and Finland
The inclination to place additional weight on the spa products and the relations with the
producers and distributors of them can be demonstrated by the cases from Denmark and
Finland. The cases illustrating the strategies are far from uniform.
Table 1. Cases of co-operation and co-branding between cosmeceuticals and wellness firms.
Strategies of spa firms and cosmeceutical firms
Development of a series of skin care products together with Matas, a retail
materialist chain. Intensive co-branding in shops and in the wellness facilities
in the hotels. Joint marketing campaigns. The “Spalosphy” series has been
very successful in the spas and as a retail product.
Vejlefjord Spa Development of private label cosmeceuticals to the spa. The products are
available in the spa and in the webshop. The suppliers of ingredients are
anonymous. The staff prepares the products in the “back office” on a regular
base, and there is a great concern about the freshness and the full and open
declaration of the ingredients.
The theme of the bath is medieval, and historical line has also been chosen for
the spa product series, developed in collaboration with a local supplier of
cosmeceuticals. The concept will be developed in order to create a wider level
experience for the spa-users.
SeaWest Spa SeaWest imports an Islandic spa product series, chosen for its image of being
“clean”, and with ingredients from the Nordic natural environment. The
products are also available in the spa shop and on the web.
A distinct concept is the ‘wellness bar’ (following the idea of minibar), which
are found in Art&Design villas. The bars are filled with Finnish wellness
products from Lumene and Cutrin (both labels owned by LUMENE Oy). The
intention is to give customers a possibility to pamper themselves with
products with arctic ingredients.
Hotel Kalevala Hotel Kalelava uses Frantsila’s supplies, which concentrates on organically
grown and produced herbs and plants. Raw materials of the cosmeceuticals
are mainly cultivated for the purpose, but in addition some of the ingredients
are gathered from nature. All herbs and plants that are used are well known in
folk medicine, and as such used to enhance health and wellbeing and cure
Designermudder The firm is a cosmeceuticals producer diversifying into experiences and
events. The strategy to offer good and interesting skin care products, for
example coloured muds. However, additional services that enhance the
experience of the spa-user are also offered, and the specialists from the firm
are responsible for fun-events such as producing your own soap. The strategy
is also about building mutual relations with the spa facilities employees.
Guest Comfort Guest Comfort is a cosmetic supplier who acts as a creative intermediary
between cosmeceuticals and businesses in the tourism sector. It is also a
knowledge intermediary between spa facilities and the producers of
cosmeceuticals, and sees itself as a motivator for continual creativity in the
Issues in Co-branding and Co-creation
The branding literature elaborates on the many dimensions of effective co-branding. Aaker
(1996) demonstrates that the companies in collaboration must have a deep understanding of
their customers’ motivations in order to create and enhance the loyalty for more products in a
co-branding group. Furthermore, the quality levels must be comparable, and the product
character stable and unshakeable, as compromising will harm the collaborating partners. In
the cases of successful co-branding, a mutual respect and trust has been built up over time.
Suppliers are likely to be more willing to launch into risky partnerships if they have the
prospects of lasting contracts that guarantee a return from their innovation and other
investments (Crotts et al. 1998).
According to Lee and Decker (2008) there are three distinguishable effects of co-branding:
• Mutual effects which occur if there is a high degree of product fit, where the two
products are interlinked. That is the case in cosmeceuticals, as the products are directly
applied during the treatments and exposed to the customers, while the treatments take
place. If the customer gets a sense of wellbeing after the treatment, he/she will build
up a favourable attitude towards both the spa and the particular cosmeceutical.
• Extension effects happen later as a responsive consumption behaviour. By
remembering the spa-experience, the customer will also be likely to bring back gifts
from the spa gift shop and to choose the spa product during daily shopping.
• Reciprocity effects are the long term effects where the customer on a more permanent
base perceives the quality of a product in a certain manner. At this time the
collaboration between the supplier of cosmeceuticals and the spa facility can expand
their collaboration and utilize the established brand equity, for example by introducing
more cosmeceutical products or by appealing to new market segments.
In the private label case of Vejlefjord, there is of course no co-branding, and none of the
effects are materializing. It demonstrates a careful strategic choice, which coincides with for
example the strategies in professional staffing.
Other cases in this collection are examples of the harvesting of the effects of mutuality. Thus,
the Hotel Kalevala and the Seawest work with producers with a distinct image, which
supports the brand of the place as “Nordic”, “clean”, and “responsible”.
In the co-operation model of Anttolanhovi and Lumene, Lumene’s products are introduced to
different customer segments and possibly also to people that have not tested Lumene products
before. This can encourage customers to buy Lumene products also from other places, e.g.
during daily shopping. Comwell/Matas likewise expand the likelihood of extra business for
both partners, not least because the Matas shops are found in nearly all towns in Denmark.
Designermudder is an example of a supplier that has the reciprocity in mind to have products
that appeal to categories of spa goers that most spas are not yet geared to serve. The
intermediating of Guest Comfort also helps spa providers and cosmeceutical products that are
not experienced in, or capable of, exploiting the potentials of co-branding.
Generally speaking, there are several driving forces for innovation in tourism, for example the
technological developments, suppliers’ provision, market demand/customer requirements, and
governmental regulation (Hjalager, 2002). Innovative suppliers can be decisive for tourism,
due to the fact that much innovation is already embedded in technology and raw materials.
Suppliers’ innovations are “released” when integrated in the service delivery in the next step
in the value chain. Barras (1986) declare this a typical “reverse” road to innovation in
services. Cosmeceutical producers can be analysed in this logic. Eventually, the most
innovative producers of cosmeceuticals may theoretically be able revolutionize the product
that the spa facilities are offering to their customers. Seen from that perspective, spa and
wellness enterprises are in a situation where they have to consider existing and emerging
cosmeceutials not exclusively as enhancers of products, features and functions, but also as
facilitators of experiences. The case study of Designermudder exemplifies that more colourful
spa muds and scrubs can be a stepping stone for the spa experiences for new target groups,
and thereby a re-orientation or a diversification for the spa and wellness facility. Likewise,
Guest Comfort has a “push effect” on its customers in the spa business.
The literature on service design (Pine & Gillmore, 1998; Voss & Zomeijk, 2007) widely
advocates to use metaphors from the theatre in order to enhance the experience and make the
products innovative as far as the user is concerned. Producers of cosmeceuticals possess
distinct chances to contribute to the development in the spa business in a proactive way.
Systematic approaches as suggested by Edensor (2001) and Mossberg (2007) reveal that there
might be a plea for enhanced understanding of the theatrical focus in spa innovations, and the
cases in this study illustrate that co-creation with cosmeceuticals can be seen as a construction
of dramatic progressions.
• Scripting is about creating the story and the rituals. Scripting is a multifaceted process
that integrates issues about the socio-economic and educational background of the
customers and the type of business. The scripting process can reflect a range of
matters: What is the place of origin of the ingredients? What scientific evidence is
available? What auxiliary remedies? Spa ceremonies are often very rigidly scripted,
and the customers more or less know what to expect. However, spa providers are
attempting to make variations in order to create surprises. A uniqueness of the
cosmeceuticals and the producers’ contributions to the script are methods of enhancing
the period of time - before some other business is copying elements from the concepts.
The renaissance case of Queen Dorethea’s Bath is good illustration of the potentials of
a thematic script with monks and their medical herbs.
• Sceneography and stage-design. There is an ongoing architectural and ethnic
proliferation and thematic remodeling of the spa interiors. The importance of the décor
seems to increase, as the colours, shapes, sounds, surfaces etc. tend to create the
signature of the place and contribute to the overall feeling of wellbeing. The cases in
this study vary from very classical, to modern Finnish design and to the medieval
Queen Dorothea’s Bath. However, these specific wellness facilities exhibit limited
attempts to bind together and co-create the cosmecuticals and the sceneography, for
example underlining the views to pine trees outside and a Nordic ambiance with pinebased
• Casting and instructing deal with the recruiting and managing the staff who are
capable of enacting the story that is laid out in the script and embraced in the
sceneography. From the point of view of the suppliers of cosmeceuticals, it is hardly
enough that the staff are professional therapists or cosmetologists and able to apply the
products in exactly the required way. Innovating goes beyond that and includes for
example the use of costumes that are harmonized with the setting and potentially also
the image of the cosmeceuticals. Instruction also contains preferred behavior and
procedures that reinforce the image with some scope for improvisation. Innovativeness
in the field of casting and instructing is about creating norms and cultures of a place,
which contributes to uniqueness, and which creates a learning environment for the
producers of the cosmecuticals to achieve relevant and reliable feedback for their
innovation processes. Enhanced sales methods for merchandise and after sales services
are also a part of this picture and crucially relevant in terms of cosmeceuticals. The
proprietors’ interviews emphasis the need for training as part of the co-creation and
• Directing the tourists’ performance. Tourists in spa and wellness establishments are
not only spectators, they are also co-producers of their own and other people’s
experience and therefore partly responsible for the success of the theatric play. There
is normally a good deal of guiding of the visitors through treatment programmes and
offers, and most customers are accepting the implicit conformism. Self-pampering
requires particular advice and encouragement, as seen in Anttolanhovi and Comwell
cases. When appealing to broader audiences, there might be a need to introduce other
ways of play directing into the spa product. Designermudder sees the opportunities in
organizing events for children where they produce their own soaps or lotions. Such
events – however in line with the objectives of both spas and cosmeceutical producers
– may require new modes of interacting with the customers.
Discussion and Implications
This study approaches a tourism niche from the point of view of the suppliers, and this is a
method that is not conventional in tourism research. By accumulating an understanding for
the business models and marketing strategies from the suppliers’ side, it is possible to broaden
the perspective in terms of innovation and knowledge transfer. Accordingly, the study unveils
that the co-branding and co-creation is taking place under quite different understandings of
boundaries of the enterprises. It is a conclusion from the cases that there are both existing and
emerging overlaps in the roles of the cosmeceutical producers and the spa wellness
enterprises. Collaboration tends to soften the boundaries and opens up inspiration and
communication, enlarging the knowledge base can contribute to the competitiveness of a firm
(Howell et al. 2003) and influence innovativeness (Tether 2005, Walsh 1996).
The cases suggest that co-branding is an emerging issue in the spa industry, and that that the
cosmeceutical industry seems to be responsive. However, in the Nordic cases there is only
marginal emphasis on creating destination/nation specific wellness cosmeceuticals.
Accordingly, the destination signature expressed through products with names of specific
locations or geographical features is generally weak. Rather, both the spa industry and the
producers tend to rely on the international practice in the business, where oils, fragrances are
acquired from all parts of the world and assimilated into the spa product. There are many very
persistent traditions in the ingredients sector, but the choice of ingredients also has an
economic background. When it come to the collection and processing of ingredients from the
natural environment where supply is distributed over large spaces in remote areas, the
obtaining of an economics of scale in countries with high labour costs becomes very difficult.
As it is illustrated by Finnish Frantsila and Lumene it is possible to create some economies of
scale in this field. It is important to envisage that particularly Lumene has experienced growth
and now the firm represents a major actor in its home market.
For those enterprises and governments who intent to proceed along the road of creating
stronger alliances or backward integration with the value chain there are a number of focus
points to be aware of and to address:
• Is there a resource base for a cosmeceuticals in the Nordic countries?
• Are “lived Nordic values” (Nordisk Råd and Nordisk Ministerråd, 2009) contributing
leads for wellness and wellbeing tourism?
• Are there supportive business structures and a collaborative network? Are the spa and
wellness industry and the cosmeceutical producers prepared to enter into collaborative
agreements and trustful interaction?
• Do the regulatory regimes challenge and support the endeavours to create Nordic
When it comes to meanings and values the Nordic elements in spa and wellness are intrinsic,
and there is still substantial research to be undertaken when it comes to a better grasp of cobrand
management in this context (Pechlaner et al. 2006). None of the actors in this study
have yet to achieve a consistent and full-bodied co-branding and co-creation profile, and that
is not a surprise. We are talking about a discipline in tourism that is still emerging in terms of
academic research and in terms of practical implementation. Destinations still have to be
invited in to do a job.
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An exploratory study of consumer choice and motivation of medical
tourism in Thailand: A case study of healthcare consumers visiting a
private hospital in Pattaya
Miss Wanvipha Hongnaphadol
The University of York, UK
According to Gee (1997), travellers are now travelling with different expectations; rather than
going for sightseeing in different places those tourists seek more meaningful experiences.
Therefore, any country’s economy depending on the tourism sector needs to create uniqueness
in their tourism products or come up with a special interest tourism product such as cultural
tourism, adventure tourism and health tourism. Health tourism, the concept of travelling for
healthcare, has been developed for centuries since the Greek and Roman periods or, according
to Burkett (2007) and Swarbrooke and Horner (2007), since the sixteenth and seventeenth
centuries. Health tourism, in the first place, was just the utilisation of natural resources, e.g.
mineral springs, sea water, including social activity. Healthcare has been combined with
leisure facilities and entertainment since then. Later in the seventeenth and eighteen centuries,
many wealthy Europeans visited places like France for medical expertise. Yet, this can be seen
as a regional health travel. Global health travel occurred afterwards, as Swarbrooke and
Horner (2007) point out the most sophisticated recent form of health tourism is where people
travel abroad for medical treatment.
Context of the Research
Tourism in Thailand
International tourism in Thailand started its journey in the seventeenth century when
Europeans travellers began visiting the country both for commercial and sightseeing purposes
(Oppermann and Chon, 1997). More recently, tourism has played a significant role in the
growth and development of the country’s economy as the country shifted from an agricultural
base to a more industrialised and service based economy. The first five-year Tourism
Development Plan (1977-1981) was undertaken in 1976. The industrialisation of the Thai
economy resulted in the increased export value of tourism as well as textile products, rice and
rubber during the 1980s (Higham, 2000). By 1995 the foreign exchange income from
international tourism exceeded the country’s top ranking exports (TDRI, 1998). The ‘Visit
Thailand Year’ campaign in 1987 succeeded in gaining a dramatic increase in the number of
foreign tourists and the ‘Golden Decade of Thai Tourism’ followed between 1987 and 1996.
The rise of Thai tourism continued into the mid-1990s and rapidly dropped in 1997 due to the
economic recession. Overall, the number of international arrivals in Thailand has increased
from 1.2 million in 1975 to about 7 million arrivals in 1995 and risen to 14 million in 2007
Healthcare services in Thailand
Thailand has a market-oriented healthcare system as people have free choice in selecting a
healthcare facility (Janjaroen and Supakankunti, 2002). Although public providers play a
major role in delivering healthcare services, the private sector is significantly growing.
Regarding the health insurance system in Thailand particularly the universal coverage (UC) 2
2 The Thai government has implemented national health insurance consisting of the Civil Servant Medical
Benefit Scheme (CSMBS) – covering government officials, their parents, spouses and children, the Social
scheme, although this theoretically increases individuals’ access to healthcare and provides the
same quality health services as offered by other health schemes, it can lead to healthcare
service and provision not being equally accessible to many local people with the same quality
standards (Sreshthaputra and Indaratna, 2001). Unlike the developed countries, their public
healthcare can not only reach everyone for free, but also with good quality and standard of
care. Pachanee and Wibulpolprasert (2006) argue that the UC scheme, the incoherent health
policy implemented by the Thai government, hinders the promotion of international trade in
health services. The UC scheme has large impact on healthcare system in Thailand including
financing system, quality of care, manpower, etc. Although the UC scheme increases people’s
health security and decreases people’s healthcare expenditure (Ngosurachet and
Sornlertlamvanich, 2004), some middle- and upper-classes eligible for it decide not to use the
service because of long queues, and non-confidence in the quality and standard of care
(Sreshthaputra and Indaratna, 2001; NaRanong, 2005). Therefore, they rather visit private
hospitals. As any individual claiming for this health insurance benefit can mainly receive the
service at public hospitals, the promotion of healthcare services to medical tourists in public
medical providers is unlikely due to the existing high demand of the local people, and the
contribution of major affordable resources to firstly serve most local people. Consequently,
medical tourism business in Thailand is focused on private hospitals 3 which provide good
images of hotel-like atmosphere in medical settings and create positive attitudes towards Thai
healthcare services and medical expertise for medical tourists.
Medical tourism is an emergence of a new and distinct niche market in terms of the deliberate
articulation of the healthcare and tourism industry where patients travelling overseas for
medical care – involving specific medical intervention – treatments and operations in hospital
context combined with a vacation (Cornell, 2006a; 2006b). However, medical tourism is not
considered as a new concept in terms of travelling for healthcare as evidenced since the Greek
and Roman periods. While Caballero-Danell and Mugomba (2007) agree with Connell by
shedding light on tourism experience gained from leisure activities after medical treatment,
others emphasise the cost effective medical care provision (Awadzi and Panda, 2006).
In this research, the term ‘medical tourism’ will be used to denote foreign patients travelling to
seek medical treatments and operations from the healthcare services in Thailand. However, the
participation in tourism either before or after treatment and the degree of participation is not
yet defined in the term as this can be highly diverse and really depends on the types of
treatments medical tourists have. This is yet to be investigated in the research if medical
tourism in Thailand is about tourism. Although medical tourism covers a wide range of
products and services (elective and non-elective treatments), cosmetic surgery, such as
Security Scheme (SSS) – covering employees in private companies, and the universal coverage scheme (UC or
30 baht scheme) – covering the rest who is not eligible for the first two schemes, since October 2001
(Ngosurachet and Sornlertlamvanich, 2004). Each scheme has different types of payment: fee for service on
CSMBS; capitation on both SSS and UC. With the UC scheme, the beneficiaries have to register to particular
health facilities and pay only 30 baht per hospital visit for most of diseases in public hospitals which are the
main providers. Therefore this leads to a huge workload but low pay to doctors in public providers, and to an
increasing internal brain drain of doctors to private hospitals which provide better incentives. 30 baht is about
£0.58 (51.52 baht equivalent to £1, rated on 2 August 2010).
3 Private hospitals, accredited by Thailand’s Ministry of Public Health (MoPH), deliver not only expertise in
healthcare but also excellent service. Private hospitals sometimes cooperate and liaise with ‘medical travel
agencies’, which work just like traditional travel agencies except that they specialise in medical travel services
and can help consumers make medical appointments, make arrangements for travel-related needs (e.g., flight and
accommodation bookings), and also include leisure and sightseeing activities in customer itinerary.
enhancement and beauty, will be more in focus as considering significant figures of foreign
patients travelling to Thailand for this particular purpose.
The development of medical tourism in Thailand
According to Connell (2006b), Thailand became a medical tourism destination in the 1970s
with its expertise in sex change operations and cosmetic surgery. The medical tourism industry
played an important role again due to the currency collapse and rapid devaluation of the Thai
baht 4 in the Asian Economic Crisis in 1997. Many Asian governments, including Thailand, all
promoted economic diversification, with the notion of turning round health service earnings
through attracting foreigners. They considered medical tourism as a potential growth factor of
the economy and promoted it because they foresaw its business opportunities and as a catalyst
to their economies. Thus, a big budget for improving healthcare services in these countries
was established to develop the best international standards. In support of what Teh (2007)
points out, merging medical expertise and tourism has become a government policy in many
Asian countries. The Tourism Authority of Thailand (TAT) launched a campaign to promote
Thai traditional healthcare including massage, herbs and authentic Thai food to attract more
foreign tourists. The TAT started a promotional programme for health tourism with the first
‘Thailand Health Travel Mart’ in 1999, repeated in 2000. The purpose of medical tourism at
the beginning was to generate another way of earning foreign income and to help the
hospitality business such as private hospitals and hotels during the recession. Medical tourism
thus became the new trend of Thailand’s tourism industry.
Previous studies of medical tourism research
In research on people travelling for health reasons or so-called ‘health tourism’, Goodrich and
Goodrich (1987) started by conducting an exploratory study of health-care tourism 5 with
travellers visiting hotels or resorts for healthcare treatments. In studies discussing motivating
factors of travellers seeking wellness and spa experiences, Chen, Prebensen and Huan (2008)
and Mak, Wong and Yang (2008) focused more on the motivation of wellness travellers by
addressing how visitors are motivated. While the former study revealed that cost and variety
of attractions rather than healthcare facilities at the destination were the main reasons to select
and visit the destination, the latter found that relaxation, health consciousness, and
attractiveness are among the most salient motivations attracting customers to wellness resorts
which corresponds well with the marketing schemes emphasising tranquility, enjoyment and
body pampering, in other words relaxation. Psychological benefits accordingly appear to be
the most important driving force pulling customers to wellness resorts. Although these studies
emerge from people travelling for health reasons, the settings are in a more relaxing context
i.e. hotels, resorts. Unlike the proposed study, it aims at exploring motivations for people
seeking healthcare in medical settings i.e. hospitals. However, it can be contributed to this
study as an initial guidance in exploring tourist motivations in search of healthcare as there is
little investigation of tourist motivation in relation to health seeking behaviours.
Caballero-Danell and Mugomba (2007) emphasise that little academic research has been done
on the medical tourism market due to the fact that it is a relatively new niche market.
Rittichainuwat, Qu and Mongkhonvanit (2008) additionally agree that there is little empirical
The devaluation of the Thai baht, on the other hand, provided the opportunity for hospital to attract overseas
patients due to the relatively lower charges.
“[T]he attempt on the part of a tourist facility (e.g. hotel) or destination (e.g. Baden, Switzerland) to attract
tourists by deliberately promoting its health-care services and facilities, in addition to its regular tourist
amenities” (Goodrich and Goodrich, 1987: 217).
study identifying the motivation of travellers to Thailand generally, and far less on medical
Theory of consumer motivation
The study of motivation in tourism is obviously important due to its role as a trigger to travel.
Tourism literature emphasises the significance of both push and pull factors in shaping tourist
motivation 6 (Crompton, 1979). Many scholars have worked on the definition of tourist
motivation partially by identifying the underlying reasons for travel. Each individual tourist
motivation framework may not fully explain the circumstance. According to Fodness (1994),
the most common empirical studies on tourist motivation are from the works of Dann (1977),
Crompton (1979), and Pearce and Caltabiano (1983), all of which explored push and pull
motives. Pull factors are the destination’s extrinsic forces, such as attractiveness and specific
features of the destination, perceived by potential tourists and pull people to choose that
particular destination whereas push factors are consumer’s intrinsic forces establishing the
desire to travel and push people to travel in the first place. In other words, according to Bolles
(1975), human behaviour is pulled through the perception of valuable characteristics in the
environment and pushed through the action of motivating drives. Klenosky (2002) further
suggested that a single pull factor of a particular destination can be driven by multiple push
motivational forces. People may have multiple and possibly very different push motivational
reasons for evaluating positively the same pull factor. Likewise, tourists with different
demographic profiles may have different push and pull travel motivations in visiting a
Interestingly, according to Chen et al. (2008), no academic literature has shed light on the
types of motivation of consumers visiting medical tourism settings, therefore investigating
those different motivations will help identify the possible leading attributes influencing the
demand since tourists often possess more than one motive (Pearce, 1993, as cited in Chen et
al., 2008). Additionally, as Sangpikul (2008) points out, there is limited research on the pull
motivational factors or destination-based attributes segmentation in a Thai context. According
to Kozak (2002), the destination attributes of a particular destination or pull factors, could be
various and different from one destination to another depending on the perception of travellers
towards a particular destination. According to Lubbe (1998, as cited in Sangpikul, 2008),
travellers’ motivations to visit any particular destination begin when they become aware of
certain needs and perceive that certain destinations may be able to satisfy those needs. Thus,
the investigation of pull factors in Thailand’s medical tourism context is important in
developing a successful marketing program.
Consumer behaviour and decision making
Following Bourdieu’s (1990, as cited in Dressler, 2007) idea of medical anthropology, which
draws on the disciplines of medicine, anthropology and history (Comelles, 2002), to
understand human behaviour, requires the analysis of the intersection of social structure and
cultural construction. Understanding human behaviour in general, and human health seeking
behaviour - the intrinsically motivated behaviour (Deci, 1975, as cited in Deci, 1978) - in
6 Tourism motivation has been defined by several tourism scholars as “a meaningful state of mind which
adequately disposes an actor or group of actors to travel, and which is subsequently interpretable by others as a
valid explanation for such a decision” (Dann, 1981: 211); “a dynamic process of internal psychological factors
(needs and wants) that generate a state of tension or disequilibrium within individuals” (Crompton and McKay,
1997: 427). Crompton and McKay’s definition reflects Murray’s (1938) psychological needs as deep-seated
driving factors of motivation.
particular, thus requires the exploration of how shared cultural constructs, known as cultural
consonance in behaviour, meet social structure. As Comelles (2002) contends, it is impossible
to study health seeking behaviours without taking account of the long development of
healthcare providers which have delivered care services from the late Middle Ages to the end
of the 20 th century and cultural context.
Due to the different pattern of previous and new healthcare consumers, a consumer influence
has reflected into different levels (Hjertqvist, 2002). Previously, the healthcare provider was
not designed to serve a real consumer influence. Similarly later, in the welfare state, the
patients’ specific demands could not be fully responded as need, not demand consideration,
was the key to the healthcare provision. Western healthcare consumers today, however, seek
to influence the organisation of the healthcare system and the services provided. Apart from
being used to making complex decisions, Western healthcare consumers are also provided
with greater access to various means of information sources which they require to create
satisfying information in order to compare the providers’ quality and choices among those
offered (Borgenhammar, 1997, as cited in Hjertqvist, 2002). Freedom of choice and the use of
healthcare facilities in many countries are predominant in the current healthcare consumer’s
framework when they can benefit from shorter waiting times and better quality services.
Hence, this kind of framework promotes the development of healthcare provision both
regionally and globally. As commented by Hjertqvist (2002), the more consumers supported
by public or insurance funding cross borders, the more pressure that is exerted on providers to
offer competitive price information. Herzlinger (1997, as cited in Belien, 2000) agrees that, in
order to achieve patient empowerment or consumer-oriented healthcare, competition in
healthcare services as well as an unrestricted supply of these services, both of which create an
expansion and differentiation of services and make prices decrease, are required (Herzlinger,
1997, as cited in Belien, 2000).
Identity: patient, consumer, citizen
Patients, according to Hogg (1999: 6), are ‘people with particular health problems who may be
taking medicines or receiving treatment’. As Edwards and Elwyn (2001) point out, the term
‘patient’ tends to describe associated images of stereotypical patient with passive role seeking
and following physician advice. ‘Consumer’, on the other hand, depicts those who seek
healthcare in active role and perhaps making their own decisions and having the ability of
exercise choice. Contemporary thinking in the healthcare arena leads health professionals to
view patients as consumers.
As the role of market raises the significant issue of identity, in terms of healthcare market, the
identity of health service users is considered whether they are patients receiving services
passively, consumers shaping and controlling the receipt of services, or citizens utilising their
rights to free healthcare (Milewa, 2009). Therefore, it is essential to explore how health
service users have engaged with these identities, i.e. patient, consumer, citizen as these words
can be differently conceptualised due to different healthcare systems and the role of those
receiving healthcare, and how they are considered in terms of individual consumer (individual
identity) and independent collective mobilisations (collective identity).
Generally, the consumer’s decision to purchase a particular service involves many more risk
considerations than purchasing a product. This is because heathcare service provision is
different from other areas of economic activity, products or services due to the prevalence of
irregular, uncertain and unpredictable demand and supply in healthcare (Arrow, 1963). As
highlighted by Folland et al (2001), consumers are uncertain of their health status and need for
healthcare in any particular time. There is additionally a product uncertainty associated with
the health context as consumers may not know the expected outcomes of treatments without
their physicians’ advice. This is supported by what Arrow (1963: 302) suggests, ‘the patient is
forced to trust his physician, lacking the latter’s knowledge and experience; the customer
cannot test the product before using it; recovery from disease is as unpredictable as its
incidence; and entry into the field of healthcare is limited by professional and licensing
restrictions’. Consequently, these characteristics make the healthcare market difficult to
achieve when compared to other types of market.
In conclusion, healthcare is no longer defined by people receiving services when they are ill –
the stereotypical patient. Instead, the term ‘healthcare consumers’ engaging with healthcare
professionals as a formal equal have been used more widespread in the development in
healthcare phenomenon when mentioning people acquiring healthcare where traditionally
people sought and received healthcare in their own locality, and certainly within their own
country. However, healthcare consumers have recently challenged the healthcare seeking
patterns by travelling across country.
Consumerism in healthcare
Consumerist approaches can be categorised under the form of marketisation reforms. The idea
of consumerism was introduced in the 1980s by the British and American governments due to
its significance to people’s lives (Miles, 1998). In Britain, the ideology of consumerism
providing consumers with the rights and political citizenship is defined through charters (e.g.,
The Patient’s Charter, The Citizen’s Charter) rather than in terms of active domestic
participation. The marketisation of the welfare state represents a response to the growth of
individualism and rising consumer expectations about service delivery, which have led to calls
for more user involvement and greater consumer choice (Glendinning and Kemp, 2006). A
consumerist approach, according to Needham (2007), is possible to damage citizenship
gradually by making public services as commodities in the marketplace and putting people in
the situation of caveat emptor. Some commentators have argued that consumer-style
approaches to choice undermine the collective provision of welfare (Needham, 2003).
However, for others increasing choice is a way of ensuring that the welfare state can survive,
by making it more responsive to the needs and aspirations of those who use it (Glendinning
and Kemp, 2006). According to Cullum, Deputy Chief Executive of the National Consumer
Council (2004), it can be argued that a consumer-centred approach is important to the
development of public services as it does not concern turning the public sector into the private
sector or so-called privatization, or introducing market values onto public services. Instead, it
is the means to ensure that everybody has access to necessary services with as high standard as
According to Shackley and Ryan (1994), the main barrier to consumer sovereignty in
healthcare is the asymmetry of information between buyers and sellers. The nature of
healthcare is that providers of healthcare have a large informational advantage over
consumers. The existence of informational asymmetry between buyers and sellers is common
in other markets as well. In general, sellers know more about a product than buyers, e.g.
sellers will be better informed than consumers regarding the characteristics of a product and
the technology that was used to produce it. Yet this does not prevent consumers from freely
exercising their own preferences in making their consumption choices regarding the product.
The essential difference between healthcare and other commodities is that for other
commodities the consumer is more aware than the seller of what these products’
characteristics mean to him/her. They know their own needs.
The situation in healthcare, on the other hand, is quite different. The acquisition of information
is costly in terms of time and resources. There is little opportunity for consumers to learn by
experience as they will be infrequent users of the market. Doctors, on the other hand, use the
market regularly. In many instances consumers will be unaware that they actually need
healthcare, e.g. women in the early stages of breast cancer, therefore the consumer may no
longer be deemed to be the best judge of his/her own interests. Because of the complex
relationship between healthcare (which consumers do not value per se, i.e. individuals derive
no direct utility from consuming healthcare, rather healthcare is consumed in the expectation
that health status will be improved as a result) and health status, the consumer becomes very
reliant upon the much better informed provider to make the link between the consumption of
healthcare and the resultant effects on health status. Hence, there is a special relevance of the
agency (doctor-patient) relationship in healthcare.
Patients want to be treated as consumers of healthcare in the sense that they want better
information about treatment options and to be more involved in making the decision as to
which option to follow. How far patients behave as consumers depends on the severity of their
illness, the nature of the procedure involved and their individual circumstances. Most severely
ill patients face complex treatment options and many prefer decisions to be made on their
behalf by a well-informed and trusted health professional. On the other hand, they may not
want to be treated as consumers as the nature of healthcare product and service, which is
unpredictable, does not support the role of being a consumer.
However, as suggested by Appleby, Harrison and Devlin (2003), choice is not always
advantageous as it should be counterbalanced by the costs of creating it. Choice for some may
limit and impact on the choice of others. Tritter et al (2010) agree with this as greater choice
may, in fact, even add to a further health inquality burden. In summing up, choice seems
structurally associated with enhanced marketisation of healthcare provision and the arena of
the consumer tends to be based on the economic rationality of maximising personal benefits
within market-based systems. However, evidence about what is driving patients’ choices in
reality is currently limited.
In conclusion, the conceptual frameworks of push-pull, consumer behaviour, consumer choice
and consumerism in healthcare are proposed due to several important factors. According to
Snepenger et al. (2006), the push-pull theory has prevailed over other paradigms in examining
motivations underlying tourist and visitation behaviour (Dann, 1977, 1981; Crompton, 1979),
attracting most attention from several scholars (e.g. Dann, 1977, 1981; Crompton, 1979;
Klenosky, 2002; Kim et al., 2003; Kao, Patterson, Scott and Li, 2008). Due to its theory
having been used much in travel motivation research, this provides a better opportunity to
compare and contrast findings with previous studies. Consumer behaviour literature identifies
the interrelationship between needs and motivations (Goodall, 1988; Witt and Wright, 1992)
as the presence of the former constructs the latter. In other words, people’s needs for
healthcare create their motivations in searching for it. The examination of differences of
motivations between sample populations representing different cultures is important in
understanding tourists’ behaviour (Kim, 1999, as cited in Kozak, 2002). Different cultural
conditionings and different healthcare and insurance system of healthcare consumers will
influence their expectations and perception. As a result, the investigation of health seeking
behaviours and motivations of medical tourists having different cultural and social
ackgrounds is expected to accomplish in this study as they are likely to have different
motivations and perceptions in seeking healthcare services
Aims of the Study
The present research project aims to explore the reasons why consumers from major Western
countries where English is the main language travel to Thailand for their medical treatment.
The research will investigate the motivations of potential medical tourists, differences in these
motivations among different groups both from the same and different countries,
interrelationships among these motivations, consumer choices in selecting a particular
treatment in Thailand over other medical tourism destinations, and the degree of tourism
participation of those medical tourists.
What are the significant motives that influence the decision of medical tourists from the US
and the UK to travel to Thailand, and to Bangkok Pattaya Hospital in particular?
How are these motives different with respect to age, nationality and gender?
How does Bangkok Pattaya Hospital perceive the consumer motivation from these countries?
To what extent does Bangkok Pattaya Hospital applied perceived consumer motivation to
service provision for medical tourists? How is a healthcare provider’s service provision
related to what motivates medical tourists to visit the hospital?
What are the major keys influencing consumer choices about provider and destination? Why
does a medical tourist choose one destination over another?
To what extent do medical tourists take tourism component as a part in their decision making
Is medical tourism in Thailand about tourism? Is medical tourism likely to
utilise the tourism component?
What is it about the tourist part of medical tourism?
To what extent do medical tourists participate in tourism?
Research Rationale and Methodology
This research will consist of three stages of data collection: exploratory study (observations
and small interviews with patients in a first visit to hospital), designing the questionnaire, and
the main study (a second visit to hospital).
Rationale for selection of hospital
Bangkok Pattaya Hospital (BPH) was chosen as the study site for two principal reasons.
Firstly, it met the following parameters: segmenting foreigners as a major target market;
providing internationally standardised quality of hospital, medical treatment, facilities and
infrastructure, and management personnel to the foreign patients. Secondly, BPH’s major
target market is not expatriates only but also medical tourists both in contact with the hospital
directly and via the agents in their home countries. The major target market is medical tourists
from major Western countries such as Western Europe (e.g. UK) and US; Arabic countries
such as UAE and Oman; and Australia and New Zealand. It was thus felt that with the
resources available to the researcher, a study uncovering consumer motivation and a
healthcare provider response could adequately be tackled at this hospital.
Due to the researcher’s limitation of time and funding, only the medical tourist participants
from major Western countries where English is the main language, i.e. the UK and the US are
chosen as the research target. Although expatriates 7 represent a high proportion in the foreign
patient market share in private hospitals generally, they are not selected here simply because
they do not travel to Thailand for medical care and are not representative sample of actual
medical tourists. The countries mentioned are selected since they represent a significant group
of total medical tourists. Approximately 150 patients, or about 75 patients from each country
will be sought for the questionnaire study to generate a representative sample as equally as
possible in terms of nationality and gender. These countries additionally provide a
comparative study of two different continents in terms of cross-cultural study with similar
Western background in order to compare their motivations for visiting a Thai private hospital.
Interviews with medical tourists
Piloting the questions for interview
The piloting of all the questions for actual interview with medical tourists will be first carried
out by semi-structured interviews, elaborating in-depth response, in the UK with
approximately 5 British people who have visited Thailand for some kind of medical treatment.
As supported by what Gillham (2007) mention, a proper pilot study is a reproduction of the
main study involving fewer participants who possess the same characteristics as the final
After the piloting, the first visit to BPH will take place with about 20 patients- 10 from the UK
and 10 from the US - who will be interviewed in a semi-structured format with open-ended
questions, such as ‘what motivated you to travel to Thailand for medical care?’ As suggested
by Gillham (2007), careful semi-structured interviewing before the questionnaire being
constructed can help identify the most of the likely answers. The most frequent keywords of
travel motivations from the medical tourists’ answers will be incorporated into the
Main questionnaire study
The researcher will inform the hospital during the first study visit of the requirement to survey
150 medical tourists using the quota sampling from two different countries visiting BPH. This
sampling is proposed here because it is aimed as far as possible to include an equal proportion
of participants from two different countries and from both genders (nationality and gender
distribution) in order to address a representative sample. Medical tourists from each
nationality will be approached until quotas are filled, in other words until there are at least 75
medical tourists from each individual nationality.
7 Foreigners resident in Thailand
Understanding mature traveller’s demand and choice in spring destination
Mei-ting (Jessica) Hsieh
Lecturer, Taiwan Hospitality and Tourism College
PhD candidate, University of Lincoln, U.K.
The ageing population in Taiwan is entering 11% who were 65 years old and above by 2009.
This percentage is likely to reach 20% by 2025 and 39% in 2051. Not surprisingly, after 2010
the emerging age cohort categories of 55 starting to reach retirement, and will continue to
increase in Taiwan. Mature people undoubted have much free time from working careers and
start to concern the long-term health status. This study examines how the Taiwanese mature
spring/spa travellers’ needs affect the travel motivation to choose spring destination and what
extent demand for the particular groups in springs. 200 valid responses to the questionnaire
carried out in spring destinations of Taiwan. The factor analysis of motivation factors
revealed three underlying spring/spa destination attributes and four socio-psychological
underlying dimensions. The main spring/spa travel motivations of Taiwanese were ‘Personal
health & building relationship’and ‘commercial Internal’; which appeared to be the most
important push and pull motivations, respectively. The study also suggests that there is a
significant relationship between travel motivation and age groups effect on destination choice.
Based on the results, the findings will point out spring/spa marketing implications in
conjunction with the theoretical framework, and add to other relevant organisation.
Key words: Mature traveller, Destination choice, Spring/spa tourism, Taiwan
With rapid growth in an ageing population, baby boomers comprise a large proportion of the
world travel market. The emerging age cohort categories of 55 starting to reach retirement,
and will continue to increase in Taiwan. Mature people undoubted approach an advanced life
cycle stage (e.g. the retirement stage) and are free from working careers. Nowadays, they are
likely to have sufficient savings, ample time, more motivation to enjoy, spend more freely on
activities and concentrated on personal health. Particularly in the health tourism industry, the
marketer have started to focus differentiate segmentation on the mature groups (Silvers, 1997;
Mochis, 1997). The growth of hot spring tourism since 1900s is well-known in Taiwan
society. Spring tourism in travel market of Taiwan has been acknowledged for century as
different type of natural springs has its own specific medicinal cures for improving people’s
health. In 1999, due to the Taiwanese government’s promotional spring/spa activities, visitors
are increasingly seeking a healthier lifestyle to maintain their wellness. The spring and spa
tourism would seem that become one of the pioneer “value sectors” during the modernisation
process in Taiwan. A number of re-birth spring/spa destinations increased extremely, this
potential attraction draw people to visit spring/spa destination through diverse products.
Moreover, it also tapped the potential of a rapidly expanding market, which includes sectors
such as healthcare services and the medical wellness industry.
People travelling for health in spring/spa resorts and destinations become an attraction
phenomenon for prevention on people’s health. The broad reasons for participating in
spring/spa travel nowadays are not only on socialise, improve well-being, and physical
therapy. New senses people went to the spring/spa in a quest of spiritual events and develop a
healthy lifestyle. Hence, to develop tailor facilities product and service to meet particular
groups’ needs, and upgrading the quality of spa destination are as an important for market
segmentation. Research has paid limited attention to the mature travellers studied, or the
mode of spring/spa destination choice. It is vital to be aware that mature traveller needs are
more diverse and multifaceted than ever, and this highlights the need for innovation to meet
the demand for a variety of recreational activities.
Characteristics of mature spring traveller
According to the Taiwan Tourism Bureau (2004), the Central Geological (2002) survey that
Taiwan has over 128 nature spring destinations located in different geological areas including
plains, mountains, valleys, and oceans. It has been identified different type of springs (i.e. s
hot springs, cold springs, mud springs, and seabed springs) with different destination
attributes based on the water temperature, geology, chemistry, and mechanism.
As spring have multi functions for curative effects and medical benefits of soaking. It has
gained popularity for people to ‘taking the water’ in the natural spring/spa destination,
particularly for aged people and patients. Travelling for mineral spring therefore has become
one of most representative recreational activity in Taiwan. (Hsieh et al., 2007). This vogue
beneficial effects relevant industry growing well not only for health tourism industry but also
for medical treatments, social insurance system, and national economy. The majority of
health spa tourism in Taiwan is domestic tourism, the total number of visitors increased from
approximately 4 million in the 2002s to 15 million people (23%) to visit hot springs for
experience their therapeutic techniques and leisure activities purposes, compare with inbound
demand only 17% for hot spring tourism (Taiwan Tourism Bureau, 2004). Nowadays, people
traveling for health in spa resorts and destinations as an attraction phenomenon. Particularly
the new health spring/spa revive health tourism market, the features and potential attraction
draws people to visit particular destination.
The emerging health and spa tourism is blooming in Taiwan since the government carried out
the ‘Taiwan hot spring tourism year’ by 1999. Following the Taiwan Tourism Bureau was
allied springs festival to revive the health spring/spa industry, it is not surprising to see or hear
that the reason travel for desirable health spring/spa destination in the mass medium. It
indicates the health spring/spa tourism is not only as an important curative activity for
domestic tourists but interests overseas tourists. With this potential growth health spring/spa
market, the further developments of health tourism are crucial to the Taiwan tourism industry.
With the society transformations, a number of sociologists recognised the phenomenon of
leisure activities may create a new lifestyle to good and reenergised for mature travellers. As
different value orientation on new aged have different needs in terms of attitudes and quality
of leisure. Thus, it is possibly different approaches on the ways to travel and time to spend.
Norman et al. (2001) refers to mature market as a complex phenomenon in which of
interaction on the biological, psychological, historical and social factors. It is means that
characteristics of mature traveller are response to various activities in particular the new-age
of baby boomers entry mature travel market. As people in the modern time have more
opportunities to arrange their working hours and leisure time, in addition, life expectancy
continue to rise, it impel many people doing more physical health activities during their lives.
Health spring/spa tourism products are dependent on natural resources such as mineral water
and seaside location. Although, the broad reasons for participating in spring/spa travel are to
socialise, improve well-being, and physical therapy, the new sense in a quest of health is
spiritual events and travel for the purpose of mineral cures. Research has paid limited
attention to the mature travellers studied, or the mode of spring/spa choice. It is vital to be
aware that mature traveller needs are more diverse and multifaceted than ever, and this
highlights the need for innovation to meet the demand for a variety of recreational activities.
The aim of research methodology was undertaken survey of mature spring/spa travellers
visiting natural springs of Taiwan. Besides, the study designed to extend the theoretical
framework for Taiwanese mature spring/spa traveller. This design was chosen because it
provides a highly accurate picture of the phenomenon under study. Questionnaire was
developed based on relevant literature review, conversations with mature spa/springtravellers,
and amendatory pilot survey. The questionnaire considered what information
would be essential related to the respondents’ needs of destination attributes in spring/spa.
Structured questions were used to gather information on natural spring/spa attributes and
socio-demographic. The sample was randomly selected from spring/spa travelers, who had an
interest in staying and visiting spring/spa destinations for particular purposes such as health,
activities, or being in a nature-based environment. The empirical evidence for the relationship
between motivation and destination choice is investigated in order to see what those factors
may mean for particular spring/spa groups, government policy reform, and market
Data for this research were collected from 33 spring/spa destinations with 15 different
geology natural springs and on cold spring region in Taiwan. The data collection phase was
conducted over a period of seven months beginning in October of 2007 and finishing in April
2008. The questions on the destination attributes are based on using internal and external
forces to represent intrinsic and extrinsic factors. It contains the real reason for visit,
companions, and geographical characteristics in the health spring/spa destination. 285 mature
spring/spa travellers were invited to fill in the questionnaire at destinations after they had
visited or stayed in the spring/spa. Analysis of numerical data was followed by data entry of
200 valid responses.
Accordingly, the statistical method of analysis was summaries of the broad category of
descriptive statistics to describe mature spring/spa traveller’s characteristics related to
motivation, and how destination feature in spring/spa tourism experiences. Following the
study used exploratory factor approach as an analysis technique to explain traveller
motivations and to explore if there are differences between demographics and destination
choice. A principal component factor analysis was used to examine the importance of push
and pull motivation factors within the spring/spa travel groups; and if there were differences
in terms of destination attributes. Subsequently, the analysis proceeded to investigate if there
is a significant difference in socio-psychological characteristics and demographic variables
that influence mature spring/spa travellers’ to a certain destination. Variables consist of
demographic traits, trip purpose, characteristics of trip, and socio-psychological factors.
Factor analysis of motivation factors revealed three underlying spring/spa destination
attributes: commercial internal, commercial external, and natural & friendly service.
ANOVA analysis revealed that the main effects of age groups effect on destination choice are
The study proceeds to find whether variations in these factors have an effect on the choice of
Taiwanese mature travellers as measured in the study. The findings will point out spring/spa
marketing implications in conjunction with the theoretical framework, will add to knowledge
of the practical spring/spa market and will highlight methodological concerns in further
Data analysis and discussion
A principal component factor analysis was used to investigate the importance push-and-pull
factors within the Taiwanese mature travel groups, the underlying motivations of travellers,
and the differences in terms of destination attributes. Independent samples T-test was used to
compare the difference between the means of two groups, such as the mean push factors of
male and female travellers in spring destination or if there are any significant differences
between two means according to the demographic characteristics.
A summary of the demographic characteristics examined is show below in Table 1. The
sample was composed of the 200 mature traveller respondents from health spring/spa
destinations. It shows that 61.5% of respondents were males 38.5% were females. The
majority of the mature travellers to spring/spa were male, compared with younger group in
which over half of younger respondents were female. 42.5% of respondents were aged
between 50 and 54, only 27.5% were over 60 years old with a mean of 57.1. The majority of
population in Taiwan was young age group (15-45), while 73.3% mature group (45-65) and a
minority (nearly 11%) aged 65 and above.
Overall the sample of Taiwanese spring/spa mature travellers was less highly educated with
college or university degree. 34.5% of respondents present that they are retired and others
state their occupation as business owner. The similarity to white-collar worker (31.5%) was
the most common occupation from respondents.
When considering aspects of individual health status, most Taiwanese mature travellers
generally replied that they perceived their own health to be good (50%) or excellent (15.5%).
Only 3% of mature travellers feel they have some health problems, and 6.5% of them feel that
they have poor health (either in physical or mental health in their daily living, including
disease, impairment, disability, and handicap).
Table 1 Travellers’ demographic profile (N = 200)
Female 77 (38.5)
Under college 130 (65)
College above 68 (34)
Under NT$10,000 28 (14)
NT$10,001-NT$20,000 26 (13)
NT$20,001-NT$30,000 38 (19)
NT$30,001-NT$40,000 42 (21)
NT$40,001-NT$50,000 28 (14)
NT$50,001 and over 37 (18.5)
Bad 6 (3)
Poor 13 (6.5)
Fair 50 (25)
Good 100 (50)
Excellent 31 (15.5)
Blue-collar worker 47 (23.5)
White-collar worker 63 (31.5)
Professional 21 (10.5)
Retired and Others 69 (34.5)
The result in travel behaviour shows nearly 77% of respondents indicate that they tend to a
visit spring/spa destination more than once each year, whereas the remainders visit spring/spa
destinations only annually. The vast majority of respondents (about 77%) have visited
spring/spa destinations more than once before, whereas the rest have visited spring/spa
destinations for the first time. This result indicates that Taiwanese mature travellers have
experience in purchasing spring/spa products.
The majority of respondents indicated that they usually make visit to spring/spa destinations
or stay only one night in these destinations. This suggests that mature travellers in Taiwan
generally stay for a very short time at spring/spa destinations. Nearly half of respondents
reported that they have visited natural spring/spa destinations for curative purposes.
In visiting group, more than half of the respondents (60%) were travelling with family as the
primary party, and about 30% visited spring/spa with friends and colleagues. The social
change in Taiwan increased opportunities for target marketing based on different family life
cycle stages, for example, increased economic status and leisure time combined with shorter
working hours in modern life. The notion of travelling with family members was the most
commonly reported motivation. Regarding the spending at sparing/spa destination variables
present more than 50% of respondents that they spend less than NT$10,000 (less than £200)
on spring and spa products each year whereas the remaining 39% of mature and 17% of
younger travellers spend NT$10,000-$40,000 on spring and spa products each year.
Factor analysis was performed to identify the underlying dimension of travel motivations in
this study. These include 24 push and 19 pull motivation variables were initially chosen to be
factor analysed. Using the PCFA orthogonal varimax rotation was performed to reduce the
push items and pull items of Taiwanese mature spring/spa travellers’ motivations into specific
underlying constructs. In addition, by using the statistical technique is to determine the linear
combinations of motivation variables and investigate the interrelationships between. Items
were dropped from further analysis while low correlations with the overall score of the
The first step of PCFA was examining if the inter-correlation among the variables meet the
similarity variables. Followed, the latent root criterion factors were extracted only eigenvalue
greater than one. As the rules of principal components with higher variance than the
standardised original variables should be extracted. The extracted factor communality loading
greater than 0.50 was valid to include items in a factor. Regarding the reliability and validity
of factors was measured by Chronbach’s Alpha, it was calculated for each of identified
dimensions to test the internal consistencies and reliability of each specific dimension.
The PCFA technique came up with three underlying spring/spa destination attributes:
commercial Internal, commercial external, and nature & friendly services. Four underlying
push motivation factors were ‘personal health & building relationship’, ‘education &
learning’, ‘feeling good’, ‘arranged treatment’. The main distinguishing of motivation
dimensions were the ‘personal health & building relationship’ and ‘commercial external’,
which appeared has a significant differences regard to the age groups.
The results of this study suggest that at least four main motivation dimensions benefit
spring/spa tourism exist in Taiwan. In addition, it appears that mature travellers are looking
for different products and services of benefits in order to meet their needs. These imply that
the marketing segmentation should be clearly identified. Those information can be use to
guide decisions related to marketing strategies development, quality of spring/spa
environment, or social responsibility expansion.
Conclusions and implications
The mineral springs tourism is much different and beginning to change in Taiwan society.
People visit spring or spa destination can be relaxation or for curative with alternative
therapies purposes. In the new emerging spring and spa marketer start conscious that the
opportunities of the market segments; and promote different packages and services in order to
attract health travellers. One of the most important for marketing strategies is the need for a
clear of the wellness concept from the therapeutic. The findings will point out health
spring/spa marketing implications in conjunction with the theoretical framework, will add to
knowledge of the practical mature travel group, will help make improvements to government
policy, and will work towards the methodological concerns in the further research. To have a
leading edge in the competitive health tourism, spring/spa marketers need to keep in mind that
the changeable motivaions and trends for understand different spring or spa travellers’ needs.
The further recommendations are aimed in the spring/spa tourism market:
• To distinguish spring and spa travellers from spiritual and rehabilitation
• Manage the high level of qualifed staff with further training in treatment skills
• Establish good relationship and cooperate with policy makers
• Explore suitable wellness programmes to meet different group needs
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Natural wellness - Health and wellness as nature-based tourism product
Edward H. Huijbens
Director,Icelandic Tourism Research Centre
This paper is set in the context of a two year research project funded by the Nordic Innovation
Centre (NICe), dealing with Nordic wellness and wellbeing. The researchers of the project
collaborate with budding health and wellness destinations, one in each of the Nordic countries
in order to establish a Nordic wellness concept and develop user-drive product improvements.
This paper deals specifically with the Icelandic case being studied under the terms of the
project and will combine nature-based tourism with that of health and wellness. Nature-based
tourism is by far the most prominent form of tourism in Iceland. Albeit vaguely defined it
entails tourism in natural settings, tourism focusing on elements of the natural environment
and tourism developed to conserve or protect natural environments. This paper looks at a
development of a geo-thermal spa, much like the Blue Lagoon, but in the NE corner of
Iceland near Lake Mývatn, a famed nature-based tourism destination in Iceland. The current
spa facility was erected in 2004. It builds on a long history of locals using the thermal waters
and steam coming from the ground for wellbeing, and is gaining steadily in visitor number per
annum. Emerging from research amongst stakeholders involved in the building up of the
Mývatn Nature Baths in NE Iceland was the role nature plays in health and wellness. Both as
a fundamental concept of being in nature and/or at one with nature, and more specifically
through health and wellness related activities in a natural setting. The paper will explore some
of the tentative product manifestations and ideas of these emerging themes and their
implications for product development in health and wellness tourism for NE Iceland.
Budapest’s thermal spas on screen
Associate Professor, Kodolányi János University of Applied Sciences, Tourism Department.
The phenomenon of film-induced tourism has been well-documented in a number of locations
world-wide. Feature films have become one of the most powerful tourism marketing tools
offering an alternative selling method for destinations. Budapest’s famous thermal spas
several times hosted international film productions, such as Red Heat (1988) with Arnold
Schwarzenegger and I, Spy (2002) with Eddie Murphy and Owen Wilson. The Hungarian
capital, well-known for its health tourism, but not for film-tourism, is clearly identified in
these movies as a city of spas. The types of attracting qualities are as diverse as the films in
which they reside. Usually viewers attach an icon to the location they have seen in a film,
therefore locations which carry an emotional charge can easily be identified. Swimming pools
used by the Hungarian national water polo team are strongly linked to national identity. The
primary sites for the CCCP-Hungary, so called ‘blood in the water match’ in The Children of
Glory (2006) were swimming pools used by the Hungarian athletes (BVSC on Szőnyi street
and Alfréd Hajós).
In film-induced tourism literature much emphasis has been given to the significance of films
and locations in terms of its economic generation and on the motivations of visitors
(Provenzano 2008; Beeton 2005; Riley-Baker-Van Doren 1998; Toke-Baker 1996), or
recently a growing interest exists in the study of the impact of successful television
programmes on local enterprises (Connell-Meyer 2009; Irimiás 2008; Messina-Bocchioli
2008; Connell 2005). There, however, appears to be very little research on the films’ impact
on a different tourism product, like health and wellness tourism, and the role of a successful
movie production in reinforcing the image of the spa and the location.
The aim of this paper is to analyse the relationship between film-induced tourism and health
tourism and to elaborate a model of a possible collaboration. The research is based on a
questionnaire survey carried out in 2009 among foreign tourists staying in Budapest (the
collected data was analysed with SPSS), and on semi-structural interviews with Hungarian
Keywords: film-induced tourism, destination image, Budapest, spas.
Films provide the objects and subjects for the gaze of many people, and movies may induce
them to travel to the location where the film was set (Riley-Baker-Van Doren 1998). Image is
central to marketing, even more so in tourism destination marketing, which promotes an
intangible product. Destination imaging is multi-dimensional, comprising both symbolic and
tangible features (Beeton 2005). Image influences tourism related attitudes and it affects the
individual’s perception and consequent behaviour (Gallarza-Saura-Calderòn Garcìa 2001).
Moreover, image has long been considered as a primary decision-making factor in holiday
travel. The importance of tourism destination image has been widely studied and the image
has emerged as a crucial marketing concept in the tourism industry (Hall 1999).
Visual culture may influence many aspects of everyday life and the effect of film on human
behaviour has long been debated mainly in psychological and sociological studies. In some
feature films the development of a country’s identity, image and cultural representations can
be traced through popular film and television series. The Lord of the Rings saga and its impact
on New Zealand’s tourism is one of the best examples of film-induced tourism (Buchmann-
Moore-Fisher 2010; Corl-Kindon-Smith 2007).
Tourism images are developed from the stories of returning travellers as well as the media of
the day. In a wider sense, news coverage and popular culture (as in films, television programs,
and literature) can provide substantial information about a place in a short period of time.
Additionally, while watching a film, people usually are more open to all the information
because they do not feel to be targeted for selling promotion compared to traditional
advertising. Further, news and popular culture products are so deeply embedded in every day
life that they are likely to have high market penetration. Thus, portrayals of places in news
and popular culture can alter an area’s image significantly, even in a short period of time.
Motion pictures are an important element of popular culture. They may impact on many
people and few would deny that movie-going and television watching are the major leisure
activities in the Western world. Usually popular films dominate the movies for a relatively
short period, however, the impact of popular films on individual and societal beliefs and
behaviours will continue to increase as cable television, DVD use, and internet downloads
diffuse rapidly. A film may create and prolong interest in a destination. According to Butler
(1990) what is shown in movies, videos, and television will become even more important than
print media in shaping images of, and visitation to, places, due to expanding accessibility and
high credibility of these information sources. It can be affirmed that contemporary tourists’
organic images of places are shaped through the consumption of film and television series
without the perceived bias of promotional material. Recognising that movies can enhance
awareness of places and affect decision-making processes, marketers are increasingly working
with film producers to promote their destinations as possible film locations (Beeton 2005;
Seaton and Hay 1998).
Tourism holds an important position in the substantial political, economic and social
restructuring processes which have taken place in Central and Eastern Europe (CEE) in the
past two decades. The ‘re’-imaging of the region faces different challenges and niche tourism
products need to be developed and marketed in response to the changing nature of tourism
demand. Similarly, CEE cities like Budapest in order to enhance their role as tourism
destinations are trying to create new and unique experiences for visitors (Rátz-Smith-
Michalkó 2008). Brand identities are based on culturally distinctive features and new tourism
trends like film-induced tourism may have a key role.
This paper is concerned with the process of image formation related to film tourism. In the
focus of the research the analysis of Budapest’s identity on feature films can be placed, with
special attention on spas and baths. The featuring of spa locations in the Hungarian and
international film productions may offer different aspects of health and wellness tourism
image formation and a co-operation between film commissions and the Hungarian tourism
authorities would be auspicious.
Budapest as film location
The power of film to motivate travellers, create new images, alter negative images, strengthen
weak images, and create and place icons is recognised by many as a major factor in tourism
promotion (Beeton 2005).
Films familiarise audiences with places and attractions featured in them. Riley and Van Doren
stated that ‘Extended exposure to attractions through the medium of film allows potential
tourists to gather information and vicarious knowledge, therefore lowering the anxiety levels
caused by anticipated risk’ (1992:269). Thus, it is proposed that observing a movie can
increase the degree of familiarity with the places it portrays.
That is, the popular view of a place offered by media may prompt that place to recreate its
own identity in this image. This recreation of place identity implicates different levels of
culture, and language, including the visual language of television, films, and other mass
media. This implication provides representations that produce meanings which may reinforce
place identity. These meanings regulate social practices, influence people’s behaviour, and
consequently might have real practical effects. In particular, movies, as visual language, have
been one of the major vehicles to construct and transmit meaning, often of places with which
people do not have first hand experience.
The Hungarian capital has recently became ‘film friendly’ with a number of film commissions
and film offices working on the promotion of the city as an ideal film location. Korda Studios
established in the nearby of Budapest offers a wide range of film locations that might be
attractive to film producers. Macionis (2004) discovered the international exposure a film can
provide a destination; a film is an advertisement potentially viewed by millions of people who
may be tempted to become film induced tourists.
Films are often not shot at the locations they purport to be, however benefits of film-induced
tourism can be traced only if the viewers can clearly identify the film location with the
destination they are interested to visit. Moreover, considering the issues of cultural identity of
a place and its role on films it seems to be clear that a film can reinforce the country’s identity
if they are interrelated.
Natural landscape or atmosphere can be featured as backgrounds in a film, however the
storyline and the characters add some emotional charge to places. This interrelationship of
cognitive and affective image components eventually determines the predisposition for
visiting a destination.
Research hypothesis and study methods
Based on the conceptual framework described in this study, two hypotheses were considered:
Ha 1: The perceived destination image of Budapest will be reinforced through the films set
Ha 2: Budapest identity as a city of spas will be reconfirmed through the films
The study was conducted using bilingual (English and Italian) questionnaires among foreign
tourists staying in Budapest. The research was carried out in March-April 2009 and 600
tourists were asked to fill in the questionnaire. Due to incomplete questionnaires a total of 67
were dropped out of the sample. Consequently, 533 usable responses were available at the end
of the research, meeting the criteria for statistical estimation for data analysis.
The questionnaire comprised 17 questions and classified the respondents by age, gender,
origin, first visit to Budapest, length of stay, whether they travelled independently or as part
of a package.
To measure the cognitive component of participants’ image of Budapest, 11 image attributes,
which were measured by five-point Likert type-scale, were included in the questionnaire.
These 11 items refer to historical attractions, atmosphere of the destination, and lifestyle of
local people. In order to measure the impact of films on Budapest tourism destination image, a
popular motion picture was defined as a film produced for the entertainment of the general
public employing plot and characters. A total of 38 film titles were selected to be included in
the questionnaire. The selection of the films was based on the film location, all the 38 was set
in Budapest, and the productions are Hungarian (17 films) and international (21 films) as
Tourists who were familiar with some of the film titles were asked to underline those films
which according to them, were set in the Hungarian capital city. They were also asked to
nominate those films that give a positive image of the city, as well as those that give a
negative image of the city in the film productions.
Budapest identity and its role in film tourism
Tourists’ perception of Budapest was measured by the 11 image attributes given in the
questionnaire. In a five-point Likert-type scale these image attributes were measured, and the
mean value 4.05 (n=533) clearly shows that those tourists who participated in the research
identify Budapest as a city of spas (Figure 1.). Budapest’s imposing baths such as Gellért Spa
Baths and Hotel on the Buda side, and Széchenyi Baths in the Pest side of the city are
considered to be the landmarks of the capital, as well as to be the leisure places preferred by
Figure 1 Perception of tourists on Budapest
City where is good to live
City where is good to have holiday
The city of spas
0 1 2 3 4 5
Source: data collected by the author (2009)
Usually viewers attach an icon to the location they have seen in a film, therefore locations
which carry an emotional charge can easily be identified. Swimming pools used by the
Hungarian national water polo team are strongly linked to national identity (Table 1.). The
Children of Glory (2006) Hungarian film production is a commemorative film about the
national revolution of 1956 against the Soviet ‘Empire’. The days of heroic fight and struggle
against the Soviet army on Budapest’s streets and in the major cities of Hungary coincide with
the world-famous water polo match played in the finals of the Melbourne Olympic Games. In
the film, the primary sites for the CCCP-Hungary, so called ‘blood in the water match’ were
located in swimming pools in Budapest used by the Hungarian athletes (BVSC on Szőnyi
Street and Alfréd Hajós). In certain types of place-oriented movies, viewers are offered the
opportunity to learn about the place by imaginatively participating in the place-related
experiences of the characters (Kim-Richardson 2003). These swimming pools, however not
considered as tourism attractions, may be identified as the spaces of national proud of
Hungarians and the icon attributed to the film (national proud) could be indentified as a
thematic icon. In The Children of Glory film the above mentioned water polo match against
the Soviet national team takes place in Melbourne, and the name of the athletes swimming
pools are not cited at all. The identification of the film location using the film icon related to
the place may induce film tourism only if the film viewers are aware of original place where
the film was actually set. In this case, it could be stated that The Children of Glory may not
generate any film tourism phenomenon in Budapest, however it reinforces the image of
Hungarians as heroic and proud people through a significant water polo match and film
viewers may have the opportunity to learn about the city from a different angle of view.
In the case of these two movies, Hypothesis 1 (The perceived destination image of Budapest
will be reinforced through the films set there) seems to be confirmed and film images could
be used to reinforce Budapest’s tourism destination image.
Table 1. Film icons in spa-located movie productions
Title of Film Spa-locations in
The Children of Glory 2006 BVSC Budapest National
Made in Hungária 2009 Csillaghegyi
Swimming Fun, youth
I, Spy 2002
In bed with the opposition 1997
The Children of Glory 2006
Mrs Ratcliffe’s Revolution 2008
Gellért Spa Baths Aristocratic beauty, built
Hajós Alfréd Swimming National proud
The Double Life of Mrs. Mici 1962
Lukács Thermal Baths Third-age love affair
Red Heat 1988 Rudas Thermal Baths Mystery
Just sex and nothing else 2005 Szécheny Spa Budapest Built heritage, human
Io e mia sorella 1987
Source: data collection by the author 2009. Table structure based on Riley&Baker&Van
Doren (1998: 924)
Some icons, like built heritage and aristocratic beauty of the traditional spas in Budapest, can
be recurrent or continuing images within a film, highlighted by the strong marketing
communication based on these places as well. Other icons which may attract visitors can be
single exciting events (the water polo match) which viewers can identify with the space they
are interested to visit.
Film icons may not all be visual as they may be storyline themes or atmospheric background
for the plot that may become associated with locations. Example of visual icons is the
American production I, Spy starring Eddie Murphy where Gellért Spa Baths, along with the
Buda Castle district and the Chain Bridge over the Danube offer a powerful overview of the
riverside and an outstanding panorama of Budapest. Gellért Spa Baths is not featured as the
main spa and baths centre of Budapest, instead the location was used to host scenes in an
elegant and sophisticated environment. In this film, the name Budapest and the Gellért Spa
Baths are mentioned several times and film viewers may easily identify the locations.
Hungarian film productions, even if translated, have limited distribution within Europe and
even less overseas, on the contrary the I, Spy film has been broadcasted in the United States of
America and in numerous European countries as well. Major films may have more than one
icon that film tourist associate with locations. The physical icon has been illustrated above,
however a detailed research on the effects of the I, Spy film on Budapest, and even more
precise on Gellért Spa Baths still has to be done.
The above mentioned film productions are clearly linked to Hungarian culture, to Budapest
and to the spa traditions. However, in several feature films Budapest plays the role of another
European capital, and the identification process is accessible only to those who are keen to
search for the real location of the film or already has some knowledge of Budapest’s iconic
spas and baths. In the case of the Red Heat (1988) film starring Arnold Schwarzenegger,
Rudas Thermal Baths is featured in the opening scene of the film. Schwarzenegger plays the
role of a Soviet soldier searching for a cruel criminal within the spa. In a mysterious and
vaporized atmosphere created by suffused lights the film viewer is guided through different
parts of Rudas Spa, however the city plays the role of Moscow, the Russian capital.
The other case of Budapest missed identity is the example of Mrs Ratcliffe’s Revolution
(2008) in a recent film production, twenty years after the Red Heat. This comedy is about a
British family eager to move to East Germany during the years of the Cold War because they
believe in the ideal life on the Eastern side of the iron curtain. In Mrs Ratcliffe’s Revolution
Budapest plays the role of East Berlin, and mainly derelict areas of the city were used as a
film location. The Hajós Alfréd Swimming Pool is featured in the scene when Mrs Ratcliffe
tries to organise her family’s escape from ‘East Berlin’ and the only neutral place to discuss
such a crime is the swimming pool.
Budapest missing identity in several films when the Hungarian capital plays the role for
example of Buenos Aires (Evita), München (München), Moscow (Red Heat) or Berlin (Mrs
Ratcliffe’s Revolution) is evidenced also by the questionnaire research carried out among
tourist staying in Budapest. From the 38 film located in Budapest, only a few films were
linked to the Hungarian capital as the film’s location. The respondents could indentify
Budapest as the film location only in those films that can be clearly related to Hungarian
culture or history (like Sunshine, The Children of Glory, Fateless). This means that the other
films, even if successful movie productions, miss to contribute to Budapest promotion
through films because the featured sites, however being of national pride and the key tourist
attractions, for the general movie-goers can hardly be recognized and linked to Budapest.
In the second part of the questionnaire, respondents were asked to value on a scale from 1 to 4
six different statements, all related to film tourism in Budapest. In the questionnaire the
statements follow the 38 film set in Budapest in order to help association of Budapest as a
film location, and to make the participants remember the films they might have seen. The
mean value of the answers shows that those who participated in the research think the
Budapest’s thermal spas are well represented on films (2.15) and that it is interesting to know
which films were shot in Budapest (2.21). However, according to the mean value of the
answers it cannot be stated that films strongly influence tourism towards Budapest.
Table 2. The perception of Budapest as influenced by films
Item Scale Mean
The films set in Budapest contribute to the positive image of
I can know Budapest better through the films set there. 1-4 2.51
It is interesting to know which films were shot in Budapest. 1-4 2.21
A film can influence my choice of a travel destination. 1-4 2.42
If a movie map was available in my hotel, I would use it and
would visit the film locations.
I think that Budapest’s thermal spas are well represented on
films, and give a good impression about the city.
Scale: 1= Strongly Agree and 4 = Strongly Disagree.
According to the mean value of the answers given for the statements, it can be stated the
Hypothesis 2 (Budapest identity as a city of spas will be reconfirmed through the films)
cannot be reconfirmed, nevertheless several key attraction spas feature in different movies
located in Budapest. In the research it has been evidenced that Budapest’s missing identity,
her acting as other European cities, might cause some confusion in place identification.
Films have been, without a doubt a tourist inducing ingredient, turning destinations of little or
no importance into much visited tourist attractions. Even if not all films have such an effect,
nonetheless it cannot be disputed that films in general do affect the image of destination. For
that reason, it is important that a well-planned image management plan to be produced for
destinations. A tourist visiting a destination after seeing the location in a film or television
series is an emerging phenomenon and due to the momentous impacts, many films have had
their locations research into the issues relating to film induced tourism.
Film-induced tourism in Budapest is a new phenomenon and what has emerged from the
research is that tourist even if they are familiar with some films set in the Hungarian capital,
would not acknowledge a strong motivational influence on their decisional process when
selecting their holiday destination.
By understanding the film tourist phenomenon, tourism and film stakeholders can better meet
experiences, thus expanding on the positive impacts of such destinations. Tourism destination
marketing ideally requires cooperation and input from all the sectors of community –
businesses, interest groups and local inhabitants. During the planning of tourism development,
conscious destination strategies that aim to create positive images of the destinations and
imprint them in potential visitors’ imaginations are developed.
In Hungary health- and wellness tourism have become key tourism products and a strong
marketing strategy has been based on them, promoting the medical and treatment services,
leisure time in spas and baths. However, in the marketing strategy the powerful images shot in
different spa locations of Budapest are unfortunately missed out. As stated above, several
feature films, Hungarian and international productions as well, used Budapest’s flagship
attractions like Gellért Spa Baths, Széchenyi Spas or Rudas Spas as key film locations.
On screen Budapest’s spas carry a well-defined identity and emotional links to the location
may be recognised in some feature films. The meaning of a place reinforced in some movie
productions and the film-viewers familiarity with the place starring on screen could offer
unparalleled possibilities to enhance the marketing strategy based on different tourism
products. Film commissions in Budapest are already promoting and selling the unique places
of the Hungarian capital city to host films, but until now this promotion has not been linked to
tourism marketing. A possible collaboration between the film industry and the tourism
industry could reinforce Budapest’s cultural identity.
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THE EVOLUTION OF ATTITUDES TOWARDS SPA HOLIDAYS IN CANADA
Marion Joppe, PhD,
School of Hospitality and Tourism Management
University of Guelph, Guelph, Ontario
Hwan-Suk Chris Choi, PhD, Associate Professor
School of Hospitality and Tourism Management, Macdonald Stewart Hall, University of
Guelph, Guelph, Ontario, CANADA, N1G 2W1
Canada is a fairly recent newcomer to the world of spa tourism. According to a
PricewaterhouseCoopers study on the spa industry, undertaken on behalf of the International
Spa Association, between 1990 and 2001, the number of spa establishments in North America
went from 1400 to 10,900, of which 1300 were in Canada, and occupancy went from 40% to
an average between 70 and 80%. Instead of slowing things down, the events of September 11,
2001 actually spurred growth in this sector. By 2003, the International Spa Association
(ISPA) estimated the number of establishments to have reached 12,100 spas throughout the
U.S and 2,100 in Canada, a 26% growth in the States but 65% growth in Canada!
In North America, health has become a major societal preoccupation, since all media bombard
citizens with warnings about too sedentary a life, the health dangers of too much weight,
cholesterol and stress, too little sleep, and high tension. Foods are considered too fatty, too
sugar and salt-laden; both the air and the water is making people sick. If all that were not
enough, North Americans have been made anxious, if not downright paranoid, about
everything from possible terrorist attacks to catching SARS (Severe Acute Respiratory
Syndrome), the avian flu or H1N1. At the same time, the strong baby boom cohort is
becoming obsessed with aging, refusing to give in to wrinkles and sagging bodies. So it is not
surprising that North Americans are desperate to find an oasis, a place where it is possible to
be at peace, breathe deeply, regain one’s internal balance, re-establish the harmony between
body, mind and soul so that they can confront this fast-paced, complex and increasingly scary
world another day. Yet that older cohort is no longer prepared to make big efforts and huge
sacrifices to look and feel better, as they did just a decade previously. The time has come to
be kind to ourselves: to strive for balance, harmony but also pleasure. Spas are seen as a
means of escaping the pressures and getting re-energized” (Association Resource Centre Inc.
Health is no longer considered just an absence of illness, but rather an optimum state of
physical, mental and social well-being that requires a more holistic approach and proactive
participation by the individual (Nahrstedt 2004). The World Health Organization 8 defines
8 World Health Organization (1946). Preamble to the Constitution of the World Health Organization as adopted
by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the
representa-tives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into
force on 7 April 1948.
health as “a state of complete physical, mental and social well-being”, which reflects a
preventive way of living that reduces, and even eliminates, the need for remedies. Thus,
health tourism refers to someone who has one or more medical conditions that would make
him travel to experience therapies that help to make him well - or to improve his health. On
the other hand, the concept of wellness emphasizes personal responsibility for making lifestyle
choices and self care decisions that will improve our quality of life. People who engage
in wellness tourism are generally healthy, but seek therapies to maintain this state of wellbeing.
While Europeans and Asians have recognized the benefits of “taking the waters” for
centuries, and the concept of “wellness” has been recognized as a major force in the United
States for more almost 20 years, it has really been part of the Canadian consciousness for only
about 10 years. In that time, however, a significant change in attitudes has taken place.
One of the first comprehensive assessments of travel behaviour and motivators, including
interest in vacations at health spas, was the Travel Activities & Motivation Survey (TAMS),
completed in 1999, and repeated in 2006. For both studies, Statistics Canada undertook the
survey of Canadians, using random digit dialing to obtain samples stratified by census
metropolitan area (CMA). The samples were restricted to all persons aged 18 years of age and
older in the ten Canadian provinces and full-time residents of institutions were excluded.
Travellers who took an out-of-town trip of one or more nights in the past two years were
identified via the screening telephone interview.
In 1999, the telephone survey was completed by 18,385 individuals. Respondents were
selected randomly within the household. 24,635 qualified for the mailback questionnaire. Of
these 5,490 (35.2 %) returned the questionnaire. Using gender, age, education level and
income, responses were weighted to project the results to the national level. 2.4% (470,853
when weighted to the population) of Canadians (as compared to 4% of Americans) had stayed
at a health spa during the past two years. This survey also asked about travel intentions in the
next two years, and identified 6.7% (1,314,463 of the population) of respondents as
expressing an interest in visiting a health spa.
In 2006, the telephone survey was completed by 53,150 individuals and a total of 24,692
(53.5%) travelers completed the mail-back survey questionnaires. This survey contained two
activity variables of interest: “Day visit to a health spa and wellness spa while on a trip of one
or more nights" and “staying at a health spa”. For each variable, it was possible to choose
either “On out-of-town trips of one or more nights in past 2 years” or “Main reason for taking
any of these trips”. Among 24,692 Canadian overnight travellers, 2,538 made a day visit and
1,426 stayed at a health spa. When weighted to the Canadian population (Statistics Canada,
2006), it was determined that 11.0% or over 2.23 million of Canadian overnight travelers
visited a health and wellness spa and/or stayed at a spa resort while on an out-of-town,
overnight trip of one or more nights.
In addition to analysis of the weighted data using frequency, chi-square and analysis of
variances techniques, the odds ratio was used as a measure of association. Due to the large
sample size, all results were significant at the 0.001 level or better.
Demographic characteristics of spa-goers
While only 2.4% had visited a spa during the previous two years while on an overnight trip in
1999, this percentage had increased to 11% seven years later. In addition, 34% (almost
800,000 respondents) reported that this activity was the main reason for taking at least one
trip. While only Saskatchewan showed a high participation rate in 2000 (8% of overnight
pleasure travelers), by 2006, Saskatchewan (13.6%), British Columbia (9.3%) and Quebec
(8.3%) were all above average. In 1999, women were 47% more likely to have visited a health
spa, but there was relatively little variation by age in the incidence of health spa visits, and the
levels of formal education and household income were only weakly associated with health spa
visits. By 2006, the picture had changed quite dramatically: women were 70% more likely to
have visited a health spa, and spa visitors were over-represented among those 25 to 54 years
of age and especially among Mature Couples. In addition, they were the third most likely to
have a university degree and had the highest household income of any of the culture and
entertainment activity types.
Indeed, there was a significant shift between 1999 and 2006 in the income groups that are
both staying at health spas and participating in health and wellness spa activities. Whereas in
1999 the majority of health spa goers earned $60,000 and more, by 2006 the majority earned
$80,000 and more. This middle-aged group is, however, increasingly introducing both their
parents (mainly mothers) and children (mainly daughters) to the spa experience, contributing
to the extraordinary growth in demand for facilities as well as treatments.
Segmenting the spa segment
Spa-goers made an estimated 14.1 million visits to Canadian spas. Half of these visits were
taken to spas in Ontario and four out of five spa visits in Canada were made to day spas (11.3
million). Over 40% of the Canadian adult population visits day spas while at home (Table 1):
Table 1 Frequency of Spa Visitation
During the past 12 months, how
often did you visit a day spa?
Frequently 398,952 5.4
Occasionally 2,603,110 35.1
Rarely 4,404,814 59.5
Total 7,406,876 100.0
Source: Lang Research Inc. (2007).
It is clear that the spa segment is not a homogeneous one. In a 2006 study by The Hartman
Group, three types of spa-goers were identified, based on the frequency with which they seek
out these experiences and their attitude towards them: core spa-goers are knowledgeable
about treatments and feel that learning about and going to spas is important to their lifestyle,
while periphery spa-goers (at the other extreme) enjoy going to spas but otherwise show little
interest in them. Between these two segments is a mid-level spa-goer segment that is
interested in learning about spas but lacks the commitment and passion of the core spa-goers.
If we take a closer look at that 40-50% of spa-goers that will travel for the purpose of spa and
wellness tourism, it is probably not surprising that these tend to be more core spa-goers, who
are not only experienced, but have already tried a range of products and services and are thus
the most critical. The majority considered themselves to be in good or excellent health and of
average weight. In spite of this, they worry about their health, including what they eat and
how much exercise they get. Two-thirds of them take vitamins; and 61% limit the amount of
fat they eat. So, while relaxation is their primary motivation for choosing a spa during their
holidays (rated 2.74 on a 3-point benefit scale in terms of importance), with pampering and
stress reduction as secondary motives, a majority reported healthy meal choices to be
important in the selection of accommodations. This does not mean that spa-goers forsake
pampering: indeed, they are 2.5 to 2.7 times more likely to seek this as a somewhat to highly
important benefit compared to other pleasure travellers. But only 37% said workout facilities
were important which corresponds to their general attitude towards active involvement in
regular fitness programs (rated 2.8 on a 5-point Likert scale). Nonetheless, odds are 50%
higher than for other pleasure travelers that being physically challenged/energized is a highly
important benefit sought of their spa vacation and .
This, then, is the dramatic shift in perception we have seen from spas as “indulgence”,
providing the ultimate in luxury and pampering: today, luxury is a given at any spa, but the
“spa experience” that incorporates a tranquil, airy setting and information about health,
wellness and self- or at-home care, in order to maintain a balanced lifestyle, is seen as a
component of long- term, healthy living.
The need for quality assurance
Considering the demographic profile of spa-goers, it is somewhat surprising that no
government has felt the need so far to impose any quality standards or regulate against
possible fraudulent claims coming out of the many different treatments proposed, vitamins,
supplements and lotions used, and statements made as to the psychological and physical
improvements to be expected. Even ISPA has recognized that “as the spa industry continues
to grow and expand to mainstream consumers and their health and wellness regimes,
therapists’ credentials as well as the overall effectiveness of the spa experience (menus,
pricing, environment, “extras,” etc.) will come under greater scrutiny by all segments of
consumers.” (The Hartman Group, 2006: 3).
Indeed, one of the more recent research studies clearly indicates the quality of the treatment
and services as well as the hygiene of staff and cleanliness of the spa facilities are the top
concerns of spa goers (The Hartman Group, 2006).
Table 2 Spa Traveller Concerns with Spa Treatments
Quality of treatment/services 35% 47%
Cost of services 36% 41%
Hygiene of staff and cleanliness of spa facilities 41% 39%
Benefits of treatments 29% 27%
Certification/Training of personnel performing treatments
Source: The Hartman Group (2006).
Premier Spas of Ontario as well as its Quebec counterpart, Relais Santé, are the only industry
associations in Canada that have recognized the need to provide consumers with a guarantee
concerning both the facilities and treatments they will find at a spa, and the professionalism
and credentials of the staff. Acquiring the Premier Spa accreditation by Spas Ontario Inc. is a
comprehensive process involving application, inspection, report submission, and acceptance
by the Board of Directors. The “Insight” lays out the stringent criteria for membership which
give consumers comfort and reassurance about the professionalism and credentials of the
person or persons into whose care they are putting their body, their mind and their soul.
Relais Santé follows a similar approach. Thus, these two organizations have laid a solid
foundation to take advantage of the growth in what can be considered a ‘super-trend’ and
squarely address one of the major consumer concerns: quality assurance and consistency with
respect to the facilities, spa products, services and treatments provided. For instance, massage
therapy training in Ontario is more extensive than that found elsewhere and this province’s
therapists are controlled by a government regulated college – both go a long way to reassuring
Reaching the spa tourist
As profound as the changes in the demographic characteristics of spa-goers have been since
1999, so have the changes in information sources to which they resort. By far the most
common source of information in 2006 was websites: over 80% of people who participated in
health and wellness spa activities used them. This compares to less than 37% using the
internet in 1999. Perhaps not surprising given their profile, the most visited types of websites
involved travel (68%), entertainment (55%) and health (53%).
The only other sources of any significance that were more popular in 2006 than in 1999
included recommendations from friends and relatives (63% compared to 55%) and the
respondent’s own past experience (59% compared to 57%). Even though all other forms of
information sources have seen more or less steep declines over the years (e.g., the use of
travel agents has dropped from 61% to 51% over the seven year period), the odds are quite
high that spa-goers use them For example, spa-goers are twice as likely as non spa-goers to
use a travel agent as an information source.
Spa visitors are also very inclined to use the Internet to plan travel (89%), and rely heavily on
accommodation (67%), airline (57%), travel planning/booking (e.g., Expedia, Travelocity –
54%), and DMO websites (54%). They are also among the heaviest users of travel media, and
are particularly avid readers of health and wellness magazines and websites, city lifestyle,
fashion and beauty magazines, and watch ‘better living’ programming (Lang Research Inc.,
2007). Finally, spa-goers have always been more likely to book travel over the internet as
well: already in 1999, 29% of those who had visited a health and wellness spa booked their
trips this way, compared to 23% of those who were merely interested and 18% of those who
were not interested in visiting them. (Lang Research Inc., 2000). By 2006, fully 68% of spagoers
booked their stay over the internet, while 77.3% booked their accommodation and 76.9
% booked their airline ticket, behavior that is significantly higher than pleasure travelers in
Since spa-goers are particularly interested in “luxury resort vacations that are relaxing and
pampering, and that offer novelty, intellectual stimulation and physical challenge” (Lang
Research Inc., 2007: 1), it is important that any promotion focus on these benefits. Spa-goers
are one of the most likely segments to book their vacation experience over the internet (68%),
largely through accommodation websites (77%).
Generally speaking, “spa visitors are extremely active in both outdoor activities and in culture
and entertainment activities while on trips. They frequently exercise and jog, and are much
more likely than the average Canadian pleasure traveller to participate in strenuous winter
activities (e.g., cross-country skiing and snowshoeing, downhill skiing) and summer sports
(e.g., golf, tennis). They also frequently attend live art performances (e.g., live theatre, high
arts, comedy clubs and festivals) while traveling and exhibit particular interest in fine cruise
(e.g., wine, beer & food tastings, inn or resort with gourmet dining)” (Lang Research Inc.,
2007: 1). Indeed, there are a number of activities where the odds range from close to three to
four times as likely that they will participate compared to non-spa goers. These include: ice
climbing, dog sledding, hang-gliding, hot air ballooning, bungee jumping, horseback riding,
windsurfing, cross- or back-country skiing, playing squash and tennis, working out, attending
jazz concerts, recreational dancing, dining in restaurants with an international reputation,
shopping/browsing in gourmet food retail stores and for clothing, shoes and jewellery. They
are also three times more likely than non-spa goers to stay in a resort, whether it is located on
a lakeside/riverside, in the mountains/ski or the seaside. And they are 5.5 times as likely to
have stayed in a cooking school; indeed, over 40% of those who participated in health and
wellness spa activities also stayed in one of these schools!
The explosion in spa products for sale in almost any store that carries personal care and
beauty products is both a result of, and a contributor to, the growth in spa visits. This
“personal introduction” is likely also the reason why even first-timers seem to have very high
expectations regarding their visit. Men, who are introduced to the spa experience, often by
their spouses, will usually start with a massage as they tend to be driven by notions of “work",
i.e., improving some aspect of their body, their emotional state or their long-term spiritual and
personal dispositions (The Hartman Group, 2004). Increasingly, however, they are warming
up to manicures and facials, largely as part of the broader societal trend that has seen a return
of the acceptability of male grooming, along with greater acceptance of the gay culture and
the rise of the “metrosexual” who has many of the characteristics of his gay counterparts, but
As the spa consumer becomes more knowledgeable and educated about available treatments
and their expected outcomes, he or she will increasingly look to the spa industry to provide
ever more information about every aspect of a wellness program, and spas will be judged on
their ability to make informed decisions and provide guidance in every aspect from menu
design and implementation, to which training and treatment programs to engage in and why.
But messages must go beyond addressing the core segment in terms of communications,
menu designs and available spa treatments: even though they are the most committed, they
represent the smallest percentage of the overall spa population, and thus, to convert the midlevel
and periphery spa-goers, the messages must also address their lower level of knowledge.
It is also important to realize that visits to day spas are an activity largely undertaken by
women, but spa travel is not: 42% of the Canadian health spa resort clientele is men. Staying
at such a resort is no guarantee, however, that they will actually participate in spa-related
activities as only 37% indicated that they did so, based on 2006 TAMS study. Still, facilities
at resorts and hotels must be adapted to a very discerning, mixed clientele, by also offering
male-focused activities like golf, outdoor adventure, male cosmetic programs, and highoctane
It is clear that this industry will have to place much greater emphasis on learning, by bringing
in knowledgeable speakers from both the conventional and complementary or alternative
medical fields to educate consumers who want to make informed decisions about their own
health. Especially the core spa-goers are craving this type of knowledge, and avidly pursue
their own understanding. Nutrition is already playing a much greater role as people become
more aware of health effects procured by different food items, and weigh different dietary
approaches to combat everything from obesity to medical problems. People’s anxiety over
genetically modified foods, additives and preservatives will lead them to sustain the growth in
organic foods and the popularity of farmers’ markets, regional cuisines, and traditional foods,
all of which are perceived to be more “natural” and therefore healthier.
Association Resource Centre Inc. (2006). 2006 Canadian Spa Sector Profile. Vancouver,
B.C.: Canadian Tourism Commission
Lang Research Inc. (2007). TAMS 2006: Canadian Travel Market - Visiting Spas While On
Of One or More Nights: A Profile Report. Toronto, ON: Ontario Ministry of Tourism and
Lang Research Inc. (2001). Interest in Health Spas (Profile Report), Travel Activities &
Motivation Survey (TAMS). Ottawa: Canadian Tourism Commission.
Nahrstedt, W. (2004). “Wellness: A New Perspective for Leisure Centers, Health Tourism,
and Spas in Europe on the Global Health Market” in Weiermair, K. & Mathies, C. (eds.).
The Tourism And Leisure Industry: Shaping The Future. New York: Haworth Hospitality
PricewaterhouseCoopers (2004). The ISPA 2004 Spa Industry Study. Lexington, Ky:
International SPA Association
PricewaterhouseCoopers (2002). The ISPA 2002 Spa Industry Study. Lexington, Ky:
International SPA Association
The Hartman Group (2006). Identifying the Spa Traveler: A Look at US and Canadian
Consumer Attitudes and Motivators for Spa Vacations. Canadian Tourism Commission
and International SPA Association.
The use of the internet in wellness promotion by Portuguese spas
Professor Auxiliar, DESG, CETRAD (ECHS),
Universidade de Trás-os-Montes e Alto Douro (UTAD),
Avenida Almeida Lucena 1, 5000-660 Vila Real, Portugal.
Until 2004, Portuguese spas were traditionally thought of as establishments in which noninvasive
therapies based on naturally-occurring sources of mineral water are provided under
professional supervision. With the publication of the Decree-Law Nº 142/2004, Portuguese
legislation regulating spas changed quite drastically: from that moment on, spa-owners,
numbering some 40 establishments countrywide, were allowed to open up what had hitherto
been a strictly health-orientated sector. Since then much has changed in the Portuguese
mineral springs spa market: one of the main innovations has been the introduction of a large
variety of services that may be termed “wellness treatments”, i.e. therapies not strictly related
to pre-existing health conditions. These are now being offered as a product range in its own
right along with traditional medical treatments, thus diversifying the services provided, all
based on the same highly therapeutic naturally-occurring mineral water. Thus spa services are
no longer just a health product, but have also become a tourist attraction, thereby legally
formalising something that, to a limited extent, had always been the case. With the change in
the services offered, the typical customer profile has also changed significantly: users of
today’s spa facilities are younger (between 25 and 45 years of age) than in the past, from the
middle to middle-upper socio-economic stratum, live in a large urban centre, have a
reasonably high level of education, and could be either male or female. Such clients prefer
making various short trips over the year to test out different destinations, and choose
registered hotels with 3 or more stars for their stays. The changing client profile has meant
changes in the means employed by firms to establish a growing and loyal client base. Indeed,
over the past five years, a large majority of Portuguese spa service providers have
significantly upgraded not only their services and infrastructures, but also their use of internet
sites. With these changes in mind, the study reported on here 9 aimed to analyse the way such
firms currently communicate with prospective clients using the web. The existing sites were
therefore systematically screened during the Spring of 2009 (30 sites) and 2010 (34 sites),
with a view to finding answers to the following questions: (i) how do they position their
medical/wellness products? (ii) to what kind of public do they address their internet-based
marketing efforts (iii) do they only mention their own services or do they also provide
prospective clients with links that give information on other service providers, such as travel
experts, sports organizations or nature guides? (iv) do the online marketing tools used by
these spas stimulate user-communities? The results of this study may offer not only
Portuguese but also spas in other locations the opportunity to further improve their dialogue
with current and potential spa-goers.
In Portugal, the supply side of health and wellness tourism consists of traditional spas based
on natural mineral water springs (that have existed since Roman times at least), some
9 This preliminary study was undertaken on our own initiative but the intention is to convert it into an
international comparative project furnishing results that may be applicable to the sector under consideration.
thalassotherapeutic establishments (registered from 1990, and using therapies exclusively
based on sea water), as well as a fast growing number of non-mineral water spas (established
since the beginning of the 21st century, based on water from the public supply network). In
numerical terms this situation translates into the following structure of suppliers: 38 mineral
springs spas that, in 2008 10 , were open to the public (Turismo de Portugal, 2009b); fewer than
10 sea-water units functioning in 2010 (Fernandes, 2006; Turismo de Portugal, 2009a); and
approximately 130 hotels with spa facilities reported by the Portuguese Hotel Association
(AHP) for the same year, which corresponds to an increase of more than 1500% over the last
8 years in the number of functioning “spa hotels” (Turismo de Portugal, 2010a). Meditative
and holistic retreats (on the one hand) and medical tourism focusing particularly on
aesthetic/cosmetic, dental and surgical treatments (on the other hand) are still in the
introductory stage of their life cycle and consequently it is impossible to quantify their current
share of the market – either because they are not yet the object of intensive promotion efforts
and/or because these subsectors' activities still remain largely unstructured.
This paper focuses on the spas that are based on mineral springs, commonly referred to in
Portuguese as termas (the local adaptation of the Latin thermae, meaning hot springs/baths).
In order to avoid misunderstandings and to emphasize the unique Portuguese context, it
should be underlined that for the Portuguese consumer the concept of “going to the termas”
has long meant undergoing therapy based on mineral water springs, i.e. only those who were
ill would “take the waters” and, consequently, mineral springs spa facilities were sought only
by the unhealthy and elderly. However, the number of spas nowadays greatly exceeded the
number of termas and recent massive marketing and awareness campaigns have facilitated the
introduction of the spa concept in Portugal, where the latter is now understood as a place (in
an urban/rural environment, in a hotel/fitness complex, in a beauty centre or even in the
traditional termas) where one can be pampered, but not necessarily with (mineral) water
treatments. We have to stress another difference, important for the development of tourist
products, between spa hotels and termas: the latter normally do not offer accommodation. On
the other hand, the traditional termas are no longer seen as mere therapeutic infrastructures
but also, and increasingly so, as places of leisure, recreation and relaxation. While, in
principal, the two dimensions – therapy and recreation – are two facets of nowadays spas that
can coexist in perfect harmony, the services provided by the emerging wellness tourism
market in Portugal are still thought of as being quite separate from those offered by the
turismo termal market (spa-based medical tourism), since Portugal has a much longer
tradition in the latter field (Lapa, 2009).
The main reason for finding these spas of analytical interest is the fact that they (i) are owned
by relatively small public or private investor’s groups, (ii) are typically autonomous rather
than part of a major grouping or conglomerate and (iii) are experiencing a phase of significant
adaptation that obliges them to market their services more directly and aggressively.
Based on a previously-conducted literature review, the empirical research analysed half of the
existing spa websites in order to find out (i) how the termas position and promote both their
traditional and new products, (ii) what kind of public they appeal to, (iii) whether they only
mention their own services or also provide information on complementary service suppliers,
such as travel experts, sports organizations or nature guides, to which potential clients are
redirected, and (iv) whether they use interactive techniques. However, before presenting the
results of this survey, the general context in which these mineral springs spas have evolved
will be described.
10 The most recent official statistics referring to the sector date from 2008.
The main characteristics of Portuguese mineral springs potential
In Portugal 408 springs with mineral water are reported to have therapeutic properties, and
three quarters of them (300) are recognised by the local population as having curative
properties (Sousa, 2006). In the spring of 2010 already 44 such spas were officially being
exploited. However, only 39 were open to the public, two more than in the previous year. The
Central region of Portugal has 20 spas (or 45% of the total), the North has 18 (41%), while
only 14% of the total number of termas are located in the remaining four regions – three in
the Alentejo and one each in Lisbon, the Algarve and the Azores (ATP, 2010; Turismo de
It is not compulsory for spas to be registered members of the Associação das Termas de
Portugal, the organisation that defends the interests of the country’s subscribing mineral
springs spas. However, most spas are in fact members, with only the northern termas of
Moledo, Eirogo and Carlão never having joined the ATP. These 3 independent spas (indicated
in blue) and the limits of the NUTS II sub-regions (in green) are also indicated on the map
below. Figure 1 shows the geographical spread of ATP-member spas across the country.
In the Central region, as a matter of fact in São Pedro do Sul, the largest Portuguese termas
are to be found with 17.017 medical spa goers in 2008. The second largest facility with regard
to this kind of public, Termas de Chaves, another municipal company, however, handled
6.374 medical attendants over the same period, only a little more than one third of the number
TERMALISTUR reached. This considerable discrepancy explains why the North only served
25.814 mineral springs spa goers in 2008 and the Centre more than double (58.870) (Turismo
de Portugal, 2009b).
It is also important to note that of the 44 units under consideration (41 ATP members and 3
independent ones), 21 (48%) already renovated their premises since 2000 and that another 5
(11%) will reopen within a short span of time. This year the brochure Saúde & bemestar, in
which 20 innovative and differentiating qualification projects sponsored by Turismo de
Portugal over the last decade are listed in an appealing way, included mineral springs spa
(along with spa hotel) renovation projects with a total investment value between 470.000€ and
20.900.000€ (Turismo de Portugal, 2010b).
Figure 1. Geographical spread of Portuguese mineral springs spas in 2010
Termas (Nº indicates District Region Figure
location on map)
04 Caldas de Chaves Vila
05 Termas do Vidago
06 Águas Santas de
09 Termas de Pedras
001 Caldas de Moledo
003 Caldas do Carlão
14 Caldas de Aregos
01 Termas de Viana
02 Caldas de Monção Castelo North
03 Termas do Gerês Braga
002 Termas de Eirogo
08 Caldas das Taipas
11 Termas de Vizela
10 Caldas da Saúde
13 Termas de Entreos-Rios
16 Caldas de S. Jorge
21 Termas do Vale da
25 Termas da Curia
26 Termas do Luso
20 Termas de S.
Pedro do Sul
18 Caldas da Cavaca
28 Caldas do Cró
29 Termas de Unhais
30 Termas de
31 Termas de Ladeira
32 Termas de Monte
33 Termas das
34 Caldas da Rainha
35 Termas do
39 Termas do Estoril Lisbon Lisbon
36 Termas de
Fadagosa de Nisa
37 Termas de Monte
38 Termas de Cabeço
40 Caldas de
41 Termas das Furnas Azores Azores
Source: Mapped by the author (based on ATP, 2010; INETI, 2004; Turismo de Portugal,
The data presented in Table 1 show that exactly half of the units are publicly-owned and the
other half are in private hands. Contrary to what we might expect, 62% of the 21 renovation
projects so far executed were initiated by publicly-owned companies. Of the 5 that still have
to reach their final stage, however, 80% are private. Of the 18 establishments where nothing
has been undertaken yet, in turn, 44% are publicly-owned.
Table 1. Renovation of publicly- and private-owned termas in 2010
Publicly-owned termas Private termas Total
Renovation projects (concluded) 13 8 21
Renovation projects (in progress) 1 4 5
Without renovation projects 8 10 18
Total 22 22 44
Source: Elaborated by the author based on the termas websites (see list and respective
addresses in Table 2 below) and on the following publications: (ATP, 2010; Medeiros &
Cavaco, 2008; Turismo de Portugal, 2009b).
We also noted that the smaller the unit is, the less probable it is that it will be quickly
renovated. Of the 15 termas that had less than 1.000 medical clients in 2008, 7 remain in
exactly the same physical state as in 2000, 2 are under reconstruction and 6 have already
concluded their renovation work. In contrast, the 10 termas with the best sales figures all had
concluded such projects by 2010.
Further calculations indicated that ownership of spa hotels tends to be private (78%): of 18
such hotel units, 2 are owned by INATEL (a public body) and only those at Carvalhal and
Monção are run by the local municipality. Of the balneários (spas without residential
facilities), one-third have private owners and two-thirds are in public hands.
Today’s typical spa goer
In this section, in order to concentrate on “new” spa goers, “traditional” spa-goers (by which
is meant elderly persons with medical conditions that require curative treatments, with very
limited purchasing power, and with low expectations as to the quality of spa and lodging
facilities that function only during the warmer months of the year) have been disregarded
(Medeiros & Cavaco, 2008). Nowadays not only the mineral springs spas, but all the other
types of spas want to widen their clientele and for this reason increasingly use websites as a
means of attracting new clients to this niche market. Gustavo (Gustavo, 2009), drawing on his
ongoing doctoral research, argues that spas occupy a privileged market position not only
because they are associated with the principles of both health and well being, but also – and
probably mainly – because they are able to reinvent themselves in line with a global and
hybrid philosophy that mirrors the world in which we currently live.
In order to discover clients’ motivations, the kind of services they prefer during a spa
visit/stay and their daily health care practices at home, Gustavo collected responses from 824
clients during May to August 2009 in 21 “classic” and “new” hydrotherapeutic leisure spaces.
His results led him to conclude that the typical spa-goer today is predominantly female (70%),
in their thirties (average age 39, with 40% of the sample between 30 and 39), has a degree
(74%), with those in a stable conjugal relation being equal in number to single persons (24%
and 25% respectively), many without children, living in an urban area (72%), in Portugal
(73%); the vast majority (92%) are in employment, predominantly in high level managerial or
technical capacities, 89% of the employed having jobs in the service sector. In almost half of
the cases, the family net income exceeds 3.000€ per month i.e. more than six times the 2009
Portuguese guaranteed minimum income of 450€/month. These clients are most likely to visit
a spa facility during the week (45%) or to integrate it into a (short) holiday break (41%).
Those interviewed by Gustavo regularly visit spas (31% of them once a month) in order to
relieve stress or to relax (74%) and/or to upgrade mental and physical health (50%). Massage
and body treatments are the spa services with most demand. Notwithstanding the dominant
historical and cultural influence of the classical termas, nearly 50% of the clients said they
had not undergone hydrotherapeutic treatments during their last spa visit.
The same survey also revealed that future clients consider the quality of treatment, the quality
of customer service, hygiene and cleanliness, the cost of services and the location of the spa
as the most relevant factors influencing their decisions to visit or revisit particular sites.
Another important conclusion to draw is that spa clients are essentially healthy people: 87%
of those surveyed consider their routines as healthy, stressing the importance of food (89%)
and physical exercise (83%) and their personal attitude in favour of a healthy lifestyle tout
court (54%). 42% only consume alcohol at the weekends or on special occasions, while 69%
are non smokers. They undergo annual medical check-ups every year on their own initiative.
70% of the sample has a normal or below average Body Mass Index. For marketing purposes,
finally, it is relevant to bear in mind that 14% of those answering the questionnaire were in
the spa at the time as a result of having received a gift voucher.
Portuguese spa managers may also find the annual SpaFinder forecasts a source of inspiration
in defining their marketing strategies: these reports are compiled by “a team of experts who
visit thousands of spas”, interview top industry analysts and research organizations, and do
ongoing consumer and industry research in the spa, travel, wellness, and beauty sectors. In
December 2009, the Top 10 Global Spa Trends to Watch in 2010 was launched, identifying
global spa trends that will influence spa experiences for both consumers and the industry in
2010 and for years to come. They argue, for example, that prevention is the new “P”-word
(substituting its predecessor – “pampering”) and claim that belonging to a spa, rather than just
visiting it, increases one's emotional health. They defend that, while the spa industry’s virtual
presence will continue to grow, room has to be made for “wellness tourism”; and they also
foresee an era of integrated spa, fitness, health, spiritual, wellness and beauty facilities
(SpaFinder’s Seventh Annual “Top 10 Global Spa Trends to Watch in 2010” (Press Release),
Since prior knowledge of the customer is so important, greater adherence on the part of spa
managers to the SPA & Thalasso Monitor, launched by the Portuguese Hotel Association
(AHP) in May 2009, would seem appropriate. All participating hotel units in the sector are
provided with free access to this benchmarking system that produces operational management
information relevant for this market. The Monitor is supported by software that allows, at any
time, all member businesses to review their (historical) data and weigh the position of their
own unit relative to others in the same or in different regions of Portugal. It fills a serious
lacuna in technical information available on this segment, making accessible monthly-updated
operational indicators as well as data on market activity, providing a business management
tool, and guarantees that public tourism officials (local, regional and national) can access
whenever necessary, reliable information relative to their geographical area (AHP, 2009;
Principal results of the analysis of 15 mineral springs spa websites
It is not only those who want to decide how they are going to pamper themselves who take
advantage of the internet, but also those active on the supply side. The internet constitutes the
only medium capable of furnishing round-the-clock, “instant” and up-to-date information on
new techniques, products and services. This makes it easy for service providers to innovate,
reinvent and promote service packages and incentivise termas to continuously develop their
communicative capacities and to explore the marketing techniques to the limit in the context
of a market niche of substantial commercial interest (Gustavo, 2009).
So far no research has been undertaken in Portugal into the internet marketing strategies of
spas, neither have their websites been analyzed in any systematic way. The study reported on
here concentrated on the years 2009 and 2010: one year ago, 37 termas were open to the
public and 30 of them had a website, while in 2010 two more termas (39) were functioning, of
which 34 promoted their services through the internet. In the two years under consideration,
the arguments firms advanced for not employing a website were: (i) that the firm was in a
remodelling phase and therefore there would be few if any returns deriving from an internet
site; or (ii) that the firm’s main clients were principally local elderly customers, the spa
facilities were limited, and only open during a short period of the year and therefore there was
little hope of attracting new segments of spa goers. Only Moledo and Eirogo, two of the three
independent spa units, are examples of the latter situation, while the other cases fit into the
first group. As a matter of fact, in three (Almeida, Monte Real and Nisa) of the four cases of
new websites created in 2010, the website launched coincided with the reopening of the
premises after renovation, while the creation of the Taipas website has to be interpreted as
part of the 2010-2013 plan of its newly elected board that, amongst other objectives, intends
to redefine its public and modernize the spa (Taipas Turitermas, 2010).
In the same period, 9 termas merely offered basic information posted on the website of an
umbrella institution (the Carvalhelhos spa on the website of the bottled water firm of the same
name; those of Entre-os-Rios and Manteigas are to be found on INATEL’s website; Almeida,
Vale da Mó, Sangemil, Cró and Cabeço de Vide on the website of the municipality that owns
them; and Caldas da Rainha on the Ministry of Health’s website). With the exception of
Cabeço da Vide, the termas with over 2.000 medical spa goers per year (corresponding to 1/3
of the termas with a website link) have their own appealing websites, whereas of the 15
smaller spas (receiving less than 1.000 visitors in 2008), 4 have no website at all and 4 only
furnish the most basic details through an umbrella website. The internet presence of termas
open to the public and with accommodation is 100% and 85% of those without integrated
In order to find out how the termas use the internet to sell their services, it was decided to
focus on those that had created their own web page (excluding those with information inserted
on an umbrella site) and that had been functioning in 2009 and 2010. This universe of spa
units (i) was representative of the regional distribution of spas, (ii) included both private and
public initiatives, (iii) took in both well-visited and less-visited businesses and (iv)
incorporated both spas functioning without accommodation (balneários) and mineral springs
spa hotels. As there were only 2 eligible sites in the South of Portugal, the sample taken from
this universe was adjusted so as to include 7 sites in the Centre of the country and 6 in the
North, respecting the 14% - 45% - 41% spatial distribution ratio referred to above, as can be
verified in Table 2 below.
Table 2. Spa websites analysed
g Nº of
Centre 1 17.017
Chaves North 2 6.374
Felgueira Centre 4 4.511
São Jorge North 6 3.655 2003
Private hotel www.termasdafelgueira.pt
Gerês North 8 3.443 2007 (Jan) Private
Centre 10 2.358
Saúde North 15 1.326
North 16 1.258
Private hotel www.monfortur.pt
Private hotel www.termas-svicente.pt
Luso Centre 18 1.176 2010 Private hotel www.termasdoluso.com
Longroiva Centre 21 1.004 2009 (Oct) Municipali
Vimeiro Centre 22 637 none Private hotel www.termasvimeiro.com
Aregos North 24 604 2009
Cavaca Centre 28 421
Furnas Azores no data no data 2008 (Oct) Private hotel www.furnasspahotel.com
Source: compiled by author, based on the websites listed, INETI, 2004 and Turismo de
As mentioned above, modernisation efforts on the part of the owners of mineral springs spas
did not stop at infrastructural renovation projects: many also established internet sites, on
which they placed and managed different types of information. Some of the more interesting
aspects of the internet sites encountered in the survey are presented below.
Almost all sites (Aregos and Longroiva being the only ones that offer only classic treatments)
use different subpages to recommend both medical and wellness products. However, the
degree of detail in the information provided is variable, with the Furnas site being the least
impressive example, referring to nothing more than the installations where the treatments take
place. In the majority of cases, sites not only summarise the treatments available, but also
explain them: Three do so with photos and the São Jorge site supplies a glossary of almost 30
terms. Only a small group bring together frequently asked questions in a dedicated “FAQ”
sub-page. All units, apart from Furnas, present a detailed price-list; however, it is only on rare
occasions that potential clients are informed of the time needed for each treatment. Almost all
termas differentiate their prices following one or more of the following criteria: (i) the longer
the stay and/or the more treatments acquired, the cheaper the unit price; (ii) prices vary
according to whether the visit is made in the low, middle or high season; (iii) returning
customers receive discounts; (iv) group bookings pay less; (v) in spa hotels, prices change
according to whether the treatment is bought with or without accommodation.
None of the termas created a subpage with general tips on healthy lifestyle, although some do
mention that they have a staff nutritionist and it is in this context that certain advice is given.
None of the termas elaborated a code of ethics, but São Jorge does mention a small list of
commitments regarding the quality of the services offered. None of the termas explicitly
mentions its concern for the principles of sustainability and local development. Implicitly,
some display pro-nature values, describing the spa’s healthy surroundings in their
introductory texts or including “green” pictures on the opening page of the site or in the site’s
photo gallery. Only on the São Pedro do Sul site is there a subpage entitled “quality and
environment” that includes a manual of environmental good practices («Boas práticas
The way the termas address their public is still very general. However, there are exceptions to
the rule. The São Jorge, São Pedro do Sul, Felgueira and Monchique units let us know in a
more or less obvious way that they welcome children: Felgueira provides them with a junior
passport and has created the mascot Felgui, following the example of the São Pedro do Sul
termas that uses the frog Afonsinho and the squirrel Amelinha. Monchique has a Kids’ Club.
Monfortinho to some degree focuses on clients in the area for the hunting, while Monchique
does something similar to attract the sailing community and Vimeiro targets horse riders and
golf players. Águas do Gerês hopes to conquer nature tourists, mentioning its unique
localization in the Peneda-Gerês National Park.
Only the Caldas de Aregos site had the Web Access Symbol for people with disabilities (a
blue globe, marked with a grid, tilted at an angle with a yellow keyhole in the middle) at the
bottom of its main page. There is no guarantee that a site using this symbol will be 100%
accessible, or was even designed according to the guidelines: it is the responsibility of website
users to “let the webmasters know when a site is or is not accessible to the disabled, and to
offer suggestions for greater accessibility. Those who use the symbol should do so at their
own discretion, understanding the goals of the growing group of people dedicated to making
the Web useful for all” (Web Access Symbol, [S.d.]).
Two-thirds of the websites consulted try to retain the loyalty of their clients by offering them
the possibility of subscribing to their newsletter. It should be noted that, in most cases,
prospective clients will not receive a real newsletter, but be notified of all the promotion
actions of the enterprise. Eight websites used the main page of their website as an alternative
way of announcing these kinds of special promotional campaigns.
São Pedro do Sul is the only termas that can afford the luxury of investing in a year round
programme of events and activities for its guests. The monthly programme can be
downloaded from the internet. Smaller units like Chaves, São Jorge and Monchique only
produce this kind of programme in the high season. In most cases though, future clients are
not informed or are only informed in a very brief and vague way about complementary tourist
activities in the surrounding area. São Pedro do Sul and Chaves, owned by the municipality,
limit themselves to inserting links to other organisations patronised by the municipality. No
more than a handful of links were oriented towards “independent” companies offering
specialised tourist activities: Aregos links to “Douro à Vela” a company specialising in river
trips, São Jorge has a link to the Lourosa Zoo and to the “Visionarium” Science Museum and
the Monfortinho unit has a link to the “Naturtejo” Geopark. Monfortinho is also an exception
inasmuch as it mentions direct competitors, be it Vimeiro (which belongs to the same group)
and the Portuguese Spa Association (which can also be accessed via the website of São Pedro
do Sul). All the spas that are integrated into hotels refer to their own lodging facilities, while 6
balneários mention the addresses of local lodgings, and Longroiva and Cavaca also list local
All the termas bet on being reachable by internet, offering the possibility to open an emailbox
by clicking on their e-mail address. 1/3 offers the possibility to fill out an online
“message” form. More than half offer online reservation possibilities, although in 3 cases this
is limited to a hotel reservation. São Jorge and Felgueira give their clients on top the
possibility to telephone them for free.
With regard to other aspects of online interactivity, scores are still very low: no unit has set up
a discussion forum; only São Jorge has a website poll question, with questions such as: “Are
you aware that a spa cure can benefit from refunds from the national health service?” Five
spas give customers’ opinions, albeit in a partly “censored” form; São Jorge is connected to
Twitter, São Pedro do Sul and Felgueira to Facebook, and Felgueira created a blog in January
2010. São Pedro do Sul and Felgueira offer merchandised products. In the former case they
can be individually ordered online and paid for in the traditional way (by cheque, ATM or
bank transfer); in the latter case an online shopping option (with a cart) is to be established,
but was not working at the time of the survey. Of the three units that offer vouchers, São
Jorge’s facilities are the most elaborate.
Having noted that the large majority of the mineral springs spa service providers have been
significantly upgrading not only their services and infrastructures, but also their websites over
the past five years, the survey analysed the way they currently communicate with their
(prospective) clients through the internet. We conclude that the Decree-Law Nº 142/2004 has
brought about real changes: the majority of Portuguese mineral spring spas now offer medical
along with wellness services and inform prospective clients correctly and honestly about what
to expect. Nevertheless, here are still numerous opportunities for spas to improve their
internet presence in many directions: by putting more (and more accurate) information on
their sites, they will be able to target special groups and market segments, redirecting
prospective clients to complementary tourist activities and expressing their concern over
environmental, sustainability and local development issues. Termas would be well advised to
develop their interactivity by creating discussion forums, making their sites more accessible,
offering more online shopping possibilities, taking more advantage of social networks or
creating more transparent subpages in which clients’ opinions can be expressed. Our sample,
moreover, provides evidence that the more content and links are put on the internet, the better
informed clients will become and the more likely it will be that (potential) clients will be
attracted by the product under consideration. We are also convinced that even “extremely
small” spa units can benefit from developing focused and functional websites.
In our opinion the results of this study offer not only Portuguese mineral springs spas but spas
in general the chance to further improve their internet dialogue with current and potential spagoers.
In conclusion, researchers in this field are encouraged to develop a more comprehensive
international comparative study of spa websites in order to work out guidelines for common
I would like to thank Barrie Abbott, Louis Joukes and, most of all, Chris Gerry for their
contributions to the final form of this text and also the first year students of UTAD's Tourism
degree (Ana Carina Lima, Ângela Silva, Carla Machado, Cátia Rodrigues, Marta Mota,
Natércia Lourenço, Rita Teixeira, Sara Rebelo, Sara Teixeira, Sónia Ala, Telma Castilho,
Telma Guerra, Teresa Gonçalves and Tiago Araújo) who assisted in the collection, during
February of 2009, of some of the data necessary for this paper.
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termais e talassoterapia. Lisboa: CEPCEP da Universidade Católica Portuguesa.
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Health Spa and Wellness – Competition or Supplement?
The Czech Republic Case
Vysoká škola obchodní v Praze/ University of Business in Prague, Prague, Czech Republic
This paper examines the relations between health spa and wellness in the Czech Republic.
While the importance of health spa to the Czech economy is generally acknowledged wellness
is often seen as a second-rate activity with no or very low effect on health because of the
average length of stay and lack of treatments complexity.
The Czech Republic combines a number of important attributes as a destination for health spa
tourism, with a long lasting tradition of health spa culture. It offers climatic spas, healing hot
and cold springs, healing torf and mud - all for treatment and recuperation and a high standard
of services for medical and wellness tourism at cost–effective rates. The paper starts with a
short introduction of tourism in the Czech Republic followed by health state and aging
characteristic of the Czech Republic and implications for tourism. Together with the
introduction of the Czech health spa industry the place of wellness in the Czech Republic
tourism industry is explored and complements this with simple statistics.
It reports about an exploratory case study that looked at the relation between health spa and
wellness in the Czech Republic from the point of view of tourists. The aim of the study was to
explore the relation of both and to consider the expectations of tourists in this field.
Accordingly, the management of facilities has been contacted individually; tourists were
investigated through a survey. The concluding sections discuss options in attracting tourists to
motivate them to frequent health spas and wellness visits.
Keywords: Tourism, Health Spa, Wellness, Czech Republic
The Czech Republic is a landlocked country, situated in Central Europe with the total area of
78.866 sq km. Its total boundaries are 1.881 km (border countries: Austria 362 km, Germany
646 km, Poland 658 km, Slovakia 215 km). Climate is temperate, affected by the interaction
of oceanic and continental effects.
Map of the Czech Republic Picture 1
Source: Downloaded from: https://www.cia.gov/library/publications/the-worldfactbook/geos/ez.html
(last accessed 7 March 2010)
The number of population of the Czech Republic is 10.230.000. The Capital of the Czech
Republic is Prague. The Czech Republic joined NATO in 1999 and the European Union (EU)
The Czech Republic is one of the most stable and prosperous of the post-Communist states of
Central and Eastern Europe. 11 The per capita GDP reached 25.100 USD (2009 est.), the
inflation rate is 1.1% (2009 est.), the unemployment rate is 9.3% (2009 est.), and 56.2 % of
labor is employed in services. 12
The conditions for tourism development are excellent – there are twelve historical monuments
on the UNESCO Heritage list, 13 over 2.000 castles, chateaux and monuments, and more than
40 protected historical towns and cities in the Czech Republic.
Four national parks 14 were established to protect the country´s most rare and valuable nature,
8 mountain ranges, and over 1.200 protected landscape areas and natural spots are covering
more than 10 % of territory of the Czech Republic offering 38.500 km walking trails, 19.024
km cycling routes, 1.240 km skiing tours to visitors. The country is dotted with over 20.000
lakes and ponds and more then 40 water basins.
11 CIA. The World Fact Book – Czech Republic. Downloaded from:
https://www.cia.gov/library/publications/the-world-factbook/geos/ez.html (last accessed 7 March 2010)
12 CIA. The World Fact Book – Czech Republic. Downloaded from:
https://www.cia.gov/library/publications/the-world-factbook/geos/ez.html (last accessed 7 March 2010)
13 The historic centre of Prague, Český Krumlov, Telč, and Kutná Hora, the pilgrimage church of St. John of
Nepomuk on Zelená Hora at Žďár nad Sázavou, South Moravia´s Lednice-Valtice Chateau and landscape area,
the Archbishop Chateau in Kroměříž with Květná and Podzámecká gardens, South Boheniam village of
Holašovice, Litomyšl Castle, the Baroque Holly Trinity Column in Olomouc, Villa Tugendhat in Brno, and the
Jewish Quarter and cemetery and the St. Prokop Basilica in Třebíč. Downloaded from:
http://whc.unesco.org/en/statesparties/cz (last accessed 7 March 2010)
14 Krkonoše, Šumava, Dyje, České Švýcarsko. Downloaded from: http://www.hory12.cz/narodni-parky-cr (last
accessed 7 March 2010)
The Czech Republic is rich in spas (over 30), some of them with abundant tradition e. g.
Karlovy Vary, Mariánske Lázně, Luhačovice, Teplice. 15
Spas in the Czech Republic Picture 2
Source: Downloaded from: http://www.czechtourism.com/cze/cz/docs/practicalinfo/map.html
(last accessed 7 March 2010)
Wide range of accommodation facilities, e. g. 41 five-star and 360 four-star hotels, 4.082
other hotels and boarding houses, 509 tourist campsites, 941 holiday chalets and 1.772 other
accommodation facilities are at disposal of the visitors. 16
Tourism has grown to be an activity of high importance and significance in the Czech
Republic. Above all after 1989 it becomes an important social and economic force in different
regions of the country.
The development of direct share of tourism on GDP as showed in Table 1 had a positive
tendency up to 1996 when reached its maximum (7.1%) followed by decrease to 3.5 % in
The share of tourism receipts on export reached its maximum in 1997 and 1998 respectively
as showed in Table 1. From 1999 decreasing tendency can be observed as a result of
increasing export incomes.
The share of foreign exchange receipts from tourism on the foreign exchange receipts from
services reached its maximum in 1997 and 1998 respectively as can be observed in Table 1.
Decrease can be seen from 1999 (44.8%), followed by drop to 41.7% in 2002. A light
increase to 45.8% is evident in 2003 followed by drop to 34.7% in 2008.
15 Spa & Wellness Catalogue. Downloaded from: http://www.czechtourism.cz/files/lazenstvi/lazne_2008_aj.pdf
(last accessed 7 March 2010)
16 Tourism in the Czech Republic. Facts and Figures 2008. Downloaded from:
http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7 March
Share of Tourism on National Economy Table 1
Share of tourism
receipts on GDP (in
Share of tourism
receipts on exports
1993 5.0 11.0 33,0
1994 5.5 14.0 43,2
1995 5.6 13.4 42,8
1996 7.1 18.6 49,8
1997 6.9 16.3 50.9
1998 6.8 15.0 50,6
1999 5.8 12.0 44,8
2000 5.9 10.3 43,5
2001 5.5 9.3 43,8
2002 4.2 7.7 41,7
2003 4.2 7.3 45,8
2004 3.8 6.2 43.4
2005 3.7 6.8 39.7
2006 3.9 5.8 39.7
2007 3.8 5.4 38.7
2008 3.5 5.5 34.7
Source: Downloaded from: http//:www.cnb.cz (last accessed 7 March 2010)
Share of tourism
receipts on service
receipts (in %)
Tourism as one of the largest international industries has also a noticeable impact on the
balance of payments of the Czech Republic. The development of the foreign exchange
receipts and expenditure could be divided into two main stages – in the first stage, the
receipts increased and reached its pick in 1996 with 4,1 bn USD, decrease of receipts is
typical to the second stage, especially 1999, followed by 2000. Table 2 shows a light increase
in 2001 but the situation after September 2001 and the floods in 2002 resonated in decrease of
tourism receipts in 2002. The following years – 2003 - 2008 show increase in receipts again.
Foreign Exchange Receipts and Expenditure Table 2
Receipts Expenditure Balance
1992 1.1 0,5 0.6
1993 1.6 0.5 1.1
1994 2.2 1.6 0.6
1995 2.9 1.6 1.3
1996 4.1 3.0 1.1
1997 3.6 2.4 1.2
1998 3.9 1.9 2.0
1999 3.2 1.5 1.7
2000 3.0 1.3 1.7
2001 3.1 1.4 1.7
2002 2.9 1.6 1.4
2003 3.6 1.9 1.6
2004 4.2 2.3 1.9
2005 4.7 2.4 2.3
2006 5.5 2.8 2.8
2007 6.6 3.6 3.0
2008 7.7 4.6 3.1
Source: Downloaded from: http//:www.cnb.cz (last accessed 7 March 2010)
The survey “Incoming Tourism – Number of Visitors and Their Expenditure in the Czech
Republic” was carried out in January 2008 – December 2008. 17 The main objective was to
find out the number of foreign visitors coming to the Czech Republic and their consumer
behavior. Data were collected at selected border crossings, the Ruzyně airport in Prague and 2
railway stations in Prague. 18
According to the survey the main reason for visiting the Czech Republic for foreign tourists
was recreation and entertainment (52.4%), visiting friends and relatives (22.1%), business trip
(20.7%), and others (2.9%).
Tourism the Czech Republic - Facts & Figures 2008. Research by STEM/MARK for Ministry for Regional
from:http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7
Tourism the Czech Republic - Facts & Figures 2008. Downloaded from:
http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7 March
The main purpose of the one-day visitors coming to the Czech Republic was shopping
(73.7%), business trip (11.5%), recreation and entertainment (6.6%) and visiting friends and
Health State and Aging - Implication for Tourism
The World Health Organization (WHO) defines health as ‘a state of complete physical,
mental, and social well-being and not merely the absence of disease, or infirmity’. This broad
definition can be applied equally to developed and developing countries and to both genders.
Health is a cumulative state, to be promoted throughout life in order to ensure that the full
benefits are enjoyed in later years. Good health is vital to maintain an acceptable quality of
life in older individuals and to ensure the continued contributions of older persons to
Health state is an important part of the standard of living and quality of life of inhabitants of
each country and is perceived as country´s development criteria. Healthy life expectancy
(HALE), defined by WHO as „Average number of years that a person can expect to live in
"full health" by taking into account years lived in less than full health due to disease and/or
injury“ 20 is a indicator which is monitored also in the Czech Republic.
One of the common characteristic features of most European countries is demographic
ageing: it occurs mainly as a result of decreasing or low and stagnant natality, along with
decreasing mortality and related increasing life expectancy. 21 The share of children in the
population diminishes while the share of persons at ages 65 years or more grows. The age
preference index used for comparison of population age structures exceeds the value 100 (i.e.,
the number of persons over 64 years exceeds the numbers of children) 22 in increasing
numbers of countries including the Czech Republic (102.4 in 2007 and 105.1 in 2008). Due to
a marked decrease of natality in the early 1990s it has low proportion of children up to 15
years old (14.2 % in 2008), but it still belongs to countries with relatively low proportion of
persons in the age group of 65 or more years (14.7 % in 2008). The latter proportion will
further increase as the age limit 65 is crossed by the strong generation born after World War
Another common characteristic of all European countries is the decreasing natality that
dropped also in countries where it was traditionally high. In several countries including the
Czech Republic a slow increase can be observed as the number of live born children steadily
grows since 2002, in 2006 the number of live born children per 1 000 inhabitants exceeded
again the value 10 and the value 11 in 2007. 23
The indicator of total fertility, i.e., the average number of children live born to one woman
during her reproductive period, does not reach the limit of simple replacement, i.e., the value
2.1 children per one woman, in any European country including the Czech Republic where
19 Ageing – exploding the myths. Ageing and Health Program (AHE). Geneva WHO, 1999, p. 1–21
20 WHO Statistical Information System (WHOSIS). Healthy life expectancy (HALE) at birth (years).
Downloaded from: http://www.who.int/whosis/indicators/2007HALE0/en/ (last accessed 7 March 2010)
21 European Health for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March
22 The index is defined as the number of persons aged 65 years or more per 100 children aged 0–14 years.
23 European Health for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March
the total fertility exceeded the value 1.3 in 2006, for the first time since 1994, and in 2007 and
2008 it reached the values 1.44 and 1.50. 24
The increasing ages of first marriage and childbirth are also common trends in all Europe.
Nevertheless, differences between countries of central and Eastern Europe and those of
western, northern and southern Europe still persist. Women in Central and Eastern Europe
begin their reproduction earlier, the trend of postponed childbirth started only in the 1990s. 25
Decreasing mortality connected with growing life expectancy are additional common features
of most European countries. However, marked differences still persist between mortality
levels in Western Europe and in countries of Eastern and Central Europe. Mortality began to
improve gradually in most post-communist countries in the 1990s, along with increasing life
expectancy. The average value of standardized death rate (SDR) shows a long-term
decreasing trend in European Union while the Czech Republic still has higher SDR values
both for men and women than the averages of the whole EU. The most frequent groups of
causes of death are circulatory system diseases. 26
The position of the Czech Republic in Europe remains unchanged, in spite of the fast growth
of life expectancy in the 1990s. Behind countries with the highest life expectancy at birth,
Czech men lag by about 6 years and women by 4 years. The Czech Republic with 3.1 and 2.8
per mille in 2007 and 2008 attains a foremost position in Europe and in the world. 27
Common features of most European countries are decreasing natality and improving situation
of mortality connected with growing life expectancy. This trend results in demographic
ageing of the population. Europe became the oldest-age continent.
The most dominant factors impacting upon the growth of the health spa and wellness industry
• Increasing number of aging “Baby Boomers”– their interest and desire for travel
opportunities that also meet their health needs is becoming a market force that greatly
influences the development of health spa and wellness market. These “new seniors” no
longer conform to the stereotype of an elderly stay-at–home. They are well educated,
independent, able to enjoy life on their own terms, eager to make choices, excited to
learn, living a fast-paced lifestyle, experiencing a sort of personal awakening. 28
• Fascination with fitness and alternative therapies and their use for promoting and
enhancing health and healing; 29 for healthy lifestyle education; for nutrition
counseling; for preventative medicine; for solving personal problems like stress or
depression; for holistic, naturopathic, alternative or eastern medicinal
25 European Health for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March
28 Péloquin, C.: Are Senior Travelers Really so Different? Downloaded from:
http://tourismintelligence.ca/2005/05/22/are-senior-travellers-really-so-different/?tagged= (last accessed 7 March
29 Ross, K.: Health Tourism: An overview. In: HSMAI Marketing Review December 2001. Downloaded from:
30 Verschuren, F.: Spa, Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism
Commission. CTC 2004, p. 5.
• Seeking something new and different in a holiday experience. Customers often want
something educational or experiential, and many aspects of health and wellness
tourism also fulfills those requirements.
The Czech Health Spa Industry
There are just a few other activities that can better characterize the economic, cultural and
social development of the Czech Republic in the last decades as health spa industry. Service
development boomed in the last 20 years in the Czech Republic, and health spa industry as an
integrated part of wide service industry boomed as well. The biggest changes can be seen in
privatization and inflow of foreign investment. The role of state toward health spas has
changed indeed although it keeps still its important legislative role.
The Czech health spa industry is an integral part of the European health spa industry history
of which starts in ancient Rome and Greece. It is a matter of fact that in south Moravia the
Romans operated the first spa in the city of Carnuntum in the 3rd century A. D.
The history of Czech health spas development can be sectionalized as follows: 31
• Before 1800 – small number of spas, guests from high society only, little influence of
scientific progress, high social prestige of spa visits.
• 1800 – 1918 – dynamic development, which reached its peak before the World War
1 st , fast growth of number of visits, improvement of transport infrastructure especially
railways, positive impact of science especially medicine, physics, chemistry, changes
in structure of guest with focus on high society, spas are mostly under German
• 1918 – 1945 – health insurance companies as a new element in spa development, spas
are opening themselves to underprivileged. The further development has been
influenced by economic and political situation, post-war restoration, the economic
crises, the 2 nd World War), some of the spas get under, and new substitutes to spa are
• 1945 – 1989 – spas are nationalized (in 1945), more spas get under, changes in
financing system (state and labor union´s influence), most of the spa guests utilize spa
treatments as a part of complex spa care, changes in incoming spa guests´ structure
(most of them came from the socialist countries), high level of spa treatments,
problems in service quality, obsolete spa infrastructure, the average length of stay is
about 25 days, the remedial function of spas are preferred prior to other.
• After 1989 – privatization, direct influence of state failed, but continued in legislation,
quality and variety of services are improved, number of commercial and foreign
The International Spa Association (ISPA) defines spas as places devoted to overall well-being
through a variety of professional services that encourage the renewal of mind, body and
ISPA presumes combined utilization of ten following healing elements: 33
31 Attl. P., Nejdl, K.: Turizmus I. VSH, Praha 2005, ISBN 80-86578-37-2, p. 75
1. Waters - the internal and external use of water in its many forms.
2. Nourishment - food, herbals, supplements and medicines.
3. Movement - vitality and energy through movement, exercise, stretching and fitness.
4. Touch - connectivity and communication embraced through touch, massage and
5. Integration - the personal and social relationship between mind, body, spirit and
6. Aesthetics - concept of beauty and how botanical agents relate to the biochemical
components of the body.
7. Environment - location, placement, weather patterns, water constitution, natural agents
and social responsibility.
8. Cultural Expression - the spiritual belief systems, the value of art and the scientific and
political view of the time.
9. Social Contribution - commerce, volunteer efforts, and intention as they relate to wellbeing.
10. Time, Space, Rhythms - the perception of space and time and its relationship to natural
cycles and rhythms.
Because of the different perception and different historic experience, spas are handed out by
ISPA into seven categories: 34
1. Club Spa - a facility whose primary purpose is fitness and which offers a variety of
professionally administered spa services on a day-use basis.
2. Cruise Ship Spa - a spa within a cruise ship providing professionally administered spa
services, fitness and wellness components, and spa cuisine menu choices.
3. Day Spa - a spa offering professionally administered spa services to clients on a day
4. Destination Spa - a spa whose sole purpose is to provide guests with lifestyle choices
improvement, and health enhancement through professionally administered spa
services, physical fitness and exercise, educational programming, such as nutrition and
stress management and a sense of community through such features as on-site
accommodations. Spa cuisine is frequently exclusively served.
5. Medical Spa - a spa whose primary purpose is to provide comprehensive medical and
wellness care in an environment which integrates spa services, as well as conventional
and complementary therapies and treatments.
6. Mineral Springs Spa – a spa offering on-site natural mineral, thermal, or seawater
baths, which are used in professionally administered hydrotherapy treatments.
7. Resort/Hotel Spa - a spa within a resort/hotel that provides professionally administered
spa services, fitness and wellness components and spa cuisine menu choices.
The European Spa Association (ESPA) divides spas according naturally occurring local
remedies, which are the basis for differentiation between several types of spas and health
resorts such as:
International SPA Association's Global Best Practices for the Spa Industry. Downloaded from:
http://www.experienceispa.com/education-resources/global-best-practices/ (last accessed 7 March 2010)
Ten Spa Domains. Downloaded from: http://www.experienceispa.com/education-resources/facts-andfigures/10-spa-domains/(last
accessed 7 March 2010)
ISPA Bylaws. Downloaded from: http://www.experienceispa.com/about-ispa/bylaws/; Verschuren, F.: Spa,
Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism Commission. Canadian
Tourism Commission, Vancouver 2004 (last accessed 7 March 2010)
• Mineral spas;
• Brine spas;
• Thermal spas;
• Peloid spas;
• Spas at the seaside and in a healthy climate;
• Kneipp spas.
According to ESPA „despite common EU law there are still considerable differences in the
use of these remedies depending on the country - definitions, parameters or legal basic
conditions have been developing from different traditions. 35
This overview shows that the ISPA´s perception of spas is wider than the European classical
one – the closest approach to European approach is a destination spa, medical spa and mineral
spring spa. The other categories represent more or less combinations of wellness and fitness
with catering services, or ambulatory services only.
Based on specification above and with focus on European specifics, the Czech health spa
industry can be defined as one which is based on:
• Utilization of natural resources, which are locally bounded, specific and unique;
• Medical character of services and high expertise of the staff, including medical doctors
and medical staff;
• Complex effect of the elements of environment, as a result of mutual action of natural,
cultural, social, architectonic and esthetic elements;
• Traveling to and staying in places outside usual environment what is necessary for
enrichment of the medical treatment;
• Remedy, after-treatment, precaution (especially remedy makes a difference between
health spa and wellness);
• Long lasting beneficial effect of all the above mentioned elements on the guest.
Health spas are classified according to indications - treated diseases in the Czech Republic.
The list of indications is prepared by the Ministry of Health: 36
• A - oncologic diseases;
• B - circulatory diseases;
• C - digestive diseases;
• D - metabolic diseases;
• E - respiratory diseases;
• F - neurological diseases;
• G - musculoskeletal diseases;
• H - urinary diseases;
• I - mental diseases;
• J - dermatological diseases;
• K - gynecological diseases;
• L - Functionally infertile;
• M - Obesity and overweight;
35 Credo of the European Spas Association. Spas and Health Resorts in Europe. Downloaded from:
http://www.espa-ehv.com/content/view/176/267/lang,en/ (last accessed 7 March 2010)
36 Downloaded from: http://www.czechtourism.cz/files/lazenstvi/lazne_2008_aj.pdf (last accessed 7 March
• N - Postoperative and posttraumatic conditions and convalescence.
Spa care has been traditionally perceived as a part of health and social care system and one of
the 3 pillars of medical treatment in the Czech Republic (besides hospital care and ambulatory
care). The Czech health spa care system consists of:
• Sequential professional spa care;
• Professional spa care for chronic patients;
• Professional ambulatory spa care;
• Professional preventive spa care.
From the point of view of tourism, one of the most important characteristics of health spa care
system is reimbursement of costs. There are four different approaches applied in the Czech
• Complex spa care - fully covered by health insurance companies (excluded travel
• Allowance spa care - medical treatments costs are partly covered by health insurance
companies, catering and accommodation is covered by guests;
• Commercial spa care – all costs are fully covered by guests;
• Ambulatory spa care – guests are staying at their homes and are regularly visiting spa
treatments without utilizing catering and accommodation services. 37
The fundamental economic unit of output in health spa is a nursing day with following
• Investigation and treatment
• Cultural, sport and supplemental activity. 38
The health spa industry is perceived as an important branch of economic activities with long
history. It is a part of the traditional and successful economic activities with positive social,
health, economic, ecological and regional effects.
UNWTO stated spa care as one of the basic motivators in tourism, as it is defined as „the
activities of persons traveling to and staying in places outsider their usual environment for not
more than one consecutive year for lemure, business and other purposes” 39 , but there is still a
discussion among a number of medical doctors and tourism stakeholders in the Czech
Republic on relation and/or interconnection of tourism and health spa.
37 In 2008, as in the preceding years, the predominant part of health expenditure was financed by the system of
public health insurance that covered 76.4 % of the expenditure in the Czech Republic. The State and territorial
budgets covered 7.0 % of the total and private expenditure covered 16.6 %. The relative proportions of these
components remained roughly the same in recent years faster increase is only registered in private expenditure
consisting mainly of expenses of households. Total expenditure on health increased from 2007 by 20 710
mill.CZK and in 2008 their absolute value was 262.645 mill. CZK (i.e. 25.182 CZK per inhabitant). This total
expenditure on health represents 7.12 % of the GDP in 2008. Public expenditure, i.e., that of the public budgets
and of the public heath insurance system, was 219.119 mill. CZK, by 12.554 mill. CZK more than in the
preceding year. The average expenditure of the public health insurance system per 1 client was 19.353 CZK. In:
Czech Health Statistics. ÚZIS ČR 2009. ISSN 1210-9991, ISBN 978-80-7280-845-8
38 This indicator can be used only when the health spa guest employ all above mentioned services.
39 WTO Ottawa Conference on Travel and Tourism Statistsics, 1991. In: Collection of Tourism Expenditure
Statistics. Technical Manual No. 2. WTO, 1995 p. 1, ISBN 978-92-844-0106-2
There is a “rigid medical” approach, a very conservative and protective one which does not
tolerate the coexistence of different forms of health tourism and does not consider health spas
as a part of tourism.
The second, more open approach considers health spa as one of dynamically developing
forms of tourism.
Globalization creates a big pressure to health spa industry as well as the international
competition and the substitutes - there are about 850 spa companies in more than 500 biggest
spa places in Europe.
Czech health spas are visited by 600.000 guests every year. The rate of foreign guest to
residents in spa accommodation facilities was close to one to one in 2008 with a moderate
change for the benefit of residents in 2009 as can be seen from Table 3. About 50% of
international guests come from Germany the second biggest market is Russia, followed by
Austria, Slovakia, the USA, Poland and Israel (Table 3). 40 Guests coming from Germany,
Slovakia and some other countries are often taking advantage from Czech allowance spa care
as the health care system in their home countries allows them to travel for health spa care
abroad and it covers their medical treatments costs.
40 Lázeňský cestovní ruch – komparace zemí střední a východní Evropy. Downloaded from:
http://www.czechtourism.cz/files/statistiky/lazne.pdf (last accessed 7 March 2010)
Foreign guests at accommodation facilities (spa): by country
Number of guests Index % % Average Number
2009/200 share share length of of nights
2 008 2 009 8 2008 2009 stay
Guests Total 674 313 647 568 96% 11.5 6 689 216
Residents 337 392 341 520 101% 50.03
52.74% 12.8 4 031 776
Foreign Guests 336 921 306 048 91% 49.97 47.26% 10.1 2 657 440
1 Germany 193 799 176 560 91% 57.52
57.69% 9.3 1 471 844
2 Russia 68 237 54 102 79% 20.25
17.68% 13.7 685 800
3 Other Asian 21 699 22 535 104% 6.44% 7.36% 7.2 139 052
Ukraine 7 893 6 456 82% 2.34% 2.11% 13.3 79 433
5 Austria 5 396 5 515 102% 1.60% 1.80% 6.9 32 294
6 Israel 4 339 4 466 103% 1.29% 1.46% 13.8 57 215
4 822 4 365 91% 1.43% 1.43% 9.9 38 676
8 Slovakia 3 594 4 345 121% 1.07% 1.42% 5.1 17 999
9 U.S.A. 3 315 3 304 100% 0.98% 1.08% 9.8 29 183
Poland 3 301 3 012 91% 0.98% 0.98% 4.6 10 981
France 1 847 1 907 103% 0.55% 0.62% 4.5 6 666
Italy 1 474 1 802 122% 0.44% 0.59% 5.3 7 806
UK 1 692 1 592 94% 0.50% 0.52% 4.6 5 708
1 531 1 421 93% 0.45% 0.46% 6.8 8 225
Switzerland 1 246 1 252 100% 0.37% 0.41% 5.3 5 347
Belgium 741 1 124 152% 0.22% 0.37% 5.1 4 602
Sweden 878 1 081 123% 0.26% 0.35% 5.1 4 478
Hungary 1 252 1 081 86% 0.37% 0.35% 3.8 3 048
China 1 014 1 044 103% 0.30% 0.34% 2.2 1 223
Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8
Table 4 shows a systematic increase in number of guests and number of nights from 1997, but
decrease in average length of stay although it is still quite high – 10.1. This average length of
stay is motivated by focus on health spa care as a remedy and by cost reimbursement of spa
care by health insurance companies.
Foreign Guests at Health Spa Accommodation Facilities Table 4
Year Number of Guests
Average Length of
Number of Nights
1997 98 054 10.9 968 576
1998 119 772 11.6 1 269 054
1999 117 635 11.3 1 207 287
2000 114 975 11.8 1 238 579
2001 128 244 12.1 1 425 347
2002 125 936 12.8 1 485 997
2003 123 242 12.9 1 465 567
2004 131 476 12.2 1 473 570
2005 228 110 10.9 2 265 149
2006 295 911 10.3 2 831 269
2007 317 023 10.2 2 904 923
2008 336 921 10.1 3 059 764
Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8
Table 5 shows that the occupancy of health spa accommodation capacities is increasing
systematically from 2000 for the benefit of residents. The similar development can be seen in
the number of overnight stays.
Occupancy in Health Spa Accommodation Facilities in the Czech Republic Table 5
Czech Republic Total
Year Number of
1=2+3 2 3 4=5+6 5 6
2000 437 308 176 387 260 921 5 709 748 1 658 234 4 051 514
2001 435 200 203 166 232 034 5 983 085 2 028 945 3 954 140
2002 451 505 201 028 250 477 6 431 035 2 139 202 4 291 833
2003 450 346 202 126 248 220 6 509 168 2 198 472 4 310 696
2004 481 120 217 134 263 986 6 538 058 2 215 747 4 322 311
2005 497 248 234 141 263 107 6 557 320 2 336 223 4 221 097
2006 571 101 295 911 275 190 6 743 893 2 831 269 3 912 624
2007 650 667 317 016 333 651 7 163 718 2 904 912 4 258 806
2008 674 313 336 921 337 392 7 045 620 3 059 764 3 985 856
Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8
Table 6 shows the number of guests in health spas according to costs reimbursement. It is
visible that the number of complex spa care guests as well as the allowance spa care guest is
decreasing for the benefit of commercial spa care guests in both groups – residents and nonresidents
Number of Guests in Health Spas According to Costs Reimbursement Table 6
2004 2005 2006 2007 2008
112.670 105.324 94.429 92.605 91.488
19.147 18.253 18.572 15.708 15.149
Spa Care 45.282 55.853 66.688 91.896 112.987
117.003 119.929 134.518 133.761 153.704
Total 294.102 299.359 314.207 333.970 373.328
Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8
While the minimum length of stay for complex and allowance spa care was traditionally 21
days, the average length of stay decreased to 18.4 days in 2004 followed by additional
decrease to 14.8 days in 2008 in the Czech Republic.
There is no official statistics on age structure of health spa visitors in the Czech Republic. The
only research in this field was conducted by the agency Psyma in 2002. As it can be seen from
Table 7 the most important group is a group of 60 years old guests (53.06%), the second
important group is the one of 30 – 44 years old guests (10.88), followed by the group of 45 –
59 years old guest (3.25%). It is assumed that the number of guests in the group of 45 – 59
years old increased in the last decade.
Age Structure of Health Spa Visitors in the Czech Republic Table
Age Structure in %
0 -14 15-29 30-44 45-59
Germany 0.22 1.29 6.58 21.25 68.72 1.94 100.00
Russia 1.25 0.83 18.67 50.62 17.01 11.62 100.00
Israel 0.00 5.63 8.45 39.44 46.48 0.00 100.00
0.00 0.00 19.05 31.75 47.62 1.58 100.00
Netherland 0.00 0.00 12.50 18.75 68.75 0.00 100.00
Switzerland 0.00 0.00 14.29 42.86 38.09 4.76 100.00
0.00 3.03 18.18 60.61 18.18 0.00 100.00
0.00 0.76 21.21 63.64 14.39 0.00 100.00
0.00 9.37 9.37 15.63 62.50 3.13 100.00
Total 0.31 1.44 10.88 3.25 53.08 3.06 100.00
Source: Psyma, Prague 2002
The CzechTourism agency conducted a visitor monitoring in Western Spa Region in summer
and winter seasons 2005. 41 According to this monitoring 65% of all summer visitors are
residents, 58% of foreign visitors come from Germany, 6% from Russia. Two third of visitors
reached the destination by car, 28% of them arrived from places more than 100 km remote
from the destination. The average length of stay of 1/5 of visitors is 7 days, 2/3 of them stay
longer than 1 day and 2/3 are frequent visitors. 45% of visitors prefer to stay in hotels and
43% prefer to eat in restaurants. Among the main motives visitors indicated was learning
about new places (30%), relax (15%), and health (15%). 95 % of all respondents were looking
for information in tourism guides and Tourism Information Centers.
Sixty eight per cent of all winter visitors are residents, 67% of foreign visitors come from
Germany. Two thirds of visitors reached the destination by car, 48% of them arrived from
places more than 100 km remote from the destination. More than 55% of all visitors stay in
the destination longer than 1 day, the average length of stay of 18% of visitors is 7 days. 45%
of them prefer to stay in hotels and 36% prefer to eat in restaurants. Among the main motives
winter visitors indicated was learning about new places (21%), visiting family (15%), and
health (11%). 89 % of all respondents were looking for information in tourism guides and
Tourism Information Centers, 55% used Internet as information tool.
The Place of Wellness in the Czech Republic Tourism Industry
The term “wellness” was originally used by Halbert L. Dunn in the book “High Level
Wellness” released in 1961 42 when he connected the word well-being with the word fitness.
41 Monitoring of Visitors in Czech Republic Regions – Profiles of Tourism Regions. Downloaded from:
http://www.czechtourism.cz/files/regiony/07_01_08_monitoring_navstevniku_fakta_inspirace.pdf (last accessed
7 March 2010)
42 Ardell, D.: What is Wellness. 2000. Downloaded from: www.seekwellness.com (last accessed 7 March 2010)
M. Zuckerman defines wellness as programs devoted to an individual’s health and fitness,
designed to make the guests feel significantly better than when they arrived. The combination
of fun, exercise, a healthy and balanced diet, pampering relaxation, and education on
managing stress offers magnificent chance for renewal. According to Zuckerman a spa is a
comfortable environment in which guests learn how to use the tools of life enhancement and
get motivated to go back into the real world and practice what they have learned. 43
M. Joppe emphasizes the holistic aspect of wellness products and identifies some of the daily
stressors that drive users to access these services. 44
Some researchers propose that there are four essential ingredients associated with wellness:
• A lifelong approach emphasizing permanent lifestyle changes;
• Taking responsibility for one’s own actions;
• Adding to the quality of one’s life, not simply extending the length of life;
• Making choices that improves an individual’s position on the lifestyle continuum. 45
According to German experts, numerous definitions of wellness share common features: the
importance of life style, self-responsibility for health, and the exploitation of a person’s
potential for a better quality of health. 46
By many accounts, wellness can be seen as a state of health featuring the harmony of body,
mind and spirit with physical fitness, healthy nutrition and diet, relaxation, meditation, mental
activity/learning, environmental sensitivity and social contacts, a process in which an
individual makes choices and engages in activities in a way that leads to health-promoting
lifestyles, which in turn positively impact the multiple dimensions of the individual’s well
Wellness is a dynamically developing industry in the Czech Republic with start-up around
2000. There is no widely accepted definition of wellness and the way how it is perceived is
very different. There are three main views on wellness in the Czech Republic:
• Wellness is a heterogeneous element which does not come under spa care and had not
had to be a part of health spa facilities or of spa destinations.
• Wellness is an appropriate supplement to spa care which can under the correctly
defined condition be a part of spa destinations but not a part of health spa facilities
(some experts accept wellness as a part of health spa facilities).
• Wellness is a part of all health spa facilities, with no contradiction between spa care
Verschuren, F.: Spa Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism
Commission, Canadian Tourism Commission, Vancouver 2004.
Joppe, M.: The Impact of the Wellness Revolution on the Spa Industry. 2003
Adapted from: Cardinal, B. J., Krause, J. V.: Physical Fitness: The Hub of the Wellness Wheel. Dubuque:
Kendell Hunt Publishing 1989.
Mueller, H., Lanz Kaufmann, E.: Wellness Tourism: Market analysis of a special health tourism segment and
implications for the hotel industry. University of Berne, Switzerland: Research Institute for Leisure and Tourism
2004. Downloaded from: http://www.lanzkaufmann.ch/doc/pub_art_vacationmeeting.pdf (last accessed 7 March
Finnicum, P., Zeiger, J. B.: Tourism and wellness: A natural alliance in a natural state. Parks and Recreation.
Vol. 31, Issue 9/1996, p. 84
The above mentioned conditions are defined by the German Health Spa Association as
• The wellness facility is managed by a medical doctor;
• The medical doctor is at the disposal of the guests;
• The staff is qualified;
• Integrated concept;
• Stability of offer;
• High quality of equipment;
• Documented quality management. 48
Some experts define “wellness tourism” as a “the sum of all the relationships and phenomena
resulting from a journey and residence by people whose main motive is to preserve or
promote their health.” 49
Wellness tourism activities prevent illness and preserve, promote or enhance overall health
and well being of people and their desire to prevent problems so they stay well, both
physically and mentally.
Based on the above remarks, it can be stated that health spa and wellness are two different
products although there is a lot of overlap between them, especially in terms of their markets
and in terms of the range of services offered.
Tourists who are generally healthy are motivated to travel so that they can experience
therapies and activities that will promote, enhance, and otherwise maintain a sense of well
being. Tourists with various medical conditions are motivated to travel so that they can
experience therapies that will help to make them well or to improve their health.
To be able to consider complementary or competitive relation between health spa and
wellness in the Czech Republic, a field study took place in November 2009. The field study
comprised a survey consisting of in-depth face-to-face interviews of 25 health spa and
wellness managers and other stakeholders including 50 guests. The management has been
contacted individually. Interviewees were contacted during regular operation days. Each
interview took 25 minutes and was conducted in a structured fashion. Each of the topics was
introduced by an open-ended question.
Given the qualitative nature of most of the information gathered and the size of the sample,
the survey responses were not amenable to statistical analysis. The findings are, therefore,
generally qualitative and descriptive.
The main problem in the field of health spa and wellness coexistence, seen by interviewed
managers, is in perception of both by medical doctors managing health spas. Traditionally, a
health spa manager had to be an experienced medical doctor responsible for all parts of
48 Medical Wellness. Gemeinsame Erklärung bzw. Letter of Intent. Deutcher Heilbäderverband. Downloaded
from: http://www.deutscher-heilbaederverband.de/cms/pages/positionen/medical-wellness.php (last accessed 7
Today´s health spa hotels are mostly managed by managers graduated from business or
tourism schools but the investigation and treatment part of the hotel is managed by medical
doctors. Most of them represent the conservative approach on health spa and they do not
tolerate the coexistence of different forms of health tourism and do not consider health spas as
a part of tourism. Their view on wellness as a heterogeneous element which does not come
under spa care and had not had to be a part of health spa facilities or of spa destinations is at
the same time a very rigid one.
Managers, who consider health spa as one of the dynamically developing forms of tourism,
understand also the role of wellness as well as an appropriate supplement to spa care or even a
part of health spa facilities.
From the point of view of both approaches there is a difference among complex spa care
guests, allowance spa care guests and commercial spa care guests. The complex spa care
guests must fully regularize themselves to complex spa arrangement. The allowance spa care
guests have more free scope in the field of accommodation and catering, as well as cultural,
sport and other services. They can make changes in treatments with permission of the health
spa medical doctor. Commercial spa care guests are independent guests who have free scope
in the field of accommodation and catering, as well as cultural, sport and other services. All
changes in treatments must be discussed by a medical doctor.
Health spas managed by medical doctors are strongly oriented on particular components of
health spa care system and wellness components are incorporated into product offered to
guests as sport activities only. According to diagnosis guests always receive tailored treatment
with the possibility to order additional treatments on a commercial basis.
Managers, who consider health spa as one of dynamically developing forms of tourism,
understand also the role of wellness as an appropriate supplement to spa care or even a part of
health spa facilities. They are regularly innovating products offered to customers and looking
for new opportunities as wellness which they incorporate into their offer.
Such health spa facilities offer different types of massages (e. g. thai, reiki, chocolate, honey,
stone, and alike) meditation therapies, drum circles, beer or wine bath, salt caves, Nordic
walking, yoga, oxygen therapy, crymotherapy, Finish sauna, Russian bath, Turkish bath,
phototherapy, sound therapy, special food arrangement, possibilities to learn about nutrition
and healthy food preparation practices and alike.
Managers observe some trends in health spa which bring health spa close to wellness and can
be defined as follows:
• Shorter length of stay (the most common is a long weekend stay – 3 nights);
• Higher number of frequent visitors (visiting a spa 3 or more time per year);
• Increasing number of guest from 25 – 40 age group;
• Demand for special packages (Eastern, Christmas, New Years Eve, etc.);
• Demand for special events in spas (wedding party, birthday party, etc.);
• Demand for special targeting packages (weight-loosing, anti-stress, managerial,
• Demand for special/exotic treatments (massages, catering, training, etc.);
• Demand for additional services e. g. cosmetics, manicure, pedicure, visage,
• Demand for some plastic surgery treatments e. g. botulotoxine, hyalurone acid, laser
therapies, chemical scrubbing, etc.
Based on of visitor survey (commercial health spa care guest have been asked) the following
results can be presented:
• 84.2 % of guest were satisfied with the quality of accommodation services;
• Satisfaction with quality of catering services was pointed out by 81.5 % of guests;
• 78.3 % of guests were comfortable with medical treatment;
• 82.6 % of guest were happy with quality of professional medical staff;
• The health spa environment was satisfactory for 82.7 % of guests;
• 82.9 % of guests were pleased by service staff quality;
• Cultural offer was satisfactory for 58.9% of guests;
• Sport offer was treated as satisfactory by 48.8 % of guests;
• 63.8 % of guests consider shopping facilities as satisfactory;
• Tourist information services were satisfactory for 69.4 % of guests;
• Tourists attractions were consider by 69.1 % of guests as satisfactory;
• Supplementary services were perceived by 59.8 % guest as satisfactory;
• 72.7 % of health spa guests were happy with services as a whole.
To the most frequently indicated remarks belong those on sport, culture, information,
attraction, shopping, and supplementary services offer. Today´s guest visiting a health spa
want to combine spa treatment, fun, exercise, a healthy and balanced diet, education on
managing stress, education on relaxing methods, rejuvenation, image and visage counseling,
personal couching, etc.
Based on the results of exploratory research and well-founded with showed statistics it can be
stated that there is no competition between health spas and wellness in the Czech Republic.
Wellness is a complement to health spa and in some ways both blend together.
Through industry research ISPA has pinpointed the following spa trends for 2010: 50
• Social Media – Twitter and Facebook are used by health spa and wellness industries to
• Customer Service - Consumers are more aware of every coin spent, and with that
comes higher expectations on the level of service they receive. Spas will respond by
providing exceptional service and making each visits a customized experience for the
guest. Implementation of customer feedback mechanisms and customer loyalty
programs should help to win frequent visitors.
• Spa Sampling Menu - Mini services at lower price points are popular ways to get a
taste of treatments offered at health spas and wellness as well.
• Preventive Care - According to the World Health Organization, by 2020 the top five
diseases will all have the underlying contributing factor of stress. Spa treatments like
massage, acupuncture and meditation have been proven to aid in stress reduction and
recovery time for pre and post-op patients.
• Spa Partnerships - Spas are becoming more accessible through partnerships with
established franchises, hotels and local businesses. Popular partnerships include:
developing wellness programs at local hospitals, accommodating guests at local hotels
50 2010 International SPA Association Trend Watch. 11/17/2009. Downloaded from:
http://www.ispaconference.com/articles/index.cfm?action=view&articleID=248&menuID=75 (last accessed 7
without spa facilities and service discount trades between spas and local business
• Cell Phone Applications - Spa-ing is easier than ever with the convenience of doing it
from cell phone. Internet application allows customers to browse health spa or
wellness services and check room availability.
• Giving Back - Spas are offering promotions and free services to people who serve the
community such as teachers, hospice workers and military personnel. Some spas are
teaming up with local hospitals and providing wellness education to help educate
consumers on the spa lifestyle. Community outreach is a great way to generate
business and show how easy it is to incorporate spa into once life.
• The Millennials Take Over - This group now outnumbers the baby boomers. They
grew up in a culture where taking care of themselves, learning proper grooming
techniques and leading a healthy lifestyle were not options, but the norm.
• Simplified Spa Menus - Everyone is cutting back and spa menus are no exception. The
No. 1 spa treatment that people seek out world wide is massage because of its healing
and stress-reducing benefits. And, the No. 1 reason people go to the spa is to
relieve/reduce stress and relax.
• Beauty Rest - The spa makes rest a priority by offering treatments targeted to get guest
some shut eye. They can actually book time to sleep at the spa or stay after a
treatment to take a nap when they are feeling relaxed.
The Czech Republic combines a number of important attributes as a health spa destination
with a long lasting tradition of health spa culture. More than 30 health spas including climatic
spas, healing hot and cold springs, healing torf and mud - all for treatment and recuperation
and a high standard of services at cost–effective rates makes the Czech Republic an attractive
destination for health spa visitors.
Wellness as a part of tourism industry has a shorter tradition in the Czech Republic but
develops fast. It is an important supplement to health spas with a wide spectrum of treatments
and services offered to visitors often making each visit a customized experience for them.
The Czech health spa industry is an important part of Czech tourism industry with a wide
potential of development including wellness as a complement to health spa care. Relaxation
and stress reduction, healthy lifestyle, self-responsibility for health are reasons why people
visit health spas and wellness. Health spa and wellness is not a luxury; it is a necessity to a
Today´s health spa and wellness visitor seeks to look and feel better; to lose weight; to slow
the effects of aging; to relieve pain or discomfort; to manage stress or depression; to improve
fitness level; to experience holistic, naturopathic, alternative, complementary or eastern
medicinal practices and/or therapies. Treatments like massage, acupuncture and meditation
often belong to standard spa and wellness offers.
Health and wellness are all-season activities for visitors. They are booking their stay during
all seasons including off seasons which greatly contributes to making the health spa and
wellness industry available any time of year.
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tourism segment and implications for the hotel industry. University of Berne,
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RURAL TOURISM, A FORM OF WELLBEING TOURISM?
Raija Komppula, professor
Juho Pesonen, researcher
Centre for Tourism Studies
University of Eastern Finland
The aim of this paper is to compare rural tourism motivations with the motivations of
wellbeing tourists, and investigate, if rural tourism could be seen as a form of wellbeing
tourism. A questionnaire was developed based on literature on wellness and rural tourism
motivations. Data were collected on a Finnish rural tourism website during summer 2009.
Altogether 727 responses were analysed using K-mean cluster analysis to create segments.
The results show that among Finnish rural tourists a segment of rural wellbeing tourists can be
distinguished. The segment values significantly more such factors as relaxing away from the
ordinary, escape from a busy everyday life, hassle-free vacation, getting refreshed, having a
sense of comfort, and having an opportunity for physical rest than the other segments. A
typical rural wellbeing tourist is a 45-54 year old female, who has lived her childhood in the
countryside. She travels with her spouse less than once a year to a rural destination.
Key words: wellness tourism, wellbeing tourism, rural tourism, tourist motivation, tourist
Although wellness tourism is one of the most ancient forms of tourism, there has been an
exponential growth in the pursuit of wellness in the history of tourism in recent years (Smith
and Kelly 2006). Centuries ago tourism destinations developed around unique natural features
such as mineral healing waters, beach and mountain resorts and sacred sites (Sheldon & Park
2009). Today wellness tourism comprises a broad range of tourist motivations and benefits of
the product. A categorization of Sheldon and Bushell (2009) suggest six types of wellness
tourism: medical, health, sport and fitness, adventure, wellbeing and transformation.
According to Smith and Puczkó (2009) the concept of wellness contains elements of lifestyle,
physical, mental, and spiritual wellbeing, and one’s relationship to oneself, others, and the
environment. Several concepts, such as well-being, happiness, quality of life, holistic practice
and spiritual beliefs relate to the concept of wellness. (Smith and Puczko 2009, 12)
Tourists are pushed by their own motivation towards the places where they expect their needs
will be satisfied (Leiper 1990). The push motivations have been seen to be useful in
explaining the desire for travel, as they are recognized as the starting point of understanding
tourists’ behavior (Crompton, 1979). Pull factors are those that attract people to a specific
destination once the decision to travel has been made. They are destination-specific attributes,
such as natural attractions, food, people, recreation facilities, or activities, which determine
whether the traveler will go to destination A or B, if both destinations fulfill the expectations
derived from the push factors. The aim and desired outcome of the tourist product for the
customer is value, which at each given time is a subjective experience (e.g. Gunn 1994).The
basis for value expectancies in tourism can be derived from the person’s underlying holidaytaking
motivations (e.g. Ryan 1997, 28).
In terms of push factors, wellness tourists are likely to be ’Active Health Seekers’ who are
highly motivated and determined to play a role in their own health. Smith and Kelly (2006)
present dimensions of wellness tourism, where various motivations refer to different kinds of
wellness tourism locations and activities, which refer to pull factors. According to Smith and
Kelly (2006) the destination in wellness tourism is often an alternative space in which one can
engage in self analysis without the stresses and distractions of home. For example, tourists
motivated by escapism and relaxation may prefer beach, spa and mountains, and those with
existential and psychological motivations may be interested in holistic centres focused on self
development and philosophical contemplation. According to Kulczycki and Lück (2009) a
substantial number of tourists highlight the importance of a specific location on their travels.
As wellness tourism is usually connected to luxury products and five-star hotels, in Finland
the concept of well-being tourism is often used instead, containing products and services from
a wider scale than the concept of wellness. It can include pampering, activities and
experiences of luxury, but is does not necessarily require high-class hotels (Konu et al. 2010).
According to Park and Reisinger (2009) luxury may refer to uniqueness, excellency,
sensuality, dream or superior quality and high price, but it may also refer to as difficult to
obtain, a means to reach happiness, personally rewarding, providing emotional benefits or
intrinsically rewarding. It must also be noted that luxury is dependent on the subjective and
situational perceptions of consumers, and is also understood differently across cultures (Park
& Reisinger 2009). Wellbeing tourism is mentioned also by Sheldon and Bushell (2009) as
being one of the types of wellness tourism. Wellbeing refers to a connection with community
or nature, inner and outer beauty therapy, massage, spas, sauna, relaxation, energy balancing,
art, music and diverse treatments (p. 10). Nevertheless, Sheldon and Bushell do not discuss
the level of quality, price or luxury of the offering in their typology.
According to Konu et al. (2010), the positioning of Finnish wellbeing and wellness tourism
should necessarily be based on the best natural resources, namely the lakes. The Lakeland
Finland, Eastern part of Finland, is an area where rural tourism is a predominant form of
tourism offering. Rural tourism typically refers to tourism outside densely populated areas and
tourism centres. In some countries, the term farm tourism (agritourism, agrotourism) is
synonymous with rural tourism. In many countries, rural tourism is understood to be more or
less synonymous with nature tourism or at least travelling in nature (Komppula 2007).
A typical Finnish rural holiday includes accommodation in a cottage, local food, sauna and
some kind of nature activities: swimming, rowing and walking in the forest. Rural tourism
establishments are often located in remote countryside, far away from neighbors. Villages and
services (shops, restaurants etc.) are often in a distance of several kilometers from the site.
Most common is a holiday in a self catering cottage, but also accommodation in B&B
establishments is available as well as half board or full board holidays with versatile services.
The largest intermediary of rural holidays is Finnish Country holidays Ltd, which has around
2700 cottages for rent. Nevertheless, a significant part of around 4000 rural tourism
enterprises sell and market their services directly and together with regional tourism
organizations to the potential customers.
According to several studies on rural tourism, many of the rural tourists are motivated by the
same factors as wellbeing tourists: they seek relaxation, escape from busy job, peace and
quiet, sports, and healthy gastronomy. A rural holiday as a product means peace and quiet, an
easy-going and warm atmosphere, nature, scenery and activities related to nature.
Interestingly, a new Finnish website www.hyvinvointimatkailu.fi (wellbeingtourism) presents
a wellbeing tourism network of one traditional spa and a fitness centre, one college of
physical education and five rural tourism enterprises. This is an example of the growing
interest of rural tourism enterprises in developing their services towards wellbeing offering.
Because of this growing interest of rural tourism sector in Finland in developing wellbeing
services there is a need for understanding customer needs and expectations. In this paper, our
aim is to compare rural tourism motivations to the existing research on motivations of
wellbeing tourists. The purpose is to investigate if there are similarities in motivations of rural
and wellbeing tourists and if rural tourism could be seen as a form of wellbeing tourism.
Motivations of wellbeing tourists
Despite the remarkable interest in wellness tourism, motivations influencing consumers’
desire to make a wellness holiday is almost an unexplored phenomenon (Bushell and Sheldon
2009, Chen and Prebensen 2009). Studies showing empirical evidence of wellness tourist
motivations are few, mostly referring to spa goers or spiritual tourists (Smith and Puczkó
2009). Out of the 17 wellness tourism case studies in the book of Smith and Puczkó (2009)
the great majority is about spas. Also their profiling of wellness visitors has a strong
emphasis on spa goers, differentiating types of wellness into four different types of spas
(traditional spas, hotels and day spas, purpose built recreational spas, seaside resorts and
thalassotherapy centres) and five other types of wellness, namely holistic retreat centres, yoga
centres, meditation retreats and medical centres (p. 134).
A study of Mak et al. 2009 examines the underlying factors that motivate travelers to search
for spa experiences. Based on the findings from a focus group interview and a review of
literature, an instrument consisting of 21 motivating items was developed and used in a survey
of Hong Kong spa-goers. From the individual items Seek physical relaxation, Pamper oneself,
Reward oneself for working hard, Seek mental peacefulness, Get away from the pressures of
work and social life and Improve overall health were the most important motivators.
According to Mak et al. (2009) luxury does not seem to be an indispensable attribute of a spa
experience, since Indulge in luxurious experience was rated only the 10 th important
motivating factor after Seeking spiritual refreshment and Getting away from daily routine.
Items relating to family togetherness or fostering friendship ties were rated as less important
factors, and the least important were factors relating to loosing weight and being fashionable.
Of the five factors identified, Relaxation and relief had the highest mean score and was
considered as the most important of the motivating factors of spa goers. The Escape factor got
the second highest grand mean. This factor was comprised of the items Get away from the
pressures of work and social life and Get away from daily routine.
In a study conducted by Koh, Yoo and Boeger (2010) the purpose was to identify market
segments among spa goers, based on a set of 21 important reasons for visiting a spa. These
benefit variables were identified through a three-stage process and a pilot study. Four factors
were identified, namely Social, Relaxing, Healthy and Rejuvenating. Social factor illustrate
the desire to share a special, pleasant experience with family and friends while relaxing and
meeting other health-conscious people in a spa setting. The factor Relaxing indicates the
desire to relieve stress in a tranquil setting and to escape the daily routines. Healthy equates
the spa experience with improving mental and physical health, and Rejuvenating focuses on
experiences that renew the spirit. The results of a cluster analysis showed that spa goers could
be grouped into three distinct segments according to benefit variables. One group was named
hedonists due to their extreme responses: for this group “social” rated 4.36, relaxing 4.78
healthy 4.65 and rejuvenating 4.78 on a five point Likert scale. In contrast, Escapists want to
relax and rejuvenate. The third group, Neutralists, only want to relax and are not concerned
with socializing, improving their health or rejuvenating.
The results of Chen and Prebensen’s (2009) study in three upscale Taiwanese wellness resorts
showed that beyond body pampering, wellness seekers are interested in pursuing other leisure
activities as well. Relaxation, recreation and experiencing nature were popular motivators for
Taiwanese wellness tourists. In addition, Smith and Puczkó (2009) present a review on few
findings about motivations of holistic tourists, yoga tourists, New age tourists, spiritual
tourists and medical tourists. They conclude that there is a clear need for more research on
various sub-sectors of wellness tourism.
Motivations of rural tourists
Studies on motivations of rural tourism are more common than those of wellness tourism.
According to Cai and Li (2009) several earlier studies indicate that rural tourists are most
often motivated by opportunities to learn and explore nature or different cultures, participate
in outdoor activities or search for peace and solitude. They may expect peace and quiet,
friendly reception, change from routine and good food. In a study of Frochot (2005) in two
Scottish locations one of the four rural tourist segments, which were based on the desired
benefits, was Relaxers, who were mainly seeking relaxation and had a lower participation rate
in most activities. They took shorter holidays than the other segments but had a higher
recurrence of countryside holidays. These findings are also supported by Royo-Vela’s (2009)
results in Spanish context.
According to the results of Park and Yoon (2009) in Korea rural tourism is an extremely
diverse sector leading to a wide range of visitors’ needs and expectations. Relaxation
represented a central distinguishing motivational theme among rural tourists, reflecting an
intrinsic emotional element. Relaxation factor consisted of items like getting refreshed, escape
from a busy job, relaxing away from the ordinary, having no rush, being physically active,
and feeling at home away from home. Also Molera and Albaladejo (2007) share the notion of
rural tourists being a heterogenous segment with diverse motivations. In their study push and
pull motivations were included in the same factor analysis. Items like calm atmosphere, non
crowded place, relaxation, attractive landscape, and independency and flexibility formed the
factor Nature and peacefulness. In their cluster analysis 25 % of respondents put a high value
on this factor, giving a low value to activities. This result is congruent with the findings of
According to Komppula (2005) also Finnish rural tourists expect to have a peaceful, quiet and
rush-free country holiday. For Finns, nature, particularly lake and forest scenery, is a selfevident
part of a rural vacation. For both target groups, families and those travelling with
other adults, the destination should be such that it is possible, on the one hand, to enjoy peace
and quiet on one’s own, and, on the other hand, to have interaction with the other visitors. The
choice of rural tourism as the type of holiday seemed to be related to the respondent’s own
background: the countryside was felt to be part of one’s own roots and the countryside
brought back positive childhood memories in the respondents (Komppula 2005). Zamora et
al. 2004 also propose that the rural origin of a tourist has a positive effect on his willingness to
pay for a rural holiday, despite the current settlement in the city.
Method and data
In several studies these factors have also been identified as motivators of rural tourists. In our
empirical study the aim is to find out if it is possible to distinguish a special wellbeing
segment among customers interested in rural tourism in Finland. The target group of the study
was potential rural tourism customers in Finland, which were supposed to be found among
visitors of the website of Finnish Cottage Holidays, the oldest, biggest and best known
intermediary organisation on rural tourism services in Finland.
Data were collected on the Finnish Cottage Holidays website www.lomarengas.fi during
summer 2009. Respondents were asked to state their interest in rural holidays and provide
information on what kind of rural holiday they are planning to have or would like to have.
Also a wide range of questions on travel motivation were asked. Altogether 1043
questionnaires were completed by users of the website, of which 316 had to be deleted
because of missing answers. That left 727 filled questionnaires which were suitable for the
analysis methods used in this study.
This study uses k-mean cluster analysis to create segments based on 31 motivation statements
(scale: 7-point Likert, ranging from not at all important to very important) based on the
literature on tourist motivation and customer value in tourism, especially in rural tourism
context. The respondents were asked to assess, how important they find the statements when
considering a holiday in the countryside. The variables were based on a literature review on
rural tourism segmentation studies (Frochot 2005, Molera and Albaladejo 2007, Park and
Yoon 2009, Pesonen, Komppula and Laukkanen 2009, Royo-Vela (2009) as well as studies
on customer value, and experiences in tourism (Otto and Ritchie 1996, Tapachai and
Waryszack 2000, Williams and Soutar 2000, Duman and Mattila 2003, Komppula 2005,
Sánchez, Callarisa, Rodríguez and Molinar 2006, Gallarza and Gil 2008).
Typical problem with cluster analysis has been that respondents’ answering pattern affects the
formation of clusters (see e.g. Laukkanen 2007). To avoid this, average mean score across all
motivation statements was calculated for each respondent and it was used to calculate relative
importance of each item for each respondent. Final number of clusters was determined by
examining graphical results (dendogram) and the best discrimination result between the
groups. Clusters were compared using ANOVA. Because multiple tests were computed based
on the same data sets, p-values had to be Bonferroni corrected (Boksberger & Laesser 2009).
In this analysis in hand, attention was paid to motivations usually connected with wellbeing
tourism, namely items that refer to family togetherness, hassle-free time, escape from a busy
everyday life, getting refreshed and pampered, relaxing away from the ordinary, having
opportunity to physical rest and activities, having sense of comfort, and having chance to
meet interesting people.
Different cluster solutions using k-means clustering were used to find the correct number of
segments. Trials with two to seven clusters were executed. Final cluster solution of four
clusters proved to be the most meaningful based on the results of the cluster formation and
Results of the discriminant analysis reveal that the travel motivations I would like to relax
away from the ordinary, I would have a feeling of romance and I could visit places my family
comes from have most discriminating power between all clusters (in descending order). Three
discriminant functions were generated. Function 1 explains 72.3 % of variance with
eigenvalue 3.668, function 2 explains 18.2 % of variance with eigenvalue 0.924 and function
3 explains 9.5 % of variance with eigenvalue 0.481. Based on the classification matrix, 95.0
% of all cases are correctly classified.
The results of the cluster analysis are presented in Table 1. Two motivations, I would have a
feeling like I was being pampered and I would have an opportunity to be physically active do
not differ statistically across clusters. The other wellbeing motivations however do differ.
Cluster B clearly values wellbeing related motivations more than other segments, not
including statements I would have a chance to meet interesting people, which segment A
values more than any other segment. Member of clusters C and D also think wellbeing related
motivations to be important, but not as much as respondents in cluster B, which is the third
biggest segment, containing 22.6 % of all respondents.
Table 1. Cluster analysis results
Travel motivation Overall
That I would have a
That I would like to
escape from a busy
D 0.921 A That I would have a
feeling like I was being
0.081 0.148 -0.079 0.164 0.079 1.090
That I would get
D 1.253 A 106.18
That I would have an
opportunity for physical
That I would have an
D 0.673 56.978
opportunity to be
-0.121 -0.274 0.049 -0.045 -0.153 2.153
That I would like to have
a sense of comfort
A,D 1.222 A 171.67
That I would like to relax
away from the ordinary
D 1.362 A 253.10
That I would have a
chance to meet
D -1.366 -0.944 B
Superscript in the mean value of a cluster denotes those clusters that have significantly lower
Profile of rural wellbeing tourists is presented in Table 2. A typical representative of the
segment is a female in the age of 45-54 with a college level degree. She has lived her
childhood in a rural area. The annual income of her household is 30 000- 45000 euro, which
can be regarded as an intermediate level. She travels with her spouse less than once a year to
a rural destination.
Table 2. Profile of wellbeing segment
Age Who would you travel with?
Under 25 5 (3.4%)
25-34 33 (22.4%)
Family with children under 12
35-44 39 (26.5%)
Family with children in several age
45-54 46 (31.3%)
55-64 21 (14.3%) Alone 7 (4.3%)
65 or older 3 (2.0%) Other 11 (6.7%)
Number of annual visits to rural
University degree 40 (24.8%)
Less than once a year 68
Technical / Trade school /
Once a year 58
Upper secondary school 11 (6.8%)
Two or three times a year 36
Elementary school 16 (9.9%) More than three times a year 2 (1.2%)
Annual income of the
Less than 15 000 € 8 (5.1%)
I lived during my childhood and/or
adolescence in a rural area
I did not live during my
15 000 – 29 999 € 39 (24.7%)
childhood/adolescence in a rural
area, but I visited rural areas often
to see my relatives
30 000 – 44 999 € 40 (25.3%) I have no roots in the countryside
45 000 – 59 999 € 30 (19.0%) Gender
60 000 – 74 999 € 25 (15.8%) Male 15 (9.3%)
75 000 – 89 999 € 11 (7.0%) Female
At least 90 000 € 5 (3.2%)
The results show that among Finnish rural tourists a segment of rural wellbeing is clearly to
be distinguished. For them the motivating factors relaxing away from the ordinary, escape
from a busy everyday life, hassle-free vacation, getting refreshed, having a sense of comfort
and having an opportunity for physical rest represent a significantly higher value than for the
other segments. The profile of the segment shows that this group is quite homogenous in two
aspects, namely 91 % of the segment members are female and 85 % have spent a remarkable
part of their youth in a rural environment. It can be argued that this segment may have a rural
place identity, which refers to dimensions of self that define the individual’s personal identity
in relation to a physical environment (Kulczycki and Lück 2009, 172)
The results of this study support the findings of Park and Yoon (2009) as well as Molera and
Albaledejo (2007) by confirming the notion of rural tourists being a heterogeneous target
group with diverse motivations, needs and expectations. It also supports earlier results of
Frochot (2005) and Royo-Vela (2009) by showing that among rural tourists there may be a
special segment searching for a “lazy” relaxing holiday without an emphasis on any special
Bushell and Sheldon (2009) call for further research on motivations behind wellness tourism.
They distinguish between luxury forms of wellness tourism and more holistic attempts to
create wellness for the individual. (p. 221). We argue that there are several sub segments in
wellness as well as in rural tourism. We assume that people seeking to escape and relax in
luxury are a separate segment from those pampering themselves with lazy holiday in a rural
environment. They may be same people but behave in a different way depending on their life
situation, and other internal and external situational factors.
Both wellness and rural tourism concepts clearly mean different things in different contexts
and countries. Nevertheless, one conclusion can be drawn from this study: rush free rural
settings with nature and beautiful landscapes offer an ideal environment for a wellbeing
holiday motivated by search for relaxation, comfort and escape, not including any material
luxurious elements. Further research is needed on the characteristics of the segment as well as
their pull motivations.
In the end it can be said that rural tourism indeed is a form of wellbeing tourism, but not for
everyone. In this study one of the four segments, namely segment B, clearly values wellbeing
related motivations more than any other segment. On the other hand members of an another
segment, segment A, do not go for a rural holiday in sake of their wellbeing but are motivated
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Predicting factors of tourists’ interest towards wellbeing tourism
holidays – A Finnish case
University of Eastern Finland,
Centre for Tourism Studies
FI-57101 Savonlinna, FINLAND
University of Eastern Finland,
Department of Business
P.O. Box 111,
FI-80101 Joensuu, FINLAND
Many studies about motivations and profiles of health and wellbeing tourists have focused on
different sub-sectors of health, wellness and wellbeing tourism but more general research,
concerning wellbeing tourists, has been quite rare. This study aims to investigate tourist
motivations as predictors of tourists’ interests in wellbeing tourism holidays as opposed to
tourists that are not interested in wellbeing holidays.
Data is collected in Finnish Travel Fair in January 2009. In total 406 effective responses were
used. To evaluate the predictive influence of push and pull factors, the data was analyzed by
using logistic regression analysis with backward stepwise method.
Results show that the previous experience of wellbeing holidays, number of annual holiday
trips, together with pull factors “water park and/or spa”, “natural sights” and “accessibility in
destination”, and push factors “refreshing myself”, “experiencing fashionable/trendy places”
and “aesthetic experiences” significantly increase the odds of tourists’ interest to make
Keywords: tourist motivations, push and pull factors, previous travel experience,
wellbeing/wellness tourism, Finland
The demand of wellbeing and wellness (tourism) services has increased while many people
are stressed of living in work-obsessed, time-pressured, materialistic and over-individualistic
societies (Laing & Weiler 2008, Sheldon & Bushell 2009, Smith & Puczkó 2009). People are
seeking more often balance in their busy lives and wellbeing and wellness services are
thought to be helpful in achieving this balance. For example, it is estimated that in spa tourism
(sub-sector of health and wellbeing tourism) there are nearly 100 million active spa-goers
worldwide (ISPA 2007).
There are several wellness and wellness tourism definitions some being very wide-ranging
(e.g. Müller & Lanz Kaufmann 2001) and some more limited (e.g. Connell 2006). Sheldon
and Bushell (2009, 11) have defined wellness tourism as follows: “Wellness tourism is a
holistic mode of travel that integrates a quest for physical health, beauty, or longevity, and/or
a heightening of consciousness or spiritual awareness, and a connection with community,
nature, or the divine mystery. It encompasses a range of tourism experiences in destinations
with wellness products, appropriate infrastructures, facilities, and natural and wellness
resources.” All in all there is not one widely accepted definition. In the Finnish language the
words wellness and wellbeing are complex, especially in the tourism context. Reason for this
is that both words are translated into ‘hyvinvointi’ which causes confusion and misuse of the
words. In marketing point of view wellness tourism is usually connected to luxury products
and five-star hotels. However, wellbeing tourism can contain products and services from a
wider scale as it can comprise pampering, different (sport and fitness) activities and
experiences of luxury. The concept of wellbeing tourism suits better in Finnish context
because the wider content and description highlights better the Finnish understanding of
‘hyvinvointi’. (Kangas & Tuohino 2007, Konu et al. 2010.) Altogether, the definition of
Sheldon and Bushell (2009) is suitable for this study as it includes widely motivation factors –
more detailed both push and pull factors.
The motivations and profiles of health and wellbeing tourists have been studied rather little.
Some studies have focused on different sub-sectors of health, wellness and wellbeing tourism
– such as spa tourism or spiritual tourism (Lehto et al. 2005, Mak et al. 2009, Smith & Puczkó
2009) – but more general research, concerning wellbeing tourists in general, has been quite
rare. In addition, most of the studies concentrating on examining wellbeing tourism
motivations have focused on push factors (internal motivations) and have ignored the
importance of pull factors. It is necessary to understand both push and pull motivations and
their relationship to market efficiently a particular destination (Baloglu & Uysal 1996).
This study aims to enhance the rather slim body of knowledge on wellbeing tourism by
providing information about the push and pull factors that can explain the interest towards
wellbeing tourism holidays. Goal is to investigate possible predictors – push and pull factors,
socio-demographical factors and previous travel behaviour – of tourists’ interests in wellbeing
tourism holidays as opposed to tourists that are not interested in above mentioned holidays.
Tourist Motivations – Push and Pull Factors
Motivation has for long been a major topic in tourism research (Crompton 1979, Dann 1981,
Mak et al. 2009, Nowacki 2009, Park & Yoon 2009, Pearce 2005). Backman et al. (1995)
emphasised that motivations are interconnected with individuals’ basic needs for developing
preferences, participating diverse activities, and expecting satisfaction. The motivations of
wellbeing and wellness activities, participating in wellbeing holiday or purchasing wellbeing
and wellness products and services are also connected to customers’ needs and interests.
The push and pull model (Crompton 1979) is one of the most popular typology of tourist
motivation. The model emphasizes that tourist’s choice of a travel destination is influenced by
two forces – push and pull factors. Push factors are underlying individual motivations that
push individuals from home, and pull factors are attributes and features of a destination,
service or a product that pull individuals toward a destination. That is to say, people travel
because they are pushed by their internal motives and pulled by external forces of a travel
destination (Lam & Hsu 2006). It has been remarked that most push factors derive from
individual’s intrinsic or intangible desires, for instance, from dream fulfilment, rest and
relaxation, health and fitness, desire for escape, adventure seeking, novelty seeking, prestige,
and socialization (Chon 1989, Lam & Hsu 2006, Uysal & Jurowski 1993). Pearce and Lee
(2005) identified in their study 14 factors of general tourist motivation. These factors were
novelty, escape/relax, relationship (strengthen), autonomy, nature, self-development (host-site
involvement), stimulation, self-development (personal development), relationship (security),
self-actualise, isolation, nostalgia, romance and recognition. The push motivations are noticed
to be useful in explaining the desire for travel, as they are recognized as basis of
understanding tourists’ behaviour (Crompton 1979, Kim et al. 2008). Pull factors are more
tangible and they are related often to attractiveness of a destination (e.g. Baloglu & Uysal
1996, Bowen & Clarke 2009). Pull factors can be diverse destination attributes (e.g. spa
facilities, high quality accommodation, amusement parks, national parks) and activities (e.g.
outdoor activities, courses, excursions) that tourists are interested in.
There are only few studies that have concentrated on wellness and wellbeing tourism
motivations. These studies are mainly focused on sub-sectors of wellness tourism, such as spa
or spiritual tourism (Koh et al. 2010, Lehto et al. 2005, Mak et al. 2009) or on the push factors
(internal motivations) (Chen & Prebensen 2009, Koh et al. 2010, Mak et al. 2009) and Asian
(see Chen & Prebensen 2009, Mak et al. 2009) or US target groups (Lehto et al. 2005).
Mak et al. (2009) have studied underlying motivations for spa visits. They found five
motivation factors among Hong Kong spa-goers. These factors were friendship and kinship,
health and beauty, self-reward and indulgence, relaxation and relief, and escape. The top five
motivations (mean over 3 on five-point Likert scale) were ‘to seek physical relaxation’, ‘to
pamper oneself’, ‘to reward oneself for working hard’, ‘to seek mental peacefulness’ and ‘to
get away from the pressures of work and social life’. Koh et al. (2010) have segmented spa
goers using benefit segmentation. The benefit attributes they have used are very similar to
motivation attributes used in different studies. They identified four motivation factors: social,
relaxing, healthy, and rejuvenating. They also grouped spa goers valuating similar benefits
into three clusters – escapists, neutralists and hedonists. For instance, escapists were interested
in improving their health (mean 3,95 on five-point Likert scale) and rejuvenating themselves
(mean 3,99). Hedonists were interested the most in relaxing and rejuvenating (means in both
Lehto et al. (2006) examined motivations of yoga tourists by using 18 motivation statements.
They identified four motivation factors in their study 1) seeking spirituality, 2) enhancing
mental wellbeing, 3) enhancing physical condition, and 4) controlling negative emotions.
They found out that the top five motivations (measured using five-point Likert scale) were to
renew myself (mean 4,46), to relax (mean 4,46), to be more flexible in body and mind (mean
4,42), to let go of stress from a busy life (mean 4,41), and to help me gain a sense of balance
(mean 4,38). Kelly and Smith (2009) also found out in their case study that the focus of retreat
holidays is “the self”.
Chen and Prebenson (2009) have studied wellness motivation attributes for Taiwanese tourists
by using 16 different variables: health consciousness, physical therapy, social activity,
recreation, enhancement of quality of life, effortless activity, affordable activity, pursuing
multiactivities, relaxation, business engagement, word of mouth, curiosity, mental therapy,
attractiveness, experiencing nature, and meditation (measured using 7-point Likert scale).
They found out that the most important motivation factors were relaxation (mean 5,40),
pursuing multiple activities (mean 5,24), recreation (mean 5,16), and experiencing nature
(mean 5,04). The results show that a stay in a wellness destination or resort is not just for
being pampered, and tourists are interested in doing also different activities during their
wellbeing holiday (Chen & Prebenson 2009). Smith and Puczkó (2009, 262-263) have also
listed reasons in more general level, why people are travelling and going to spas and wellness
centres. For instance, one of the main motives is stress relief. They also highlight that fitness
and exercise have a very important role in wellbeing and wellness too. Smith and Puczkó
(2009) emphasize as well that trends and reasons of individuals of participating wellbeing and
wellness activities vary considerably, and these trends are connected closely to leisure
patterns. Konu and Laukkanen (2009) identified in their study that motivation factors
connected to health and physical activity and self-development were affecting the most to
intention to make a wellbeing trip. Based on the studies presented above, it can be stated that
the main push factors in wellbeing tourism sector seem to be things such as relaxation,
rejuvenation, pursuing multiple activities, experiencing nature, escape, health and beauty.
Many studies are highlighting the importance of environment in wellbeing tourism (Kelly &
Smith 2009, Smith & Puzckó 2009). Some of the wellbeing tourism concepts, such as Alpine
Wellness (Pechlaner & Fisher 2006) and Lake Wellness which is under development (Konu et
al. 2010) base strongly on the natural resources of the destination. In addition, some of the
wellbeing and wellness services are depend on natural resources. Good examples are hot
springs and mineral waters that are believed to have healing powers (Erfurt-Cooper & Cooper
2009). However, it is very difficult to find studies that have actually empirically tested the
importance of pull factors of wellbeing tourism.
In this study more general motivation factors (push and pull) are used as the questionnaire is
directed to potential wellbeing tourists, and as the aim is to find out the motivational
differences between tourists who are interested in wellbeing holidays, and tourists who are
unsure/not interested in wellbeing holidays.
Demographic Variables, Travel Experience, and Past Wellbeing and Wellness Tourism
Some studies have concentrated on describing demographic profiles of wellbeing and
wellness tourists. Studies have shown that most of the wellbeing and wellness tourists are
female (Koh et al. 2010, Lehto et al. 2006, Smith & Puzckó 2009), approximately over 30years-old
(Koh et al. 2010, Lehto et al. 2006, Smith & Puzckó 2009), and highly educated
(Koh et al. 2010, Lehto et al. 2006). In addition, studies that have examined different subsectors
of wellbeing and wellness tourism highlight, for instance, that spa-goers (Koh et al.
2010) as well as yoga tourists (Lehto et al. 2006) have high average income.
Pearce (2005, see also Pearce & Lee 2005) has discussed the relationship between past
experience and tourist motivation when he developed travel career patterns (TCP) concept.
Pearce argues that all travellers are influenced by the most important travel motives (e.g.
escape/relax and novelty) as well as less important motives (e.g. social status and isolation).
He also claims that when tourist’s travel career level develops (tourists grow older, pass
certain stage in life-cycle and gain more experience) the moderately important travel motives
will change from internally-oriented needs to externally-oriented needs. Mak et al. (2009)
studied the relationship between past spa experience and tourist motivations. They found out
that spa-goers who had visited spa two to five times during last two years were more
motivated by attributes connected to escape than spa-goers that had visited a spa only once.
Thus, it can be assumed that demographical factors, travelling habits (travel experience) and
past wellbeing tourism experiences can have roles as explaining factors of wellbeing holidays.
Data and Methods
To examine tourist motivations (push and pull factors), a computer aided survey was
conducted to potential Finnish tourists in Matka 2009 travel fair in Helsinki, Finland.
Altogether 32 push factor statements (mainly Pearce 2005, Pearce & Lee 2005) and 20 pull
factors including statements covering the six As (attractions, accessibility, amenities,
available packages, activities, ancillary services) defined by Buhalis (2000) were adapted
from the earlier studies. For the purposes of this study, a total number of 406 effective
responses without missing values were used. The data is divided into two groups using an apriori
segmentation based on the interest respondents have towards wellbeing holidays.
Logistic regression analysis with backward stepwise selection procedure was used, with the
cut-off statistical significance selected at the 0.10 level. The target (dependent) variable is a
binary/dichotomous variable in which 0 = unsure/not interested in wellbeing holidays, and 1 =
interested in wellbeing holidays. The independent variables included push and pull factors,
demographic factors, travelling habits (how many short and long trips taken during last 12
months), and past wellbeing tourism experiences. Age as a demographic variable was
excluded from the analysis due to a large number (24%) of missing values.