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

Health, Wellness and Tourism: healthy tourists, healthy business?
Proceedings of the Travel and Tourism Research Association Europe 2010
Annual Conference 1-3 September, Budapest, Hungary
Puczkó, L. (Ed) (2010).
Health, Wellness and Tourism: healthy tourists, healthy business?
Proceedings of the Travel and Tourism Research Association Europe 2010 Annual
Conference
Dalarna, Sweden: Travel and Tourism Research Association Europe.
ISBN: 978-91-633-4666-8
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
of life
• Developments in medical tourism and the shift from traditional curative towards
complementary and preventative activities, or even hedonistic aspirations
• The role of well-established forms of tourism (e.g. spa, sports, social, cruise) and
newer forms of tourism (e.g. holistic, occupational, adventure) in the development of
health and wellness
• The special characteristics of investment and return in health and wellness tourism
• The special characteristics of planning, management and marketing of health and
wellness tourism

Acknowledgements
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
facilitator:
Conference Organizers:
László Puczkó, 2q Tourist Research Partnership
&
Conference Secretariat Weco Travel Ltd- Chemol Travel
Conference Chair:
László Puczkó, 2q Tourist Research Partnership
Dinner Speaker:
Dee Ann McKinney
TTRA Europe gratefully acknowledges the support of the conference:
GOLD SPONSOR:
SILVER SPONSORS:
www.hungary.com
www.kjf.hu
www.budapestinfo.hu

BRONZE SPONSORS:
MEDIA SPONSORS:
www.spasbudapest.com
www.danubiushotels.com
www.kastelyszanatorium.hu
www.omorovicza.com
www.raczhotel.com
www.thermarium.com
www.xellum.hu
www.turizmus.com
www.eumta.org
TTRA Europe is also indebted to the members of the Scientific Committee, who reviewed
121 contributions that were submitted for participation at the conference:
Anja Touhino, Project manager, ITÄHYVÄ, Finland
Aurkene Arzua, Director, CIC tourGune, Spain
Babu George, Assistant Professor of Tourism, University of Southern Mississippi, USA
C Michael Hall, Professor, Department of Management, College of Business & Economics,
University of Canterbury, New Zealand
Edward Huijbens, Docent, Icelandic Tourism Research Centre, Iceland
Frederic Dimanche, Director, Center for Tourism Management, SKEMA, Business School
Nice - Sophia Antipolis, France
Ian Henderson, Managing Partner, TTC International Ltd, U K
Isabelle Frochot, Lecturer, CEMAGREF Grenoble & Université de Savoie
Jana Kucerova, Department of Tourism and Hospitality, Matej Bel University in Banska
Bystrica, Slovakia
Jennifer Laing, Lecturer, Tourism Research Unit, Monash University, Australia
Joseph Sirgy, Professor, Virginia Politechnic Institute &State University, USA

Kai Illing, Professor, Joanneum, Austria
Kaija Lindroth, Degree Program Manager, HAAGA-HELIA, Finland
László Puczkó, Managing director, Xellum Ltd, Hungary
Melanie Smith, Senior Lecturer, Corvinus University of Budapest, Hungary
Pauline Sheldon, Professor, University of Hawaii, USA
Rob Davidson, Senior Lecturer in Business Travel & Tourism, University of Westminster,
UK
Roos Gerritsma, Docent, InHolland, The Netherlands
Sheila Flanagan, Director, DIT, Dublin, Ireland
Sonia Ferrari, Professor of Place, Tourism and Museum Marketing, Università della Calabria,
Italy
Tamara Rátz, Head of Institute, Institute of Tourism, Kodolányi János College, Hungary
KEYNOTES
ÁKOS KOZÁK
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,
2008.
He is an author and co-author of several college and university lecture notes and course books
on market research. Email: akos.kozak@gfk.com
ROGER ALLEN
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: rallen@thermarium.com, 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.
Email: melanie.smith@uni-corvinus.hu
KEVIN TURNBULL
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
marketing.
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.
Email: kevin@spafindereurope.com
KATHRIN SPILLER
… started her professional career by working for a radio station and as a journalist.
Up to now 26 years experience in managing positions in tourism and hotel management.
From 2001 till June 2009 she was responsible at the State Tourist Board of Baden-
Württemberg (Southwest Germany) for marketing and advertising, for the cooperation with
tour operators and travel agencies in Germany and Switzerland.
Especially she participated in the establishment of the quality-certificate and the brand
WELLNESS STARS, which is standing for certified quality in hotels, spas and medical
wellness facilities.
Since July 2009 she’s consulting in destination-management, auditing and consulting hotels
and spas, offers spa- and marketing concepts as well as public relations. Since 2008 she is the
coordinator of the German Medical Wellness-Group.
Email: kathrin.spiller@wellness-stars.de
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).
Email: gerrybodeker@gmail.com

ELISABETH IXMEIER
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.
Email: deeann.mckinney@ded.mo.gov

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,
381
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
Factors
Inoormaziah Azman
Postgraduate Centre
inoora83@hotmail.com
And
Jennifer Kim Lian Chan
School of Business and Economics,
University Malaysia Sabah (UMS),
88450, Kota Kinabalu,
Sabah, Malaysia
E-mail: jkimchan@yahoo.co.uk; jenniferchan@ums.edu.my
Abstract
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
Introduction

Over the past centuries, health and wellness-oriented activities have been recognized around
the world, with existing of different health practices of the people in different regions for
staying healthy, and for healing/curing remedies as well. The development of health tourism
can be resonated with the echoes of the great economic growth and major demographic shift,
occurring in most countries across the globe. Consequently, the society is aligned between the
consumer’s strong interest in health and the rising affluence, resulting in plethora of consumer
products, whether anti-aging creams or medical procedures, as everyone is in search for health
and well-being (Yeoman, 2008). Additionally, people are practicing a healthy lifestyle to keep
them fit and healthy. This lifestyle, Ryan and Travis (1981); in Kammermann et. al. (1983); in
Nahrstedt (2004), had termed “wellness” which can be described as a way of life, that an
individual create to achieve his/her highest potential for well-being, consists of actions that
the individual able to control, such as how they exercise, eat, manage stress, and perceive the
environment, and achieving a high-level wellness involves continual striving for a more
healthful way of living.
Benner, King and Milner (2004) suggested that health tourism is any pleasure-oriented
tourism which involves an element of stress relief could be considered to be a form of health
tourism. They highlighted the importance of distinguishing between health tourism and the
wide phenomenon of tourism because product perceptions on the part of both suppliers and
consumers will influence the extent to which more specialized travel experiences such as
medical treatment are promoted to mainstream market. Likewise, subsuming spa as a sub
sector of the health and wellness tourism, the spa sector is concomitantly mushrooming in the
past decades as one of the destination’s tourism offerings, especially in the hotel sector. It has
increasingly become an important economic and marketing strategy for hoteliers, resort and
tourist destinations to attract tourist visitations. McNeil and Ragins (2004) suggested that spa
participation is currently showing incredible growth, as more consumers turn to spa facilities
as venues to improve their health and well-being. Although it is luxury, it is seen as much
more necessity, and factors like, personal space, time out, escapism, retreats contribute to spa
visitation. Additionally, Smith and Puczkó (2009) stated that, in historical terms, health and
wellness practices have been very much embedded in regional and local traditions and
cultures, with available natural resources also determining the forms of wellness that were
developed. Therefore, it is arguable that there are extended key motivation factors of tourists’
visitation to health/spa facilities at a particular holiday destination. Despite the expansion and
popular demand of health and spa services/activities by both local and international tourists,
there is a little understanding of the health and spa consumers in Malaysian context.
Therefore, this exploratory qualitative study attempted to understand the health and spa
tourists’ motivation that are grounded in their own words during their visits to health and spa
service centers in Sabah, Malaysia by extending the push-pull motivation theory, to provide
some insights of this popular business. The purpose of this paper is to provide a deep
understanding of tourists’ profiles and their key motivations in health and spa tourism context
which is vital in order to sustain the growth of this tourism business.
Having brief on the issue, the research is aimed at providing a starting point for understanding
Sabah’s health and spa tourism market, particularly from demand perspective, by establishing
a preliminary profile of the health and spa tourists, and identify the key motivators of these
tourists in the health and spa tourism products and services in Sabah, Malaysia. The research
objectives were undertaken in an effort to answer the following questions:
• Who are the health and spa tourists in Sabah, Malaysia?
• Why the tourists utilized any of health and spa products and services while they travel in
Sabah, Malaysia?

Literature Review
Health and Spa Tourism
In recent years, many researches have been undertaken in addressing the issues related to
population health and health tourism. Smith and Puczko (2009) suggested that health tourism
can be viewed from two different perspectives, which are medical and wellness. Spa is one of
the sub sectors of health tourism which positioned in between medical and wellness,
depending on the purposes and types of treatments received when visiting spas. There are
many studies related to health tourism, especially in the field of medical tourism, but very
limited on health, spa and wellness that can be found in tourism literature. Nonetheless, the
studies focused on the development, marketing and positioning the spa establishments – the
supply side, rather than the demand side of health and spa goers/tourists.
According to Mcneil and Ragins (2004), spa participation in the United Stated of America is
showing an incredible growth in the early 1990s when the participation in gyms and health
clubs for fitness slowed down. The researchers stated that many consumers turn to spa
facilities as venues to improve their health and well-being, and the industry continues to grow
at amazing rates and marketing opportunities abound. They highlighted the current issues and
trends in the US spa industry, which the major challenges would be; (i) to meet the
consumers’ needs effectively as a shift in paradigm in spa concept – from indulgence to
wellness, (ii) to stay abreast of the changes in the spa consumer profile; as spa facilities
nowadays are not only cater to women, but also to men, and cater to all age-group of people,
(iii) to provide a more comprehensive array of treatments, services, and activities combined in
a highly conceptualized setting, and (iv) to stay up to date with technological advances in
provision of spa information to prospective consumers. The researchers suggested the uses of
strategies and techniques that respond to consumers’ demands, in the context of target
markets and the four Ps – product, place, promotion and price. They concluded that the spa
marketers must remain flexible and adapt to changes of spa users’ wants and needs, and
continue to improve communications about the spa experience and its benefits.
In line with aforementioned, Chon and Singh (1995) provided a review of trends in marketing
the resorts in USA. One of the product development trends they highlighted was the one that
evolved health awareness – concerns about personal health and fitness which increased the
demand for health-related holidays. Consequently the resorts are adjusting their amenities and
services to accommodate the health demands on vacationer, such as fitness facilities and
health spas have been added to release stress and improve nutrition and physical conditioning.
Moreover, they also stated that the presence of spa at a resort was cited as a primary reason
for drawing them. The trend is expected to continue as more and more people travel for health
reasons to resorts and spas which provides fully monitored and individualized beauty
treatments, and health programs.
Tourist Motivation
Motivation has long been a central subject of study in psychology from varieties of ways,
including from the physiological, psychological or philosophical approaches (Petri and
Govern, 2004: 3-14). The study of motivation is widely being used in understanding human
behaviour and can be found in the literature of many disciplines. Likewise in tourism, the
concept of motivation has been used in understanding tourist behaviours and their travel
decision-making which can be indicative to tourism providers as to attract tourists and fulfil
their needs during their travel at a particular destination.

Page and Connell (2006: 63) stated that motivation as a subject is an integral part of the study
of consumer behaviour in tourism. Mountinho (1987), as cited in Page (2009), defined
motivation as a “state of need, a condition that exerts a push on the individual towards certain
types of action that are seen as likely to bring satisfaction”. It indicates the intrinsic reasons
why the individual is embarking on a particular trip (Weaver and Lawton, 2002: 189). This
psychological concept refers to tourists and the reasons why they embark on a particular trip.
It is too, directly linked to the demand for tourism, which can affected by a range of factors,
and to consumer/tourist behaviour, which does not only affect the initial purchase but also the
tourist experience as well as future decisions (Lomine and Edmunds, 2007: 125).
Consequently, motivation models and studies are seen in a variety in understanding tourist
behaviour in relation to many aspects of tourism, for example, the destination choice (e.g.
Chan and Baum, 2007; Park and Yoon, 2009), tourists’ purchase decision/spending pattern
(e.g. tourists’ souvenir purchase decision by Swanson and Horridge, 2006), and tourism
business marketing and planning strategies (e.g. Oh et. al., 1995; Bansal and Eiselt, 2004).
The results lead to a greater understanding of tourists’ behaviours and thus contributing to
effective marketing strategy in targeting the right tourist market. One of the concepts that are
considered in tourist’s motivation and purchasing process is in term of push-pull factors
which has been widely adopted in researches mostly associated with tourists’ behaviours and
segmentation, from general holiday-takings to special interest tourism, but rather in different
contexts and countries.
Push-Pull Factors of Tourist Motivation
Among the most well-known tourist motivation theory is the push-pull concept (Dann’s,
1977; Crompton’s, 1979; Iso-Ahola’s, 1982), in which activity is seen as a product of a pullpush
relationship. Dann (1981, as cited in Cooper et. al. 1993: 34) pointed out that the
destination pull in response to motivational push, which distinguishes between the motivation
of the individual tourist in terms of the level of desire (push) and the pull of the destination or
attraction. Similarly, Page and Connell (2006: 68) stated that push factors are those that
propel a desire to travel; pull factors are those that influence which destination is selected,
given the initial push, and arise from on a desire to travel. Crompton’s (1979) identified seven
psychological (push) motives: (i) escape from a perceived mundane environment, (ii)
exploration and evaluation of self, (iii) relaxation, (iv) prestige, (v) regression, (vi)
enhancement of kinship relationships, (vii) facilitation of social interaction, and two cultural
(pull) motives: (viii) novelty and (xi) education. This concept has been extensively studied
and widely accepted in tourism literature (e.g., Chan & Baum, 2007; Yoon & Uysal, 2005;
Jang & Wu, 2006; Kim, Lee & Klenosky, 2003; Oh et. al., 1995; Swanson & Horridge, 2006).
It is suggested that push-pull motivation concept is a useful approach for examining the
motivations underlying tourist and visitation behaviour. Gilbert (1991) acknowledged the
push and pull factors influencing the tourism consumer decision-making process (as cited in
Page and Connell, 2006: 68).
The idea of the push-pull model is the decomposition of a tourist’s choice of destination into
two forces, which are push and pull factors (Bansal & Eiselt, 2004). The push factors are
considered to be socio-psychological motivations that predispose the individual to travel,
while the pull factors are those that attract the individual to a destination once the decision to
travel has been made (Oh et al., 1995; Kim and Lee, 2002). This motivation concept
encompasses the push motivation factors, which are related to the tourists’ desire, and pull
motivation factors which are associated with the attributes of the destination choices (Yoon &
Uysal, 2005; Oh, Uysal & Weaver, 1995; Kim and Lee, 2002; Kim, Lee and Klenosky, 2003;
Jang and Wu, 2006).

Yoon & Uysal (2005) stated that push motivations are more related to internal emotional
aspects, while pull motivations are connected to external, situational, or cognitive aspects. On
the other hand, the push factors are origin-related, intangible or intrinsic desires of the
individual travellers, such as the desire for escape, rest and relaxation, health and fitness,
adventure, prestige, and social interaction. Meanwhile, pull factors are those that emerge as a
result of the attractiveness of a destination as it is perceived by the traveller. They include
tangible resources such as beaches, recreation facilities and historic resources as well as
travellers’ perception and expectation such as novelty, benefit expectation and marketing
image of the destination.
Chan and Baum (2007) investigated the motivation factors of ecotourists in ecolodge
accommodation by adopting the push and pull motivation factors. The findings revealed that
the eco-tourists are primarily attracted by the destination attributes (natural attractions,
wildlife, local lifestyle and eco-activities), where ecolodges are located (pull factors), and they
are also pushed by their social psychological desire to escape from their routine of normal life
(push factor). The identification of motivational factors in this study provides a clearer
account of what attracts the ecotourists to stay at ecolodges and suggested that the marketing
strategies for ecolodges should focus more on the destination attractions around the ecolodge
accommodation by positioning the ecolodges based on the unique destination attributes.
Nonetheless, conservation and protection the surrounding natural resources are important too
as these are the main motivational factors for tourists to patronize ecolodges. In contrast, Kim,
Lee and Klenosky (2003) examined the influence of push and pull factors on visitors to the
national parks in Korea. The results of a factor analysis identified four push factor domains
and three pull factor domains underlying respondents’ push and pull factor ratings. The push
factor domains suggested that the visitors to national parks in Korea considered the park to be
valuable recreational resources that provide important opportunity to appreciate natural
resources or enhance health or building friendship (consistent with results of 1999 Report of
Korean National Travel). Meanwhile the pull factor domains reflected the fact that the
national parks in Korea are relatively accessible and located close to most residential and
work areas. The study also provided the additional analyses investigated differences in push
and pull factor domains for different socio-demographic sub-groups and examined the
interrelationships among the push and pull factor domains. The study provided valuable
information in understanding Koreans’ motivation to visit national parks and the results hold
useful implication for park managers and researchers in studying how push-pull factors
impact tourists and visitors behaviour.
In line with aforementioned, it argues that the push and pull theory of tourist motivation can
be applied into health and spa tourism context. Similarly, there must be underlying factors
that motivate tourists for health and spa services while travel to a holiday destination, and
there must be certain health and spa attributes that attract the tourists to health and spa
facilities at the destination countries. Therefore, this research attempted to adopt push and pull
theory motivation concept in identifying the health and spa tourists’ motivation factors and
profiling these tourists.
The push-pull concept was utilized, with modifications being made to focus into health and
spa tourism, which is likely to be more central on the healthy lifestyles of the health and spa
goers and the holiday destination’s health and spa attributes. Accordingly, the push factors are
considered to be socio-psychological motivations that predispose the individual to travel (Oh
et. al., 1995), which evolves tourist’s personal attributes, or a demand-side approach which is
to understand tourist’s decision-making process, such as attitudes, perceptions, and learning

and motivation factors – the four major psychological factors of the individual’s purchase
behaviour (Knowles, Diamantis and El-Mourhabi, 2004: 57). Meanwhile the pull factors are
those that attract the individual to a specific destination once the decision to travel has been
made (Oh et. al., 1995). This may include tangible resources such as beaches, recreation
facilities and historic resources, as well as travellers’ perception and expectation such as
novelty, benefit expectation and marketing image of the destination (Yoon and Uysal, 2005).
Petri and Govern (2004: 20-21) suggested that some behaviour can be understood as
motivated by internal states that activate the individual to respond in genetically determined
ways. Other behaviours seem clearly the result of external information that is acted upon in
light of acquired experiences. This approach of motivation provides a dimension at which
motivation can be studied concerning the source of motivation, that is, the internal motives
versus external motives. The researchers stated that needs are commonly viewed as internal
sources of motivation that activate and direct behaviour to items in the environment that
alleviate some state of deprivation. It implies of physiological terms, and may also include
social and psychological needs. Meanwhile, the external sources of motivation are
emphasized on the motivating effects of either various goal objects or social relationship.
From this point of view, it is suggested that the motivation can be activated by changes in the
external environment.
Similarly in tourism, (Page, 2009: 90) stated that the intrinsic motivation approach recognized
that individuals have unique personal needs that stimulate or arouse them to pursue tourism
(the desires to satisfy individual or internal needs – self-improvement, self-realization, or
achieve state of happiness, and ego-enhancement). In contrast, the extrinsic motivation
approach examines the broader conditioning factors that shape individuals’ attitudes,
preferences and perceptions, but are more externally determined (the society and the culture
one lives in). Goeldner and Ritchie (2006: 254) suggested that the extrinsic and intrinsic
motivation must be able to consider that travellers are variously motivated by intrinsic, selfsatisfying
goals and at other times are motivated by extrinsic socially controlled rewards (e.g.
other’s opinions). The framework in this research integrated the individual’s psychological
factors and the destination’s health and spa attributes adopting push-pull factors motivation
concept, in order to explain tourist’s motivations in utilizing health and spa services when
they travel to Sabah, Malaysia and the key attractiveness of local health and spa to the tourists
on the other hand, by moderating the demographic variables with the push-pull dimension in
explaining the tourist motivation on health and spa services. This contributes to a better
understanding of health and spa tourists in Sabah, Malaysia and also to the development of
the sector in the coming future, as it benefits the health and spa operators in term of
developing appropriate marketing strategies and thus enhances tourist satisfaction.

Push factors
Internal motives – physiological, social and
psychological needs
(Needs that activate and direct behaviour)
Petri and Govern (2004)
Intrinsic Factors
(Unique personal needs that stimulate or arouse
them to pursue tourism)
Page (2009)
Push Factors – Psychological Factors
(Oh et. al., 1995; Yoon and Uysal, 2005; Cooper
et al. 1993: 36; Knowles, Diamantis and El-
Mourhabi, 2004)
Health-related attitudes
Health, spa and wellness perceptions & learning
Health-related motivations
Pull factors
External motives – the motivating effects of
either various goal objects or social relationship
(Motivation can be activated by changes in the
external environment)
Petri and Govern (2004)
Extrinsic Factors
(The broader conditioning factors that shape
individuals’ attitudes, preferences and
perceptions, but are more externally determined)
Page (2009)
Pull Factors – Destination Attributes
(Oh et. al., 1995; Yoon and Uysal, 2005)
Spa as a tangible resource
Unique spa treatments and experiences
(marketing image)
Health and Spa Tourists
Motivation Factors
Figure 1: The Framework for Health and Spa Tourist Motivation Factors
Health-related Tourist Motivation
Though health tourism has longevity in historical terms, health and spa tourism can be
considered at its infant stage, at which health and spa tourists’ motivation remains a
substantive interest for researches. There is generally lack of empirical studies on health and
spa tourism motivation in understanding the fundamental needs of the health and spa goers
during holiday, as there is a growing concern on health among the population at present. It is
suggested that research investigating health, spa and wellness from demand perspective is
needed as many of the available literatures (as presented above) are basically focusing on the
development, marketing and positioning studies of the health, spa and wellness
services/facilities.

One of the available researches that directly linked to health and spa goers is of Mak and
Wong (2007), who examined the underlying factors that motivate Hong Kong travelers to
search for spa experiences while travelling away from Hong Kong. The structured
questionnaires were employed to conduct the survey and received a total of 302 responses.
The findings revealed that the Hong Kong spa goers perceived spa as a place for relaxation,
pampering, beautifying treatments, and enhancement of overall health. The motivation
factors; ‘relaxation and relief’, ‘escape’, ‘self-reward and indulgence’, and ‘health and beauty’
are the most important factors that motivate Hong Kong travelers to visit spas. The result was
found to be an integration of European spa goers health perspective and American spa goers
self rewarding perspective. The findings of their study provide researchers and practitioners in
the spa industry with useful insights into understanding the present nature of the demand of
spa in the Asian market.
On the contrary, there are studies integrating healthy lifestyle into consumer/tourists
behaviours by Gonzalez and Bello (2002) show that a strong dependency relationship
between tourists’ behaviours and lifestyle, and the segmentation of the market that emerged
makes a division into five clusters: home-loving, idealistic, independent, hedonistic and
conservative. The labels give a general idea of the lifestyle of each segment. Similarly, the
study by Hallab (2004) on healthy-living oriented lifestyle in the field of travel and tourism
show that the connection between healthy-living habits of US citizens and their travel
characteristics with respect to travel push and pull motivational factors and sociodemographics.
It revealed significant findings in regard to individuals who have a healthyliving
lifestyle and their travel behaviour and shed a light on their socio-demographic
characteristic. The researcher also suggested future researches to use more variables in
seeking to understand further the mentioned segment’s travel behaviour.
Page (2009: 88) stated that there is no all embracing theory of tourist motivation due to the
problem of simplifying complex psychological factors and behaviour into a universally
acceptable theory that can be tested and proved in various tourism contexts. In this study, the
concept of push and pull motivations is used to refer to the perceived importance of health
and spa services for international tourists during their holiday in Sabah, Malaysia. This
implies that certain reasons for health and spa services during travel may correspond to
certain benefits to the tourists that are to be valued and obtained at the destination site.
Therefore, the tourism providers, health and spa providers must understand the tourists with
regards to their health and spa perceptions, expectations and decisions; and so, matching the
destination’s health and spa attributes to the tourists’ diverse needs.
Research Methodology
Research Method and Study Site
The qualitative approach was used in this research to provide an insightful understanding of
the underlying motivation factors and perceptions that encourage the utilization of health and
spa services/facilities. Collis and Hussey (2003: 53) stated that the qualitative approach is
more subjective in nature and involved examining and reflecting on perceptions in order to
gain an understanding of social and human activities, which this research dealt with – the
tourists’ ideas, perceptions and involvement in health and spa during holiday. Moreover,
Weaver and Lawton (2002: 388) stated that the qualitative research is suited for situations
where little is known about the subject matter.

Respondents were the international tourists who stayed at four respective resorts in Kota
Kinabalu, Sabah (Shangri-La Tanjung Aru, Shangri-La Rasa Ria, Sutera Harbour, and Nexus
Karambunai) and had used the spa facilities/services provided during their stays at the resort.
The mentioned resort hotels were chosen as the study sites due to reasons; (i) they provide spa
services as part of the hotel services, (ii) they are in the same ranking – can be considered as
five-stars resort hotels, and (iii) they provide similar leisure and recreational activities and
facilities. However, due to the policy of the resort, in protecting the guests’ privacy, which is
not allowed the guests to be interviewed, the interviews were conducted at the Kota Kinabalu
International Airport (KKIA) before they depart back to their home countries or to their next
destinations. The semi-structured interview questions for in-depth interview with the tourists.
It comprised of five sections: questions related to the destination (Sabah) selection;
accommodation selection; spa and wellness experiences in Sabah; the individual’s healthrelated
perceptions and attitudes; and demographic questions. Besides that, the Englishspeaking
international tourists were specifically chose to alleviate the interview conversation
in order to maintain the genuineness of the data, and avoiding translation into other languages,
since nuances may be lost in this process possibly resulting in bias and loss of meaning.
Data Collection
In-depth interviews were conducted with 21 health and spa tourists at the Kota Kinabalu
International Airport (KKIA) from January to February 2010. Approximately 150
international tourists were approached, about 80 were staying at the respective resorts, less
than 40 of them had spa experiences at the resorts, 21 accepted to be interviewed but only 15
in-depth interviews completed (notably tourists from America, Europe and Australasia
regions) due to time constraint.
In-depth interview were conducted using recordings and lasted an average of 40 minutes.
They were conducted with the consent of the health and spa tourists on the day they were
leaving the city (Kota Kinabalu). The in-depth interviews were conducted using the interview
guide approach with a semi-structured format to enable the researcher to identify the topic and
issues in advance and therefore sequence and words the questions during the course of the
interview. The interview started with an introductory note and followed up with demographics
characteristics of the informants. The informants were first asked with questions pertaining to
their destination and accommodation selection, the purposes for coming to Sabah and reasons
to stay at the particular resort, as well as the key attracting factors of the destination and
accommodation selected. Then they were asked about their views on health-related activities
during holiday, and also their spa experience in Sabah (particularly at the resort). The final
section of the interview sought on their perceptions and attitude on health especially
pertaining to spa services and treatments during holiday in Sabah. The informants were asked
and probed for detail explanation wherever required throughout the interviews.
Data Analysis
The recorded interviews were transcribed into a written format for data analysis. The data was
revised and analyzed in three stages to identify and develop appropriate themes. First, the
sample will be profiled by socio-demographic characteristics. This is because the relative
importance of the motivational forces has been found to vary as a function of tourists’ sociodemographic
characteristics (Kim, Lee and Klenosky, 2003). Second, push and pull
motivation items will be identified by drawing out the key themes and variables relating to the
descriptive themes – push-pull motivation and push and pull forces (Oh et. al., 1995; Yoon
and Uysal 2005). It was then linked to the tourist motivation factors from the previous studies
based on push-pull motivation factors that relate to health and spa tourism. The final data

analysis was based on health, spa and wellness concept suggested in the literature (Mak and
Wong, 2009; Smith and Puczkó, 2009), at which health and spas are seen as promoting the
individuals’ health and well-being rather than cure (medically), and also the main motivations
of having health-related and spa services during travel associated with the individuals’
awareness of health and well-being. In addition, as push-pull concept was adopted in this
research, therefore, the main health and spa’s attributes were recognized. This provides an
interpretation of health and spa tourism in Sabah, Malaysia.
Findings and Discussions
Profiling Health and Spa Tourists
Table 1 summarizes the demographic profile of the study informants, who are mainly from
the America, Europe and Australasia regions. Majority of the informants were female (75%),
aged more than 30 years old (80%), worked as professionals (80%), had university degree
(73%), and annual income more than 50,000 USD (67%).
Table 1 Profiles of Health and Spa Tourists in Sabah
No Demographic variables % No. Demographic Variables %
1 Nationality (regionally) 4 Occupation
America 20 Professional 80
Europe 80 Non professional 7
Australasia 80 Housewife 13
2 Gender 5 Annual income
Male 25 50000 – 70000 USD 20
Female 75 Above than 70000 USD 47
Not given answer 33
3 Age
Less than 30 20 6 Educational Level
30 – 49 47 Self-taught 7
More than 50 33 College/University 73
Not given answer 20
By looking at the results of the demographic analysis, it can be said that informants reflected
general demographic information of health and spa tourists, who are mostly female in
professional and executive jobs; baby boomers dominate this market, which fall into the 30-
49 age group, and also the finding of younger spa goers who are less than 30 years old. These
findings indicate an encouraging interest in healthy lifestyle, health and spa tourism among
the tourists. Therefore, it can be said that tourists would likely to go to spa during holiday.
There is an absent of data from a few of informants regarding their annual incomes and
education levels including the housewives. But generally it reveals that the informants have
an annual income of more than 50,000 USD and are university graduates.
Health and Spa: Perceptions and Attitudes

Perceptions, learning and attitudes may be influential to ones’ motivation factors and thus
influence the consumer/tourist behaviours. Accordingly, the informants think that it is
important to participate in activities that contribute to ones’ health and well-being. They seek
to find balance or moderation in their lifestyles which is believed to makes ones healthy or
healthier thus ones may live longer and able to lead more enjoyable lives. The informants
seem to be health conscious, most of them claimed to have being part of the health regimes,
for examples, they do regular exercises, walking or running, Pilates and Yoga, practice
healthy eating, involve in sport activities and occasionally go to spas, have massages,
pedicure and manicure. Few informants confessed that they do not have much time to involve
in any health activities due to the nature of their works (physical jobs, a demanding work): “I
don’t do daily activities in England. No time, because of my work. My work is long, so after
work I have no time to the gym, swimming, or… (Interview informant 14)”, “I don’t do them
but I would like to do them. I don’t have time to do them. (Interview informant 15)” This
indicates that the informants are health conscious but they do not have much time for health
remedies.
According to the findings, holiday seems as the best time and opportunity for the informants
to do things that they do not normally do at home to improve their health and well-being –
relaxation being part of their holiday as majority of the informants came to Sabah for holiday
and relaxation. They travelled mainly to see the wildlife (Orang Utan, Proboscis monkey, and
turtles) and natural environment (rainforest, mountain, beaches and islands) in Sabah. Other
than that, they also came because of the resorts, weather, culture, proximity to Hong Kong
(transit flights to home countries) and the range of activities like trekking up Mount Kinabalu,
golfing and water activities (snorkelling and diving). Previous travel experiences, the travel
agents’ and friends’ recommendations also influenced tourists’ decisions to come to Sabah,
especially for the first-time tourists. The travel agents and the internet were the main sources
of information for the tourists when selecting a travel destination.
In line with aforementioned, spa is not at all considered to be one of the reasons in selecting
Sabah as a holiday destination. However, when selecting an accommodation, the informants
generally consider spa as part of the resort/hotel’s facilities provided to the guests and would
have expected it if the accommodation is a 5-star resort/hotel. According to the responses, the
informants perceive spa as a place that has the ideas of relaxation, pampering, luxury, the idea
of massage and varieties of treatments, regeneration, clean and calm, tranquillity, enjoyment,
and expensive. Interestingly, there were informants associated spas with hot tubs or hot
springs. This suggests that the spa is associated with water and hot springs are the common
sources for building spas, which can be evidenced from the following quotes: “Luxury,
expensive… I think tranquil… hot tub… (Interview informant 13)” and “Different, because I
lived in Japan, so now I know the spa there was different, kinds of hot springs. So, that’s what
I initially thought about spa. (Interview informant 14)” Therefore, it is suggested that the
informants generally go on holiday for relaxation; spa is not the main reason to select a
holiday destination, but rather as part of the relaxation options/remedies during holiday.
Besides of being relaxed during holiday, the spa experience is regarded as part of the
enjoyment of holiday experience. This is reflected in the response “It is part of the enjoyment
of my holiday and it also adds to the relaxation of my holiday and the experience of my
holiday” (Interview informant 7)
Moreover, majority of the informants thought that it is important to involve in health-related
activities during holiday. They suggested that ones need healthy activities all around and not
just during holiday, or to keep moving and keep doing things even if during holiday, but it is

not the most important, the most important is relaxation; as evidenced from the following
quotes: “We try to incorporate relaxation, walking and tourism” (interview informant 12), “I
think you’ll feel better. (Health activities) It’s important but it’s not the most important. You
generally feel better” (interview informant 14), “The one thing that we try to do each day is
to go for a walk every morning, for at least it makes me energetic” (interview informant 15),
and “Relaxation is the most important, not exercise” (interview informant 18). Interestingly,
the lifestyle factor also motivates the health and spa tourists to visit spa during holiday. This is
evidenced from the quote: “When you’re away from home, and even if you’re relaxing on
holiday, where you have been, you still have to take care of your body. You still need to take
care of your face, of your nails…” (Interview informant 6). The informants thought that spa
experiences during holiday are very nice, enjoyable and relaxing as part of the holiday. To
some informants, it is one of the things that they always do on holiday which gives them the
opportunity to relax and a nice excuse for pamper, and mainly because they have time to do it
during holiday.
Health and Spa Tourists Motivational Factors
The following main themes emerged; (a) Self-satisfying/push factors: rewards after working
hard. (b) Self-fulfilment/push factors: Distress and time-out (relieve from work-stress and
take a break), unwind and rejuvenate and regeneration (busy and stressful life, distant travel
and activities involvement). (c) Spa attributes/pull factors, which consists of two sub-themes:
physical look – tangible resource (environment, atmosphere, decoration) and marketing image
of the spa (affordability, availability and accessibility, range of treatments and
professionalism). The findings are presented in Table 2.
Responses from the interviews show that the individual tourist’s wants/needs-related factors
are the main motivations for the informants to visit health-related and spa facilities during
their holiday in Sabah, Malaysia. When asked why the informants used spa and health
services at the resorts, majority of them answered for relaxation, pampering, distress, unwind,
rejuvenate and enjoyment; all that related to ones’ health and well-being in a more goaldirected
way (self-satisfying goals and self-fulfilment). Very less of mentioning the attributes
that attracts them to the spas – accessibility, affordability and the physical look of the
establishments. The informants simply answered their reasons for having spa experiences
were to relax and pamper themselves during holiday; for example: “We wanted some time-out
just to relax” (Interview informant 4), or “To relax and to get pampered” (Interview
informant 5) and “I wanted to be pampered” (Interview informant 6), “Just to relax and have
the opportunity that we don’t normally have” (Interview informant 8).

Table 2 Themes of Motivation Factors and Push/Pull Factors
Themes / Push and Pull Factors
Sub-themes
Push factor :
Self-satisfying goal Escape - relax and pamper
Reward after working hard
Self-fulfilment Distress / Time-out
Relieve from work-stress
Take a break
Unwind / Rejuvenate / Regeneration
Recovery from tension in busy life
Distant travel / long flights
Travel activities
Pull factors :
Spa attributes Physical looks – tangible resource
Environment / Atmosphere
Well-decorated
Spa attributes Marketing image
Affordability
Availability and accessibility
Range of treatments
Professionalism
In addition, the reasons of having spa treatments were also related to the tiredness of being
involved in activities during holiday and the travelling itself (e.g. had long flight). This is
evidenced from the following quotes: “To distress, to relax and after playing physical sports,
it helps my muscles rejuvenate” (Interview informant 10) and “Because I come from the Sri
Lanka, from the Safari and needed to… had a long flight, and it’s good to unwind” (Interview
informant 14). Interestingly, it is discovered that notion of “escape” from daily life, which
commonly as one of the main motivators for holiday exists and related to motivation of
having health and spa experiences at the holiday destination selected. This can be reflected
from the responses: “To relax, that’s the biggest thing. When you go on holiday because you
want to get away 8-10 hours a day working high pressure, come home cook and clean. So you
want to have that spa experience, as I said, to just relax before you go back and face it again”
(Interview informant 9), and “Just to recharge my battery while I am here. So, when I go
home, I’ll feel refresh and back to routine and work” (Interview informant 15)
Clearly, the motivating factors that emerged from the responses, as shown in Table 2,
suggested that health and spa tourists were generally motivated from the individual’s
psychological aspects including variety of reasons related to relaxation during holiday (needs
and wants). From the themes and sub-themes of informants’ motivational factors, it also
suggests that informants are mainly attracted by the spa attributes such as the tangibility of the
spa itself and the marketing image it conveys which have considerate influences on the
informants’ main motivations to visit spas/have spa treatments. These factors include the

environment and decoration of the spa establishment, the affordability, availability and
accessibility of the spa, the varieties of treatments and the professionalism of the staffs.
Interestingly, the motivation factor of “culture/learning” seems exists with relation to health
and spa motivations. However, it is not at the “core” of the motivation to go to spa or to have
spa treatments on the first place, but in influencing the decisions/preferences in choosing
types of spa treatments – traditional/local types of massages.
Push and Pull Factors
It is discovered that the notion of understanding the consumer/tourists behaviours is to study
their travel/holiday motivations. These motivations often related to tourists’ behaviours and
decisions during travel and holiday. It is interesting to note that there is an existence of pushpull
motivational dimension; push factors – the real goal-satisfying and self-fulfilment in
relation to informants’ needs and wants for relaxation and pamper, either as a reward for
oneself after working hard in their careers/jobs or a relieve of stress and tension of their daily
life and works; and pull factors – the spa attributes itself that play an important role in
activating the needs and wants for spa treatments during holiday and resulting health and spa
demands at the destination country. In many circumstances, the initial needs and wants are the
unconscious motivators that are activated upon the actions (spa visitation) by the tangibility
sources of the spa itself.
Although the two different motivating factors emerged in motivating spa visitation among the
tourists, it is the push factors that have a comparative greater effect in influencing the health
and spa tourists’ behaviours to visit spas when they go on holiday. These tourists are the
people who practice generally a healthy lifestyle – involve regular exercises, healthy eating
and perhaps occasional visits to spas or health-related facilities. This indicates that the tourists
are health conscious and well-educated pertaining to their health and well-being, which
increased the demand for health-related holidays (Chon and Singh, 2005). Although some
tourists might not be a regular spa goers at their home countries (generally due to time
constraint and their nature of works), but most of the tourists would have spa treatments
during holiday which commonly related to relaxation purposes, and/or other sociopsychological
factors, which reflected the findings of Mak and Wong (2007); Smith and
Puczkó (2009). It signals the importance of viewing the tourists’ needs and wants in
developing range of products and treatments that fulfilling these needs and wants.
However, it is discovered that health and spa tourists may be conscious on their needs and
wants before their actual travel, but these sub-conscious needs and wants may be evolved or
become significant within the actual travel period. Therefore, it suggests the primary focus
and attention for health and spa providers should be on the aspects of fulfilling the tourists’
health-related needs and wants – that push the individuals to go to spas during holiday. As
concluded by Mc Neil and Ragins (2004), the spa marketers must remain flexible and adapt to
changes of spa users’ wants and needs, and continue to improve communications about the
spa experience and its benefits. Apart from that, the push factors of health and spa tourists in
Sabah also reflected the wellness dimension of health tourism (Smith and Puczko, 2009).
Nevertheless, in some circumstances, the spa attributes equally play a significant role in
motivating spa visitations at the holiday destination, particularly in stimulating the “subconscious”
needs and wants. Meanwhile, to occasional or regular spa goers, there certainly
perceptions and expectation established prior to their visitation to spas at a particular holiday
destination. As spa is perceived to be a place for relaxation, with parallel to health and spa
tourists’ needs and wants, the spa establishment should be designed in a way that promote

elaxation as this is generally the main motivator for the tourists to visit spas. The spa
attributes include the physical environment and decoration of the spa itself, the reasonable
price and accessibility of the spa, the wide range of treatments or signature treatments that
blend with different/local cultures, and the professionalism of staffs. Apart from the actual spa
presentation, significantly the marketing image of the spa through media advertisement such
as brochures and resort’s websites has attracted the tourists to decide for spa visitation during
their holiday in Sabah, Malaysia. Within the framework of push and pull factors, it suggests
that these are the important elements that promote the overall spa experiences from the very
beginning of the spa visitation; at which it is perceived as an experience rather than just a
treatment, and also as part of the holiday relaxation.
Conclusion and Implications
Health and spa tourism in Sabah, Malaysia is still at an infant stage, and there is no
established definition of this growing niche tourism business which indicates an importance to
study within this tourism context. As Pearce (1989:113) stated that motivation is set of needs
and attitudes which predispose a person to act in a specific touristic goal-directed way, it is
discovered that the informants’ motivation to spas are associated with tourists’ motivation to
travel for holiday – relaxation, which this paper has explored and presented the motivational
factors of health and spa tourists in Sabah, Malaysia thus provides an insightful understanding
of what motivates health and spa tourists to visit spas during holiday in Sabah. It is clear that
both self-satisfying and self-fulfilment (push factors) and the spa attributes (pull factors) serve
as the motivational factors to spa visitation.
Moreover, the profiles of the tourists have reflected the findings of previous researches (e.g.
Mak and Wong, 2007; Smith and Puczkó, 2009). The growth of health and spa tourism indeed
affected by the major demographic shift of the world population. As previously stated,
majority of the spa goers are from the retired age group, but current findings show that there
are emerging groups of younger spa goers, within less than 30 years old. The health and spa
market also evolved among the professionals who perceive spas as a way to rest and relieve
from their work stresses, besides having the affordability for holiday and spa treatments as
indicated from their level of income. In addition, health and spa seemingly begin to be
acceptable among the male spa goers. These have directly indicated the needs for products
development to cater different groups of health and spa tourist market.
Particularly, the findings presented in this paper may indeed be significant on an international
scale, as it certainly possible that the tourists (notably from the America, Europe and
Australasia regions) to be indirectly attracted to spa attributes at the holiday destination (in
this case, Sabah, Malaysia) because their main travel motivators are mostly associated with
relaxation when holiday. This paper suggests that marketing strategies for health and spa
should focus on the individual tourist health-related needs and wants. As relaxation and
pamper are the significant motivational factors for health and spa tourists, the health-spa
providers should position their spas based on the relaxation attributes that may stimulate a
relaxing mood throughout the spa experiences – the atmosphere, the layout and decoration,
the staffs, and the spa treatments.
A major limitation of this study is due to the nature of the exploratory study and the type of
respondent (foreign tourists) which limit the generalizability of the research findings. It
suggests a comparative work in a similar context in different locations and countries would
prove beneficial for the possible validation of the findings. Additionally, the generalization of
the research findings can be extended through further research such as the use of these

motivational factors as variables in the quantitative approach in other context of health and
spa tourism – health and spa tourists’ satisfaction, spa treatment preferences, or perceptions
and expectations.
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Holidays as Health: The No Leave, No Life Campaign
Sue Beeton
La Trobe University, Australia
s.beeton@latrobe.edu.au
Abstract
The current interest in health, wellness and tourism tends to focus on travel for medical reasons
(Connell, 2006; Henderson, 2003; Herrick, 2007), travel for mental and physical rejuvenation
(Mueller and Kaufmann, 2001; Smith and Puczkó, 2009) and travel connected to physical activities
that require and/or encourage certain levels of fitness. It may be a primary, secondary or even
tertiary motivator. However, taking a vacation is in itself a removal from everyday, stressful living,
and recreation leave is considered in many nations as a necessary enabler of one making a
productive and healthy contribution to society.
Furthermore, the potential financial, social and community health costs of workers not taking their
allocated annual recreation leave has been recognised for some time, with researchers and tourism
professionals calling for programs to encourage holiday taking. For example, during 2002, just
under a third of Australians did not take any holidays, and of those who did, only 30 percent took
their maximum allowance of four weeks (Woolcott Research, 2002). Close to a quarter of those
studied stated that the primary reason for not taking any leave was a sense of being too busy at work
(Woolcott Research, 2002). According to Beeton and Pinge (2003: 309), “The very conditions that
taking a break are held to ameliorate have become the reasons for not taking a break”.
Tourist commissions and other government organisations have developed programs over the years
to encourage people to take holidays, especially domestic short breaks. However, the problem of
people stockpiling their leave remains, with 123 million days of annual leave by Australian full time
employees accrued in 2009, equating to AUD$33 billion in wages (Tourism Australia, 2009a).
Consequently, the liability for companies with high levels of accrued leave on their books is
substantial, presenting two major issues in addition to the need to develop what has become a flat
domestic tourism industry: that of community health and business viability.
It is clear that workers need to be persuaded to take their recreation leave, and employers to
encourage the development of a supportive corporate culture. In 2009, the Australian government,
under the auspices of Tourism Australia, developed an innovative program to encourage workers to
take their leave and at the same time holiday in Australia. The No Leave, No Life campaign has two
core strategies:
1. To work with employers to encourage the creation of a positive leave culture in their
organisations;
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
elsewhere.
Persuasive Communication
In any case where a change in people’s behaviour is required, it is important to understand the
barriers to participating in the desired activity. Persuasive communication theory can assist in
analysing the process and frames this particular Case Study.

According to Ajzen, “persuasive communication can produce a profound and lasting change, a goal
not easily attained by other means” (Ajzen, 1992: 6). Some years prior to that statement, Ajzen
(1988) argued that behaviour is a function of behavioural beliefs that influence a person’s attitudes
towards the behaviour, normative beliefs that determine the subjective norms (perceived social
pressures), and control beliefs that underpin perceptions of behavioural control, advancing
advanced the Theory of Planned Behaviour, outlined in Figure 1.
Figure 1. Ajzen’s Theory of Planned Behaviour
Source: Ajzen (1988: 133)
According to the theory, the intention to act precedes the actual behaviour, with intentions based on
three elements, or salient beliefs: personal attitudes towards the behaviour, one’s perception of
social pressures to undertake the behaviour (or subjective norm), and the perception of how much
personal control one has over that action (perceived behavioural control). In relation to visitor
behaviour, Fishbein and Manfredo (1992) present some strong cases supporting the role of
persuasive communication theory in affecting national park visitor beliefs, attitudes and intentions
and,, ultimately their behaviour.
The perceived control one has over one’s behaviour is significnat as it relates to a sense of personal
choice and the power to do so. This is similar to locus of control theory, which consists of two loci,
namely internal and external (McCool and Braithwaite, 1992) - where a person believes that their
future is controlled by others, they reflect a belief in an external locus of control, which is similar to
a low level of perceived behavioural control in Ajzen’s model.
While the model has three areas of salient beliefs, they are not necessarily evenly weighted, with
some being so weak at times that they are over-ridden by the most dominant belief. For example,
there are times when there may be little or no influence from attitudes and subjective norms, so
consequently a person my move directly from ‘perceived behavioural control’ to an intention to act
(Ajzen, 1988). Such differences are also reflected in the model, presenting a flexible and effective
model that has been applied many times in relation to persuading others (for some tourism and
recreation examples, see Lackey et. al., 2002, Beeton et; al., 2005).
The Case of No Leave, No Life
As noted earlier, the Australian No Leave, No Life campaign commenced in 2009, with the longterm
aim to reduce the amount of accrued recreation leave by Australians and to increase domestic

tourism. Previous attempts in the late 1980s and early 2000s to encourage local holidays by
Australians was only partially successful, with accrued leave continuing to rise and domestic
tourism growth remaining flat. In order to address this, Tourism Australia shifted from the
traditional supply focus of a Destination Marketing Organisation (DMO) to attempting to influence
demand by enlisting the employers along with the tourism industry.
Tourism Australia employed research consultants, Jones Donald Strategy Partners to undertake the
research, using Focus Groups, In Depth Interviews and Online Surveys in 2005 and 2009, along
with Single Source Surveys from 2006 to March 2009 in order to gather the required data (Tourism
Australia. 2009b). They divided their findings regarding barriers to taking leave into two groups
using ‘workplace and personal barriers’ as the differentiators.
The industry provides the domestic holiday options, while Tourism Australia developed tactical
promotions aimed at company employees through a dedicated TV travel show (No Leave, No Life)
and other collateral. The target employees are full time staff deemed to have ‘stockpiled’ over 25
days (or five weeks) of annual leave, as one in four full-time employees in Australia have that
amount of leave owing, pointing to a significant issue. Unsurprisingly, this group tend to be older
males, longer serving employees who typically manage staff, as well as parents of school aged or
older children and empty nesters (Tourism Australia, 2009b). The younger, single, child-free and
women workers did not feature, underlining the broadly accepted fact that the Australian workforce
remains dominated by men at the higher levels of organisations, and as longer-serving employees
due to the continued over-representation of women as family carers. Due to this unusual step for a
DMO to focus on changing the domestic tourism demand environment (or ‘push’ factors as
described by Dann, 1977) via employers, this paper focuses on that aspect of the campaign.
Tourism Australia has taken a three-stepped approach to working with employers, with the first
providing background data on leave stockpiling, the second suggesting some workplace strategies
to address the issue, with the third focusing on enabling employers to change the culture and
attitudes towards taking leave within the organisation through engaging with the No Leave, No Life
program. All of this material was made available via the internet as training modules and videos
(see http://www.noleavenolife.com/employer/businessBenefits.aspx).
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
Attitude:
Move up corporate ladder
Prefer to work
Saving (for emergencies)
Saving (for big trip)
Hard to find things to do
Subjective Norms:
Taking leave is a sign of weakness
Cause work for others
Internal work culture

Behavioural Control:
Workload
Lack of
resources
Support from
management
Job security
Source: Tourism Australia, 2009b
Will not meet targets
Hard to fit around projects
Unable to take when it suits
Lack of money
Partner’s availability
Children’s availability
Time taken planning
As can be seen, most of the salient beliefs regarding the barriers are in the ‘behavioural
control’ area, which responds directly with organisational culture. If these outweigh the
reasons for taking leave, the intention NOT to act is formed, consequently there is no action
taken. In order to shift this, Tourism Australia has adopted a strategy aimed at the demand
side of the tourism system (ie the ‘push’ factors). Their stated strategy is to ‘raise the
awareness’ of employers and employees, but they are doing more than this – they are working
to change the salient beliefs of those not taking holidays.
However, Tourism Australia has not looked at those who DO take leave, which would
provide a more holistic perspective and provide data that can be used in the Theory of
Planned Behaviour. By getting both sides and then ascertaining the strength of these beliefs in
the targe group (leave stockpilers) and range of consistent messages can be developed.
‘Strength’ does not relate to how many people believe something, but how much that belief
influence’s one’s decision to act. By ascertaining what are the strongest drivers and inhibitors,
much of the subjectivity of such research can be removed. While this may still produce a
similar outcome to what has been done, this approach would provide a more rigorous result.
Conclusion
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.

References
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Research job no 5435-M. Sydney

A Case Study of Innovative Wellness Tourism: The Case of RP Vacations,
Netherlands
Ed Brooker
Griffith University, Australia
ebniagara@gmail.com
and
Marion Joppe
University of Guelph, Canada
Introduction
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
services.

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,
including:
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.
Methodology
In order to gain insights, it was essential for Roompot personnel to speak to the concept of
wellness tourism within their parks in their own words and from their individual perspectives.
This study therefore employed qualitative methodology where the research tool comprised of
a single case study based on semi-structured interviews with two individuals with specific
connections to the program. The first interview was conducted in 2006 with the visionary
staff person who was instrumental in developing the concept and a follow up interview in
2010 with the current manager overseeing RP Care and RP Wellness.
RP Care
Johannsson (2004) suggests the best chance to innovate is found in the ‘intersection’ – a
connection between two different fields. Roompot has clearly found the intersection, by merging
health care and vacations, within its existing operation. The result is known as RP Care, yet
another extension of the Roompot offering.

RP Care is an innovative modular extension of Roompot Vacations, providing guests (both
domestic and European Union) to obtain a variety of quality health and wellness services while
also enjoying a Dutch sea and sand vacation. RP Care has been established in part in response to
the international focus of health care tourism, in particular, the number of Dutch, German and
English who travel abroad in response to long waiting lines and/or electing to undertake elective
medical procedures while on vacation. Roompot felt that it could expand on its initial entry into the
health care, started five years ago with the offering of kidney dialysis at the Banjaard, a five-star
holiday bungalow park, located 10 kms from the first established Roompot Park.
The kidney dialysis service stemmed from the local hospital’s inability to service the needs of an
expanded vacation market and local knowledge, as the founder of Roompot was a member of the
local hospital board, was therefore aware of both the need for additional dialysis service and the
hospital’s desire to establish an off-site clinic. Thus in true entrepreneurial spirit, a separate
building was constructed within the park to house the dialysis service. Patients no longer had to
travel to and remain in a hospital for the procedure. Rather they have the option of visiting the
clinic three times a week, for 2 weeks, enjoying a non-sterile, relaxed but professional
environment. Appointments can be made on line through the Roompot Vacations website, with the
knowledge that the onsite medical staff are all associated with the local hospital.
The dialysis service is a radical innovation amongst holiday parks that traditionally offer
recreational opportunities to a variety of markets. However, previously, the mature market has
been viewed simply as a market opportunity based on their numbers only, as no serious efforts
have been made to alter the product mix in order to attract and retain a larger percentage of this
market. Roompot/RP Care has.
The success of the kidney dialysis service has led Roompot to extend its modular service offerings
into care and cure, augmenting the existing recreation facilities. Thus RP Care was created.
However, the creation of the service has not come without any difficulties. At first, it was a
difficult sell getting medical professionals to partner with RP Care. But Roompot’s founder
understood the value of networks, both in and outside of the business (Grulke, 2005). Based on his
relationships with external organizations, including the local hospital board, he managed to create
the necessary interest in the offering. In 2010, professional personnel from the local hospital staff
the dialysis center, but a local doctor also spends a day now visiting the park booking appointments
with park guests. Other doctors are inquiring about participating in the program.
Table 1 outlines the modular services and amenities planned for various Roompot locations within
Zeeland in partnership with local health providers. A clinic specializing in plastic surgery is
intended to be located in Goes, centrally positioned close to other Roompot parks and the regional
hospital. The location is of benefit to both doctors and patients, who will be able to convalesce in a
quality holiday setting, with family and/or friends.
The strategy to focus initially on the province of Zeeland is based in part on local knowledge of
health care providers, networks and also represents the location of Roompot’s base of operations.
The strategy can be expanded into other provinces within Holland based on local success and
learning curve.

Recreation Care Cure
• Fun stuff
• Care facilities
• Conference facilities
• Pools
• Sauna
Table 1 - RP Care building blocks
• Plastic surgery
• Cosmetic
• Orthopaedic
• Eye
• Pain reduction
• Radiology
• X-rays
• Physiotherapy
• Preventative
• Therapy
• Sauna
• Nutrition
• Acupuncture
The strength of the concept is based on various factors. First, Roompot has essentially created a
win win situation for a variety of players, including local hospitals, health insurance companies,
individuals and for its own corporate opportunity. Local hospitals can now partner with a reputable
private sector business to continue to offer its services but within a decentralized framework.
Health insurance companies benefit from the preventative nature of the services, and the solid
reputation of Roompot to deliver quality care. It eliminates the uncertainty attached with travel to
Asia or other areas of Europe. The individual benefits from the opportunity to avoid lengthy
waiting lists, select the necessary service from the extensive offering, and to recuperate in a
comfortable location, where family and friends can visit, recreate, and remain in the Netherlands.
Roompot is the other winner in this situation, using a radical approach to capitalize on disruptive
social trends. The development of RP Care capitalizes on the aging population in a manner far
removed from what the competition has considered. This competitive advantage can also be
sustained as Roompot has first mover advantages with government health care providers. In
addition, the addition of RP Care addresses the issue of seasonality head on through the
introduction of a new service line and market that may otherwise not frequent a Roompot Park.
Facilities and amenities designed for use during the busy summer months now will be occupied
and used during the spring and fall, raising occupancy rates, and creating new opportunities for
programs and events. Current estimates suggest that two to three percent of Roompot patrons
utilize RP Care services. That number is expected to grow to ten percent as a result of promotion
efforts and the demographic changes noted earlier – older population will seek out care at Holiday
Parks The addition of RP care sends a clear message to the loyal customers who have frequented a
Roompot park over several summers – we’re not abandoning you as you age. In fact, we want to
keep you as a customer, so we’ve developed new programs designed with your needs in mind.
The modularity of the three cornerstones – recreation, cure and care provide the flexibility for
application to a diverse set of circumstances. Health services can be added to a vacation or
conference. Convalescents can recover in a comfortable setting, knowing their needs are looked
after, and the care is available locally.
Roompot’s decision to capitalize on disruptive social trends, focusing on collaboration – aligning,
exchanging, and leveraging opportunities (Dvir et al, 2004) builds on a modular business model.
Such a modular approach gives the company the capability to couple and decouple service delivery
on demand, based particularly on three building blocks – recreation, cure, and care. On demand
business enables a customer to connect in a flexible manner – for instance health services to a
holiday or vice versa, contingent on his/her circumstances or personal preferences. It offers
convalescents a sense of security that they can recover in a comfortable setting, in the knowledge
that their needs are looked after in a professional manner.

The introduction of its modular business model enabled its subsidiary RP care to thrive in an
intensely competitive tourism environment. It also demonstrates Roompot’s leadership in the trade
and beyond, particularly that a radical innovation approach can bring rewards well worth the risk.
In 2010, RP Care facilitates care, cure and wellness opportunities through partnerships with
various health oriented organizations. For example, it provides facilities for disabled guests,
kidney dialysis, accommodations for people with allergies, and automated external
defibrillators at certain properties. It provides arrangements for home care, medical
equipment, and health checks for those vacationing at a Roompot Park, thereby leveraging its
strengths as a Holiday Park chain, with the wide range of health service partners.
The number of requests to capitalize on these facilities and services is growing, as noted in the
increased bookings from 2007 to 2009, illustrated in Table 2.
Bookings
accommodations
for adjusted
Bookings for home care and medical
equipment
Bookings from foundations and
organizations
Table 2 – Increased RP Care Bookings
2007 2008 2009
3,500 4,800 6,000
279 597 799
833 1,081 1,387
The results showcase a growth in patron response to capitalizing on the opportunities for care
and wellness facilities and services, a trend which is expected to grow as awareness of the
program is extended. The actual number of bookings may appear to be low, but the program
itself is quite unique, given that care, cure and wellness are not automatically associated with
a caravan or holiday park experience. The bookings provide opportunities for increased
business for the parks during the shoulder periods, a time when “holiday” patronage has
decreased substantially.
As with many innovations, there is a test and measure component to the implementation of
the program. Currently, five resorts within the Roompot Parks ‘chain’ have wellness centres,
two which are directly managed. The other three are parks within the RP Parks vacation
umbrella, i.e. vacation bookings. The overall success of the existing wellness programs will
impact future extension of facilities, services and partnerships. Broadly speaking, however, it
is anticipated that the program will continue to grow, given the needs of an aging population,
the opportunities to provide an enhanced visitor experience, and additional business
opportunities for the parks themselves.
Conclusion
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.
References:
Bencis. (2005). “Roompot Company Description”. Amsterdam.
Buhalis, D. (2000). “Marketing the competitive destination of the future”. Tourism
Management, (21) pp.97-116.
Drucker, P (1985). Innovation and Entrepreneurship. New York: Harper & Row, Publishers.
Dvir, R., Lettice, F, and Thomond, P. (2004). Are you ready to Disrupt it? Israel: The
Disrupt-IT Consortium.
Go, F. & Israels, R. (2010). “Innovation of Care and Cure in the Netherlands” in K.
Weiermair, P. Keller, H. Pechlaner and F. Go (Eds.) Innovation and Entrepreneurship:
Strategies and Processes for Success in Tourism, Berlin: Erich Schmidt Verlag.
Grulke, W. (2005). People Management. 11(21) pg. 44.
Johansson, F. (2004). “The Medici Effect”. Boston: Harvard Business School Press.
Klemm, M. and J. Rawel (2001) ‘Extending the School Holiday Season: The Case of
Eurocamp’ In Seasonality in Tourism, T. Baum and S. Lundtop, (Eds). Oxford : Elsevier.
Rogers, E. M. (1962). Diffusion of innovations. New York: Free Press.
Walder, B. (2006). “Sources and determinants of innovations – the role of market forces” in
Innovation and Product Development in Tourism, B. Walder, K. Weiermair, A. Perez,
(Eds.) Berlin: Erich Schmidt Verlag.

UNDERSTANDING THE IMPACT OF LEISURE TRAVEL ON THE QUALITY OF
LIVES OF PEOPLE WITH MOBILITY IMPAIRMENS
Shu Cole
Indiana University
colest@indiana.edu
Abstract
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.
Method
Two focus group discussions were held among avid travelers with mobility impairments at the
13 th Congress of Society for Accessible Travel and Hospitality (SATH) in 2009. A total of 12
people participated in the focus groups. Two questions were asked: 1) What was the role of
travel in your life before you became mobility impaired (or “What is the role of travel in your
life?”, if the impairment is a congenital condition)? and 2)Based on your past travel
experience, has travel in general impacted your quality of life? How?
Results & Implications
Focus group discussions revealed the essential role of travel in the lives of people with
mobility impairments. Many considered travel as a basic need in life, such as food and air.
Participants confirmed the positive impact of leisure travel on their quality of lives. They
believed that leisure travel had helped them to 1) regain control of life; 2) overcome the fear
of leaving their mundane environment; 3) complete the rehabilitation successfully; 4) enhance
their relationship with family members; 5) continue learning and exploring of different
culture; and 6) keep the adventurous spirit in their lives. Findings of this study suggested the
psychological, mental, and health benefits for people with mobility impairments. Policy
makers should protect the rights of this population to travel, and business owners/managers
should make sure their facilities and services are accessible.

The Impact of Tourism on Community Wellbeing and Quality of Life: A
Longitudinal Study
Margaret Deery
Centre for Tourism and Services Research Faculty of Business and Law, Victoria University
and PO Box 14428, Melbourne City, Victoria, Australia 8001
Tel: (613) 9919 4626
Marg.deery@vu.edu.au
Leo Jago
Centre for Tourism and Services Research, Victoria University, Faculty of Business and Law
PO Box 14428, Melbourne City, Victoria, Australia 8001
Tel: (613) 9919 1541
The Impact of Tourism on Community Wellbeing and Quality of Life: A Longitudinal
Study Introduction
Over the last few decades, substantial research has been undertaken examining the social
impacts of tourism on communities (see for example Sharma, Dyer, Carter and Gursoy, 2008;
Easterling, 2004) with the focus, often, on the level of support residents have for tourism
development. While these studies are extremely useful for tourism planners and policy
makers, they provide less information for those concerned about the wellbeing of the
community and the individuals that comprise communities. Some studies have, in fact,
examined the impact of tourism on the community and residents’ quality of life (QOL),
beginning with the early work by Milman and Pizam (1988) and Perdue, Long and Allen
(1990). More recent work by Tovar and Lockwood (2008), Andereck, Valentine, Knopf and
Vogt (2005) and Jago, Fredline and Deery (2006) have focussed on the specific tourism
impacts that either enhance or detract from the quality of residents’ lives. Much of this
research, however, is a ‘point in time’ examination of the social impacts with little or no
understanding of how perceptions of these impacts change over time. Although studies such
as that by Huh and Vogt (2007) and Getz’s (1994) study of residents’ perceptions in the Spey
Valley of Scotland have provided some insights into the changes that may occur over time,
few other studies have added to this area. This current study aims to address the paucity of
studies on the impacts of tourism on residents’ quality of life over time.
Method
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.
Findings
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.
References
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
Nice
France
Frederic.DIMANCHE@cote-azur.cci.fr ; f.dimanche@skema.edu
Abstract
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.
References
DeFrank, R. S., Konopaske, R., & Ivancevich, J. M. (2000). Executive travel stress: Perils of
the road warrior. The Academy of Management Executive, 14(2), 58-71.
García-Altés, A. (2005). The development of health tourism services. Annals of Tourism
Research, 32(1), 262-266.

Hamer, D., & Connor, B. (2004).Travel health knowledge, attitudes and practices among
United States travelers. Journal of Travel Medicine, 11, 23-26.
Henderson, J. (2003). Health care tourism in Southeast Asia, Tourism Review International,
7(3-4), 111-121.
Heung, V., Kucukusta, D., & Song, H. (2010). A conceptual model of medical tourism:
Implications for future research. Journal of Travel & Tourism Marketing, 27(3), 236-
251.
Keystone, J., Kozarsky, P., Freedman, D., Nothdurft, H., & Connor, B. (Eds.). (2008). Travel
Medicine (2 nd ed.). New York: Mosby Elsevier.
Lawlor, D., Burke, J., Bouskill, E., Conn, G., Edwards, P., & Gillespie, D. (2000). Do British
travel agents provide adequate health advice for travellers? British Journal of General
Practice, 50(456), 567-568
Lawton, G., & Page, S. (1997). Evaluating travel agents' provision of health advice to
travelers. Tourism Management, 18(2), 89-104.
Lepp, A, & Gibson, H. (2003). Tourist roles, perceived risk and international tourism. Annals
of Tourism Research, 30(3), 606-624.
Liese, B., Mundt, K. A., Dell, L. D., Nagy, L. & Demure, B. (1997). Medical claims
associated with international business travel. Occupational and Environmental
Medicine, 54, 499-503.
Sonmez, S. & Graefe, A. (1998). Influence of terrorism risk on foreign tourism decisions.
Annals of Tourism Research, 25(1), 112-144.
Striker, J., Luippold, R., Nagy, L., Liese, B., Bigelow, C., & Mundt, K. (1999). Risk factors
for psychological stress among international business travelers. Occupational
Environmental Medicine, 56, 245-252.
Welch, D., Welch, L., & Worm, V. (2007).The international business traveller: A neglected
but strategic human resource. The International Journal of Human Resource
Management, 18(2), 173-183.
Wilks, J., & Page, S. (2003). Managing tourist health and safety in the new millennium.
Oxford: Elsevier.

“A Happy Tourist Experience”
Filep Sebastian
Victoria University
sebastian.filep@vu.edu.au
Abstract
Happiness is a concept that has fascinated thinkers for centuries because it is central to
understanding the meaning of human life. Research on happiness has flourished in recent
years in many social sciences. The concept can be defined from multiple perspectives. In
positive psychology (a research field that studies wellbeing in psychology), happiness is
typically defined in terms of three main dimensions: engagement, meaning and positive
emotions. A happy person would therefore be actively involved (engaged) in his or her daily
activities, would lead a personally meaningful life (eg believe in God or contribute to a cause
that he or she believes in) and would regularly experience positive emotions of interest, joy,
contentment and love. Each of the three dimensions of happiness is measurable. Happiness is
therefore a concept that is worthy of scientific research - it can be defined and scientifically
assessed and it is a conscious state of mind.
A qualitative doctoral thesis on tourist experience and happiness was recently finalised and
awarded. In this PhD project, a study of a tourist experience of a group of study abroad
university students was conducted. The study assessed travel motivation and travel
satisfaction of the group in three phases of the students’ travel experience (anticipatory, on
site and reflective phases). Travel motivation themes were identified in the anticipatory phase;
immediate and post hoc satisfaction themes were identified in the on site and reflective phases
of the tourist experience. The students’ motivation and satisfaction themes were identified
through qualitative positive psychology approaches. An exploratory picture of a happy tourist
experience has emerged from this psychological investigation. In this picture, the three
dimensions of happiness from positive psychology – meaning, engagement and positive
emotions – are linked to the students’ travel motivation and satisfaction themes in their three
travel phases.
A series of future quantitative and qualitative studies of tourists’ positive emotions, meaning
and engagement has emerged from this micro analysis of the students’ tourist experience. The
suggested studies are important agendas for future research as the three happiness dimensions
have been linked to a range of health benefits by other happiness researchers. An example of
these health benefits is the improvement in cardiovascular health as a result of experiencing
positive emotions. Investigations of happy tourist experiences from positive psychology and
other social science perspectives therefore need to continue in tourism studies.

URBAN ZEN – AND HOW TO EXPLORE THIS PHENOMENON?
Roos Gerritsma
University of InHolland, Amsterdam/Diemen
The Netherlands
roos.gerritsma@inholland.nl
Abstract
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)
References:
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
ESHTE
Rua do Campo da Bola, Quinta da Raposeira, Mosqueiros
2460-203 Alfeizerão, Portugal
nuno.gustavo@eshte.pt
Abstract
This paper is part of a work-in-progress PhD dissertation entitled “Tourism, Leisure and
Health – discovering the new SPAs”, the first national study in this particular field.
Having Portugal as a case study, a country in which Health Tourism was recently pointed out
as one of the ten strategic segments for tourism development, this paper aims at presenting
and discussing the new SPAs customers' profiles, as well as helping to understand how
relevant leisure and tourism moments are and how they are used in health management. The
motivations of these new SPA customers, their concerns with spa consumption and health
management in general, and the meanings of SPA consumption in global health management
are other issues focused on in this paper.
This investigation has a national spectrum and it includes about twenty-one cases studies,
including SPAs in different locations (in metropolises, cities, countryside, in and out of the
Portuguese tourism regions, day SPAs, thermal SPAs, and marine SPAs), different concepts
(e.g.: holistic), services (hydrotherapies, balneoteraphies, massages, aesthetics and natural
treatments) infrastructures, and main natural resources (tap water, sea water, spring hot water,
wine, etc.).
In the twenty-one case studies mentioned, and as the main investigation resource, a survey
was developed. This survey focused on SPA customers' consumption and on their health
management practices (the data was collected during three months with support from the SPA
Staffs). The data collected (824 surveys) was analyzed with SPSS (Statistical Package for
Social Sciences). It was map out the average profile of SPA Goers in Portugal. Different
consumer clusters were outlined with a scalable cluster analysis algorithm - The SPSS Twostep
– log-likelihood.
Keywords: Health and Body management, Leisure, Health Tourism, SPAs
Introduction
With the pace of globalisation, urbanisation, state-of-the-art technologies and on-line
consumerism in 21 st century western societies, people now live out the illusion of a new
paradigm – the myth of eternal life. In the euphoria of longevity, the adoption of healthy life
styles takes on a singular importance to postmodern daily life. Founded on biomedicalisation
and promoted by neoliberal philosophies of government, health has been reinvented as a
capital to be valued and optimized, taking on a unique centrality within the lifestyle concept
(Clarke, 2003).
In the light of a new social centrality of health, that is, the growing medicalisation of western
habits, the universe of health services proliferates, a reality which manifests itself in a
growing allocation of leisure and tourism time to body care. This reality is particularly
reflected in the discovery of leisure and tourism periods as privileged opportunities for body
care and management. In accordance with the new concepts and dimensions which

circumscribe the scope of health at the outset of the 21 st century, this niche market has
witnessed a significant diversification in supply. Alongside the pathogenic view of health and
associated services, this market also currently incorporates a new range of services, now
focused on a holistic approach to the body, congregating highly disparate and different
motivations and services within the same market niches thereby expressing this new vision of
the health concept (Yeoman, 2008).
Founded on the wellness ideal (an integrated and holistic view of health), SPAs have imposed
themselves as a leading players in this new health universe as a result of the appropriateness
of their concepts and services to meeting the new challenges emerging from the globalised,
agitated and eminently urban consumer of the 21 st century. “SPAs and wellness resorts may
therefore be conceptualised in cultural/sociological terms as modern day temples where
people can experience rituals, learn to deepen their personal wellness practices, raise their
consciousness, become open to enhanced ways of being and deepen their experience of being
alive” (Cohen, 2008: 8).
The growing centrality of these spaces, expressed through the growth in supply and demand
in postmodern western societies, is the departure point for this article in which we aim to
contribute towards a greater understanding of the demand profile using Portuguese SPAs as
the case study following a nationwide data collection survey.
Literature Survey
The significance and meanderings of health in the 21 st century
Today, the meaning and the universe of health find expression in a private, lucrative and wide
ranging market of products and services where slogans and sound bites abound, such as
eternal youth, the most beautiful, the strongest or the healthiest. This is a new notion of public
health which goes beyond the paradigm of disease-free and establishes a holistic and positive
vision of health supported by a specific, socio-political environment which permeates
postmodern 21 st century societies (Minkler, 1989). In the face of growing levels of economic
prosperity, in no way comparable to those prevailing in the post World War Two boom ("The
Glorious Thirty Years”) inaugurating the model of Welfare States when the nationalisation of
the services and the social responsibility of health was taken on by national health services.
Subsequently, the development of new and contemporary, neoliberal governing principles and
policies, were complemented and articulated with the fostering of a vast private market of
health services leading to a new alternative health management model in which the individual
now plays an active and self-responsible role (Rose, 2001). In a society which is profoundly
marked by globalisation, by information technology and communication as well as by the
liberalization of markets, new “health brokers” are affirming themselves in health
management in competition with the traditional “experts”. These offer new, more
“autonomous” and more “accessible” health management products and solutions, which
circulate freely in a new and vast private health market where the laws of marketing rule.
This transfer of responsibility in the health care field, as presented in the new model, is from
the outset a reflection of a scenario marked by the growing disappointment as to the limits of
medicine and its capacity to overcome the new challenges, such as chronic illness or the
unrelenting quest (the myth) for eternal life. “A 2005 report by the WHO (…) estimates that of
all the 58 million deaths in the world in 2005, 35 million (60%) will be caused by chronic
diseases such as heart disease, stroke, cancer, chronic respiratory disease and diabetes”
(Cohen, 2008:10).

Whether we opt for more realistic scenarios, or those more visionary as regards the current
issues (EFILWC, 2004), it is clear that health faces a set of new paradigms at the outset of the
21 st century. These require ongoing analysis and reflection, conditioned by a unique scenario
of uncertainty expressed in the paradoxical perception of loss of “power” over the body in no
way consensual with human ambitions and within the scope of new self-management
practices, a hybrid and universal approach to the body and its control have been presented as
the solution.
Simultaneously and in response, a new private health market has emerged rendering new
services, many of which represent genuine technological revivalisms of health practices from
a ‘golden’ pre-scientific era, expressing a new ideological promotion of health, sold under the
holistic sign of wellness, in which the individual is morally responsible for demanding the
best physical and psychological setup able to play a determinant role in day-to-day
performance.
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
such services.
When combining the underlying physical dimension with an integrated and holistic view,
these facilities transform themselves into veritable temples for the worship of the body

focused on the paradigm of wellness, SPAs are today a meeting point between western and
eastern views of health “The initial pioneers of the modern-day SPA concept concentrated
upon the physical aspects of wellness by providing their guest with visible results to nagging
physiological problems. (…) Over the years more and more players in the industry have
adopted holistic philosophies, and integrated Eastern and Western wellness systems into their
menus” (Haden, 2007: 1).
In the image of 21 st consumer societies, these spaces have today adopted an eminently
commercial philosophy dedicated to a clientele valuing health, the body, the environment,
social justice, personal development and sustainability. In these facilities, health continues to
be a business of an essentially liberal nature, predominantly out of medical reach and where
branding laws are sovereign. In our days, SPAs emerge as places of greater affirmation of the
ideals of self-health and of self-responsibility where individuals learn to control and monitor
their bodies by resorting to a set of specified techniques which lead precisely into a dialogue
and rediscovery of their own bodies.
Method
Sample
It is currently impossible to quantify the universe of the SPA sector in Portugal given the
absence of a legal framework regulating SPA activities: there is only a legal framework for
hot spring thermalism, and within that, for Thermal SPAs. Thus, we must begin by
establishing minimum selection criteria. Only those SPA infrastructures which significantly
render the following services were selected: health care involving recourse to water,
specifically as regards thermal bath treatments and hydrotherapy techniques and the provision
of alternative therapies. Most of the aforementioned infrastructures are integrated into hotels.
In partnership with an expert (invited) from the National Tourism Authority (Turismo de
Portugal) so as to identify the establishments which could be classified as SPAs,
approximately 60 infrastructures were identified. In addition to the aforementioned criteria,
this selection additionally considered geographical location so as to guarantee full coverage
both geographically and the actual SPA concept thus safeguarding the representation of as
many different SPA types as possible.
29 SPAs from the resulting universe agreed to participate in this study with 20 later being
validated. Taking into consideration that a significant part of the questionnaire contemplated
variables of a clinical nature, a minimum of 30 questionnaires was established as the base
requirement for the autonomous validation of an entity. The participant Day Spas, Resort
Hotel SPAs, Destinations SPAs, Medical SPAs ensured the completion of a total of 824
questionnaires by their SPA Goers between May and August of 2009.
Procedure and questionnaire design
The questionnaire was produced within the scope of a PhD project which in its first phase
carried out a review of the available literature on themes such as health, body, leisure and
tourism. The second part of this research, of an empirical nature, first contemplated analysis
of articles and messages conveyed by the major woman’s and men’s magazines in circulation
in Portugal and later, the application of the aforementioned questionnaire. The questionnaire
was produced after analysis by experts in SPA management and involved a pre-test period of
one month. The final version of the questionnaires consisted of four parts: a first section on
SPA consumption (regularity, services used, motivations, satisfaction level and factors of
choice), a second part focused on the representation and meaning of wellness and health, and
a third on health care (practices and routines) and finally a fourth aiming to define the social

and cultural and socio-economic profile of the respondent. The questionnaire was essentially
composed of closed questions, except in the second part where open questions were preferred.
The validation of the applied questionnaire was based on a panel of experts (SPA Managers)
and on a pre-test carried out over one month in March 2009. The final version of the
questionnaire was produced in five languages (Portuguese, English, Castilian Spanish, Italian
and French). The questionnaires were applied in the form of a survey with the cooperation of
the managers and receptionists of the SPAs. Clients would be invited to participate in the
survey after their SPA session.
The statistical processing of the information was carried out using the SPSS -Statistical
Package for Social Sciences- software version 1.7. Based on a descriptive statistical analysis,
the typical profile of the SPA consumer was obtained. So as to identify possible segments in
this demand universe, grouping analysis was later applied with recourse to a TwoStep
algorithm – log-likelihood (considering the nature of the variables in question and the
questionnaire structure).
Survey Findings
Based on the sample gathered through the aforementioned questionnaire, one can immediately
present a social and cultural profile of the client who currently frequents Portuguese SPAs. As
regards age, the average SPA client is 38.5, with individuals aged between 30 and 39
representing the client age range with greatest weighting (38.7%). As for gender, women
dominate, accounting for approximately 69.8%. In the case of family structures, those without
dependents (49.5%) emerge as the main users, that is, couples (married or in common law
relationships) (24.4%) and single people without dependents (25.1%). However, the
married/common law relationship with children prevails as the single most important family
structure category with 34.6%.
The Portuguese SPA client is mostly permanently resident in Portugal (73%), despite some
being of other nationalities. Clients permanently residing in other countries represent 27% of
demand with United Kingdom residents (30%) significant in this sample. The typical area of
residence of the SPA client is also classified as being eminently urban (71.7%), be it in a city
(49.5%) or in a metropolis (22.2%).
In terms of educational levels, there is a clear domination of individuals with higher education
(73.9%), particularly honours degrees (56.1%). In line with the social and cultural profile is
also the socio-economic profile with particular emphasis on individuals engaged in
employment (91.7%) and mainly of employee status (73.2%). These individuals mostly work
in the tertiary sector (89.1%), essentially holding executive responsibilities, at corporate
management level (28.0%) or in specialised intellectual and scientific professions (37.0%).
The average monthly net salary of the family aggregate immediately reflects the sociocultural
and socio-economic level of the current population, with the vast majority earning
more than €2,000 monthly. It must also be mentioned that 48.9% of the households of
individuals attending SPAs report average monthly earnings in excess of €3,000.
The study shows that the range and frequency of SPA use is an emerging practice, despite
already being an integral part of the monthly routines of 31.2% respondents. Despite it not
being a regular practice for 40.7% of SPA service clients, it is nevertheless engaged in with a
certain regularity. This scenario is reinforced by the fact that SPA service consumers apply
their daily leisure time as preferential moments for use of these facilities (44.4%),

immediately followed by specific holiday periods (41.3%). The choice of SPAs located in
their own residential areas (28%) or an intentional journey to outside the regular area of
residence to frequent a SPA (36.5%) reinforces the routine and preferential consumption of
these types of services/facilities. In fact, 75% of the clients from our sample mentioned that
when selecting their holiday accommodation they took into consideration whether or not there
was a SPA, with 25% of clients declaring that this is a determinant factor in their final choice.
The main motive of these individuals in visiting a SPA is connected to relieving stress and/or
relaxation. Across the 824 questionnaire respondents, 74.3% mentioned this reason as very
important in their visiting a SPA. It must also be noted that improving mental and physical
health was the determinant reason given for visiting a SPA by over 50%.
From the universe of the most relevant services available at SPAs, clients clearly mention
massages (90.9%) and body treatments (including thermal water therapy – 70%) as the most
sought after. As regards the most relevant services used at SPAs, it must also be noted that
50% of the clients, did not use hydrotherapy services (vichy shower, simple immersion bath,
hydro massage, etc.) during their last visit to a SPA.
Overall and still in terms of services consumed, SPA clients classified their experiences as
positive with 64.7% saying that the services met all their expectations and 31.1% declaring
their expectations were exceeded. Only 4.2% of clients declare that their SPA experiences
globally fell short of their expectations. When deciding which SPA to visit, clients from our
sample identified the quality of treatment, service, hygiene and cleanliness, the service cost as
well as the SPA location as the most relevant factors. 78.6% declared they personally paid for
their last visit to a SPA. Worthy of note is the fact that 14.4% of SPA experiences were gifted,
namely in the form of vouchers.
In addition to the variables described thus far, the current questionnaire also focused on a set
of behaviours and health care attitudes which the SPA clients adopt in their daily lives. When
questioned globally on their lifestyles, 87.3% declared that on a merely personal assessment
they had a healthy lifestyle. The majority of SPA clients questioned declared that a healthy
life depends essentially on their personal care (53.5%), while 45.4% declared that in addition
to taking care of their health, there are also external factors which can condition that healthy
life. Only 1.1% of the sample declared that a having a healthy life does not depend on them
but solely on external factors over which they have no control, such as work, stress imposed
by the pace of daily routines, environmental quality, economic conditions or interpersonal
relationships, specifically with family members and close friends.
As for necessary personal care for a healthy life, the clients questioned transversely referred to
“food and diet” (89.4%) and “physical exercise” (82.9%) as fundamental care. “Alternative
medicine and techniques” were also mentioned as an important recourse in the universe of
personal care” (for example: meditation and pilates, tai-chi, yoga, the SPA, etc.). Other
aspects mentioned, while not as unanimous, were “relaxation” (for example: sleeping duration
patterns, searching for calm environments) “deviating behaviours” (alcohol and tobacco
consumption) “hygiene” and “recourse to monitoring by conventional medicine” (visiting the
doctor) and “associated techniques” (regular check-ups). Only in passing was a direct
reference made to (considered in the category of “others”) external factors (beyond the control
of the individual) which have implications for a healthy life. Although not as consensual in
comparison with the main personal health care factors already described, these are related to
“work” (such as the number of working hours, the workplace and conditions, relations with
colleagues, satisfactory payment conditions), with “everyday stress” (resulting from the

various timetables and obligations to comply with, traffic and the urban rhythm of life in
general) – 36.9% of those questioned mentioned they had a very stressful daily life, the
“environment” (pollution, area of residence) “interpersonal and economic constraints” (family
wellness, resources/economic limitations) are major issues. Among the “other” factors
referred, are “genetic/hereditary”, “epidemics” and “frequenting places which are also
frequented by smokers”.
When confronting those questioned with their wellness practices, on the one hand we see the
prevalence of the aforementioned set of personal care initiatives with the objective of
achieving a healthy life, such as “physical activity” (67.1%), “food and diet”, recourse to
alternative medicine and techniques and visits to SPAs – 33.7% – here, this is a systematically
mentioned and autonomous category in contrast with that initially observed, and on the other
hand, a set of practices diverse in nature. This new universe encompasses sociability practices
– 24.6% – (for example: dinner with friends, going on family outings, going out in the
evening with friends) and hobbies – 21.0% – (for example: travelling, going to the cinema or
theatre, listening to music, reading, painting, gardening, etc.). Recognition of the importance
of physical exercise and an appropriate diet for a healthy life is reinforced by the general
incorporation of these practices in lifestyles. Among those questioned 71.2% regularly
exercise or include exercise in their lifestyle, with only 28.7% of individuals never having
practised regular exercise or only now not involved in regular exercise.
As regards, special care with food and diet (for example: purchasing diet or organic products
etc.) and as mentioned, the scenario is very identical in that 70.2% of individuals regularly
watch what they eat and actually consider it an integral part of their lifestyle. Additionally,
70.1% of those questioned take or have taken food supplements, while 34.1% take or have
taken weight control products (natural or synthetic) These two care initiatives are reflected
namely in the body mass index (BMI) of those questioned (23.2 Kg/m 2 ). Overall, the sample
shows that 69.5% of SPA goers present a normal or below average BMI.
There is yet another set of practices and habits complimentary to those mentioned, for
example, the non-consumption of alcoholic drinks and/or no smoking. Among those
questioned, 51.3% do not drink alcoholic beverages outside mealtimes or do so very rarely
while 41.9% of individuals limit consumption to the weekends and special occasions. In this
sample, 69.4% of individuals are non-smokers and only 18.1% smoke. The remainder are
occasional smokers (particularly at parties or commemorative events). This series of care
initiatives is complemented by a set of monitoring practices such as simple weight watching.
This habit is common to 59.5% of those questioned, with the vast majority routinely watching
their weight at home. In addition to weight watching, 80.4% of the SPA goers who make up
our sample regularly have medical check-ups and in this particular universe 56.7% do so on
their own initiative with 43.3% acting based upon medical recommendation. This scenario
inverts only in the case of illness, upon which 66.3% resort primarily to a doctor and 33.7%
initially seek out the chemist (12.2%), self-medicate, (11.9%) or turn to alternative medicine
(9.6%).
The use of health management equipment in the home is another common practice. Overall,
52.9% of those questioned have equipment at home, with 28.5% having medical equipment
(such as blood pressure, glycaemia or cholesterol measurement devices etc.) and 38% have
physical fitness equipment (for example: bicycle, exercise machines, etc.). These practices
incorporate yet another formative/informative dimension on health, sustained by women and
men’s magazines, which are assiduously read by 52.6% of SPA goer respondents. Here,

particular reference must be made of the women’s magazine Happy Woman (17.9%) and the
men’s magazine Men’s Health (7.8%). The internet complements this information source,
with the specific objective of obtaining information necessary to health management by
63.5% of questioned SPA goers, as well as regular reading of specialized magazines and
books on health (40.4%). Despite the overwhelming majority of those questioned being
beneficiaries of their respective national health systems (84.2%), 65.7% have also taken out
additional health insurance coverage.
Finally, and as regards specific beauty care, 78.1% of the sample regularly consume typical
beauty products and 21.0% use or have used the latest technologies to carry out plastic
surgery treatments (for example: lifting, liposuction etc.), slimming or cellulite treatments,
laser hair removal or skin rejuvenation.
When applying the TwoStep agglomeration technique, with a view to identifying clusters
within the universe of SPA consumers, we identify three clusters: Fans SPA Goers, First
Experience SPA Goers, Men SPA Goers
Figure 1 – SPA Goers by cluster in relation to the use of SPAs and other health care
responsibility uses
FIRST EXPERIENCE
SPA GOERS
- MEN SPA GOERS
Health Management
Responsability
+
-
SPA FANS
GOERS
Source: Author
SPA
Services
Consumptio
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.
Limitations
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.
Conclusions
The development of the SPA market and the consumers associated seem to a great extent to
reflect a set of new ideals and a new vision associated to health and its management. Centred
on a positivist acceptation of health, where well-being is the dominating theme, SPAs have
reinvented themselves and have reinvented the whole ideal of health. In the SPA image,
health has also tended to diversify and conquer new domains thus transforming the universe
and the imaginary of health tourism, now sustained by a vaster range of services. This is an
evident reality in the consumer universe of -Salut per Aqua-, which goes much further than
the traditional concept associated to water in favour of new holistic techniques and services
founded on principals of relaxation and massage. This is the affirmation of a new, responsible
and proactive philosophy which is the antithesis of that which had previously prevailed.
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Customer perceived value of medical tourism: an exploratory study
The case of cosmetic surgery in Tunisia
Yousra Hallem
Doctoral student
Ecole de Management de Strasbourg/Institut Supérieur de Gestion de Tunis
Yousra_hallem@yahoo.fr
Isabelle Barth
Professor
Ecole de Management de Strasbourg
Isabelle.barth@free.fr
Abdelfattah Triki
Professor
Institut Supérieur de Gestion de Tunis
Abdel.triki@yahoo.fr
Abstract
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
observed.
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
value.
Our research deals with medical tourism in Tunisia and more specifically with cosmetic
surgery in Tunisia. Through a qualitative study, we will investigate some research questions:
What are the dimensions of customer-perceived value in the context of medical tourism? Is
customer-perceived value only limited to cost consideration? What are the dimensions of
customer-perceived value related to the use of the Internet in the context of medical tourism?
Conceptual background
Medical tourism: a booming business
Medical tourism is a growing market catering to patients who travel to foreign countries to
obtain medical care (Deloitte report, 2008). The Tourism Research and Marketing Report
(2006) indicates that the market included approximately 19 million trips in 2005 with a
business volume of around $ 20 billion. This report estimates that the number of trips will
have reached 40 million by 2010, with a growth of 4% for the overall market volume.
Other statistics report that, in 2005, countries like Singapore (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’
(Herrick, 2007).
Therefore, with the increasing number of medical travellers, we can suppose that elements of
value other than financial ones may motivate their decision.
The concept of customer-perceived value
Day (1990) stated that the perceived customer value represents the difference between
“customers’ perceived benefits” and “customers’ perceived costs”. The first
conceptualizations of customer-perceived value begin with the works of Zeithaml (1988),
who defined customer-perceived value as “the consumer’s overall assessment of the utility of
a product based on the perception of what is received and what is given”.
The pioneering ideas about perceived value were based on economic theory and the concept
of utility. Despite the relevance of this one-dimensional conceptualization of customerperceived
value, it remains too simplistic and does not make it possible to grasp all of the
explanatory attributes of a purchase. In a marketing context, it has been acknowledged that

value is not restricted to aspects related to price and quality but that it also combines other
functional, emotional and social aspects (Sweeney and Soutar, 2001). Sheth, Newmann and
Gross (1991) identified five consumption values that influence consumer choices, which are
functional, social, emotional, epistemic and conditional values. Sweeney and Soutar (2001)
developed a multiple-item scale for measuring consumer-perceived value (PERVAL). Four
dimensions of perceived value emerged, which are emotional, social, quality/performance and
price/value for money.
The perceived value of the Internet
The use of IT and especially the Internet in healthcare has the potential to change the
healthcare industry worldwide in terms of infrastructure, costs and quality of services
(Wickramasinghe and Goldberg, 2004; Wickramasinghe and Mirsa, 2004). The Internet has
especially become an important medium for marketers and healthcare providers to provide
information and market a wide variety of health care services and products (Bodkin and
Miaoulis, 2007). It has been confirmed that perceived value has a big impact on the use of the
Internet as a medium for the search and procurement of goods. In general, people seeking
information related to health care may act on several motives (Williams et al. 2003). They
may be searching for information as a health care professional, as a consumer looking for a
self-diagnosis or other diagnosis, as a patient to complement information from a doctor, as a
consumer to exchange information with peers or for general interest browsing. Consumers
access online health information in three primary ways: searching directly for health
information, consulting with health professionals and participating in online support groups
(Clines and Haynes, 2001)
Method
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.
Findings
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
context.
1 We decided to keep the spelling and grammar mistakes to give more credence to the talk of participants.

Functional value
Functional value is defined as the perceived utility based on the functional, utilitarian, and
physical performance of a product (Sheth, Newmann and Gross, 1991). A study has shown
that the main functional value attributes, in the context of the purchase of a tourism product,
are the quality of the travel agency’s installations, the staff’s professionalism at the travel
agency, the quality of the tourism package purchased and the price. (Sanchez et al. 2006).
Concerning the medical tourism service, several attributes have emerged, such as the cost
differential, the skills of the surgeon and nursing staff, the quality of the equipment, the
quality of care and the importance of the recovery period.
It may seem obvious that cost is a major incentive in the medical tourism industry. In fact,
some figures show that operations in India cost 80% less than in the United States (Walker,
2006). We can observe the same relation between France and Tunisia. “This difference of
price between Tunisia and France is hallucinating, until now I could hardly believe it!!!!”
“Who said it was cheap-rate surgery?? Life over there is cheaper than here and that’s why
prices are lower than here!!”
Before deciding to get an operation, future patients spend a lot of time searching for
information about the skills of surgeons.
“Someone who listens, is attentive, calm, thoughtful and is most importantly licensed, belongs
to a medical association and is very competent!” “My motivations were a competence similar
to what is available in France for a price sharply lower than in France, following the
principle of value for money! Because if surgeons were not worth the trip, I wouldn’t go
there, even if it’s cheaper!”
Concerning the modernity of foreign hospitals, it appears that in many developing countries,
public and particularly private hospitals are well-equipped and meet international standards.
“I leave for the operating room, it’s large, I recognize the respirator… it’s the same brand we
have at home, everything is exactly the same, which goes to show that some received ideas
are wrong.”
Regarding the care, many patients appreciate the reactivity and efficiency of the medical staff.
« …I wasn’t feeling very good…, immediately the anaesthetist took care of me,
electrocardiogram, drip, regular blood tests, I felt reassured in this health care
environment.” “As someone who has gone through several operations, I can EASILY SAY
that I had never got or even seen such care at this price.”
The travelling patient aims to purchase a particular service and to achieve a defined health
goal (Bookman and Bookman, 2007). Despite the importance of the medical aspect, it appears
that non-medical services are not insignificant to the medical tourism experience. Medical
tourists especially appreciate the recovery period.
«In my opinion, the advantage of being operated in Tunisia is the rest afterward, they keep
you in the clinic for as long as it takes, after that you end your stay in a hotel, where there are
no concerns such as going shopping or doing housework or what’s for dinner tonight, or the
postman ringing and so on!!”
Bookman and Bookman (2007) asked the question of why a medical tourist picks one
destination over another. They believe that factors such as cultural similarities, distance from
home, medical specialties and reputation influence an individual to favour one country.
Travelling patients think that Tunisia is well reputed in the field of cosmetic surgery. Tunisia

also has strong cultural similarities with France and it is a country where the people speak
fluent French. Finally the geographical proximity between France and Tunisia seems to play
an important role in the choice of medical tourists.
“My first criterion was the fact that the first country to have done surgery for tourists was
Tunisia, so they are more experienced than the others, the second criterion was the proximity:
a two-hour flight is very manageable, and finally the third criterion, the language. In Tunisia,
unlike in Eastern Europe, Thailand or Brazil, all the doctors speak French! It’s important to
be able to easily discuss operating techniques, etc., without asking myself whether I was
properly understood…????”
As regards the use of the Internet, the functional value of the tool lies in its ability to ensure
remote contact between medical tourists and service providers (surgeon and/or tour operator).
Novak and al (2000) considered the ease of contact as a component of a “compelling online
experience”. Through an empirical study, Heinonen (2008) highlighted how well companies
respond to customers’ inquiries using technology such as e-mails. E-mails have the potential
to improve patients’ perception of the accessibility of their managed care organization and
healthcare providers (Moyer, 1999). Therefore, several medical tourists think that the Internet
and particularly e-mails are an efficient tool to communicate with their surgeon or tour
operator.
“Doubts, questions, I immediately send an e-mail to my surgeon who replies to me within the
day, he reassures me, tells me not to hesitate to ask any questions that pop into my head and
that it's normal to be anxious. I appreciate this permanent contact.”
Several studies have also shown the usefulness of electronic mail as a medium for patientphysician
communication, as they make it possible to gain time, and improve convenience
and access to medical care for purposes such as renewing prescriptions, communicating
laboratory results and making appointments (Sciamanna et al. 2007).
In our case, it was found that administrative issues inherent to the medical tourism package
are easily and well handled by electronic communication.
“Did you send him the pictures directly by e-mail or through the website? The surgeon has to
see your pictures to make a diagnosis and assess the cost!
Then his assistant will send an e-mail or call you, anyway, the written estimate will surely be
sent by e-mail and then to show you agree, you will need to send him the confirmation of your
plane ticket reservation!”
Other studies have found that follow-up care is among the main reasons why patients use emails
(Nelson and Stewart, 1993, Houston and al, 2004).
The same finding is observed in a medical tourism context, where the follow-up is performed
remotely. The patient sends photos of the evolution following the operation to the doctor, who
examines them and then gives advice and/or renews prescriptions to the patient.
“He remained available after I got back, by e-mail and by phone and even on live chat…!
Regarding the e-mails, it’s useful to send him photos showing the progress of healing for
example!” “I just had my surgeon on the phone a moment ago, and after observing the
photos, he thinks all the same that I have a stitch that went off under the nipple…”
In the context of our study, the Internet is not only a means used to ensure remote contact, it’s
also the main source of information for medical tourists. The Internet is a wide source of
information that allows customers to access more customized information with minimal effort
and cost (Alba et al. 1997). Through forums, travelling patients can easily get information
with minimal effort.

“Before my operation, I did extensive research on the Internet…” “So I started, I began my
search! I typed “facelift in Tunisia” on my friend Google. It gave me the names of clinics and
forums. The breaking point, but yes, the forums, what an idiot not to have thought about it
before, these things are full of information, lol…. So I signed up on 2 forums, and I visit both
of them daily, I don’t post but I read.”
Social value
Social value is defined as the perceived utility based on the association of a product with one
or more specific social groups (Sheth, Newmann and Gross, 1991).
As regards social value, the attributes most often mentioned in literature are obtaining social
approval (Cengiz and Kirkbir, 2007), improving self-image, feeling accepted and making a
good impression (Sweeney and Soutar, 2001), and finally turning to a service provider known
by many other customers (Sanchez et al. 2006). The aspects which stand out the most from
the discussions of medical tourists are related to improving self-image and to turning to a
well-known service provider.
We were able to observe that a large majority of medical tourists turn to cosmetic surgery in
order to improve their self-image and physical appearance in the aim of improving their selfesteem.
“That’s it, I’ve made my decision, after having 6 children, being “obese”, having lost 50 kilos
and reached my forties, I am going to have an abdominoplasty in Tunisia!”
Moreover, medical tourists are looking for the most famous and particularly the most skilled
service provider (surgeon and/or tour operator). We can also observe the formation of groups
supporting for example a surgeon who became famous on the forum.
“It’s true that our surgeon is very attentive to details and very thoughtful. He knows how to
reassure us…” “Our surgeon will soon need a new set of arms to operate all of us!” “What a
successful man he is!”
As regards the Internet tool, the two aspects which stand out the most are related to the
sharing of experience and the formation of groups and social connections.
In addition to seeking health information, individuals can also use the Internet to
communicate with one other in support groups (Houston and al, 2004). In fact, the advent of
the Internet has given rise to many forms of online socialization.
“Thank you for your testimony on your surgical experience in Tunisia: this will be a great
contribution for forum users… so being able to have information on your experience will
provide valuable elements to forum users…” “This forum is an important tool when one
embarks on the adventure of “cosmetic surgery” and I’ve met many people on the forum
ready to help the others.”
Forums dedicated to medical tourism foster the creation of social connections among
members sharing the same opinions and interests. In the forum under study, we can observe
the formation of groups of medical tourists, such as the group of the “lololandaises” and the
“Tunis girls”. The “Tunis girls” group is formed by women who have been operated in Tunis.
The “lololandaises” group is formed by women who have undergone breast surgery.
“Congratulations! You will become a Tunisgirl!!!” “THANK YOU all for your
encouragement!!! And for the lololandaises-to-be: GO THERE stress-free, it’s wonderful to
feel so feminine!!”

Emotional value
Emotional value is defined as the perceived utility based on the ability of a product to arouse
feelings or affective states (Sheth, Newmann and Gross, 1991). Emotional value is related to
the development of positive emotions, such as happiness, interest, and pleasant surprise, and
negative emotions, such as sadness, fear, anger, disgust, and unpleasant surprise (Borod et al.
1998).
Previous studies focused on a range of positive and negative feelings arising from a tourism
experience (William and Soutar, 2000; Sanchez et al. 2006; Petrick, 2002) and from a medical
experience (Cengiz and Kirkbir, 2007), such as fear, excitement, pleasure and happiness. In
our case, members made for example comments about being “afraid” and “excited”.
“I keep jumping around because I can’t wait! In 8 days, I’ll be on the plane at this hour!” “A
small tablet before I went to bed to feel relaxed even though I was pretty wired. Not stressed
but excited at the thought of fulfilling my dream.”
“I am supposed to go there on March 2 nd for a breast operation, and now I am really afraid
because there is no way of checking the surgeon’s skills…, I am just afraid of failure.”
Epistemic value
Epistemic value is defined as the perceived utility based on the ability of a product to arouse
curiosity, provide novelty, and/or satisfy a desire for knowledge (Sheth, Newmann and Gross,
1991). Goetzinger et al. (2007) stated that the Internet has revolutionized the way consumers
search for information and has completely changed consumers’ decision-making process,
particularly in the health care industry. In the same vein, it has been acknowledged that the
Internet provides some level of epistemic value to those who use it as a resource for health
care information (Wilkins, 1999). Medical tourists conduct several searches on:
The service providers (surgeon and/or tour operators):
“Before my operation, I had done extensive research on the Internet and I had consulted
several surgeons to be sure to have a good surgeon.”
The cost of stays:
"Are rates really more interesting than in France????”
And the postoperative care:
“Otherwise, as regards post-operation care, I clean the scar using Bétadine, by tapping
gently, without rubbing, then you put a good coat of IALUSET healing cream, all over, and
use IALUSET PLUS where it weeps, because it is a healing and disinfecting cream at the
same time!”
Conditional value
Conditional value is defined as the perceived utility based on the specific context or set of
circumstances faced by the patient. An alternative acquires conditional value in the presence
of previous physical or social contingencies that enhance its functional or social value (Sheth,
Newman and Gross, 1991).
The conditional value of the medical tourism experience finds its essence in the presence of
several contingencies which tend to improve its functional value. These contingencies are
related to the high prices applied in France, the long waiting lists at teaching hospitals and the
absence of coverage for cosmetic surgery.
“It is true that in France, it can be twice as expensive as in Tunisia! Otherwise, there are
some teaching hospitals where prices are around 2,300 euros, but for some, the waiting
periods are too long”
“Concerning coverage, it’s not the lost weight that matters, it is whether or not you have a
"deck", and I have no deck and therefore no coverage…so I’m not interested in being
operated in France”

The table below recapitulates the main findings.
Value Medical tourism service Internet
Functional -cost differential
-abilities of surgeon and nursing
staff
-equipment quality
-quality of care
-importance of the recovery period
-assets of the Tunisian offer
(cultural similarity, geographical
proximity, reputation)
Social -turning to a well-known service
provider
-enhancing self-image
-Maintaining remote communication
through e-mails (making the steps
prior to the service contract easier,
and facilitating post-operative
follow-up)
-easy and quick information
gathering
-sharing experiences
-formation of groups and social
connections
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
hospitals
-no coverage for cosmetic surgery
Summary of the dimensions of perceived value in the context of medical tourism
Conclusion
This research shows that the medical tourism experience and the use of the Internet in this
context include a set of value dimensions. Knowing the contribution of each value dimension
to consumers’ choice, and in our case to the choice of medical tourists, gives valuable
information to managers (Williams and Soutar, 2000), enabling them to better understand the
concerns and expectations of medical tourists. Like in other studies, it thus seems obvious that
the contribution of functional value is highly significant in the perceived value (Cengiz and
Kirkbir, 2007), especially as regards costs. It is also interesting to note that despite the
importance of costs, medical tourists would not be able to overcome their apprehension if
services were of poor quality; which explains the importance of other aspects of functional
value, such as the surgeon’s skills, the quality of care and the modernity of the equipment. It
is therefore essential that health establishments undergo certification and accreditation to
enhance their reputation.
The functional value of the Internet tool lies in its ability to guarantee a permanent contact. It
is thus essential to optimize the potentialities of the tool. However, and in conjunction with
other studies (Williams and Soutar, 2000, Sanchez et al. 2006), the importance of the
functional dimension in the perception of value should not make us forget the contribution of
other aspects.
Medical tourists see in the Internet tool, and particularly in forums, an effective means of
sharing experience, finding positive stimulation, and especially of finding information on the

different aspects of the Tunisian medical tourism offer. The components listed are
respectively related to social, emotional and epistemic values.
Health care professionals can get more out of these value dimensions, for example by creating
their own blogs or forums, around which they will be able to rally real virtual communities,
thus improving access to information and creating positive word-of-mouth.
The conditional value of the Tunisian medical tourism offer is based on certain aspects of
Western health care systems, such as long waiting lists and the lack of coverage for certain
operations. It would be interesting to communicate more about these issues.
From a managerial viewpoint, the results obtained are a first attempt to enlighten managers on
the major dimensions of the value perceived by medical tourists and on the relative
contribution of each dimension to the perception of value. The goal is to better understand the
needs of medical tourists and thus to better guide their choices and marketing decisions.
From a theoretical viewpoint, these results are a first step in developing a synthetic theoretical
model incorporating the dimensions of both the perceived value in the context of a medical
tourism experience and the usefulness of the Internet in the same context. It is also a first step
towards understanding the key dimensions of perceived value and their impact on behavioural
consequences in a medical tourism context. The ultimate goal is to operationalize the
dimensions of perceived value and test their impact on satisfaction and behavioural
consequences.
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www.udel.edu/PR/UDaily/2005/mar/tourism072505.html

Cruise Tourism - Changing Products – Improving Wellness?
Ian Henderson
TTC International
Belfast, UK
henderson@ttcinternational.com
Abstract
“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
experience”.
Thankfully my own cruise experience 5 cruises on 3 different cruise lines has not faced that
problem because we fly to USA and avoid Southampton (where I did the highly successful
cruise tourism strategy in 2004/5).
We prefer Celebrity which is said to be four star and promotes wellness and ‘life enrichment’
and does to some extent. Good gyms and exorbitantly prices spas – plus new products that
suggest healthier eating and living on board.
Cruise Tourism Work undertaken:
Port of Southampton Cruise Tourism Strategy
Scottish Cruise Tourism Review
Economic Impact of Cruise Tourism Dover
Antigua Tourism Masterplan
St Maarten Tourism Masterplan
Limassol Cruise Terminal Feasibility
Mombassa Cruise tourism Feasibility
Dublin Cruise Tourism Feasibility

Cosmeceuticals in wellness tourism – Cases of co-branding and co-creation
Anne-Mette Hjalager
Associate professor, University of Southern Denmark, Centre for Tourism, Innovation and
Culture
Niels Bohrsvej 9, DK 6700 Esbjerg
Hjalager@advance1.dk
Henna Konu
Researcher, University of Eastern Finland. Centre for Tourism Studies
Puistokatu 5,, FI-57101 Savonlinna
Henna.konu@uef.fi
Abstract
“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.
Introduction
“Cosmetics” and “pharmaceuticals” together form the term cosmeceuticals, which embrace
anti-aging creams, moisturizers, bathing salts, lip balms and many other products. When
extending the use of cosmeceuticals and applying the rhetoric of health improvements, the spa
and wellness industry is increasingly marching into domains formerly exclusively occupied
by “serious” medical professionals. Similar movements and invasions can be observed in for
example electronics where GPS-technologies have moved from restricted military use to
become an instrument for play and enjoyment, and in the clothing sector waterproof clothes
previously used mainly for military purposes or as working clothes have also disseminated
into outdoor activities for recreation and tourism (Logue 2005, Smedstad 1995).
Wellness tourism integrates body, mind and spirit. A satisfactory tourism experience depends
on the intentions, mood and adaptability of the tourist, but also on the competencies and
professionalism of the wellness staff to interpret and meet the needs of the visitor. Relations
between human beings are found to be crucial in wellness tourism (Kelly & Smith 2009).
However, wellness experiences are not only a matter of intangible procedures and services.
The delivery process is assisted by a large number of auxiliary remedies. Thus,

cosmeceuticals are supplied to the wellness facilities, and they materialize for the tourists
during treatments. As it will be further developed and explained in this article, the image and
the commercial success of cosmeceutical products depend on the interaction between the staff
and the customers in the wellness facilities. Accordingly, it assumed that there is a mutuality
of the two industries, which may or may not be fully envisaged and exploited. It is part of a
collaborative picture that cosmeceuticals are also merchandised on the premises and often part
of the décor. Thus, the role of the cosmeceuticals is, potentially, even more far-reaching in
terms of development and branding.
Although wellness tourism is a topic that attracts many tourism researchers, the role of
cosmeceuticals in the wellness industry has not been addressed too any significant degree.
Generally, it is remarkable how few research reports are generated from the “engine room” of
the wellness industry.
The geographical framework for this study is the Nordic countries, where spa tourism has
existed for a long period of time (Aho 2007, Hemmi & Vuoristo 2004, Kangas & Tuohino
2008, Konu et al. forthcoming 2010, Smith & Puczkó 2009, Suontausta & Tyni 2005). There
are many strategically sound ways for spa and wellness tourism enterprises to move in
developing their competitiveness and brands, and developing their cosmeceutical alliances
might be one of them. One assumption here is that the producers/distributors of
cosmeceuticals are crucial partners in the creation of the experience offered in the wellness
facilities. Cosmeceutical producers play a role both in terms of innovation of new products
and services and in the marketing and branding process. The terms co-creation and cobranding
are applied in the investigation of the nature of such collaborative structures.
Literature review
Wellness tourism has its roots in the long history of spa resorts, and in that sense is not a new
phenomenon. During more recent decades it has modernized and diversified into a large
variety of categories. As demonstrated by Smith and Puczkó (2009) wellness tourism includes
a high focus in facilities for medical treatments, as well as pure leisure and relaxation sites.
There are also great variations in profiles when it comes to expectations of the tourists’
involvement and activity, either mentally or physically. The rapidly upcoming research
interest covers many issues, but there seems to be an overwhelming interest, for instance in
users’ profiles and in motivations, behaviours and experience. Generally, the rationale is that
there are significant growth prospects due to ageing and changed lifestyles (Bushell &
Sheldon 2009). In parallel, destination studies contribute to the wider perspectives with
evidence about local resources, sustainability fit and economic viability (Pechlaner & Fischer
2006).
In the pharmaceutical literature, the development of cosmeceuticals is given quite noteworthy
attention. There is a science based focus on the ingredients that influence the skin's biological
function and the discovery of new active agents (Draelos 2008, Tsai & Hantash 2008).
Spa and wellness facilities provide a long range of treatments. Not all of them imply the use
of cosmeceuticals. There is an ongoing development in the treatments, such as cooling and
hot stones, and vitaminized massages, as well as treatments of the extended body, and
combined mental and physical treatments. Simultaneously, there is a tandem process of
ongoing development with cosmeceuticals that can be applied in those treatments.
Manufacturers are enthusiastic to explore the uses of traditional and new raw materials in
their products. Trends for the near future are claimed to be that natural products and extracts

will replace chemical materials; additionally, plants and fermentation will replace animals as
ingredient sources.
The use of cosmeceuticals in wellness tourism is only fragmentarily covered in the research
literature, and then only in conjunction with the descriptions of the treatments provided. Smith
and Puczkó (2009) reviewed the many categories of wellness tourism, from medical to
recreational, relaxationally passive to sportily active, physical to spiritual, and focused to
holistic. Treatments where cosmeceuticals are prevalent occur in some of the categories and
not in others. The experiential cosmeceuticals do receive some anecdotal attention in the
literature, for example massages and body wraps based on chocolate. The general trend seems
to be that the inclusion of spa elements in for example hotels and sports centres increases the
profits, and that the growth rate of goods and merchandise is particularly impressive
(Mandelbaum & Lerner, 2008). In terms of treatments, Behrens (2007) points to the strong
diversification and internationalization trends, where large corporations with huge marketing
budgets tend to be the main driving forces. Those players in the wellness and spa market may
have alliances with suppliers of cosmeceuticals in the same league.
On a more general level co-branding with the tourism business and their suppliers is an upcoming,
but still novel research theme (Pechlaner et al. 2006). Co-branding is when two
companies form an alliance to work together, creating marketing synergy. In this situation, a
tourism enterprise will enhance its image by using respected and, preferably, already wellbranded
products, while the suppliers can achieve an extra marketing platform for its
products. Any wellness provider will apply scrubs, lotions, muds etc. during the treatments
and the brands of these can be made very visible and their merits included in verbal
appraisals. The spa-goers are expected to take the first step towards a loyalty to the particular
product. They can also find the same products in the shop to bring back for home treatments
and gifts. Additionally co-branding can include club memberships offers. The co-branding
can also take place on the websites of the enterprises, sometimes even including e-shopping
opportunities (Lee et al. 2006). The research literature is fairly tacit about strategic cobranding
alliances between the wellness industry and its suppliers in this field (Gibson, 2008;
Weiermair & Steinhauser, 2003). Smith and Puczkó (2009) talk about “signature products”, a
term that embraces the development of new spa products and treatments special to the place
and destination. Signature products might involve an active and mutually beneficial a cobranding
of the spa-facilities with the producer and the local community, from where an
element of the signature derives.
Co-creativity moves the issue further. In this case a wellness operator will collaborate
intensively with suppliers of cosmeceuticals in order to develop new products. The open
processes lead to cross-fertilization of knowledge. During the process of co-creation the
purpose for the supplier is also to gain new ideas and insights, which may eventually lead to
product introductions to a wider market (Möller & Törrönen, 2003). Accordingly, tourism
service providers and their suppliers are partners in an innovation process, and leading
tourism enterprises are responsive test benches for new supplies with a higher quality and
better market potential. Such innovation processes are not well illuminated in tourism
innovation literature (Hjalager, 2010).
Methodology
This study combines literature reviews with brief and targeted case studies. As the research is
part of a larger project on “Nordic Wellbeing” the geographical focus is the Nordic countries,
in particular Denmark and Finland. Persons selected for interviews are managers of spa and

wellness facilities and cosmeceutical manufacturers and distributors. As tourism research is
only marginally addressing issues about co-branding and co-creation, the Internet and the
trade press has been an important supplementary source of knowledge on specific practices in
the global spa and wellness industry.
Spa Industries and their Suppliers – Cases from Denmark and Finland
The inclination to place additional weight on the spa products and the relations with the
producers and distributors of them can be demonstrated by the cases from Denmark and
Finland. The cases illustrating the strategies are far from uniform.
Table 1. Cases of co-operation and co-branding between cosmeceuticals and wellness firms.
Strategies of spa firms and cosmeceutical firms
Comwell Hotel
Chain
Development of a series of skin care products together with Matas, a retail
materialist chain. Intensive co-branding in shops and in the wellness facilities
in the hotels. Joint marketing campaigns. The “Spalosphy” series has been
very successful in the spas and as a retail product.
Vejlefjord Spa Development of private label cosmeceuticals to the spa. The products are
available in the spa and in the webshop. The suppliers of ingredients are
anonymous. The staff prepares the products in the “back office” on a regular
base, and there is a great concern about the freshness and the full and open
Queen Dorothea’s
Bath
declaration of the ingredients.
The theme of the bath is medieval, and historical line has also been chosen for
the spa product series, developed in collaboration with a local supplier of
cosmeceuticals. The concept will be developed in order to create a wider level
experience for the spa-users.
SeaWest Spa SeaWest imports an Islandic spa product series, chosen for its image of being
“clean”, and with ingredients from the Nordic natural environment. The
Anttolanhovi and
LUMENE
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
illnesses.
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
field.

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
scents.
• Casting and instructing deal with the recruiting and managing the staff who are
capable of enacting the story that is laid out in the script and embraced in the
sceneography. From the point of view of the suppliers of cosmeceuticals, it is hardly
enough that the staff are professional therapists or cosmetologists and able to apply the
products in exactly the required way. Innovating goes beyond that and includes for
example the use of costumes that are harmonized with the setting and potentially also
the image of the cosmeceuticals. Instruction also contains preferred behavior and
procedures that reinforce the image with some scope for improvisation. Innovativeness
in the field of casting and instructing is about creating norms and cultures of a place,
which contributes to uniqueness, and which creates a learning environment for the

producers of the cosmecuticals to achieve relevant and reliable feedback for their
innovation processes. Enhanced sales methods for merchandise and after sales services
are also a part of this picture and crucially relevant in terms of cosmeceuticals. The
proprietors’ interviews emphasis the need for training as part of the co-creation and
co-branding process.
• Directing the tourists’ performance. Tourists in spa and wellness establishments are
not only spectators, they are also co-producers of their own and other people’s
experience and therefore partly responsible for the success of the theatric play. There
is normally a good deal of guiding of the visitors through treatment programmes and
offers, and most customers are accepting the implicit conformism. Self-pampering
requires particular advice and encouragement, as seen in Anttolanhovi and Comwell
cases. When appealing to broader audiences, there might be a need to introduce other
ways of play directing into the spa product. Designermudder sees the opportunities in
organizing events for children where they produce their own soaps or lotions. Such
events – however in line with the objectives of both spas and cosmeceutical producers
– may require new modes of interacting with the customers.
Discussion and Implications
This study approaches a tourism niche from the point of view of the suppliers, and this is a
method that is not conventional in tourism research. By accumulating an understanding for
the business models and marketing strategies from the suppliers’ side, it is possible to broaden
the perspective in terms of innovation and knowledge transfer. Accordingly, the study unveils
that the co-branding and co-creation is taking place under quite different understandings of
boundaries of the enterprises. It is a conclusion from the cases that there are both existing and
emerging overlaps in the roles of the cosmeceutical producers and the spa wellness
enterprises. Collaboration tends to soften the boundaries and opens up inspiration and
communication, enlarging the knowledge base can contribute to the competitiveness of a firm
(Howell et al. 2003) and influence innovativeness (Tether 2005, Walsh 1996).
The cases suggest that co-branding is an emerging issue in the spa industry, and that that the
cosmeceutical industry seems to be responsive. However, in the Nordic cases there is only
marginal emphasis on creating destination/nation specific wellness cosmeceuticals.
Accordingly, the destination signature expressed through products with names of specific
locations or geographical features is generally weak. Rather, both the spa industry and the
producers tend to rely on the international practice in the business, where oils, fragrances are
acquired from all parts of the world and assimilated into the spa product. There are many very
persistent traditions in the ingredients sector, but the choice of ingredients also has an
economic background. When it come to the collection and processing of ingredients from the
natural environment where supply is distributed over large spaces in remote areas, the
obtaining of an economics of scale in countries with high labour costs becomes very difficult.
As it is illustrated by Finnish Frantsila and Lumene it is possible to create some economies of
scale in this field. It is important to envisage that particularly Lumene has experienced growth
and now the firm represents a major actor in its home market.
For those enterprises and governments who intent to proceed along the road of creating
stronger alliances or backward integration with the value chain there are a number of focus
points to be aware of and to address:
• Is there a resource base for a cosmeceuticals in the Nordic countries?

• Are “lived Nordic values” (Nordisk Råd and Nordisk Ministerråd, 2009) contributing
leads for wellness and wellbeing tourism?
• Are there supportive business structures and a collaborative network? Are the spa and
wellness industry and the cosmeceutical producers prepared to enter into collaborative
agreements and trustful interaction?
• Do the regulatory regimes challenge and support the endeavours to create Nordic
value chains?
When it comes to meanings and values the Nordic elements in spa and wellness are intrinsic,
and there is still substantial research to be undertaken when it comes to a better grasp of cobrand
management in this context (Pechlaner et al. 2006). None of the actors in this study
have yet to achieve a consistent and full-bodied co-branding and co-creation profile, and that
is not a surprise. We are talking about a discipline in tourism that is still emerging in terms of
academic research and in terms of practical implementation. Destinations still have to be
invited in to do a job.
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An exploratory study of consumer choice and motivation of medical
tourism in Thailand: A case study of healthcare consumers visiting a
private hospital in Pattaya
Miss Wanvipha Hongnaphadol
The University of York, UK
wh541@york.ac.uk
Introduction
According to Gee (1997), travellers are now travelling with different expectations; rather than
going for sightseeing in different places those tourists seek more meaningful experiences.
Therefore, any country’s economy depending on the tourism sector needs to create uniqueness
in their tourism products or come up with a special interest tourism product such as cultural
tourism, adventure tourism and health tourism. Health tourism, the concept of travelling for
healthcare, has been developed for centuries since the Greek and Roman periods or, according
to Burkett (2007) and Swarbrooke and Horner (2007), since the sixteenth and seventeenth
centuries. Health tourism, in the first place, was just the utilisation of natural resources, e.g.
mineral springs, sea water, including social activity. Healthcare has been combined with
leisure facilities and entertainment since then. Later in the seventeenth and eighteen centuries,
many wealthy Europeans visited places like France for medical expertise. Yet, this can be seen
as a regional health travel. Global health travel occurred afterwards, as Swarbrooke and
Horner (2007) point out the most sophisticated recent form of health tourism is where people
travel abroad for medical treatment.
Context of the Research
Tourism in Thailand
International tourism in Thailand started its journey in the seventeenth century when
Europeans travellers began visiting the country both for commercial and sightseeing purposes
(Oppermann and Chon, 1997). More recently, tourism has played a significant role in the
growth and development of the country’s economy as the country shifted from an agricultural
base to a more industrialised and service based economy. The first five-year Tourism
Development Plan (1977-1981) was undertaken in 1976. The industrialisation of the Thai
economy resulted in the increased export value of tourism as well as textile products, rice and
rubber during the 1980s (Higham, 2000). By 1995 the foreign exchange income from
international tourism exceeded the country’s top ranking exports (TDRI, 1998). The ‘Visit
Thailand Year’ campaign in 1987 succeeded in gaining a dramatic increase in the number of
foreign tourists and the ‘Golden Decade of Thai Tourism’ followed between 1987 and 1996.
The rise of Thai tourism continued into the mid-1990s and rapidly dropped in 1997 due to the
economic recession. Overall, the number of international arrivals in Thailand has increased
from 1.2 million in 1975 to about 7 million arrivals in 1995 and risen to 14 million in 2007
(TAT, 2008).
Healthcare services in Thailand
Thailand has a market-oriented healthcare system as people have free choice in selecting a
healthcare facility (Janjaroen and Supakankunti, 2002). Although public providers play a
major role in delivering healthcare services, the private sector is significantly growing.
Regarding the health insurance system in Thailand particularly the universal coverage (UC) 2
2 The Thai government has implemented national health insurance consisting of the Civil Servant Medical
Benefit Scheme (CSMBS) – covering government officials, their parents, spouses and children, the Social

scheme, although this theoretically increases individuals’ access to healthcare and provides the
same quality health services as offered by other health schemes, it can lead to healthcare
service and provision not being equally accessible to many local people with the same quality
standards (Sreshthaputra and Indaratna, 2001). Unlike the developed countries, their public
healthcare can not only reach everyone for free, but also with good quality and standard of
care. Pachanee and Wibulpolprasert (2006) argue that the UC scheme, the incoherent health
policy implemented by the Thai government, hinders the promotion of international trade in
health services. The UC scheme has large impact on healthcare system in Thailand including
financing system, quality of care, manpower, etc. Although the UC scheme increases people’s
health security and decreases people’s healthcare expenditure (Ngosurachet and
Sornlertlamvanich, 2004), some middle- and upper-classes eligible for it decide not to use the
service because of long queues, and non-confidence in the quality and standard of care
(Sreshthaputra and Indaratna, 2001; NaRanong, 2005). Therefore, they rather visit private
hospitals. As any individual claiming for this health insurance benefit can mainly receive the
service at public hospitals, the promotion of healthcare services to medical tourists in public
medical providers is unlikely due to the existing high demand of the local people, and the
contribution of major affordable resources to firstly serve most local people. Consequently,
medical tourism business in Thailand is focused on private hospitals 3 which provide good
images of hotel-like atmosphere in medical settings and create positive attitudes towards Thai
healthcare services and medical expertise for medical tourists.
Medical tourism
Medical tourism is an emergence of a new and distinct niche market in terms of the deliberate
articulation of the healthcare and tourism industry where patients travelling overseas for
medical care – involving specific medical intervention – treatments and operations in hospital
context combined with a vacation (Cornell, 2006a; 2006b). However, medical tourism is not
considered as a new concept in terms of travelling for healthcare as evidenced since the Greek
and Roman periods. While Caballero-Danell and Mugomba (2007) agree with Connell by
shedding light on tourism experience gained from leisure activities after medical treatment,
others emphasise the cost effective medical care provision (Awadzi and Panda, 2006).
In this research, the term ‘medical tourism’ will be used to denote foreign patients travelling to
seek medical treatments and operations from the healthcare services in Thailand. However, the
participation in tourism either before or after treatment and the degree of participation is not
yet defined in the term as this can be highly diverse and really depends on the types of
treatments medical tourists have. This is yet to be investigated in the research if medical
tourism in Thailand is about tourism. Although medical tourism covers a wide range of
products and services (elective and non-elective treatments), cosmetic surgery, such as
Security Scheme (SSS) – covering employees in private companies, and the universal coverage scheme (UC or
30 baht scheme) – covering the rest who is not eligible for the first two schemes, since October 2001
(Ngosurachet and Sornlertlamvanich, 2004). Each scheme has different types of payment: fee for service on
CSMBS; capitation on both SSS and UC. With the UC scheme, the beneficiaries have to register to particular
health facilities and pay only 30 baht per hospital visit for most of diseases in public hospitals which are the
main providers. Therefore this leads to a huge workload but low pay to doctors in public providers, and to an
increasing internal brain drain of doctors to private hospitals which provide better incentives. 30 baht is about
£0.58 (51.52 baht equivalent to £1, rated on 2 August 2010).
3 Private hospitals, accredited by Thailand’s Ministry of Public Health (MoPH), deliver not only expertise in
healthcare but also excellent service. Private hospitals sometimes cooperate and liaise with ‘medical travel
agencies’, which work just like traditional travel agencies except that they specialise in medical travel services
and can help consumers make medical appointments, make arrangements for travel-related needs (e.g., flight and
accommodation bookings), and also include leisure and sightseeing activities in customer itinerary.

enhancement and beauty, will be more in focus as considering significant figures of foreign
patients travelling to Thailand for this particular purpose.
The development of medical tourism in Thailand
According to Connell (2006b), Thailand became a medical tourism destination in the 1970s
with its expertise in sex change operations and cosmetic surgery. The medical tourism industry
played an important role again due to the currency collapse and rapid devaluation of the Thai
baht 4 in the Asian Economic Crisis in 1997. Many Asian governments, including Thailand, all
promoted economic diversification, with the notion of turning round health service earnings
through attracting foreigners. They considered medical tourism as a potential growth factor of
the economy and promoted it because they foresaw its business opportunities and as a catalyst
to their economies. Thus, a big budget for improving healthcare services in these countries
was established to develop the best international standards. In support of what Teh (2007)
points out, merging medical expertise and tourism has become a government policy in many
Asian countries. The Tourism Authority of Thailand (TAT) launched a campaign to promote
Thai traditional healthcare including massage, herbs and authentic Thai food to attract more
foreign tourists. The TAT started a promotional programme for health tourism with the first
‘Thailand Health Travel Mart’ in 1999, repeated in 2000. The purpose of medical tourism at
the beginning was to generate another way of earning foreign income and to help the
hospitality business such as private hospitals and hotels during the recession. Medical tourism
thus became the new trend of Thailand’s tourism industry.
Previous studies of medical tourism research
In research on people travelling for health reasons or so-called ‘health tourism’, Goodrich and
Goodrich (1987) started by conducting an exploratory study of health-care tourism 5 with
travellers visiting hotels or resorts for healthcare treatments. In studies discussing motivating
factors of travellers seeking wellness and spa experiences, Chen, Prebensen and Huan (2008)
and Mak, Wong and Yang (2008) focused more on the motivation of wellness travellers by
addressing how visitors are motivated. While the former study revealed that cost and variety
of attractions rather than healthcare facilities at the destination were the main reasons to select
and visit the destination, the latter found that relaxation, health consciousness, and
attractiveness are among the most salient motivations attracting customers to wellness resorts
which corresponds well with the marketing schemes emphasising tranquility, enjoyment and
body pampering, in other words relaxation. Psychological benefits accordingly appear to be
the most important driving force pulling customers to wellness resorts. Although these studies
emerge from people travelling for health reasons, the settings are in a more relaxing context
i.e. hotels, resorts. Unlike the proposed study, it aims at exploring motivations for people
seeking healthcare in medical settings i.e. hospitals. However, it can be contributed to this
study as an initial guidance in exploring tourist motivations in search of healthcare as there is
little investigation of tourist motivation in relation to health seeking behaviours.
Caballero-Danell and Mugomba (2007) emphasise that little academic research has been done
on the medical tourism market due to the fact that it is a relatively new niche market.
Rittichainuwat, Qu and Mongkhonvanit (2008) additionally agree that there is little empirical
4
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.
5
“[T]he attempt on the part of a tourist facility (e.g. hotel) or destination (e.g. Baden, Switzerland) to attract
tourists by deliberately promoting its health-care services and facilities, in addition to its regular tourist
amenities” (Goodrich and Goodrich, 1987: 217).

study identifying the motivation of travellers to Thailand generally, and far less on medical
tourist motivation.
Conceptual framework
Theory of consumer motivation
The study of motivation in tourism is obviously important due to its role as a trigger to travel.
Tourism literature emphasises the significance of both push and pull factors in shaping tourist
motivation 6 (Crompton, 1979). Many scholars have worked on the definition of tourist
motivation partially by identifying the underlying reasons for travel. Each individual tourist
motivation framework may not fully explain the circumstance. According to Fodness (1994),
the most common empirical studies on tourist motivation are from the works of Dann (1977),
Crompton (1979), and Pearce and Caltabiano (1983), all of which explored push and pull
motives. Pull factors are the destination’s extrinsic forces, such as attractiveness and specific
features of the destination, perceived by potential tourists and pull people to choose that
particular destination whereas push factors are consumer’s intrinsic forces establishing the
desire to travel and push people to travel in the first place. In other words, according to Bolles
(1975), human behaviour is pulled through the perception of valuable characteristics in the
environment and pushed through the action of motivating drives. Klenosky (2002) further
suggested that a single pull factor of a particular destination can be driven by multiple push
motivational forces. People may have multiple and possibly very different push motivational
reasons for evaluating positively the same pull factor. Likewise, tourists with different
demographic profiles may have different push and pull travel motivations in visiting a
particular place.
Interestingly, according to Chen et al. (2008), no academic literature has shed light on the
types of motivation of consumers visiting medical tourism settings, therefore investigating
those different motivations will help identify the possible leading attributes influencing the
demand since tourists often possess more than one motive (Pearce, 1993, as cited in Chen et
al., 2008). Additionally, as Sangpikul (2008) points out, there is limited research on the pull
motivational factors or destination-based attributes segmentation in a Thai context. According
to Kozak (2002), the destination attributes of a particular destination or pull factors, could be
various and different from one destination to another depending on the perception of travellers
towards a particular destination. According to Lubbe (1998, as cited in Sangpikul, 2008),
travellers’ motivations to visit any particular destination begin when they become aware of
certain needs and perceive that certain destinations may be able to satisfy those needs. Thus,
the investigation of pull factors in Thailand’s medical tourism context is important in
developing a successful marketing program.
Consumer behaviour and decision making
Following Bourdieu’s (1990, as cited in Dressler, 2007) idea of medical anthropology, which
draws on the disciplines of medicine, anthropology and history (Comelles, 2002), to
understand human behaviour, requires the analysis of the intersection of social structure and
cultural construction. Understanding human behaviour in general, and human health seeking
behaviour - the intrinsically motivated behaviour (Deci, 1975, as cited in Deci, 1978) - in
6 Tourism motivation has been defined by several tourism scholars as “a meaningful state of mind which
adequately disposes an actor or group of actors to travel, and which is subsequently interpretable by others as a
valid explanation for such a decision” (Dann, 1981: 211); “a dynamic process of internal psychological factors
(needs and wants) that generate a state of tension or disequilibrium within individuals” (Crompton and McKay,
1997: 427). Crompton and McKay’s definition reflects Murray’s (1938) psychological needs as deep-seated
driving factors of motivation.

particular, thus requires the exploration of how shared cultural constructs, known as cultural
consonance in behaviour, meet social structure. As Comelles (2002) contends, it is impossible
to study health seeking behaviours without taking account of the long development of
healthcare providers which have delivered care services from the late Middle Ages to the end
of the 20 th century and cultural context.
Due to the different pattern of previous and new healthcare consumers, a consumer influence
has reflected into different levels (Hjertqvist, 2002). Previously, the healthcare provider was
not designed to serve a real consumer influence. Similarly later, in the welfare state, the
patients’ specific demands could not be fully responded as need, not demand consideration,
was the key to the healthcare provision. Western healthcare consumers today, however, seek
to influence the organisation of the healthcare system and the services provided. Apart from
being used to making complex decisions, Western healthcare consumers are also provided
with greater access to various means of information sources which they require to create
satisfying information in order to compare the providers’ quality and choices among those
offered (Borgenhammar, 1997, as cited in Hjertqvist, 2002). Freedom of choice and the use of
healthcare facilities in many countries are predominant in the current healthcare consumer’s
framework when they can benefit from shorter waiting times and better quality services.
Hence, this kind of framework promotes the development of healthcare provision both
regionally and globally. As commented by Hjertqvist (2002), the more consumers supported
by public or insurance funding cross borders, the more pressure that is exerted on providers to
offer competitive price information. Herzlinger (1997, as cited in Belien, 2000) agrees that, in
order to achieve patient empowerment or consumer-oriented healthcare, competition in
healthcare services as well as an unrestricted supply of these services, both of which create an
expansion and differentiation of services and make prices decrease, are required (Herzlinger,
1997, as cited in Belien, 2000).
Consumer/Patient Choice
Identity: patient, consumer, citizen
Patients, according to Hogg (1999: 6), are ‘people with particular health problems who may be
taking medicines or receiving treatment’. As Edwards and Elwyn (2001) point out, the term
‘patient’ tends to describe associated images of stereotypical patient with passive role seeking
and following physician advice. ‘Consumer’, on the other hand, depicts those who seek
healthcare in active role and perhaps making their own decisions and having the ability of
exercise choice. Contemporary thinking in the healthcare arena leads health professionals to
view patients as consumers.
As the role of market raises the significant issue of identity, in terms of healthcare market, the
identity of health service users is considered whether they are patients receiving services
passively, consumers shaping and controlling the receipt of services, or citizens utilising their
rights to free healthcare (Milewa, 2009). Therefore, it is essential to explore how health
service users have engaged with these identities, i.e. patient, consumer, citizen as these words
can be differently conceptualised due to different healthcare systems and the role of those
receiving healthcare, and how they are considered in terms of individual consumer (individual
identity) and independent collective mobilisations (collective identity).
Generally, the consumer’s decision to purchase a particular service involves many more risk
considerations than purchasing a product. This is because heathcare service provision is
different from other areas of economic activity, products or services due to the prevalence of
irregular, uncertain and unpredictable demand and supply in healthcare (Arrow, 1963). As

highlighted by Folland et al (2001), consumers are uncertain of their health status and need for
healthcare in any particular time. There is additionally a product uncertainty associated with
the health context as consumers may not know the expected outcomes of treatments without
their physicians’ advice. This is supported by what Arrow (1963: 302) suggests, ‘the patient is
forced to trust his physician, lacking the latter’s knowledge and experience; the customer
cannot test the product before using it; recovery from disease is as unpredictable as its
incidence; and entry into the field of healthcare is limited by professional and licensing
restrictions’. Consequently, these characteristics make the healthcare market difficult to
achieve when compared to other types of market.
In conclusion, healthcare is no longer defined by people receiving services when they are ill –
the stereotypical patient. Instead, the term ‘healthcare consumers’ engaging with healthcare
professionals as a formal equal have been used more widespread in the development in
healthcare phenomenon when mentioning people acquiring healthcare where traditionally
people sought and received healthcare in their own locality, and certainly within their own
country. However, healthcare consumers have recently challenged the healthcare seeking
patterns by travelling across country.
Consumerism in healthcare
Consumerist approaches can be categorised under the form of marketisation reforms. The idea
of consumerism was introduced in the 1980s by the British and American governments due to
its significance to people’s lives (Miles, 1998). In Britain, the ideology of consumerism
providing consumers with the rights and political citizenship is defined through charters (e.g.,
The Patient’s Charter, The Citizen’s Charter) rather than in terms of active domestic
participation. The marketisation of the welfare state represents a response to the growth of
individualism and rising consumer expectations about service delivery, which have led to calls
for more user involvement and greater consumer choice (Glendinning and Kemp, 2006). A
consumerist approach, according to Needham (2007), is possible to damage citizenship
gradually by making public services as commodities in the marketplace and putting people in
the situation of caveat emptor. Some commentators have argued that consumer-style
approaches to choice undermine the collective provision of welfare (Needham, 2003).
However, for others increasing choice is a way of ensuring that the welfare state can survive,
by making it more responsive to the needs and aspirations of those who use it (Glendinning
and Kemp, 2006). According to Cullum, Deputy Chief Executive of the National Consumer
Council (2004), it can be argued that a consumer-centred approach is important to the
development of public services as it does not concern turning the public sector into the private
sector or so-called privatization, or introducing market values onto public services. Instead, it
is the means to ensure that everybody has access to necessary services with as high standard as
possible.
Patient choice
According to Shackley and Ryan (1994), the main barrier to consumer sovereignty in
healthcare is the asymmetry of information between buyers and sellers. The nature of
healthcare is that providers of healthcare have a large informational advantage over
consumers. The existence of informational asymmetry between buyers and sellers is common
in other markets as well. In general, sellers know more about a product than buyers, e.g.
sellers will be better informed than consumers regarding the characteristics of a product and
the technology that was used to produce it. Yet this does not prevent consumers from freely
exercising their own preferences in making their consumption choices regarding the product.
The essential difference between healthcare and other commodities is that for other

commodities the consumer is more aware than the seller of what these products’
characteristics mean to him/her. They know their own needs.
The situation in healthcare, on the other hand, is quite different. The acquisition of information
is costly in terms of time and resources. There is little opportunity for consumers to learn by
experience as they will be infrequent users of the market. Doctors, on the other hand, use the
market regularly. In many instances consumers will be unaware that they actually need
healthcare, e.g. women in the early stages of breast cancer, therefore the consumer may no
longer be deemed to be the best judge of his/her own interests. Because of the complex
relationship between healthcare (which consumers do not value per se, i.e. individuals derive
no direct utility from consuming healthcare, rather healthcare is consumed in the expectation
that health status will be improved as a result) and health status, the consumer becomes very
reliant upon the much better informed provider to make the link between the consumption of
healthcare and the resultant effects on health status. Hence, there is a special relevance of the
agency (doctor-patient) relationship in healthcare.
Patients want to be treated as consumers of healthcare in the sense that they want better
information about treatment options and to be more involved in making the decision as to
which option to follow. How far patients behave as consumers depends on the severity of their
illness, the nature of the procedure involved and their individual circumstances. Most severely
ill patients face complex treatment options and many prefer decisions to be made on their
behalf by a well-informed and trusted health professional. On the other hand, they may not
want to be treated as consumers as the nature of healthcare product and service, which is
unpredictable, does not support the role of being a consumer.
However, as suggested by Appleby, Harrison and Devlin (2003), choice is not always
advantageous as it should be counterbalanced by the costs of creating it. Choice for some may
limit and impact on the choice of others. Tritter et al (2010) agree with this as greater choice
may, in fact, even add to a further health inquality burden. In summing up, choice seems
structurally associated with enhanced marketisation of healthcare provision and the arena of
the consumer tends to be based on the economic rationality of maximising personal benefits
within market-based systems. However, evidence about what is driving patients’ choices in
reality is currently limited.
In conclusion, the conceptual frameworks of push-pull, consumer behaviour, consumer choice
and consumerism in healthcare are proposed due to several important factors. According to
Snepenger et al. (2006), the push-pull theory has prevailed over other paradigms in examining
motivations underlying tourist and visitation behaviour (Dann, 1977, 1981; Crompton, 1979),
attracting most attention from several scholars (e.g. Dann, 1977, 1981; Crompton, 1979;
Klenosky, 2002; Kim et al., 2003; Kao, Patterson, Scott and Li, 2008). Due to its theory
having been used much in travel motivation research, this provides a better opportunity to
compare and contrast findings with previous studies. Consumer behaviour literature identifies
the interrelationship between needs and motivations (Goodall, 1988; Witt and Wright, 1992)
as the presence of the former constructs the latter. In other words, people’s needs for
healthcare create their motivations in searching for it. The examination of differences of
motivations between sample populations representing different cultures is important in
understanding tourists’ behaviour (Kim, 1999, as cited in Kozak, 2002). Different cultural
conditionings and different healthcare and insurance system of healthcare consumers will
influence their expectations and perception. As a result, the investigation of health seeking
behaviours and motivations of medical tourists having different cultural and social

ackgrounds is expected to accomplish in this study as they are likely to have different
motivations and perceptions in seeking healthcare services
Aims of the Study
The present research project aims to explore the reasons why consumers from major Western
countries where English is the main language travel to Thailand for their medical treatment.
The research will investigate the motivations of potential medical tourists, differences in these
motivations among different groups both from the same and different countries,
interrelationships among these motivations, consumer choices in selecting a particular
treatment in Thailand over other medical tourism destinations, and the degree of tourism
participation of those medical tourists.
Research Questions
What are the significant motives that influence the decision of medical tourists from the US
and the UK to travel to Thailand, and to Bangkok Pattaya Hospital in particular?
How are these motives different with respect to age, nationality and gender?
How does Bangkok Pattaya Hospital perceive the consumer motivation from these countries?
To what extent does Bangkok Pattaya Hospital applied perceived consumer motivation to
service provision for medical tourists? How is a healthcare provider’s service provision
related to what motivates medical tourists to visit the hospital?
What are the major keys influencing consumer choices about provider and destination? Why
does a medical tourist choose one destination over another?
To what extent do medical tourists take tourism component as a part in their decision making
process?
Is medical tourism in Thailand about tourism? Is medical tourism likely to
utilise the tourism component?
What is it about the tourist part of medical tourism?
To what extent do medical tourists participate in tourism?
Research Rationale and Methodology
This research will consist of three stages of data collection: exploratory study (observations
and small interviews with patients in a first visit to hospital), designing the questionnaire, and
the main study (a second visit to hospital).
Rationale for selection of hospital
Bangkok Pattaya Hospital (BPH) was chosen as the study site for two principal reasons.
Firstly, it met the following parameters: segmenting foreigners as a major target market;
providing internationally standardised quality of hospital, medical treatment, facilities and
infrastructure, and management personnel to the foreign patients. Secondly, BPH’s major
target market is not expatriates only but also medical tourists both in contact with the hospital
directly and via the agents in their home countries. The major target market is medical tourists
from major Western countries such as Western Europe (e.g. UK) and US; Arabic countries
such as UAE and Oman; and Australia and New Zealand. It was thus felt that with the
resources available to the researcher, a study uncovering consumer motivation and a
healthcare provider response could adequately be tackled at this hospital.
Participant selection
Due to the researcher’s limitation of time and funding, only the medical tourist participants
from major Western countries where English is the main language, i.e. the UK and the US are

chosen as the research target. Although expatriates 7 represent a high proportion in the foreign
patient market share in private hospitals generally, they are not selected here simply because
they do not travel to Thailand for medical care and are not representative sample of actual
medical tourists. The countries mentioned are selected since they represent a significant group
of total medical tourists. Approximately 150 patients, or about 75 patients from each country
will be sought for the questionnaire study to generate a representative sample as equally as
possible in terms of nationality and gender. These countries additionally provide a
comparative study of two different continents in terms of cross-cultural study with similar
Western background in order to compare their motivations for visiting a Thai private hospital.
Questionnaire survey
Interviews with medical tourists
Piloting the questions for interview
The piloting of all the questions for actual interview with medical tourists will be first carried
out by semi-structured interviews, elaborating in-depth response, in the UK with
approximately 5 British people who have visited Thailand for some kind of medical treatment.
As supported by what Gillham (2007) mention, a proper pilot study is a reproduction of the
main study involving fewer participants who possess the same characteristics as the final
target group.
Exploratory interviews
After the piloting, the first visit to BPH will take place with about 20 patients- 10 from the UK
and 10 from the US - who will be interviewed in a semi-structured format with open-ended
questions, such as ‘what motivated you to travel to Thailand for medical care?’ As suggested
by Gillham (2007), careful semi-structured interviewing before the questionnaire being
constructed can help identify the most of the likely answers. The most frequent keywords of
travel motivations from the medical tourists’ answers will be incorporated into the
questionnaire.
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.
jessicah62@hotmail.com
Abstract
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
Introduction
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.
Methodology
Study Design
The aim of research methodology was undertaken survey of mature spring/spa travellers
visiting natural springs of Taiwan. Besides, the study designed to extend the theoretical
framework for Taiwanese mature spring/spa traveller. This design was chosen because it
provides a highly accurate picture of the phenomenon under study. Questionnaire was
developed based on relevant literature review, conversations with mature spa/springtravellers,
and amendatory pilot survey. The questionnaire considered what information
would be essential related to the respondents’ needs of destination attributes in spring/spa.
Structured questions were used to gather information on natural spring/spa attributes and
socio-demographic. The sample was randomly selected from spring/spa travelers, who had an
interest in staying and visiting spring/spa destinations for particular purposes such as health,
activities, or being in a nature-based environment. The empirical evidence for the relationship
between motivation and destination choice is investigated in order to see what those factors
may mean for particular spring/spa groups, government policy reform, and market
management.
Sample
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
significant.
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
research
Data analysis and discussion
A principal component factor analysis was used to investigate the importance push-and-pull
factors within the Taiwanese mature travel groups, the underlying motivations of travellers,
and the differences in terms of destination attributes. Independent samples T-test was used to
compare the difference between the means of two groups, such as the mean push factors of
male and female travellers in spring destination or if there are any significant differences
between two means according to the demographic characteristics.
Demographic Profile
A summary of the demographic characteristics examined is show below in Table 1. The
sample was composed of the 200 mature traveller respondents from health spring/spa
destinations. It shows that 61.5% of respondents were males 38.5% were females. The
majority of the mature travellers to spring/spa were male, compared with younger group in
which over half of younger respondents were female. 42.5% of respondents were aged
between 50 and 54, only 27.5% were over 60 years old with a mean of 57.1. The majority of
population in Taiwan was young age group (15-45), while 73.3% mature group (45-65) and a
minority (nearly 11%) aged 65 and above.
Overall the sample of Taiwanese spring/spa mature travellers was less highly educated with
college or university degree. 34.5% of respondents present that they are retired and others
state their occupation as business owner. The similarity to white-collar worker (31.5%) was
the most common occupation from respondents.
When considering aspects of individual health status, most Taiwanese mature travellers
generally replied that they perceived their own health to be good (50%) or excellent (15.5%).
Only 3% of mature travellers feel they have some health problems, and 6.5% of them feel that
they have poor health (either in physical or mental health in their daily living, including
disease, impairment, disability, and handicap).

Table 1 Travellers’ demographic profile (N = 200)
Mature travellers
(N=200)
Frequency (%)
Gender
Female 77 (38.5)
Male 123(61.5)
Education
Under college 130 (65)
College above 68 (34)
Income
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)
Health
Bad 6 (3)
Poor 13 (6.5)
Fair 50 (25)
Good 100 (50)
Excellent 31 (15.5)
Occupation
Blue-collar worker 47 (23.5)
White-collar worker 63 (31.5)
Professional 21 (10.5)
Retired and Others 69 (34.5)
Travel Behaviour
The result in travel behaviour shows nearly 77% of respondents indicate that they tend to a
visit spring/spa destination more than once each year, whereas the remainders visit spring/spa
destinations only annually. The vast majority of respondents (about 77%) have visited
spring/spa destinations more than once before, whereas the rest have visited spring/spa
destinations for the first time. This result indicates that Taiwanese mature travellers have
experience in purchasing spring/spa products.
The majority of respondents indicated that they usually make visit to spring/spa destinations
or stay only one night in these destinations. This suggests that mature travellers in Taiwan
generally stay for a very short time at spring/spa destinations. Nearly half of respondents
reported that they have visited natural spring/spa destinations for curative purposes.
In visiting group, more than half of the respondents (60%) were travelling with family as the
primary party, and about 30% visited spring/spa with friends and colleagues. The social
change in Taiwan increased opportunities for target marketing based on different family life
cycle stages, for example, increased economic status and leisure time combined with shorter
working hours in modern life. The notion of travelling with family members was the most

commonly reported motivation. Regarding the spending at sparing/spa destination variables
present more than 50% of respondents that they spend less than NT$10,000 (less than £200)
on spring and spa products each year whereas the remaining 39% of mature and 17% of
younger travellers spend NT$10,000-$40,000 on spring and spa products each year.
Travel motivations
Factor analysis was performed to identify the underlying dimension of travel motivations in
this study. These include 24 push and 19 pull motivation variables were initially chosen to be
factor analysed. Using the PCFA orthogonal varimax rotation was performed to reduce the
push items and pull items of Taiwanese mature spring/spa travellers’ motivations into specific
underlying constructs. In addition, by using the statistical technique is to determine the linear
combinations of motivation variables and investigate the interrelationships between. Items
were dropped from further analysis while low correlations with the overall score of the
questionnaire.
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
References
Gee, C., Makens, J. C., & Choy, D. J. L. (1989). The Travel Industry. New York: Van
Nostrand Reinhold.
Goodrich, J. N. G. a. G. E. (1987). Health-care tourism - an exploratory study. Tourism
Management, 8(3), 217-222.
Hall, C. M. (1992). Adventure, sport and health tourism. In B. W. a. C. M. Hall (Ed.), Special
Interest Tourism (pp. 141-158). London: Belhaven Press.
Holloway, J. C. (2004). Marketing for Tourism (fourth ed.). Essex: Prentice Hall.
Hsieh, L. F., Lin, L. H., & Lin, Y. Y. (2007). A service quality measurement architecture for
hot spring hotels in Taiwan. Tourism Management, May.
Norman, W. C., Daniels, M. J., McGuire, F., & Norman, C. A. (2001). Whither the mature
market: An Empirical Examination of the travel motivations of Neo-Mature and Veteran-
Mature Markets. Journal of Hospitality & Leisure Marketing, 8(3/4), 113-130.

Natural wellness - Health and wellness as nature-based tourism product
Edward H. Huijbens
Director,Icelandic Tourism Research Centre
edward@unak.is
Abstract
This paper is set in the context of a two year research project funded by the Nordic Innovation
Centre (NICe), dealing with Nordic wellness and wellbeing. The researchers of the project
collaborate with budding health and wellness destinations, one in each of the Nordic countries
in order to establish a Nordic wellness concept and develop user-drive product improvements.
This paper deals specifically with the Icelandic case being studied under the terms of the
project and will combine nature-based tourism with that of health and wellness. Nature-based
tourism is by far the most prominent form of tourism in Iceland. Albeit vaguely defined it
entails tourism in natural settings, tourism focusing on elements of the natural environment
and tourism developed to conserve or protect natural environments. This paper looks at a
development of a geo-thermal spa, much like the Blue Lagoon, but in the NE corner of
Iceland near Lake Mývatn, a famed nature-based tourism destination in Iceland. The current
spa facility was erected in 2004. It builds on a long history of locals using the thermal waters
and steam coming from the ground for wellbeing, and is gaining steadily in visitor number per
annum. Emerging from research amongst stakeholders involved in the building up of the
Mývatn Nature Baths in NE Iceland was the role nature plays in health and wellness. Both as
a fundamental concept of being in nature and/or at one with nature, and more specifically
through health and wellness related activities in a natural setting. The paper will explore some
of the tentative product manifestations and ideas of these emerging themes and their
implications for product development in health and wellness tourism for NE Iceland.

Budapest’s thermal spas on screen
Anna Irimiás
Associate Professor, Kodolányi János University of Applied Sciences, Tourism Department.
irimias@uranos.kodolanyi.hu
Abstract
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
film-commissioners.
Keywords: film-induced tourism, destination image, Budapest, spas.
Introduction
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
there
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
well.
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.
Findings
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
Hungarians.
Figure 1 Perception of tourists on Budapest
Modern city
Religious city
City where is good to live
Multicultural city
Art city
Shopping city
City where is good to have holiday
Party city
Cultural city
Historical city
The city of spas
3,37
3,38
3,44
3,5
3,6
3,79
3,83
3,88
4,02
4,04
4,05
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
Budapest
Icon
The Children of Glory 2006 BVSC Budapest National
polo team
proud, water-
Made in Hungária 2009 Csillaghegyi
Pools
Swimming Fun, youth
I, Spy 2002
In bed with the opposition 1997
Csontváry 1980
The Children of Glory 2006
Mrs Ratcliffe’s Revolution 2008
Gellért Spa Baths Aristocratic beauty, built
heritage
Hajós Alfréd Swimming National proud
The Double Life of Mrs. Mici 1962
Pool Complex
Lukács Thermal Baths Third-age love affair
Red Heat 1988 Rudas Thermal Baths Mystery
Just sex and nothing else 2005 Szécheny Spa Budapest Built heritage, human
Io e mia sorella 1987
Csontváry 1980
relationships
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
(n=53
3)
The films set in Budapest contribute to the positive image of
the city.
1-4 2.25
I can know Budapest better through the films set there. 1-4 2.51
It is interesting to know which films were shot in Budapest. 1-4 2.21
A film can influence my choice of a travel destination. 1-4 2.42
If a movie map was available in my hotel, I would use it and
would visit the film locations.
1-4 2.42
I think that Budapest’s thermal spas are well represented on
films, and give a good impression about the city.
Scale: 1= Strongly Agree and 4 = Strongly Disagree.
1-4 2.15
According to the mean value of the answers given for the statements, it can be stated the
Hypothesis 2 (Budapest identity as a city of spas will be reconfirmed through the films)
cannot be reconfirmed, nevertheless several key attraction spas feature in different movies
located in Budapest. In the research it has been evidenced that Budapest’s missing identity,
her acting as other European cities, might cause some confusion in place identification.
Conclusions
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
CANADA
mjoppe@uoguelph.ca
and
Hwan-Suk Chris Choi, PhD, Associate Professor
School of Hospitality and Tourism Management, Macdonald Stewart Hall, University of
Guelph, Guelph, Ontario, CANADA, N1G 2W1
Introduction
Canada is a fairly recent newcomer to the world of spa tourism. According to a
PricewaterhouseCoopers study on the spa industry, undertaken on behalf of the International
Spa Association, between 1990 and 2001, the number of spa establishments in North America
went from 1400 to 10,900, of which 1300 were in Canada, and occupancy went from 40% to
an average between 70 and 80%. Instead of slowing things down, the events of September 11,
2001 actually spurred growth in this sector. By 2003, the International Spa Association
(ISPA) estimated the number of establishments to have reached 12,100 spas throughout the
U.S and 2,100 in Canada, a 26% growth in the States but 65% growth in Canada!
In North America, health has become a major societal preoccupation, since all media bombard
citizens with warnings about too sedentary a life, the health dangers of too much weight,
cholesterol and stress, too little sleep, and high tension. Foods are considered too fatty, too
sugar and salt-laden; both the air and the water is making people sick. If all that were not
enough, North Americans have been made anxious, if not downright paranoid, about
everything from possible terrorist attacks to catching SARS (Severe Acute Respiratory
Syndrome), the avian flu or H1N1. At the same time, the strong baby boom cohort is
becoming obsessed with aging, refusing to give in to wrinkles and sagging bodies. So it is not
surprising that North Americans are desperate to find an oasis, a place where it is possible to
be at peace, breathe deeply, regain one’s internal balance, re-establish the harmony between
body, mind and soul so that they can confront this fast-paced, complex and increasingly scary
world another day. Yet that older cohort is no longer prepared to make big efforts and huge
sacrifices to look and feel better, as they did just a decade previously. The time has come to
be kind to ourselves: to strive for balance, harmony but also pleasure. Spas are seen as a
means of escaping the pressures and getting re-energized” (Association Resource Centre Inc.
2006: 5).
Health is no longer considered just an absence of illness, but rather an optimum state of
physical, mental and social well-being that requires a more holistic approach and proactive
participation by the individual (Nahrstedt 2004). The World Health Organization 8 defines
8 World Health Organization (1946). Preamble to the Constitution of the World Health Organization as adopted
by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the
representa-tives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into
force on 7 April 1948.

health as “a state of complete physical, mental and social well-being”, which reflects a
preventive way of living that reduces, and even eliminates, the need for remedies. Thus,
health tourism refers to someone who has one or more medical conditions that would make
him travel to experience therapies that help to make him well - or to improve his health. On
the other hand, the concept of wellness emphasizes personal responsibility for making lifestyle
choices and self care decisions that will improve our quality of life. People who engage
in wellness tourism are generally healthy, but seek therapies to maintain this state of wellbeing.
While Europeans and Asians have recognized the benefits of “taking the waters” for
centuries, and the concept of “wellness” has been recognized as a major force in the United
States for more almost 20 years, it has really been part of the Canadian consciousness for only
about 10 years. In that time, however, a significant change in attitudes has taken place.
Methods
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.

Results
Demographic characteristics of spa-goers
While only 2.4% had visited a spa during the previous two years while on an overnight trip in
1999, this percentage had increased to 11% seven years later. In addition, 34% (almost
800,000 respondents) reported that this activity was the main reason for taking at least one
trip. While only Saskatchewan showed a high participation rate in 2000 (8% of overnight
pleasure travelers), by 2006, Saskatchewan (13.6%), British Columbia (9.3%) and Quebec
(8.3%) were all above average. In 1999, women were 47% more likely to have visited a health
spa, but there was relatively little variation by age in the incidence of health spa visits, and the
levels of formal education and household income were only weakly associated with health spa
visits. By 2006, the picture had changed quite dramatically: women were 70% more likely to
have visited a health spa, and spa visitors were over-represented among those 25 to 54 years
of age and especially among Mature Couples. In addition, they were the third most likely to
have a university degree and had the highest household income of any of the culture and
entertainment activity types.
Indeed, there was a significant shift between 1999 and 2006 in the income groups that are
both staying at health spas and participating in health and wellness spa activities. Whereas in
1999 the majority of health spa goers earned $60,000 and more, by 2006 the majority earned
$80,000 and more. This middle-aged group is, however, increasingly introducing both their
parents (mainly mothers) and children (mainly daughters) to the spa experience, contributing
to the extraordinary growth in demand for facilities as well as treatments.
Segmenting the spa segment
Spa-goers made an estimated 14.1 million visits to Canadian spas. Half of these visits were
taken to spas in Ontario and four out of five spa visits in Canada were made to day spas (11.3
million). Over 40% of the Canadian adult population visits day spas while at home (Table 1):
Table 1 Frequency of Spa Visitation
During the past 12 months, how
often did you visit a day spa?
Frequency Percentage
Frequently 398,952 5.4
Occasionally 2,603,110 35.1
Rarely 4,404,814 59.5
Total 7,406,876 100.0
Source: Lang Research Inc. (2007).
It is clear that the spa segment is not a homogeneous one. In a 2006 study by The Hartman
Group, three types of spa-goers were identified, based on the frequency with which they seek
out these experiences and their attitude towards them: core spa-goers are knowledgeable
about treatments and feel that learning about and going to spas is important to their lifestyle,
while periphery spa-goers (at the other extreme) enjoy going to spas but otherwise show little
interest in them. Between these two segments is a mid-level spa-goer segment that is
interested in learning about spas but lacks the commitment and passion of the core spa-goers.
If we take a closer look at that 40-50% of spa-goers that will travel for the purpose of spa and
wellness tourism, it is probably not surprising that these tend to be more core spa-goers, who
are not only experienced, but have already tried a range of products and services and are thus
the most critical. The majority considered themselves to be in good or excellent health and of
average weight. In spite of this, they worry about their health, including what they eat and

how much exercise they get. Two-thirds of them take vitamins; and 61% limit the amount of
fat they eat. So, while relaxation is their primary motivation for choosing a spa during their
holidays (rated 2.74 on a 3-point benefit scale in terms of importance), with pampering and
stress reduction as secondary motives, a majority reported healthy meal choices to be
important in the selection of accommodations. This does not mean that spa-goers forsake
pampering: indeed, they are 2.5 to 2.7 times more likely to seek this as a somewhat to highly
important benefit compared to other pleasure travellers. But only 37% said workout facilities
were important which corresponds to their general attitude towards active involvement in
regular fitness programs (rated 2.8 on a 5-point Likert scale). Nonetheless, odds are 50%
higher than for other pleasure travelers that being physically challenged/energized is a highly
important benefit sought of their spa vacation and .
This, then, is the dramatic shift in perception we have seen from spas as “indulgence”,
providing the ultimate in luxury and pampering: today, luxury is a given at any spa, but the
“spa experience” that incorporates a tranquil, airy setting and information about health,
wellness and self- or at-home care, in order to maintain a balanced lifestyle, is seen as a
component of long- term, healthy living.
The need for quality assurance
Considering the demographic profile of spa-goers, it is somewhat surprising that no
government has felt the need so far to impose any quality standards or regulate against
possible fraudulent claims coming out of the many different treatments proposed, vitamins,
supplements and lotions used, and statements made as to the psychological and physical
improvements to be expected. Even ISPA has recognized that “as the spa industry continues
to grow and expand to mainstream consumers and their health and wellness regimes,
therapists’ credentials as well as the overall effectiveness of the spa experience (menus,
pricing, environment, “extras,” etc.) will come under greater scrutiny by all segments of
consumers.” (The Hartman Group, 2006: 3).
Indeed, one of the more recent research studies clearly indicates the quality of the treatment
and services as well as the hygiene of staff and cleanliness of the spa facilities are the top
concerns of spa goers (The Hartman Group, 2006).
Table 2 Spa Traveller Concerns with Spa Treatments
Canada USA
Quality of treatment/services 35% 47%
Cost of services 36% 41%
Hygiene of staff and cleanliness of spa facilities 41% 39%
Benefits of treatments 29% 27%
Certification/Training of personnel performing treatments
Source: The Hartman Group (2006).
25% 18%
Premier Spas of Ontario as well as its Quebec counterpart, Relais Santé, are the only industry
associations in Canada that have recognized the need to provide consumers with a guarantee
concerning both the facilities and treatments they will find at a spa, and the professionalism
and credentials of the staff. Acquiring the Premier Spa accreditation by Spas Ontario Inc. is a
comprehensive process involving application, inspection, report submission, and acceptance
by the Board of Directors. The “Insight” lays out the stringent criteria for membership which

give consumers comfort and reassurance about the professionalism and credentials of the
person or persons into whose care they are putting their body, their mind and their soul.
Relais Santé follows a similar approach. Thus, these two organizations have laid a solid
foundation to take advantage of the growth in what can be considered a ‘super-trend’ and
squarely address one of the major consumer concerns: quality assurance and consistency with
respect to the facilities, spa products, services and treatments provided. For instance, massage
therapy training in Ontario is more extensive than that found elsewhere and this province’s
therapists are controlled by a government regulated college – both go a long way to reassuring
consumers.
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
general.
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!
Implications
The explosion in spa products for sale in almost any store that carries personal care and
beauty products is both a result of, and a contributor to, the growth in spa visits. This
“personal introduction” is likely also the reason why even first-timers seem to have very high
expectations regarding their visit. Men, who are introduced to the spa experience, often by
their spouses, will usually start with a massage as they tend to be driven by notions of “work",
i.e., improving some aspect of their body, their emotional state or their long-term spiritual and
personal dispositions (The Hartman Group, 2004). Increasingly, however, they are warming
up to manicures and facials, largely as part of the broader societal trend that has seen a return
of the acceptability of male grooming, along with greater acceptance of the gay culture and
the rise of the “metrosexual” who has many of the characteristics of his gay counterparts, but
is heterosexual.
As the spa consumer becomes more knowledgeable and educated about available treatments
and their expected outcomes, he or she will increasingly look to the spa industry to provide
ever more information about every aspect of a wellness program, and spas will be judged on
their ability to make informed decisions and provide guidance in every aspect from menu
design and implementation, to which training and treatment programs to engage in and why.
But messages must go beyond addressing the core segment in terms of communications,
menu designs and available spa treatments: even though they are the most committed, they
represent the smallest percentage of the overall spa population, and thus, to convert the midlevel
and periphery spa-goers, the messages must also address their lower level of knowledge.
It is also important to realize that visits to day spas are an activity largely undertaken by
women, but spa travel is not: 42% of the Canadian health spa resort clientele is men. Staying
at such a resort is no guarantee, however, that they will actually participate in spa-related
activities as only 37% indicated that they did so, based on 2006 TAMS study. Still, facilities
at resorts and hotels must be adapted to a very discerning, mixed clientele, by also offering
male-focused activities like golf, outdoor adventure, male cosmetic programs, and highoctane
fitness programs.
It is clear that this industry will have to place much greater emphasis on learning, by bringing
in knowledgeable speakers from both the conventional and complementary or alternative
medical fields to educate consumers who want to make informed decisions about their own
health. Especially the core spa-goers are craving this type of knowledge, and avidly pursue
their own understanding. Nutrition is already playing a much greater role as people become
more aware of health effects procured by different food items, and weigh different dietary
approaches to combat everything from obesity to medical problems. People’s anxiety over

genetically modified foods, additives and preservatives will lead them to sustain the growth in
organic foods and the popularity of farmers’ markets, regional cuisines, and traditional foods,
all of which are perceived to be more “natural” and therefore healthier.
References
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
Trips
Of One or More Nights: A Profile Report. Toronto, ON: Ontario Ministry of Tourism and
partners.
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
Press.
PricewaterhouseCoopers (2004). The ISPA 2004 Spa Industry Study. Lexington, Ky:
International SPA Association
PricewaterhouseCoopers (2002). The ISPA 2002 Spa Industry Study. Lexington, Ky:
International SPA Association
The Hartman Group (2006). Identifying the Spa Traveler: A Look at US and Canadian
Consumer Attitudes and Motivators for Spa Vacations. Canadian Tourism Commission
and International SPA Association.

The use of the internet in wellness promotion by Portuguese spas
Veronika Joukes
Professor Auxiliar, DESG, CETRAD (ECHS),
Universidade de Trás-os-Montes e Alto Douro (UTAD),
Avenida Almeida Lucena 1, 5000-660 Vila Real, Portugal.
veronika@utad.pt.
Abstract
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.
Introduction
In Portugal, the supply side of health and wellness tourism consists of traditional spas based
on natural mineral water springs (that have existed since Roman times at least), some
9 This preliminary study was undertaken on our own initiative but the intention is to convert it into an
international comparative project furnishing results that may be applicable to the sector under consideration.

thalassotherapeutic establishments (registered from 1990, and using therapies exclusively
based on sea water), as well as a fast growing number of non-mineral water spas (established
since the beginning of the 21st century, based on water from the public supply network). In
numerical terms this situation translates into the following structure of suppliers: 38 mineral
springs spas that, in 2008 10 , were open to the public (Turismo de Portugal, 2009b); fewer than
10 sea-water units functioning in 2010 (Fernandes, 2006; Turismo de Portugal, 2009a); and
approximately 130 hotels with spa facilities reported by the Portuguese Hotel Association
(AHP) for the same year, which corresponds to an increase of more than 1500% over the last
8 years in the number of functioning “spa hotels” (Turismo de Portugal, 2010a). Meditative
and holistic retreats (on the one hand) and medical tourism focusing particularly on
aesthetic/cosmetic, dental and surgical treatments (on the other hand) are still in the
introductory stage of their life cycle and consequently it is impossible to quantify their current
share of the market – either because they are not yet the object of intensive promotion efforts
and/or because these subsectors' activities still remain largely unstructured.
This paper focuses on the spas that are based on mineral springs, commonly referred to in
Portuguese as termas (the local adaptation of the Latin thermae, meaning hot springs/baths).
In order to avoid misunderstandings and to emphasize the unique Portuguese context, it
should be underlined that for the Portuguese consumer the concept of “going to the termas”
has long meant undergoing therapy based on mineral water springs, i.e. only those who were
ill would “take the waters” and, consequently, mineral springs spa facilities were sought only
by the unhealthy and elderly. However, the number of spas nowadays greatly exceeded the
number of termas and recent massive marketing and awareness campaigns have facilitated the
introduction of the spa concept in Portugal, where the latter is now understood as a place (in
an urban/rural environment, in a hotel/fitness complex, in a beauty centre or even in the
traditional termas) where one can be pampered, but not necessarily with (mineral) water
treatments. We have to stress another difference, important for the development of tourist
products, between spa hotels and termas: the latter normally do not offer accommodation. On
the other hand, the traditional termas are no longer seen as mere therapeutic infrastructures
but also, and increasingly so, as places of leisure, recreation and relaxation. While, in
principal, the two dimensions – therapy and recreation – are two facets of nowadays spas that
can coexist in perfect harmony, the services provided by the emerging wellness tourism
market in Portugal are still thought of as being quite separate from those offered by the
turismo termal market (spa-based medical tourism), since Portugal has a much longer
tradition in the latter field (Lapa, 2009).
The main reason for finding these spas of analytical interest is the fact that they (i) are owned
by relatively small public or private investor’s groups, (ii) are typically autonomous rather
than part of a major grouping or conglomerate and (iii) are experiencing a phase of significant
adaptation that obliges them to market their services more directly and aggressively.
Based on a previously-conducted literature review, the empirical research analysed half of the
existing spa websites in order to find out (i) how the termas position and promote both their
traditional and new products, (ii) what kind of public they appeal to, (iii) whether they only
mention their own services or also provide information on complementary service suppliers,
such as travel experts, sports organizations or nature guides, to which potential clients are
redirected, and (iv) whether they use interactive techniques. However, before presenting the
results of this survey, the general context in which these mineral springs spas have evolved
will be described.
10 The most recent official statistics referring to the sector date from 2008.

The main characteristics of Portuguese mineral springs potential
In Portugal 408 springs with mineral water are reported to have therapeutic properties, and
three quarters of them (300) are recognised by the local population as having curative
properties (Sousa, 2006). In the spring of 2010 already 44 such spas were officially being
exploited. However, only 39 were open to the public, two more than in the previous year. The
Central region of Portugal has 20 spas (or 45% of the total), the North has 18 (41%), while
only 14% of the total number of termas are located in the remaining four regions – three in
the Alentejo and one each in Lisbon, the Algarve and the Azores (ATP, 2010; Turismo de
Portugal, 2009b).
It is not compulsory for spas to be registered members of the Associação das Termas de
Portugal, the organisation that defends the interests of the country’s subscribing mineral
springs spas. However, most spas are in fact members, with only the northern termas of
Moledo, Eirogo and Carlão never having joined the ATP. These 3 independent spas (indicated
in blue) and the limits of the NUTS II sub-regions (in green) are also indicated on the map
below. Figure 1 shows the geographical spread of ATP-member spas across the country.
In the Central region, as a matter of fact in São Pedro do Sul, the largest Portuguese termas
are to be found with 17.017 medical spa goers in 2008. The second largest facility with regard
to this kind of public, Termas de Chaves, another municipal company, however, handled
6.374 medical attendants over the same period, only a little more than one third of the number
TERMALISTUR reached. This considerable discrepancy explains why the North only served
25.814 mineral springs spa goers in 2008 and the Centre more than double (58.870) (Turismo
de Portugal, 2009b).
It is also important to note that of the 44 units under consideration (41 ATP members and 3
independent ones), 21 (48%) already renovated their premises since 2000 and that another 5
(11%) will reopen within a short span of time. This year the brochure Saúde & bemestar, in
which 20 innovative and differentiating qualification projects sponsored by Turismo de
Portugal over the last decade are listed in an appealing way, included mineral springs spa
(along with spa hotel) renovation projects with a total investment value between 470.000€ and
20.900.000€ (Turismo de Portugal, 2010b).

Figure 1. Geographical spread of Portuguese mineral springs spas in 2010
Termas (Nº indicates District Region Figure
location on map)
(NUTS
II)
04 Caldas de Chaves Vila
05 Termas do Vidago
06 Águas Santas de
Carvalhelhos
09 Termas de Pedras
Salgadas
001 Caldas de Moledo
003 Caldas do Carlão
14 Caldas de Aregos
Real
01 Termas de Viana
Melgaço
do
02 Caldas de Monção Castelo North
03 Termas do Gerês Braga
002 Termas de Eirogo
Centre
07 Termas
Caldelas
de
08 Caldas das Taipas
11 Termas de Vizela
12 Termas
Vicente
de S.
10 Caldas da Saúde
13 Termas de Entreos-Rios
Porto
Lisbon
16 Caldas de S. Jorge
21 Termas do Vale da
Mó
25 Termas da Curia
26 Termas do Luso
Aveiro
Aveiro
Alentejo
17 Termas
Carvalhal
do Viseu
Algarve
20 Termas de S.
Pedro do Sul
22 Caldas
Sangemil
de
23 Termas
Felgueira
da
24 Termas
Alcafache
de
Centre
15 Termas
Longroiva
de Guarda
18 Caldas da Cavaca
19 Termas
Almeida
de
27 Caldas
Manteigas
28 Caldas do Cró
de
North

29 Termas de Unhais
da Serra
30 Termas de
Monfortinho
31 Termas de Ladeira
de Envendos
32 Termas de Monte
Real
33 Termas das
Salgadas
34 Caldas da Rainha
35 Termas do
Vimeiro
Castelo
Branco
Santaré
m
Leiria
Lisbon
39 Termas do Estoril Lisbon Lisbon
36 Termas de
Fadagosa de Nisa
37 Termas de Monte
da Pedra
38 Termas de Cabeço
de Vide
40 Caldas de
Monchique
Portale
gre
Alentej
o
Faro Algarve
41 Termas das Furnas Azores Azores
Source: Mapped by the author (based on ATP, 2010; INETI, 2004; Turismo de Portugal,
2009b).
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),
2010).
Since prior knowledge of the customer is so important, greater adherence on the part of spa
managers to the SPA & Thalasso Monitor, launched by the Portuguese Hotel Association
(AHP) in May 2009, would seem appropriate. All participating hotel units in the sector are
provided with free access to this benchmarking system that produces operational management
information relevant for this market. The Monitor is supported by software that allows, at any
time, all member businesses to review their (historical) data and weigh the position of their
own unit relative to others in the same or in different regions of Portugal. It fills a serious
lacuna in technical information available on this segment, making accessible monthly-updated
operational indicators as well as data on market activity, providing a business management
tool, and guarantees that public tourism officials (local, regional and national) can access
whenever necessary, reliable information relative to their geographical area (AHP, 2009;
Mourão, 2010).
Principal results of the analysis of 15 mineral springs spa websites
It is not only those who want to decide how they are going to pamper themselves who take
advantage of the internet, but also those active on the supply side. The internet constitutes the
only medium capable of furnishing round-the-clock, “instant” and up-to-date information on
new techniques, products and services. This makes it easy for service providers to innovate,
reinvent and promote service packages and incentivise termas to continuously develop their
communicative capacities and to explore the marketing techniques to the limit in the context
of a market niche of substantial commercial interest (Gustavo, 2009).
So far no research has been undertaken in Portugal into the internet marketing strategies of
spas, neither have their websites been analyzed in any systematic way. The study reported on
here concentrated on the years 2009 and 2010: one year ago, 37 termas were open to the
public and 30 of them had a website, while in 2010 two more termas (39) were functioning, of
which 34 promoted their services through the internet. In the two years under consideration,
the arguments firms advanced for not employing a website were: (i) that the firm was in a
remodelling phase and therefore there would be few if any returns deriving from an internet
site; or (ii) that the firm’s main clients were principally local elderly customers, the spa
facilities were limited, and only open during a short period of the year and therefore there was
little hope of attracting new segments of spa goers. Only Moledo and Eirogo, two of the three
independent spa units, are examples of the latter situation, while the other cases fit into the
first group. As a matter of fact, in three (Almeida, Monte Real and Nisa) of the four cases of
new websites created in 2010, the website launched coincided with the reopening of the
premises after renovation, while the creation of the Taipas website has to be interpreted as
part of the 2010-2013 plan of its newly elected board that, amongst other objectives, intends
to redefine its public and modernize the spa (Taipas Turitermas, 2010).

In the same period, 9 termas merely offered basic information posted on the website of an
umbrella institution (the Carvalhelhos spa on the website of the bottled water firm of the same
name; those of Entre-os-Rios and Manteigas are to be found on INATEL’s website; Almeida,
Vale da Mó, Sangemil, Cró and Cabeço de Vide on the website of the municipality that owns
them; and Caldas da Rainha on the Ministry of Health’s website). With the exception of
Cabeço da Vide, the termas with over 2.000 medical spa goers per year (corresponding to 1/3
of the termas with a website link) have their own appealing websites, whereas of the 15
smaller spas (receiving less than 1.000 visitors in 2008), 4 have no website at all and 4 only
furnish the most basic details through an umbrella website. The internet presence of termas
open to the public and with accommodation is 100% and 85% of those without integrated
accommodation.
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.

Name
Table 2. Spa websites analysed
São Pedro
do Sul
NUTS
II
Rankin
g Nº of
medical
spagoers
Nº of
medical
spagoers
(2008)
Centre 1 17.017
Chaves North 2 6.374
Felgueira Centre 4 4.511
Renovate
d during
last
decade?
2005
(Sept) -
2007
(June)
2005
(May)
none
(1997)
São Jorge North 6 3.655 2003
Concessio
n holder
in 2010
Municipali
ty
Municipali
ty
Accomm
-odation
provided
?
balneári
o
balneári
o
Website address
www.termas-spsul.com
www.termasdechaves.com
Private hotel www.termasdafelgueira.pt
Municipali
ty
Gerês North 8 3.443 2007 (Jan) Private
Monfortin
ho
Centre 10 2.358
Saúde North 15 1.326
São.
Vicente
North 16 1.258
2000
(Aug)
none
(1994)
2008
(June)
balneári
o
balneári
o
www.termas-sjorge.com
www.aguasdogeres.pt
Private hotel www.monfortur.pt
Private
balneári
o
www.caldas-da-saude.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
ty
balneári
o
www.termasdelongroiva.c
om.pt
Vimeiro Centre 22 637 none Private hotel www.termasvimeiro.com
Monchiqu
e
Algarv
e
23 621
2002
(May)
Aregos North 24 604 2009
Cavaca Centre 28 421
2008
(July)
Private hotel
Municipali balneári
ty o
Municipali balneári
ty o
www.monchiquetermas.co
m
www.termascaldasdearegos.com
www.caldasdacavaca.pt
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
Portugal, 2009b.
As mentioned above, modernisation efforts on the part of the owners of mineral springs spas
did not stop at infrastructural renovation projects: many also established internet sites, on
which they placed and managed different types of information. Some of the more interesting
aspects of the internet sites encountered in the survey are presented below.
Almost all sites (Aregos and Longroiva being the only ones that offer only classic treatments)
use different subpages to recommend both medical and wellness products. However, the
degree of detail in the information provided is variable, with the Furnas site being the least
impressive example, referring to nothing more than the installations where the treatments take
place. In the majority of cases, sites not only summarise the treatments available, but also
explain them: Three do so with photos and the São Jorge site supplies a glossary of almost 30
terms. Only a small group bring together frequently asked questions in a dedicated “FAQ”
sub-page. All units, apart from Furnas, present a detailed price-list; however, it is only on rare

occasions that potential clients are informed of the time needed for each treatment. Almost all
termas differentiate their prices following one or more of the following criteria: (i) the longer
the stay and/or the more treatments acquired, the cheaper the unit price; (ii) prices vary
according to whether the visit is made in the low, middle or high season; (iii) returning
customers receive discounts; (iv) group bookings pay less; (v) in spa hotels, prices change
according to whether the treatment is bought with or without accommodation.
None of the termas created a subpage with general tips on healthy lifestyle, although some do
mention that they have a staff nutritionist and it is in this context that certain advice is given.
None of the termas elaborated a code of ethics, but São Jorge does mention a small list of
commitments regarding the quality of the services offered. None of the termas explicitly
mentions its concern for the principles of sustainability and local development. Implicitly,
some display pro-nature values, describing the spa’s healthy surroundings in their
introductory texts or including “green” pictures on the opening page of the site or in the site’s
photo gallery. Only on the São Pedro do Sul site is there a subpage entitled “quality and
environment” that includes a manual of environmental good practices («Boas práticas
ambientais»).
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
restaurants.
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.
Conclusions
Having noted that the large majority of the mineral springs spa service providers have been
significantly upgrading not only their services and infrastructures, but also their websites over
the past five years, the survey analysed the way they currently communicate with their
(prospective) clients through the internet. We conclude that the Decree-Law Nº 142/2004 has
brought about real changes: the majority of Portuguese mineral spring spas now offer medical
along with wellness services and inform prospective clients correctly and honestly about what
to expect. Nevertheless, here are still numerous opportunities for spas to improve their
internet presence in many directions: by putting more (and more accurate) information on
their sites, they will be able to target special groups and market segments, redirecting
prospective clients to complementary tourist activities and expressing their concern over
environmental, sustainability and local development issues. Termas would be well advised to
develop their interactivity by creating discussion forums, making their sites more accessible,
offering more online shopping possibilities, taking more advantage of social networks or
creating more transparent subpages in which clients’ opinions can be expressed. Our sample,
moreover, provides evidence that the more content and links are put on the internet, the better
informed clients will become and the more likely it will be that (potential) clients will be
attracted by the product under consideration. We are also convinced that even “extremely
small” spa units can benefit from developing focused and functional websites.
In our opinion the results of this study offer not only Portuguese mineral springs spas but spas
in general the chance to further improve their internet dialogue with current and potential spagoers.

In conclusion, researchers in this field are encouraged to develop a more comprehensive
international comparative study of spa websites in order to work out guidelines for common
best practices.
I would like to thank Barrie Abbott, Louis Joukes and, most of all, Chris Gerry for their
contributions to the final form of this text and also the first year students of UTAD's Tourism
degree (Ana Carina Lima, Ângela Silva, Carla Machado, Cátia Rodrigues, Marta Mota,
Natércia Lourenço, Rita Teixeira, Sara Rebelo, Sara Teixeira, Sónia Ala, Telma Castilho,
Telma Guerra, Teresa Gonçalves and Tiago Araújo) who assisted in the collection, during
February of 2009, of some of the data necessary for this paper.
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Health Spa and Wellness – Competition or Supplement?
The Czech Republic Case
Alžbeta Kiráľová
Vysoká škola obchodní v Praze/ University of Business in Prague, Prague, Czech Republic
alzbeta.kiralova@vso-praha.eu
Abstract
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
Introduction
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)
in 2004.
The Czech Republic is one of the most stable and prosperous of the post-Communist states of
Central and Eastern Europe. 11 The per capita GDP reached 25.100 USD (2009 est.), the
inflation rate is 1.1% (2009 est.), the unemployment rate is 9.3% (2009 est.), and 56.2 % of
labor is employed in services. 12
The conditions for tourism development are excellent – there are twelve historical monuments
on the UNESCO Heritage list, 13 over 2.000 castles, chateaux and monuments, and more than
40 protected historical towns and cities in the Czech Republic.
Four national parks 14 were established to protect the country´s most rare and valuable nature,
8 mountain ranges, and over 1.200 protected landscape areas and natural spots are covering
more than 10 % of territory of the Czech Republic offering 38.500 km walking trails, 19.024
km cycling routes, 1.240 km skiing tours to visitors. The country is dotted with over 20.000
lakes and ponds and more then 40 water basins.
11 CIA. The World Fact Book – Czech Republic. Downloaded from:
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
2008.
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
2010)

Share of Tourism on National Economy Table 1
Indicator
Share of tourism
receipts on GDP (in
%)
Share of tourism
receipts on exports
(in %)
1993 5.0 11.0 33,0
1994 5.5 14.0 43,2
1995 5.6 13.4 42,8
1996 7.1 18.6 49,8
1997 6.9 16.3 50.9
1998 6.8 15.0 50,6
1999 5.8 12.0 44,8
2000 5.9 10.3 43,5
2001 5.5 9.3 43,8
2002 4.2 7.7 41,7
2003 4.2 7.3 45,8
2004 3.8 6.2 43.4
2005 3.7 6.8 39.7
2006 3.9 5.8 39.7
2007 3.8 5.4 38.7
2008 3.5 5.5 34.7
Source: Downloaded from: http//: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
Indicator
USD)
(bn
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%).
17
Tourism the Czech Republic - Facts & Figures 2008. Research by STEM/MARK for Ministry for Regional
Development. Downloaded
from:http://www.czechtourism.cz/files/statistiky/28_07_09_statistiky_letak2008_eng.pdf (last accessed 7
March 2010)
18
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
2010)

The main purpose of the one-day visitors coming to the Czech Republic was shopping
(73.7%), business trip (11.5%), recreation and entertainment (6.6%) and visiting friends and
relatives (6.4%).
Health State and Aging - Implication for Tourism
The World Health Organization (WHO) defines health as ‘a state of complete physical,
mental, and social well-being and not merely the absence of disease, or infirmity’. This broad
definition can be applied equally to developed and developing countries and to both genders.
Health is a cumulative state, to be promoted throughout life in order to ensure that the full
benefits are enjoyed in later years. Good health is vital to maintain an acceptable quality of
life in older individuals and to ensure the continued contributions of older persons to
society. 19
Health state is an important part of the standard of living and quality of life of inhabitants of
each country and is perceived as country´s development criteria. Healthy life expectancy
(HALE), defined by WHO as „Average number of years that a person can expect to live in
"full health" by taking into account years lived in less than full health due to disease and/or
injury“ 20 is a indicator which is monitored also in the Czech Republic.
One of the common characteristic features of most European countries is demographic
ageing: it occurs mainly as a result of decreasing or low and stagnant natality, along with
decreasing mortality and related increasing life expectancy. 21 The share of children in the
population diminishes while the share of persons at ages 65 years or more grows. The age
preference index used for comparison of population age structures exceeds the value 100 (i.e.,
the number of persons over 64 years exceeds the numbers of children) 22 in increasing
numbers of countries including the Czech Republic (102.4 in 2007 and 105.1 in 2008). Due to
a marked decrease of natality in the early 1990s it has low proportion of children up to 15
years old (14.2 % in 2008), but it still belongs to countries with relatively low proportion of
persons in the age group of 65 or more years (14.7 % in 2008). The latter proportion will
further increase as the age limit 65 is crossed by the strong generation born after World War
II.
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
2010)
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
2010)

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
are:
• Increasing number of aging “Baby Boomers”– their interest and desire for travel
opportunities that also meet their health needs is becoming a market force that greatly
influences the development of health spa and wellness market. These “new seniors” no
longer conform to the stereotype of an elderly stay-at–home. They are well educated,
independent, able to enjoy life on their own terms, eager to make choices, excited to
learn, living a fast-paced lifestyle, experiencing a sort of personal awakening. 28
• Fascination with fitness and alternative therapies and their use for promoting and
enhancing health and healing; 29 for healthy lifestyle education; for nutrition
counseling; for preventative medicine; for solving personal problems like stress or
depression; for holistic, naturopathic, alternative or eastern medicinal
practices/therapies. 30
24 Ibid.
25 European Health for All Database. Downloaded from: http://www.euro.who.int/hfadb (last accessed 7 March
2010)
26 Ibid.
27 Ibid.
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
2010)
29 Ross, K.: Health Tourism: An overview. In: HSMAI Marketing Review December 2001. Downloaded from:
www.hospatality/net.org
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
influence.
• 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
discovered.
• 1945 – 1989 – spas are nationalized (in 1945), more spas get under, changes in
financing system (state and labor union´s influence), most of the spa guests utilize spa
treatments as a part of complex spa care, changes in incoming spa guests´ structure
(most of them came from the socialist countries), high level of spa treatments,
problems in service quality, obsolete spa infrastructure, the average length of stay is
about 25 days, the remedial function of spas are preferred prior to other.
• After 1989 – privatization, direct influence of state failed, but continued in legislation,
quality and variety of services are improved, number of commercial and foreign
guests increased.
The International Spa Association (ISPA) defines spas as places devoted to overall well-being
through a variety of professional services that encourage the renewal of mind, body and
spirit.“ 32
ISPA presumes combined utilization of ten following healing elements: 33
31 Attl. P., Nejdl, K.: Turizmus I. VSH, Praha 2005, ISBN 80-86578-37-2, p. 75

1. Waters - the internal and external use of water in its many forms.
2. Nourishment - food, herbals, supplements and medicines.
3. Movement - vitality and energy through movement, exercise, stretching and fitness.
4. Touch - connectivity and communication embraced through touch, massage and
bodywork.
5. Integration - the personal and social relationship between mind, body, spirit and
environment.
6. Aesthetics - concept of beauty and how botanical agents relate to the biochemical
components of the body.
7. Environment - location, placement, weather patterns, water constitution, natural agents
and social responsibility.
8. Cultural Expression - the spiritual belief systems, the value of art and the scientific and
political view of the time.
9. Social Contribution - commerce, volunteer efforts, and intention as they relate to wellbeing.
10. Time, Space, Rhythms - the perception of space and time and its relationship to natural
cycles and rhythms.
Because of the different perception and different historic experience, spas are handed out by
ISPA into seven categories: 34
1. Club Spa - a facility whose primary purpose is fitness and which offers a variety of
professionally administered spa services on a day-use basis.
2. Cruise Ship Spa - a spa within a cruise ship providing professionally administered spa
services, fitness and wellness components, and spa cuisine menu choices.
3. Day Spa - a spa offering professionally administered spa services to clients on a day
use basis.
4. Destination Spa - a spa whose sole purpose is to provide guests with lifestyle choices
improvement, and health enhancement through professionally administered spa
services, physical fitness and exercise, educational programming, such as nutrition and
stress management and a sense of community through such features as on-site
accommodations. Spa cuisine is frequently exclusively served.
5. Medical Spa - a spa whose primary purpose is to provide comprehensive medical and
wellness care in an environment which integrates spa services, as well as conventional
and complementary therapies and treatments.
6. Mineral Springs Spa – a spa offering on-site natural mineral, thermal, or seawater
baths, which are used in professionally administered hydrotherapy treatments.
7. Resort/Hotel Spa - a spa within a resort/hotel that provides professionally administered
spa services, fitness and wellness components and spa cuisine menu choices.
The European Spa Association (ESPA) divides spas according naturally occurring local
remedies, which are the basis for differentiation between several types of spas and health
resorts such as:
32
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)
33
Ten Spa Domains. Downloaded from: http://www.experienceispa.com/education-resources/facts-andfigures/10-spa-domains/(last
accessed 7 March 2010)
34
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
2010)

• 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
Republic:
• Complex spa care - fully covered by health insurance companies (excluded travel
costs);
• 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
components:
• Investigation and treatment
• Accommodation
• Catering
• Cultural, sport and supplemental activity. 38
The health spa industry is perceived as an important branch of economic activities with long
history. It is a part of the traditional and successful economic activities with positive social,
health, economic, ecological and regional effects.
UNWTO stated spa care as one of the basic motivators in tourism, as it is defined as „the
activities of persons traveling to and staying in places outsider their usual environment for not
more than one consecutive year for lemure, business and other purposes” 39 , but there is still a
discussion among a number of medical doctors and tourism stakeholders in the Czech
Republic on relation and/or interconnection of tourism and health spa.
37 In 2008, as in the preceding years, the predominant part of health expenditure was financed by the system of
public health insurance that covered 76.4 % of the expenditure in the Czech Republic. The State and territorial
budgets covered 7.0 % of the total and private expenditure covered 16.6 %. The relative proportions of these
components remained roughly the same in recent years faster increase is only registered in private expenditure
consisting mainly of expenses of households. Total expenditure on health increased from 2007 by 20 710
mill.CZK and in 2008 their absolute value was 262.645 mill. CZK (i.e. 25.182 CZK per inhabitant). This total
expenditure on health represents 7.12 % of the GDP in 2008. Public expenditure, i.e., that of the public budgets
and of the public heath insurance system, was 219.119 mill. CZK, by 12.554 mill. CZK more than in the
preceding year. The average expenditure of the public health insurance system per 1 client was 19.353 CZK. In:
Czech Health Statistics. ÚZIS ČR 2009. ISSN 1210-9991, ISBN 978-80-7280-845-8
38 This indicator can be used only when the health spa guest employ all above mentioned services.
39 WTO Ottawa Conference on Travel and Tourism Statistsics, 1991. In: Collection of Tourism Expenditure
Statistics. Technical Manual No. 2. WTO, 1995 p. 1, ISBN 978-92-844-0106-2

There is a “rigid medical” approach, a very conservative and protective one which does not
tolerate the coexistence of different forms of health tourism and does not consider health spas
as a part of tourism.
The second, more open approach considers health spa as one of dynamically developing
forms of tourism.
Globalization creates a big pressure to health spa industry as well as the international
competition and the substitutes - there are about 850 spa companies in more than 500 biggest
spa places in Europe.
Czech health spas are visited by 600.000 guests every year. The rate of foreign guest to
residents in spa accommodation facilities was close to one to one in 2008 with a moderate
change for the benefit of residents in 2009 as can be seen from Table 3. About 50% of
international guests come from Germany the second biggest market is Russia, followed by
Austria, Slovakia, the USA, Poland and Israel (Table 3). 40 Guests coming from Germany,
Slovakia and some other countries are often taking advantage from Czech allowance spa care
as the health care system in their home countries allows them to travel for health spa care
abroad and it covers their medical treatments costs.
40 Lázeňský cestovní ruch – komparace zemí střední a východní Evropy. Downloaded from:
http://www.czechtourism.cz/files/statistiky/lazne.pdf (last accessed 7 March 2010)

Foreign guests at accommodation facilities (spa): by country
Table 3
Number of guests Index % % Average Number
2009/200 share share length of of nights
2 008 2 009 8 2008 2009 stay
Guests Total 674 313 647 568 96% 11.5 6 689 216
Residents 337 392 341 520 101% 50.03
%
52.74% 12.8 4 031 776
Foreign Guests 336 921 306 048 91% 49.97 47.26% 10.1 2 657 440
Total
%
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
4
Countries
Ukraine 7 893 6 456 82% 2.34% 2.11% 13.3 79 433
5 Austria 5 396 5 515 102% 1.60% 1.80% 6.9 32 294
6 Israel 4 339 4 466 103% 1.29% 1.46% 13.8 57 215
7 Other
European
Countries
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
1
0
Poland 3 301 3 012 91% 0.98% 0.98% 4.6 10 981
1
1
France 1 847 1 907 103% 0.55% 0.62% 4.5 6 666
1
2
Italy 1 474 1 802 122% 0.44% 0.59% 5.3 7 806
1
3
UK 1 692 1 592 94% 0.50% 0.52% 4.6 5 708
1 The
1 531 1 421 93% 0.45% 0.46% 6.8 8 225
4 Netherlands
1
5
Switzerland 1 246 1 252 100% 0.37% 0.41% 5.3 5 347
1
6
Belgium 741 1 124 152% 0.22% 0.37% 5.1 4 602
1
7
Sweden 878 1 081 123% 0.26% 0.35% 5.1 4 478
1
8
Hungary 1 252 1 081 86% 0.37% 0.35% 3.8 3 048
1
9
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
Stay
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
Guests
Nonresidents
Residents
Number of
Overnight
Stays
Nonresidents
Residents
1=2+3 2 3 4=5+6 5 6
2000 437 308 176 387 260 921 5 709 748 1 658 234 4 051 514
2001 435 200 203 166 232 034 5 983 085 2 028 945 3 954 140
2002 451 505 201 028 250 477 6 431 035 2 139 202 4 291 833
2003 450 346 202 126 248 220 6 509 168 2 198 472 4 310 696
2004 481 120 217 134 263 986 6 538 058 2 215 747 4 322 311
2005 497 248 234 141 263 107 6 557 320 2 336 223 4 221 097
2006 571 101 295 911 275 190 6 743 893 2 831 269 3 912 624
2007 650 667 317 016 333 651 7 163 718 2 904 912 4 258 806
2008 674 313 336 921 337 392 7 045 620 3 059 764 3 985 856
Source: Czech Health Statistics. ÚZIS ČR 2010. ISSN 1210-9991, ISBN 978-80-7280-845-8

Table 6 shows the number of guests in health spas according to costs reimbursement. It is
visible that the number of complex spa care guests as well as the allowance spa care guest is
decreasing for the benefit of commercial spa care guests in both groups – residents and nonresidents
as well.
Number of Guests in Health Spas According to Costs Reimbursement Table 6
Number
Guests
of
2004 2005 2006 2007 2008
Complex Spa
Care
112.670 105.324 94.429 92.605 91.488
Allowance
Spa Care
Commercial
19.147 18.253 18.572 15.708 15.149
Spa Care 45.282 55.853 66.688 91.896 112.987
(Residents)
Commercial
Spa
(Non-
Care
117.003 119.929 134.518 133.761 153.704
residents)
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
7
Country of
Origin
Age Structure in %
0 -14 15-29 30-44 45-59
60 and
over
Unlisted Total
Germany 0.22 1.29 6.58 21.25 68.72 1.94 100.00
Russia 1.25 0.83 18.67 50.62 17.01 11.62 100.00
Israel 0.00 5.63 8.45 39.44 46.48 0.00 100.00
Arabic
Countries
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
USA
Other
0.00 3.03 18.18 60.61 18.18 0.00 100.00
European
Countries
0.00 0.76 21.21 63.64 14.39 0.00 100.00
Other
Countries
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
being. 47
Wellness is a dynamically developing industry in the Czech Republic with start-up around
2000. There is no widely accepted definition of wellness and the way how it is perceived is
very different. There are three main views on wellness in the Czech Republic:
• Wellness is a heterogeneous element which does not come under spa care and had not
had to be a part of health spa facilities or of spa destinations.
• Wellness is an appropriate supplement to spa care which can under the correctly
defined condition be a part of spa destinations but not a part of health spa facilities
(some experts accept wellness as a part of health spa facilities).
• Wellness is a part of all health spa facilities, with no contradiction between spa care
and wellness.
43
Verschuren, F.: Spa Health and Wellness Tourism: A New Product Portfolio at the Canadian Tourism
Commission, Canadian Tourism Commission, Vancouver 2004.
44
Joppe, M.: The Impact of the Wellness Revolution on the Spa Industry. 2003
45
Adapted from: Cardinal, B. J., Krause, J. V.: Physical Fitness: The Hub of the Wellness Wheel. Dubuque:
Kendell Hunt Publishing 1989.
46
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
2010)
47
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
follows:
• The wellness facility is managed by a medical doctor;
• The medical doctor is at the disposal of the guests;
• The staff is qualified;
• Integrated concept;
• Stability of offer;
• High quality of equipment;
• Documented quality management. 48
Some experts define “wellness tourism” as a “the sum of all the relationships and phenomena
resulting from a journey and residence by people whose main motive is to preserve or
promote their health.” 49
Wellness tourism activities prevent illness and preserve, promote or enhance overall health
and well being of people and their desire to prevent problems so they stay well, both
physically and mentally.
Based on the above remarks, it can be stated that health spa and wellness are two different
products although there is a lot of overlap between them, especially in terms of their markets
and in terms of the range of services offered.
Tourists who are generally healthy are motivated to travel so that they can experience
therapies and activities that will promote, enhance, and otherwise maintain a sense of well
being. Tourists with various medical conditions are motivated to travel so that they can
experience therapies that will help to make them well or to improve their health.
To be able to consider complementary or competitive relation between health spa and
wellness in the Czech Republic, a field study took place in November 2009. The field study
comprised a survey consisting of in-depth face-to-face interviews of 25 health spa and
wellness managers and other stakeholders including 50 guests. The management has been
contacted individually. Interviewees were contacted during regular operation days. Each
interview took 25 minutes and was conducted in a structured fashion. Each of the topics was
introduced by an open-ended question.
Given the qualitative nature of most of the information gathered and the size of the sample,
the survey responses were not amenable to statistical analysis. The findings are, therefore,
generally qualitative and descriptive.
The main problem in the field of health spa and wellness coexistence, seen by interviewed
managers, is in perception of both by medical doctors managing health spas. Traditionally, a
health spa manager had to be an experienced medical doctor responsible for all parts of
nursing day.
48 Medical Wellness. Gemeinsame Erklärung bzw. Letter of Intent. Deutcher Heilbäderverband. Downloaded
from: http://www.deutscher-heilbaederverband.de/cms/pages/positionen/medical-wellness.php (last accessed 7
March 2010)
49 Iibid.

Today´s health spa hotels are mostly managed by managers graduated from business or
tourism schools but the investigation and treatment part of the hotel is managed by medical
doctors. Most of them represent the conservative approach on health spa and they do not
tolerate the coexistence of different forms of health tourism and do not consider health spas as
a part of tourism. Their view on wellness as a heterogeneous element which does not come
under spa care and had not had to be a part of health spa facilities or of spa destinations is at
the same time a very rigid one.
Managers, who consider health spa as one of the dynamically developing forms of tourism,
understand also the role of wellness as well as an appropriate supplement to spa care or even a
part of health spa facilities.
From the point of view of both approaches there is a difference among complex spa care
guests, allowance spa care guests and commercial spa care guests. The complex spa care
guests must fully regularize themselves to complex spa arrangement. The allowance spa care
guests have more free scope in the field of accommodation and catering, as well as cultural,
sport and other services. They can make changes in treatments with permission of the health
spa medical doctor. Commercial spa care guests are independent guests who have free scope
in the field of accommodation and catering, as well as cultural, sport and other services. All
changes in treatments must be discussed by a medical doctor.
Health spas managed by medical doctors are strongly oriented on particular components of
health spa care system and wellness components are incorporated into product offered to
guests as sport activities only. According to diagnosis guests always receive tailored treatment
with the possibility to order additional treatments on a commercial basis.
Managers, who consider health spa as one of dynamically developing forms of tourism,
understand also the role of wellness as an appropriate supplement to spa care or even a part of
health spa facilities. They are regularly innovating products offered to customers and looking
for new opportunities as wellness which they incorporate into their offer.
Such health spa facilities offer different types of massages (e. g. thai, reiki, chocolate, honey,
stone, and alike) meditation therapies, drum circles, beer or wine bath, salt caves, Nordic
walking, yoga, oxygen therapy, crymotherapy, Finish sauna, Russian bath, Turkish bath,
phototherapy, sound therapy, special food arrangement, possibilities to learn about nutrition
and healthy food preparation practices and alike.
Managers observe some trends in health spa which bring health spa close to wellness and can
be defined as follows:
• Shorter length of stay (the most common is a long weekend stay – 3 nights);
• Higher number of frequent visitors (visiting a spa 3 or more time per year);
• Increasing number of guest from 25 – 40 age group;
• Demand for special packages (Eastern, Christmas, New Years Eve, etc.);
• Demand for special events in spas (wedding party, birthday party, etc.);
• Demand for special targeting packages (weight-loosing, anti-stress, managerial,
women, etc.);
• Demand for special/exotic treatments (massages, catering, training, etc.);
• Demand for additional services e. g. cosmetics, manicure, pedicure, visage,
hairdresser;

• Demand for some plastic surgery treatments e. g. botulotoxine, hyalurone acid, laser
therapies, chemical scrubbing, etc.
Based on of visitor survey (commercial health spa care guest have been asked) the following
results can be presented:
• 84.2 % of guest were satisfied with the quality of accommodation services;
• Satisfaction with quality of catering services was pointed out by 81.5 % of guests;
• 78.3 % of guests were comfortable with medical treatment;
• 82.6 % of guest were happy with quality of professional medical staff;
• The health spa environment was satisfactory for 82.7 % of guests;
• 82.9 % of guests were pleased by service staff quality;
• Cultural offer was satisfactory for 58.9% of guests;
• Sport offer was treated as satisfactory by 48.8 % of guests;
• 63.8 % of guests consider shopping facilities as satisfactory;
• Tourist information services were satisfactory for 69.4 % of guests;
• Tourists attractions were consider by 69.1 % of guests as satisfactory;
• Supplementary services were perceived by 59.8 % guest as satisfactory;
• 72.7 % of health spa guests were happy with services as a whole.
To the most frequently indicated remarks belong those on sport, culture, information,
attraction, shopping, and supplementary services offer. Today´s guest visiting a health spa
want to combine spa treatment, fun, exercise, a healthy and balanced diet, education on
managing stress, education on relaxing methods, rejuvenation, image and visage counseling,
personal couching, etc.
Based on the results of exploratory research and well-founded with showed statistics it can be
stated that there is no competition between health spas and wellness in the Czech Republic.
Wellness is a complement to health spa and in some ways both blend together.
Through industry research ISPA has pinpointed the following spa trends for 2010: 50
• Social Media – Twitter and Facebook are used by health spa and wellness industries to
attract visitors.
• Customer Service - Consumers are more aware of every coin spent, and with that
comes higher expectations on the level of service they receive. Spas will respond by
providing exceptional service and making each visits a customized experience for the
guest. Implementation of customer feedback mechanisms and customer loyalty
programs should help to win frequent visitors.
• Spa Sampling Menu - Mini services at lower price points are popular ways to get a
taste of treatments offered at health spas and wellness as well.
• Preventive Care - According to the World Health Organization, by 2020 the top five
diseases will all have the underlying contributing factor of stress. Spa treatments like
massage, acupuncture and meditation have been proven to aid in stress reduction and
recovery time for pre and post-op patients.
• Spa Partnerships - Spas are becoming more accessible through partnerships with
established franchises, hotels and local businesses. Popular partnerships include:
developing wellness programs at local hospitals, accommodating guests at local hotels
50 2010 International SPA Association Trend Watch. 11/17/2009. Downloaded from:
http://www.ispaconference.com/articles/index.cfm?action=view&articleID=248&menuID=75 (last accessed 7
March 2010)

without spa facilities and service discount trades between spas and local business
employees.
• 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.
Conclusion
The Czech Republic combines a number of important attributes as a health spa destination
with a long lasting tradition of health spa culture. More than 30 health spas including climatic
spas, healing hot and cold springs, healing torf and mud - all for treatment and recuperation
and a high standard of services at cost–effective rates makes the Czech Republic an attractive
destination for health spa visitors.
Wellness as a part of tourism industry has a shorter tradition in the Czech Republic but
develops fast. It is an important supplement to health spas with a wide spectrum of treatments
and services offered to visitors often making each visit a customized experience for them.
The Czech health spa industry is an important part of Czech tourism industry with a wide
potential of development including wellness as a complement to health spa care. Relaxation
and stress reduction, healthy lifestyle, self-responsibility for health are reasons why people
visit health spas and wellness. Health spa and wellness is not a luxury; it is a necessity to a
healthy lifestyle.
Today´s health spa and wellness visitor seeks to look and feel better; to lose weight; to slow
the effects of aging; to relieve pain or discomfort; to manage stress or depression; to improve
fitness level; to experience holistic, naturopathic, alternative, complementary or eastern
medicinal practices and/or therapies. Treatments like massage, acupuncture and meditation
often belong to standard spa and wellness offers.
Health and wellness are all-season activities for visitors. They are booking their stay during
all seasons including off seasons which greatly contributes to making the health spa and
wellness industry available any time of year.
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0106-2

RURAL TOURISM, A FORM OF WELLBEING TOURISM?
Raija Komppula, professor
Juho Pesonen, researcher
Centre for Tourism Studies
University of Eastern Finland
P.O.Box 86
FI-57101 SAVONLINNA
raija.komppula@uef.fi
juho.pesonen@uef.fi
Abstract
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
segmentation
Introduction
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
Frochot (2005).
According to Komppula (2005) also Finnish rural tourists expect to have a peaceful, quiet and
rush-free country holiday. For Finns, nature, particularly lake and forest scenery, is a selfevident
part of a rural vacation. For both target groups, families and those travelling with
other adults, the destination should be such that it is possible, on the one hand, to enjoy peace
and quiet on one’s own, and, on the other hand, to have interaction with the other visitors. The
choice of rural tourism as the type of holiday seemed to be related to the respondent’s own
background: the countryside was felt to be part of one’s own roots and the countryside
brought back positive childhood memories in the respondents (Komppula 2005). Zamora et
al. 2004 also propose that the rural origin of a tourist has a positive effect on his willingness to
pay for a rural holiday, despite the current settlement in the city.

Method and data
In several studies these factors have also been identified as motivators of rural tourists. In our
empirical study the aim is to find out if it is possible to distinguish a special wellbeing
segment among customers interested in rural tourism in Finland. The target group of the study
was potential rural tourism customers in Finland, which were supposed to be found among
visitors of the website of Finnish Cottage Holidays, the oldest, biggest and best known
intermediary organisation on rural tourism services in Finland.
Data were collected on the Finnish Cottage Holidays website 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.
Results
Different cluster solutions using k-means clustering were used to find the correct number of
segments. Trials with two to seven clusters were executed. Final cluster solution of four
clusters proved to be the most meaningful based on the results of the cluster formation and
discriminant analyses.
Results of the discriminant analysis reveal that the travel motivations I would like to relax
away from the ordinary, I would have a feeling of romance and I could visit places my family
comes from have most discriminating power between all clusters (in descending order). Three
discriminant functions were generated. Function 1 explains 72.3 % of variance with

eigenvalue 3.668, function 2 explains 18.2 % of variance with eigenvalue 0.924 and function
3 explains 9.5 % of variance with eigenvalue 0.481. Based on the classification matrix, 95.0
% of all cases are correctly classified.
The results of the cluster analysis are presented in Table 1. Two motivations, I would have a
feeling like I was being pampered and I would have an opportunity to be physically active do
not differ statistically across clusters. The other wellbeing motivations however do differ.
Cluster B clearly values wellbeing related motivations more than other segments, not
including statements I would have a chance to meet interesting people, which segment A
values more than any other segment. Member of clusters C and D also think wellbeing related
motivations to be important, but not as much as respondents in cluster B, which is the third
biggest segment, containing 22.6 % of all respondents.
Table 1. Cluster analysis results
Travel motivation Overall
mean
A
(N=213)
B
(N=164)
2.256 A,C,
D
Cluster F-value
C
(N=148
)
1.549 A,
D
D
(N=202
)
That I would have a
hassle-free vacation
1.204 0.402
0.891 A
92.783
That I would like to
escape from a busy
everyday life
1.143 0.505
2.281 A,C,
D
1.401 A,
D 0.921 A That I would have a
115.21
2
feeling like I was being
pampered
0.081 0.148 -0.079 0.164 0.079 1.090
That I would get
refreshed
1.400 0.792
2.268 A,C,
D
1.509 A,
D 1.253 A 106.18
0
That I would have an
opportunity for physical
rest
0.979 0.397
1.860 A,C,
D
1.259 A,
That I would have an
D 0.673 56.978
opportunity to be
physically active
-0.121 -0.274 0.049 -0.045 -0.153 2.153
That I would like to have
a sense of comfort
1.369 0.674
2.323
A,C,D
1.509
A,D 1.222 A 171.67
9
That I would like to relax
away from the ordinary
1.598 0.862
2.6463 A,
C,D
1.820 A,
D 1.362 A 253.10
6
That I would have a
chance to meet
interesting people
-0.425
0.482 B,C,
D -1.366 -0.944 B
-
0.238 B,
C
78.848
Superscript in the mean value of a cluster denotes those clusters that have significantly lower
mean score
Profile of rural wellbeing tourists is presented in Table 2. A typical representative of the
segment is a female in the age of 45-54 with a college level degree. She has lived her
childhood in a rural area. The annual income of her household is 30 000- 45000 euro, which
can be regarded as an intermediate level. She travels with her spouse less than once a year to
a rural destination.

Table 2. Profile of wellbeing segment
Age Who would you travel with?
Under 25 5 (3.4%)
Spouse 67
(40.9%)
25-34 33 (22.4%)
Family with children under 12
years
32
(19.5%)
35-44 39 (26.5%)
Family with children in several age
groups
29
(17.7%)
45-54 46 (31.3%)
Friends 18
(11.0%)
55-64 21 (14.3%) Alone 7 (4.3%)
65 or older 3 (2.0%) Other 11 (6.7%)
Education
Number of annual visits to rural
holiday destinations
University degree 40 (24.8%)
Less than once a year 68
(41.5%)
Technical / Trade school /
Vocational
94 (58.4%)
Once a year 58
(35.4%)
Upper secondary school 11 (6.8%)
Two or three times a year 36
(22.0%)
Elementary school 16 (9.9%) More than three times a year 2 (1.2%)
Annual income of the
houshold
Rural origins
Less than 15 000 € 8 (5.1%)
I lived during my childhood and/or
adolescence in a rural area
I did not live during my
85
(52.8%)
15 000 – 29 999 € 39 (24.7%)
childhood/adolescence in a rural
area, but I visited rural areas often
to see my relatives
52
(32.3%)
30 000 – 44 999 € 40 (25.3%) I have no roots in the countryside
24
(14.9%)
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
146
(90.7%)
At least 90 000 € 5 (3.2%)
Discussion
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
activities.
Bushell and Sheldon (2009) call for further research on motivations behind wellness tourism.
They distinguish between luxury forms of wellness tourism and more holistic attempts to
create wellness for the individual. (p. 221). We argue that there are several sub segments in
wellness as well as in rural tourism. We assume that people seeking to escape and relax in
luxury are a separate segment from those pampering themselves with lazy holiday in a rural
environment. They may be same people but behave in a different way depending on their life
situation, and other internal and external situational factors.
Both wellness and rural tourism concepts clearly mean different things in different contexts
and countries. Nevertheless, one conclusion can be drawn from this study: rush free rural
settings with nature and beautiful landscapes offer an ideal environment for a wellbeing
holiday motivated by search for relaxation, comfort and escape, not including any material
luxurious elements. Further research is needed on the characteristics of the segment as well as
their pull motivations.
In the end it can be said that rural tourism indeed is a form of wellbeing tourism, but not for
everyone. In this study one of the four segments, namely segment B, clearly values wellbeing
related motivations more than any other segment. On the other hand members of an another
segment, segment A, do not go for a rural holiday in sake of their wellbeing but are motivated
by other factors not examined in this study.
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Predicting factors of tourists’ interest towards wellbeing tourism
holidays – A Finnish case
Henna Konu,
University of Eastern Finland,
Centre for Tourism Studies
P.O.Box 86,
FI-57101 Savonlinna, FINLAND
henna.konu@uef.fi
Tommi Laukkanen,
University of Eastern Finland,
Department of Business
P.O. Box 111,
FI-80101 Joensuu, FINLAND
tommi.laukkanen@uef.fi
Abstract
Many studies about motivations and profiles of health and wellbeing tourists have focused on
different sub-sectors of health, wellness and wellbeing tourism but more general research,
concerning wellbeing tourists, has been quite rare. This study aims to investigate tourist
motivations as predictors of tourists’ interests in wellbeing tourism holidays as opposed to
tourists that are not interested in wellbeing holidays.
Data is collected in Finnish Travel Fair in January 2009. In total 406 effective responses were
used. To evaluate the predictive influence of push and pull factors, the data was analyzed by
using logistic regression analysis with backward stepwise method.
Results show that the previous experience of wellbeing holidays, number of annual holiday
trips, together with pull factors “water park and/or spa”, “natural sights” and “accessibility in
destination”, and push factors “refreshing myself”, “experiencing fashionable/trendy places”
and “aesthetic experiences” significantly increase the odds of tourists’ interest to make
wellbeing holidays.
Keywords: tourist motivations, push and pull factors, previous travel experience,
wellbeing/wellness tourism, Finland
Introduction
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
4,78).
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
Experiences
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.
As Table 1 show, the data is female dominated with 65 percent of females and 35 percent of
males, well educated, and dominated by singles or couples without children. It seems that the
respondents travel a lot, which is logical in view of the place of data collection. However,
majority of the respondents have not been on a wellbeing holiday but 70 percent of them
appear to be interested in taking part on a wellbeing holiday.
Table 1. Sample profile.
Frequency
Frequency
(%)
(%)
Gender Profession
Male 143 (35.2) Leading position 37 (9.1)
Female 263 (64.8) Official 146 (36.0)
Education Manual worker 79 (19.5)
Comprehensive school 28 (6.9) Entrepreneur 27 (6.7)
Matriculation 69 (17.0) Unemployed 7 (1.7)
Vocational education 91 (22.4) Retired 33 (8.1)
Polytechnic degree 95 (23.4) Student 69 (17.0)
University degree 121 (29.8) Other 8 (2.0)
Other 2 (0.5)
Phase of live
Annual gross
(household)
income
I live alone 118 (29.1) < 15.000 € 57 (14.0)
Couple, no children 103 (25.4) 15.000-29.999 € 75 (18.5)
Children < 7 yr. 25 (6.2) 30.000-44.999 € 81 (20.0)
Children 7-15 yr. 40 (9.9) 45.000-59.999 € 70 (17.2)
Children > 15 yr. 24 (5.9) 60.000-74.999 € 52 (12.8)
Couple, children moved 77 (19.0)
away
75.000-89.999 € 41 (10.1)
Other 19 (4.7) ≥ 90.000 € 30 (7.4)
Short (≤3d) holidays during the past 12 Have you ever been on a wellbeing
months
holiday?
None 15 (3.7) No 226 (55.7)

One 54 (13.3) Yes 180 (44.3)
2-4 216 (53.2)
> 4 121 (29.8)
Long (>3d) holidays during the past 12
months
Are you interested in attending a wellbeing
holiday?
None 51 (12.6) No / unsure 122 (30.0)
One 110 (27.1) Yes 284 (70.0)
2-4 194 (47.8)
> 4 51 (12.6)
Results
In order to test how push and pull variables, demographics and travelling behaviour influence
on tourists’ interests in conducting wellbeing holidays, we inputted 32 push factor variables,
20 pull factor variables, gender, education, profession, phase of life, annual gross income of
the household, the number of short and long holidays conducted during the past 12 months,
and past wellbeing holiday experience in the model as independent variables. The push and
pull factors were measured in a five-point Likert scale whereas demographics and travel
behaviour variables were categorical.
The results show that customers’ interest in attending a wellbeing holiday can be predicted
with five push factors and five pull factors, and in addition with all the three travel behaviour
factors inputted in the model (Table 2). However, it seems that demographic variables do not
have as strong explanatory power as the above mentioned variables given that the iteration
process excluded all the demographic variables from the model.
The Wald statistic is commonly used to test the significance of the individual coefficient for
each independent variable in a logistic regression model (Hair et al., 1998). In this case the
Wald statistic shows how well the variable explains the difference between the groups of
respondents. The Wald statistics show that previous experience of a wellbeing holiday (i.e.
has the respondent been on a wellbeing holiday) has the strongest effect in the model,
followed by two Pull Factors namely “Water park and/or spa” and “The destination is childfriendly”.
However, while previous experience and water park/spa have positive effect on the
interest toward a wellbeing holiday, the negative beta (β) value of child-friendly destination
indicates that as the importance of child-friendliness of the destination increases the interest in
wellbeing holidays decreases. This is the case also with another Pull Factor namely
“Possibility for packaged services” and two Push Factors, “Viewing the scenery” and
“Participating physical activities”. The most significant Push Factor motivating customers’
interest in attending a wellbeing holiday is the ability to refresh.
Taking a closer look on the Travel Behaviour variables, the odds ratio [Exp(B)] indicates that
the odds of those having experience on a wellbeing holiday being interested in attending a
wellbeing holiday are 5,5 times greater than the odds of those never been on a wellbeing
holiday. Moreover, the likelihood to be interested in a wellbeing holiday increases
significantly as the number of annual holiday trips increases. This is the case especially in
short holidays as the likelihood of being interested in a wellbeing holiday among those who
have made at least two short (≤ 3 days) holiday trips during the past 12 months is over 9 times
greater than the odds of those who have not made a single holiday during the past 12 months.
However, it seems that those who have made 2-4 long (> 3 days) holidays during the past 12
months are less likely to be interested in a wellbeing holiday than those who have not made

any long holiday trips during this period of time. The case is the opposite among those who
have made one or more than 4 holiday trips during the past 12 months.
Table 2: Logistic regression results
β S.E. Wald Sig. Exp(β)
Constant
Push Factors
-
5.895
1.458 16.348 p3d) holidays during the past 12 - 0.427 0.955 p=0.328 0.659
months (2-4)
0.417
Long (>3d) holidays during the past 12
months (>4)
0.580 0.636 0.833 p=0.361 1.787
Note: -2 Log likelihood=368.784; Cox & Snell R²=0.270; Nagelkerke R²=0.382;
Classification Improvement (%) = 70.0 → 77.6
*Ref. level

Discussions and Conclusions
The aim of the study was to find out what factors are the best predictors of tourists’ interest to
make wellbeing holidays. The study shows that there are only a small and distinct variety of
factors which can be proved as predictors of tourists’ interest in wellbeing holidays. The
previous experience of wellbeing holidays had the strongest effect as predictive factor. Also
the other previous travel experience affected positively to interest to make wellbeing holidays.
It can be concluded that the tourists that are interested to make wellbeing holidays are rather
experienced travellers.
Results show that the most important predictor of push factors for wellbeing trips is refreshing
(which according to Pearce (2005) belongs to the most important travel motives). This
supports also the findings of Mak et al. (2009) and Lehto et al. (2006). In addition, also less
important motives (see Pearce 2005) such as experiencing fashionable/trendy places and
aesthetic experiences affected positively to odds of the interest to make wellbeing holidays. It
seems that wellbeing and wellness destinations are seen as fashionable or trendy places to
visit. In contrast, two push factors lower the odds: viewing the scenery, and participating
physical activities. It is little surprising that the participating physical activities had a negative
effect. This is probably due that refreshing is seen to be accomplished by other ways than by
participating physical activities (cf. to the top five motivations Mak et al. 2009 found in their
study).
Pull factors that have positive effect on odds to interest to make wellbeing holidays were
“water park and/or spa”, “natural sights” and “accessibility in the destination”. The result is
supported by the studies which have shown the importance of nature environment in
wellbeing and wellness tourism. Accessibility in the destination seemed to be important too.
This will probably be one central issue in future as people are travelling also older (e.g. baby
boomers) and may have some disabilities needing special attention or arrangements.
Wellbeing and wellness destinations should thus consider accessibility, for instance, in their
infrastructure (spa and wellness facilities, wider walking paths etc.), information (clearly
marked signs etc.) and also in marketing (e.g. possibility get bigger letters on the website of
the destination/business). All in all, spa facilities as a pull factor had the most positive
influence to the odds. Two pull factors affected negatively to odds to interest to make
wellbeing holidays. These were “destination is child-friendly” and “possibility for packaged
services”. This shows that tourists that are interested in wellbeing holidays do not necessarily
want to travel places that are meant for children. One reason for this is that respondents that
were interested in wellbeing holiday were most likely going to make wellbeing holiday with
their spouse or with friends. In addition, it seems that tourists interested in wellbeing holidays
are interested individual services/wellbeing programmes as they are not interested in ready
made service packages.
It was interesting to find out that socio-demographic factors did not have statistically
significant role in predicting the tourists’ interest to make wellbeing holidays. This is
supporting the view that in the fragmented postmodern markets demographic factors can’t
reliably be used to explain differences between diverse market segments (Firaz et al. 1995,
Firaz & Shultz 1997). However, motivations, attitudes and other psychographical factors are
becoming and have become more important factors when explaining how segments differ
from each other (see. e.g. Cova & Cova 2002).
There are some similarities in the importance of wellbeing tourism motivation factors of this
study compared to wellbeing and wellness studies conducted in Asia and North America. It

seems that the internal motivations (push factors) of wellbeing tourism are rather same in
different parts of world (e.g. relaxation and rejuvenation). There was no possibility to
compare the pull factors of this study to other studies as the authors have no knowledge if the
pull factors of wellbeing tourism have previously been studied. The literature review showed
that there are different motivation batteries and statements used in wellbeing and wellness
studies, and many of them are connected to some particular subsector of wellness tourism, are
focused on push factors or are formed just for the particular study implemented. It would be
important to develop a scale (including push and pull factors) that could be used in
international studies and wider in wellness and wellbeing tourism – not just in some
subsector.
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Sand, Surf, Spa and Spirituality? Examination of a Scoping Study
of Medical and Wellness Tourism in Australia
Jennifer Laing,
Tourism Research Unit, Monash University*
Jennifer.laing@buseco.monash.edu.au
Cornelia Voigt,
School of Management, University of South Australia
Meredith Wray,
School of Tourism and Hospitality Management, Southern Cross University
Graham Brown,
School of Management, University of South Australia
Betty Weiler,
Tourism Research Unit, Monash University
Gary Howat,
School of Management, University of South Australia
Richard Trembath,
School of Management, University of South Australia
Abstract
The strong growth of medical and wellness tourism around the globe is the result of a number
of factors, such as the desire of many travellers to try new experiences and escape from
increasingly busy lives, the rising health costs in the developed world and the number and
diversity of medical and wellness tourism products now available. Australia is no exception to
this trend, with the realisation that there is great potential for promoting the destination around
the medical and wellness tourist experience or as a supplement to the traditional attractions of
the Outback, the Reef and food and wine. However, the paucity of research that currently
exists in relation to this industry needs to be addressed, if full advantage is to be taken of this
worldwide growth. To this end, a scoping study of Australian medical and wellness tourism
was commissioned by the Sustainable Tourism Cooperative Research Centre, to analyse the
current state of play and identify future research needs requiring more in-depth investigation.
A secondary aim was to compare Australia’s current offerings with international examples.
Key findings of this study include identification of the broad range of Australian medical and
wellness tourism products in existence, exploration of the potential of Australia to provide
niche medical tourism offerings, and identification of key success factors and barriers for the
Australian medical and wellness and medical tourism industries. The paper concludes by
suggesting some future research avenues.
Introduction
Australia has traditionally positioned itself as a destination based on natural attractions such
as the Outback, Uluru, and the Great Barrier Reef, as well as more the recent highlighting of
its lifestyle and culture to potential international visitors (Craik, 2001). In the wake of a global
growth in medical and wellness tourism products and services, there is interest in exploring
the potential for Australia to promote health and wellness tourism to inbound tourists, as an
element of a suite of product offerings. These forms of tourism might be argued to be
complementary to the image of Australia as a healthy destination, offering a relaxed lifestyle
amid natural beauty (Ross, 1993).

While wellness tourism in Australia is reasonably well-developed, with the number of spas
growing by 129 percent since 2002 (Intelligent Spas, 2008a, 2008b) and at least 10-12 percent
of Australians having been to a destination spa or lifestyle resort in 2007 (Research
International, 2009), Australia has yet to develop a niche in the lucrative medical tourism
market. There have been calls for Australia to remedy this state of affairs (ABC, 2008; ATEC,
2008). Reasons given for Australia to become more involved in offering medical tourism
services to international visitors include: (1) the fact that there is a successful model to be
followed in the $10 billion Australian educational tourism industry; (2) excess capacity in our
private health system, which could be utilised by international medical tourists, leading to a
reduction in fees and private health fund costs for Australians; (3) the ageing profile of key
international visitor markets; (4) Australia’s existing tourism infrastructure and strong brand
image as a quality tourist destination; (5) the quality and high standard of Australian medical
care; (6) Australia’s world-class reputation in a number of niche medical fields such as
fertility treatment, particularly IVF, and heart surgery; (7) the comparatively low-cost of
medical treatment compared to major markets such as the United States, even with an
unfavourable exchange rate and (8) cultural similarities and ties with the U.S. and Asia
(Australia Health Tourism, 2009; Hingerty, Woodbridge & Wilson, 2008; Jones, Lang,
LaSalle, 2008; Towart, 2008). One of the barriers to development of this market is however
the lack of research about the potential for Australia to develop medical tourism services.
Even the strongly-growing Australian wellness tourism market has yet to be examined in
detail from a research perspective (Voigt, 2008; Voigt et al., in press).
To this end, a scoping study of Australian medical and wellness tourism was commissioned
by the Sustainable Tourism Cooperative Research Centre, to analyse the current state of play
and identify future research needs. This paper provides an overview of the findings of this
scoping study. It commences with a brief overview of the literature, including definitions and
the historical development of medical and wellness tourism in Australia, followed by a market
and industry analysis. This paper concludes by suggesting some future research avenues.
Literature Review
There is a lack of consistency in the definitions of wellness and medical tourism across the
literature and their link with health tourism. It would appear however that health tourism is
the overarching term used to describe both medical tourism and wellness tourism (Müller &
Lanz Kaufmann, 2001; Smith & Puczkó, 2008). In this study, we focus on medical tourism
and wellness tourism as two distinct categories of health tourism, both of which are of interest
to the Australian tourism industry. The concept of wellness is defined as ‘a positive,
psychological state of well-being which is the result of practising a wellness lifestyle based on
the belief in self-responsibility for one’s own health and well-feeling’ (Voigt et al., in press).
Wellness tourism is defined as ‘the sum of all the relationships resulting from a journey by
people whose primary motive is to maintain or promote their health and well-being and who
stay at least one night at a facility that is specifically designed to enable and enhance people’s
physical, psychological, spiritual and/or social well-being’ (c.f. Voigt, 2008). Wellness tourist
experiences can be undertaken at three types of facilities – spas, lifestyle resorts and spiritual
retreats (Voigt, 2008). While research has been carried out into the beauty spa sector (Mak,
Wong & Chang, 2009; Spivack, 1998; Henderson, 2003), there has been little research to date
on the lifestyle resort and spiritual retreat, including the type of tourist that may seek out these
experiences.
Health-related tourism has its roots in ancient times, with travel to hot springs and baths,
sacred sites or places enjoying more favourable climatic conditions (Douglas, 2001). The

Grand Tour across Europe saw the rise of interest in ‘taking the waters’ at thermal or mineral
spas (Aron, 1999; Lempa, 2008). In Australia, this trend resulted in the development of baths
and spa facilities by European immigrants during the nineteenth century, in places such as
Daylesford and Hepburn Springs in Victoria (Gervasoni, 2005). This region in Victoria’s
Central Highlands is known as ‘Spa Country’ and contains over 80% of Australia’s mineral
water reserves. While there was a decline in the fashion for spas and accordingly diminishing
interest in visiting spas over much of the twentieth century, the 1980’s saw a rejuvenation of
the industry in Daylesford, assisted by growing government efforts to promote the region as a
spa destination and an escalating array of wellness tourism products, including beauty spas,
health and yoga retreats and spiritual services such as tarot readings and reflexology
(Lawrence & Buultjens, 2009; Voigt et al., in press). Its recent revival and growth can also be
partly attributed to societal concerns about mitigating stress and burnout and an interest in
alternative health therapies. Most of these visitors are daytrippers or domestic tourists. In the
year 2008, the Daylesford and Hepburn Springs region attracted an estimated 234,000
domestic overnight visitors and 520,000 day visitors. International visitation to the destination
was estimated at 4,651 visitors (Tourism Research Australia 2009). Other destinations around
Australia that have focused on wellness as a source of competitive advantage include Palm
Cove in Queensland (Scott & Harrison, 2006) and the Mornington Peninsula in Victoria
(Laing, 2009). Palm Cove offers an up-market spa experience, while the Peninsula markets its
natural hot springs to visitors. The Peninsula Hot Springs operation opened in 2005 and
provides visitors with two sources of natural mineral water for bathing, together with an
ancillary facility for beauty treatments, many of which incorporate indigenous healing
techniques or use products that are based on local and natural ingredients (Laing, 2009).
Despite the fact that Australia has experienced an increase in health-related tourism products
and services during the late twentieth and early twenty-first centuries, very little is known
about the structure of the market from both a supply and a demand perspective, as well as an
understanding of future needs to underpin strategic planning and development.
Medical tourism is also an under-researched phenomenon (Connell, 2006a; 2006b),
particularly from the demand side. From an Australian perspective, it could be argued that
travel for medical reasons has a long history. Strang (2005, p. 107) refers to Kowanyama
Aboriginal sacred sites associated with water on the Cape York Peninsula of Australia, where
women would travel to a particular water source in the belief that ‘spirit children generated by
the ancestral forces held within the landscape [would] ‘jump up’ from the water and enliven
the foetus in a woman’s womb’. In this study, however, we focus on international travel for
medical purposes, rather than domestic travel for medical purposes (see Abdullah and Ng,
2006 and Garg, 2008). Medical tourism is thus defined as ‘the sum of all the relationships and
phenomena resulting from a journey by people whose primary motive is to treat or cure a
medical condition by taking advantage of medical intervention services away from their usual
place of residence, while typically combining this journey with a vacation or touristic
elements in the conventional sense’ (Voigt et al., in press). Few tailored products or packages
are available to international medical tourists wishing to avail themselves of medical
treatment in Australia, although this has changed with the recent opening of the Cairns
Fertility Clinic in October 2009.
The Clinic is a purpose-built facility in central Cairns that incorporates a two theatre day
hospital, pathology and ultrasound services, a scientific laboratory, medical consulting suites,
allied health services such as acupuncture, and massages, on-site serviced apartments, a day
spa, retail outlets, and a restaurant and deli (Yek, 2009). The second theatre will be available
to local surgeons, adding to the medical facilities that are available to local residents in

Cairns, which has been suffering from a shortage of operating theatres and is expected to
experience a 21% growth in its population by 2021. In addition to IVF services, patients will
be able to access medical services such as cosmetic surgery, ophthalmology, urology,
gynaecology and general surgery through the day hospital. This will provide holistic and
personalised services in a discreet and comfortable environment (Yek, 2009). The destination
was chosen in part for the broad range of activities and attractions available, including
proximity to the Great Barrier Reef, and the relaxed tropical climate and lifestyle, given the
role stress plays in the outcome of IVF treatment (Voigt et al., in press). The opportunities
afforded by this kind of facility to foster medical tourism in Australia require further
examination (Voigt et al., in press), including the role played by location and climate and the
importance of leveraging off a prominent field of Australian medical expertise – IVF and
reproductive services.
Methods
The study involved a literature review, stakeholder interviews, analysis of secondary data, a
survey of medical and wellness tourism providers and in-depth case studies of (1) medical
tourism, (2) destination development, focusing on two Australian destinations closely
associated with medical and wellness tourism (Daylesford/Hepburn Springs, Byron Bay) and
an emerging destination seeking to develop and expand current product offerings (Margaret
River), and (3) the most successful wellness tourism brand in Australia – the Golden Door.
This paper focuses on the interview and secondary data.
Stakeholder Interviews
Long interviews were conducted with stakeholders, being individuals or representatives of
organisations that are ‘interested in or affected by’ wellness and medical tourism, such that
they had a ‘legitimate interest’ in the outcome of the study (Freeman, 1984; Sautter & Reisen,
1999). Interviews were conducted with representatives of 18 stakeholder organisations, who
were selected on the basis of a set of criteria developed by the project team. All but one of the
13 criteria was satisfied by at least one stakeholder. The criteria for selection of stakeholders
is detailed in Table 1:
Interviews were semi-structured and ranged between 30 minutes and 1 hour. They took place
in a location of the participant’s choosing – normally a local cafe or the participant’s
workplace. This ensured a casual atmosphere that encouraged participants to feel relaxed and
thus made the interviews potentially less intrusive (Richards, 2005). All interviews were
recorded and later transcribed. Identities of participants were de-identified for the purposes of
confidentiality.

Table 1: Medical and Wellness Tourism Stakeholders Interviewed
Criteria Description
1 Government - (F) Federal Government, (S) State Government or (L) Local
Government.– F/S/L
2 Medical/Lifestyle Retreat
3 Tourist Attraction focused on medical and wellness tourism (i.e. hot springs
facility)
4 Tourist Attraction associated with medical and wellness tourism activity (i.e.
winery with spa attached)
5 Accommodation provider offering spa facilities
6 Spiritual retreat
7 Commercial business associated with medical and wellness tourism (i.e.
specialist travel agent, spa treatments and products, spa brand, industry
magazine)
8 Medical and wellness tourism industry association
9 Medical tourism provider
10 Commercial business associated with medical tourism (i.e. specialist travel
agent, industry magazine)
11 Facility offering medical tourism services (i.e. hospital)
12 University offering courses on medical and wellness tourism/medical
tourism/wellbeing
13 Destination development organisation
Analysis of Secondary Data
The interview data was supplemented by an analysis of secondary data, encompassing: (1)
International Visitor Survey (IVS) (Tourism Research Australia, 2009b); (2) National Visitor
Survey (NVS) (Tourism Research Australia, 2009c); (3) Assorted results from the Holiday
Tracking Survey (HTS) (Roy Morgan Research, 2009); (4) The ISPA 2008 Global Spa
Consumer Study (Research International, 2009); (5) The Global Spa Economy (Global Spa
Summit, 2008); (6) Assorted results published by the market research company Intelligent
Spas (Intelligent Spas, 2006, 2008a, 2008b); and (7) Medical Tourism: Consumers in Search
of Value (Deloitte, 2008).
Results
This section of the paper provides a market and industry analysis and discusses potential areas
for future research.
Market Analysis - Medical Tourism
Australia currently offers very little in the way of targeted medical tourism services, although
the NVS, the most conservative estimate, suggests that over a three year period 2006 – 2008
there was an average of 1.04 million domestic overnight trips per annum that were health
related, while the IVS provides an estimate of 7,000 inbound trips per annum on average over
this period which were for medical reasons. It was suggested by one participant that the
market potential for medical tourism could be massive in Australia:
I don’t know of another industrial opportunity in Australia that could provide $7
billion to the GDP, if we took a two to three per cent share of an Asian corridor stake
in a market. That’s data that’s 12, 18 months old now, and the game has moved on

significantly from there, so if the market’s double the size, the opportunity [could be
also].
Some of the potential opportunities for developing this market, identified in the stakeholder
interviews, include focusing on niche medical strengths such as fertility treatments, bariatics
(lapband surgery) and cardiology. This is the approach adopted by the Cairns Fertility Clinic,
with its IVF services. Australia’s quality medical care extends ‘up and down stream’,
including services such as pathology, radiology and physiotherapy (Towart, 2008).
Other important success factors identified through the stakeholder interviews include
developing purpose-built private facilities and infrastructure, such as the Cairns Fertility
Clinic, and promoting the quality, rigorous standards and patient-focus of the Australian
health system to an international audience, particularly from the United States, where the
culture is similar to that of Australia and prices are lower, even with the recently strong
exchange rate of the Australian dollar against the US dollar. As one participant observed,
there might be a parallel with the growing popularity of Australia as a destination for higher
education:
Where are the main people coming [to Australia] for education [from]? China, India
and other areas. Why are they coming here? Perceived value, safety, personal safety,
cultural safety … So I think those are messages that North Americans will resonate to.
Potential barriers to success include lack of government support and community
misconceptions that this type of industry might reduce local access to public healthcare
services. The marketing effort, both domestically and internationally, needs to be consistent
and coordinated, as illustrated by the following quote:
I would love to see a parallel to the education industry, where we’ve got a
funded body that goes out and competes with other government sponsored
entities. SingaporeMedicine has been set up by the Singaporean Government.
It’s got input from the tourism and medical industries and the Government,
It’s entire [focus] is to go out there and promote Singapore as a holistic
[medical tourism] package. What we have right now [in Australia] are all
these well intentioned private initiatives that … collectively aren’t working
together to go and do it. So it has to be coordinated.
Industry Analysis – Medical Tourism
Australia does not yet offer medical tourism services in a systematic and organised way,
unlike established medical tourism destinations such as India, Thailand and Singapore in Asia
and Hungary in Europe (Henderson, 2003; Laing & Weiler, 2008; Smith & Puczkó, 2008).
Towart (2008) suggests that Australia should focus on developing ‘centres of excellence’
around specialisations. These services could be offered by distinct facilities as a ‘one-stop
shop’. A few niche product offerings currently exist in Australia, as identified in this study.
For example, some hotels have collaborated with hospitals for post-natal care, such as the
Little Luxuries program run by the Crowne Plaza Coogee Beach in conjunction with the
Prince of Wales Private Hospital (Voigt & Laing, in press). The Cairns Fertility Clinic has
built its own accommodation within the medical facility, but has also developed packages for
medical tourists with local accommodation providers such as the Rydges and Shangri-La
hotels (Carter, 2009).

Industry strengths include price differentials with countries such as the United States and the
quality of the medical services provided by the industry:
Whilst there's great economic value in [medical tourism], ultimately there's got to be a
product of integrity and I don't believe that we have to create that in Australia - I
believe it's already [in existence].
Development of a medical tourism industry in Australia may be supported by the strong legal
system, which will give international tourists (and their insurers where they are involved)
recourse to legal remedies in the case of malpractice or negligence. This peace of mind may
not be available in some developing countries, where legal action may be protracted and
expensive (Bookman & Bookman, 2007; Towart, 2008).
Market Analysis – Wellness Tourism
In comparison to medical tourism, Australia currently has a stronger foothold in the wellness
tourism market, with a diverse array of different providers identified in the scoping study
across the three dimensions of spas, lifestyle retreats and spiritual retreats. The most
conservative estimate of the size of the domestic market can be derived from the NVS data,
which proposes that only 0.3 per cent of all domestic tourists visited a ‘health spa or
sanctuary/wellbeing centre’ between 2006 and 2008. The RMR profile estimates that 1.3 per
cent of domestic tourists engaged in a ‘health resort / spa holiday’ in 2008. These studies are
limited by the fact that the term ‘spa’ has not been defined, and may not capture the full
spectrum of health tourism experiences. The size of the international market is also difficult to
quantify, with the IVS data estimating that an average of 152,000 international visitors to
Australia per annum between 2006 and 2008 took part in health spa’ activities. This suggests
that numbers of tourists engaging in health tourism is still relatively low, although the market
may be larger than these numbers suggest and there is potential for further growth based on
global trends. It is also unlikely that health and wellness services were the primary trip
motivation, although more research needs to be undertaken in this regard.
Key success factors identified in this study include the range of treatments and therapies
available in Australia. As one participant noted:
Australia has adopted bits from everyone. We are a melting-pot because we are so
multicultural. It’s hard to identify our spa culture – we adapt to all things. We often
use our own local ingredients and adapt treatments to the location– spas in alpine
areas using red wine or warm treatments; or hot springs. In the Yarra Valley, they use
wine too. Companies like Li’Tiya use local flora in products and they are doing well
overseas.
The links with Australia’s image as a destination were also commented upon, although it was
felt that Australia needed to do more to promote this to international visitors:
Australia is not known as a spa destination. We are mainly known for beauty, nature,
clean air, good food and wine and social population. If we have a good health and
wellness product, this adds something to the mix and is complimentary to these things.
Australians are seen as healthy people. We could incorporate health and wellness into
our promotion – this could help to meet existing needs, as a mix of many elements.

Other factors raised by participants include the importance of focusing on a particular market
segment and developing links with other regional offerings, such as food and wine.
The motivations for visiting the different wellness tourism operations were also noted by
participants. Pampering appeared to be the prime reason for visiting beauty spas, as illustrated
by the following quote:
I think it’s about pampering themselves and spoiling themselves. I think probably
people that are burnt out is probably only 10 or 20 per cent. I would say most of them
are here because they want something luxurious, they’ve saved their pennies and they
just want to spoil themselves and feel like a queen for a weekend and they’re happy to
spend the money.
The spiritual retreats and lifestyle retreats were more attractive for those seeking stress relief
or health benefits, whether physical, mental or emotional. As one participant noted: ‘I think
there’s more of a natural search, I suppose, for [holistic] cures and potions and things for their
bodies, instead of having to get antibiotics and things all the time’. A participant from a
spiritual retreat referred to the trend of the ‘worried well’ visiting their retreat, being people
who are concerned with their long-term health, rather than people who are actually suffering
from existing ailments or diseases.
Industry Analysis – Wellness Tourism
Daylesford and Byron Bay were mentioned as some of the leading Australian wellness
tourism destinations, with a range of wellness tourism providers, particularly spiritual retreats
and those providers who offer more alternative, holistic wellness services. Future industry
growth however may potentially be limited by the lack of an industry accreditation scheme
and the lack of a strong industry voice or lobby group. There have been several attempts by
the Australian-based Australasian Spa Association (ASpa) to develop an accreditation scheme
for the wellness industry, but so far these attempts have failed.
Other barriers to success mentioned by participants include staffing shortages and burnout
rates. As one participant observed: ‘There is a huge increase in businesses within this sector in
Australia and I believe more time and money needs to be invested in the ongoing training,
support and development for the staff or there will be a big drop in the quality of services on
offer’. The burnout rate might be attributed to the emotionally and spiritually challenging
nature of wellness industry-related jobs, including the use of ‘feigned intimacy’ by therapists,
the level of physical effort that is required to be expended in such a tactile experience
(Dobson, 2005), the sensitivities of dealing with the naked human body (Paterson, 2005) and
negotiating sexual boundaries (Dobson, 2005), as well as the exposure to confidential
information (Sass, 2000) and potential for over-involvement (Williams, 2001). This link
between spa tourism and emotional labour is a potential issue for exploration in future
research.
Conclusion
The study upon which this paper is based attempts to fill some of the gaps in knowledge about
medical and wellness tourism in Australia. The scoping study is a first step towards a more detailed
examination of Australia’s health tourism industry and the future directions such an industry might
take, including the implications for Australian tourism development more broadly.

Some of the potential opportunities for developing the medical tourism industry in
Australia, identified in the stakeholder interviews, include focusing on niche medical
strengths that are already associated with Australia, developing purpose-built facilities for
medical tourists, promoting the quality of the Australian health system and price benefits
compared to US or European destinations for medical services and emphasising the legal
protection inherent in undertaking procedures in Australia, in comparison with some
developing countries. Potential barriers to success might however include limited support
from government for developing this industry and the need to overcome community concerns,
albeit misguided, that offering these services to medical tourists might lead to reduced access
to healthcare services by the resident population. The focus on medical tourism as a niche
offering concords with the views of Bookman and Bookman (2007, p. 41), who are blunt in
their assessment of medical tourism as a ‘niche’ offering: ‘Such tourism does not draw masses
but rather it appeals to a select number of people whose demand is big enough to generate
sufficient business’.
The wellness tourism industry in Australia has various strengths identified in this study, such
as a diverse product offering and links with existing tourism products and services, as well as
a destination image that is associated with health and relaxation. Barriers to development and
growth however include the lack of industry accreditation and high turnover of staff,
attributed to burnout.
Areas of future research identified through this study include the need to understand the medical
tourist in greater depth, including their motivations; the role played by lifestyle resorts and spiritual
retreats in tourism; the development of a profile of tourists who engage in medical and wellness
tourism activities; the use of medical and wellness tourism as a context for destination branding
and development; exploring the potential and prevalence of health tourism as the prime focus for
international visitation and examining the potential link between emotional labour and burnout of
therapists. Many of these areas of research are important in a global context, in addition to a focus
on the particular issues and factors pertinent to Australia.
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The Impact of a Festive Event on Residents’ Quality of Life
Marc LeBlanc
École de kinésiologie et de récréologie, Ceps, Université de Moncton
Moncton, E1A 3E9, New Brunswick, Canada
marc.leblanc@umoncton.ca
François de Grandpré
Université du Québec à Trois-Rivières
Trois-Rivières, Québec, Canada
Abstract
The purpose of this study is to measure the impact of a large scale event on residents’ quality
of life in an essentially rural area of the province of New Brunswick, Canada. Initially
developed in 1994, the World Acadian Congress (WAC) is organized every five years in a
different region inhabited by Acadians. The 2009 WAC was held in the Acadian Peninsula, an
area encompassing 102 communities with an overall population of 55,000 residents.
Respondents said that the Congress brought a feeling of wellbeing in the region, improved
quality of life in the community, and contributed to their personal happiness and wellbeing.
Respondents did not perceive any negative impacts from the WAC, as indicated by the low
scores given to loss of privacy, inappropriate behaviours, and disturbance of daily life.
Overall, the presence of the World Acadian Congress proved to be beneficial for the quality
of life of residents in the Acadian Peninsula.
Keywords: tourism, social impact, event, festival, Acadian, World Acadian Congress
Introduction
Festivals are becoming increasingly popular in different regions of the world (Getz, 1993
&1997; Thrane, 2002; Gusoy, Kim & Uysal, 2004) and this type of event is an important
tourism development tool in these areas (Goeldner & Ritchie, 2000). The popularity of
festivals can be explained by the fact that tourists are attracted by them and local residents
agree to invest human and financial resources in them.
The willingness to organize a festival results in the presence of organizers who perceive its
advantages. Mayfield and Crompton (1995) studied the reasons why such organizers choose
to stage festivals. They identified eight impact categories, namely recreation/socialization,
culture/education, tourism, internal revenue generation, natural resources, agriculture, external
revenue generation and community pride/spirit. Gursoy, Kim and Uysal (2004) also studied
organizers’ perceptions of the impacts of festivals or events and combined them into four
categories: community cohesiveness, economic benefits, social incentives, and social costs.
Moscardo (2007) analyzed the role of festivals and events in regional development and
identified “building social capital” and “enhancing community capacity” as two of the three
major benefit categories (the other being economic). Small (2007) identified six underlying
dimensions of the social impacts of community festivals: inconvenience, community identity
and cohesion, personal frustration, entertainment and socialization opportunities, community
growth and development, and behavioural consequences. Durrett (2008) states that a festival
can even promote resilience “through sharing values, interests and traditions central to the
host community” (p. 107), adding that “such festivals are thus an expression of local identity

and reflect the internal life of community, not withstanding they are impacted and influenced
by external forces” (p. 107).
In his research, Reid (2007) is particularly interested in the social benefits of festivals in rural
settings. He reiterates the underlying elements of the social benefits listed by other authors,
explaining that they relate to social satisfaction, attitudes, beliefs, values, and lifestyle. He
divides the social benefits of special events in a rural setting into the following five
categories: networks and interactions, affective, learning and developing, socioeconomic, and
physical domain.
Other researchers wanted to better define the social benefits by developing various
measurement tools. These were mostly inspired by the tools used to measure the social
benefits of tourism, such as Lankford and Howard’s (1994a, 1994b) Tourism Impact Attitude
Scale. Among the instruments used to evaluate the social benefits of festivals (Delamere,
1997, 2001; Fredline, E., Jago, L. & Deery, M., 2003), we chose Delamere’s (2001) Festival
Social Impact Attitude Scale. This tool allows us to partially measure a festival’s influence on
the quality of life of the host community’s residents.
The purpose of this study is to measure the impact of a major event on residents’ quality of
life in an essentially rural area of the province of New Brunswick, on Canada’s east coast. To
our knowledge, the above-mentioned sources have not been used in a context as extensive as
the 2009 World Acadian Congress, which encompassed over 400 events taking place in 102
rural communities.
What is the World Acadian Congress?
The World Acadian Congress (WAC) is a large gathering of Acadians from all over the
world. Acadians are French descendents who arrived in America in 1604 to establish their
permanent residence there. In 1755 however, England decided to deport the Acadians who
refused to pledge allegiance to the British Crown. Thus, nearly 10,000 Acadians were
deported mostly to Louisiana, while others were returned to France. Others still hid in the
forest and were able to survive there for a few years with the help of the Natives. Throughout
the years, many returned to the territory currently known as l’Acadie.
Acadians were able to preserve their French language despite the fact that they are constantly
confronted with the reality of Canada’s strong English-speaking majority. There are
approximately 280,000 Acadians in the Atlantic Provinces, distributed as follows: 235,000 in
New Brunswick (33% of the population); 35,000 in Nova Scotia (4% of the population);
5,500 on Prince Edward Island (4% of the population); and 2,000 in Newfoundland and
Labrador (0.05% of the population). The Acadian diaspora also numbers approximately one
million descendants living elsewhere around the world, mostly in Quebec and Louisiana.
The WAC is held every five years. According to its organizers, “it is a unique opportunity for
people (from the host region) to showcase themselves for the entire world to see and to meet
their Acadian cousins from across the planet to celebrate their common history.”
(www.cma2009.ca)
The WAC program, which runs for 15 days, coincides with National Acadian Day on
August 15 th and revolves around four types of activities, including family reunions, public
celebrations, thematic and community events, and scientific and popular conferences. These
events must offer something of interest to all Acadians, young and old alike.

The mission of the World Acadian Congress is to develop closer ties among Acadians from
all over the world. (www.cma2009.ca)
The WAC was one of the most important cooperative developments for Acadians at the end
of the 20 th century. Despite the absence of specific boundaries delimiting l’Acadie, there is a
true sense of belonging to this “territory”, whether it be in New Brunswick, Prince Edward
Island, Nova Scotia or Louisiana. As mentioned by Doucet (2005), the land of the Acadians
may be hard to circumscribe, but you feel it when you’re there. The World Acadian Congress
is one of those moments that transcend the notion of territory.
The first Congress was held in 1994 in south-eastern New Brunswick, Canada. A total of nine
municipalities hosted the event. A second congress took place in Louisiana, USA, in 1999, in
22 communities of the Acadiana region. The third edition was held on Nova Scotia’s
“Acadian territory” in 2004. And lastly, the fourth WAC, which is the subject of this study,
took place in August 2009 in New Brunswick’s Acadian Peninsula.
A Few WAC Numbers
The 2009 WAC program included over 400 events and attracted a total of 75,000 people
(45,000 local residents and 30,000 tourists), for a total attendance of 220,000 people at its
various events. Overall, the event generated more than 22 million Canadian dollars (14
million Euros) in economic spin-offs (LeBlanc & de Grandpré, 2009).
Organizers of previous events summarily estimated attendance at 200,000 participants for the
1994 WAC (cnc.virtuelle.ca/congres/) and approximately 300,000 in Nova Scotia in 2004
(www.pch.gc.ca/pgm). We were unable to find relatively reliable data for the 1999 WAC held
in Louisiana. It should be noted that a systematic and rigorous measurement instrument was
used to estimate attendance at the 2009 World Acadian Congress.
For information purposes, the 2009 WAC attracted 34,000 individuals at its various family
reunions, which brought together approximately 50 Acadian families (e.g. the LeBlancs, the
Cormiers, the Deveaus, etc.). A LeBlanc family reunion can attract as many as 6,000 people,
whereas other more modest reunions might attract less than 500. The major public
celebrations, for their part, attracted more than 100,000 participants and the thematic events,
approximately 81,000 (LeBlanc & de Grandpré, 2009).
Methodology
As indicated earlier, we chose to use Delamere’s (2001) Festival Social Impact Attitude Scale
as it best reflects Canadian reality and has already been validated at events in other areas of
the country. Also, it allows us to assess, in part, the influence of a festival on the quality of
life of its host residents. This instrument takes into account both the positive and negative
impacts on a festival’s host community.
A telephone survey was carried out with residents of the Acadian Peninsula ten (10) days after
the WAC. This region is made up of 102 small communities (five communities with
somewhat less than 5,000 residents, and villages numbering a few hundred to less than a
thousand inhabitants). In total, the Acadian Peninsula has 51,975 residents spread out over
2,150 km 2 (Statistics Canada, 2006). The survey sample included 300 individuals who
accepted to complete a 28-question survey.

Respondents were generally over 20 years of age, with a greater proportion in the 55-64
(31.7%) and 45-54 (29.7%) age groups. Seven out of ten respondents were female. The
language spoken by respondents was mostly French (96.7%), which is representative of the
French-speaking proportion of the Acadian Peninsula’s population. Few Anglophones live in
this region, which is considered the most homogenous in New Brunswick from a linguistic
point of view. Respondents from rural communities (with a population of 1,000 or less)
represented 58% of the sample, compared to 42% for respondents from one of the five
communities with 5,000 inhabitants.
Participation Profile
Overall, 84.7% of the respondents took part in at least one WAC event. Extrapolated to the
Peninsula’s general population, this percentage represents 43,938 people on a possible total of
51,875.
Nearly four out of five respondents (78.7%) indicated personally knowing at least one
volunteer, employee or artist who was part of the program.
Very few residents (2%) decided to leave the Peninsula during the WAC. And finally,
respondents have lived in the Acadian Peninsula for an average of 45.04 years.
Positive Social Impacts
Using a Likert-type scale (where 1 means totally disagree and 5 means totally agree),
respondents gave each of the 15 statements a score of over 4 on a 5-point scale.
Results suggest that the success of this congress has given the region’s population confidence
in its ability to host major artistic and cultural events, since 90.3% of respondents chose 5 on a
scale of 1 to 5 in response to this question. Respondents recognize that the WAC provided
artists with a personal sense of pride and recognition (86.6%). It should be noted that most of
the hundred or so artists who performed on stage or displayed in exhibit halls were area
residents. Others were Acadians from other Acadian regions.
From the very beginning of the planning process, organizers and part of the population
wanted it to be known that the Acadian Peninsula was able to host a grand event despite its
economic challenges and the exodus of its youth to major centers elsewhere in New
Brunswick and Canada. According to respondents, it would appear that this goal was
achieved, as 86.3% believe that the CAW provided the Acadian Peninsula region with
positive recognition from visitors.
A bit more than half of the respondents totally agree that the region’s quality of life had
improved (54.4%). The same proportion felt that the WAC contributed to their personal
enjoyment and wellbeing (52%). Almost half the respondents felt that the WAC led to the
improvement of the region’s current cultural facilities or the development of new ones. One
might imagine that the respondents considered certain facilities needed at least to be improved
in order to host the event (e.g. temporary setup of tents, grandstands, etc.).
The table below demonstrates that respondents are more in favour of social impacts that affect
the overall region (the Acadian Peninsula) compared to those that affect their own daily life.
For instance, they believe the WAC brought a sense of wellbeing to the Peninsula population
in general more so than to themselves personally.

Table 1
Positive social impacts of the 2009 World Acadian Congress (n = 300)
Percentage (%)
of respondents
The World Acadian Congress showed that the Acadian
Peninsula region can host major artistic and cultural
events.
The World Acadian Congress provided artists with a
personal sense of pride and recognition.
The World Acadian Congress provided the Acadian
Peninsula region a positive recognition from people
visiting.
The World Acadian Congress provided the Acadian
Peninsula a chance to celebrate.
The World Acadian Congress brought money into the
region.
The World Acadian Congress provided opportunities to
meet with artists and various persons involved in the
event.
The World Acadian Congress brought the whole
Acadian Peninsula region together to strengthen the
community identity.
The World Acadian Congress resulted in an enhanced
image of the region.
The World Acadian Congress provided people in the
region with an exposure to a variety of cultural
experiences.
The World Acadian Congress provided residents from
the region with the opportunity to learn new things
about arts and culture.
The World Acadian Congress provided a sense of wellbeing
to the Acadian Peninsula’s population.
The World Acadian Congress provided the opportunity
for region residents to experience something new.
During the World Acadian Congress, the quality of life
in the region improved.
The World Acadian Congress contributed to your
personal enjoyment and well-being.
Associations will benefit as a result of the World
Acadian Congress, through new or improved cultural
facilities.
who answered 5
Average
score
out of 5
90.3 4.86
86.6 4.83
86.3 4.82
85.7 4.81
80.7 4.74
80.3 4.73
78.0 4.69
76.3 4.69
75.1 4.68
71.3 4.64
64.2 4.51
61.0 4.47
54.4 4.30
52.0 4.12
48.5 4.18
Negative Social Impacts
Table 2 includes the negative impacts usually associated with the hosting of a festival. As can
be seen, few respondents perceived negative impacts. Although mentioned by very few
(23.7%), the most negative impact involves the volunteers being overworked. Overall,
respondents did not perceive the congress as being a source of inconvenience or annoyance in

their daily lives, whether in their daily routine, the use of cultural facilities, overcrowding in
stores or streets, noise or other unfortunate incidents.
Table 2
Negative social impacts of the 2009 World Acadian Congress (n = 300)
Percentage (%)
of respondents
who answered 5
Average
score
out of 5
Congress organizers and volunteers were overworked. 23.7 3.31
Local cultural facilities were too crowded during the
Congress.
15.7 2.63
The Congress disrupted normal routines in the region. 15.0 2.58
Motor vehicle traffic increased to unacceptable levels
during the Congress.
12.7 2.26
During the Congress, the region experienced crowding
at certain places like parking lots and stores.
10.0 2.40
There was too much litter and garbage left during the
Congress.
8.7 1.90
The arrival of visitors to attend the Congress reduced
privacy in the region.
8.0 1.87
Noise levels increased to an unacceptable level during
the Congress.
7.7 1.82
The Congress created too many incidents of disruptive
behaviour.
6.0 1.66
Statistical tests run on different groups of respondents (those living near the main venues
versus those living further away, or respondents aged 54 and under versus those 55 and up)
did not produce any statistically significant differences.
Discussion
Results indicate that the organization and hosting of the World Acadian Congress were a
success in the eyes of Acadian Peninsula residents. They confirm comments heard during and
after the event to the effect that it was an all-round success. Residents had a wonderful
experience and the perception of their quality of life, generally and collectively, was
improved. Positive impacts largely surpassed the negative impacts expressed in the instrument
used for the survey.
There are surely various factors which can explain this favourable perception by the local
population. Firstly, there are geographical considerations, since the activities weren’t
concentrated in the limited periphery of one single community. Indeed, the 400 events took
place in most of the 102 communities. The extent of the territory and the distance between the
venues and residences were sometimes several kilometres.
The type of events can also explain the positive impacts, as most of them were family or
community oriented (e.g. meals, presentations, displays and indoor shows). The major
outdoor events, which are often the cornerstone of festivals, were few in number and attracted
approximately 5,000 people in less densely populated areas within the municipalities (such as
an ocean wharf).

The Acadians’ quest for pride and affirmation is explicitly included in the WAC organizing
committee’s mission statement. It is therefore not surprising to see such a positive collective
impact in this area. It might have been different if the theme had focused on a smaller portion
of the population. Remember that close to nine out of ten Peninsula residents are Acadian,
therefore directly affected by the congresses’ theme.
Three main roads were closed to automotive traffic to allow participants (5,000 to 8,000
people) to walk and experience a carnival-like atmosphere for at least half a day on each
occasion. Two events attracted over 20,000 people: the tintamarre (major gathering on the
main thoroughfare for the purpose of making noise for an hour so that Acadians can make
known their presence as a nation) and the outdoor concert held immediately following this
explosion of noise. Both of these events were held in Caraquet, the flagship community of the
Acadian culture.
These mass events (with road closures and traffic diversion) were preceded by consultation
sessions between organizers and the local population to discuss changes in traffic patterns,
business hours of certain services and noise related constraints. Many residents actively
participated in these meetings, helping organizers adapt their plans and thus minimize, even
slightly, the negative effects of these events. The meetings also allowed organizers to gather
feedback on how to improve the hospitality aspect of the WAC and the content of its various
events.
Secondly, one of the factors which might explain the « social » success of the congress is the
organizers’ willingness, right from the start, to have the population take ownership of the
event and make it a major celebration first for the community, and then inviting “visitors” to
join. Consequently, one of the organizers’ initial objectives was that each municipality
organize at least one community event during the congress. That is how many community
events came to be designed by local residents.
Hinch and Delamere (1993) suggest that the success of a festival probably depends on the
host community’s control of the event rather than its ownership by the tourism industry. In the
case of the WAC, it appears evident that the positive impacts are a result of this major
involvement, where barely a dozen full time paid staff was hired to organize 400 activities. It
goes without saying that local volunteers played a major role in the entire planning and
management process. Indeed, our observations since the beginning of the WAC organization
process (in 2004) have allowed us to note that organizers made every effort to communicate
with volunteers and the general population on a regular basis. According to Byrd, Bosley and
Dronberger (2009), this aspect of communications is one of the secret ingredients for
promoting the positive impacts of tourism.
Through the local population’s involvement, people perceived the congress as being a
gathering for everyone: youth, seniors, families, etc. Indeed, Huang, Li and Cai (2010)
mention that the success of a festival, even from a tourist’s point of view, depends on the local
community’s support and more precisely on the need for this host community to reflect the
image of a place where family life is valued.
Allen, Long et al. (1988) identified a correlation between the number of years a person lives
in an area and his or her perception of the presence of tourists. Since residents of the Acadian
Peninsula have lived there on average for 45 years, they may have a better understanding of
the importance of an event such as the WAC for their community.

The results of the survey indicate that 84% of local residents took part in at least one event
during the congress. This level of involvement is considerable and confirms, in our view, the
local population’s positive perception of the congress. At least one study (Anderek, Valentine
et al., 2005) suggests that those who benefit from tourism activities are favourable to the
existence and hosting of such events. The benefits, in this case, are the social impacts, since
Acadians from the Peninsula seem to confirm that the community benefited from some form
of enjoyment and well-being thanks to the congress. A study by Allen, Hafer et al. (1993)
indicated that local residents were more in favour of recreational activities than tourism
development. Do residents of the Acadian Peninsula see the value of the congress more so as
a recreational activity than a tourism initiative? They probably do, since the involvement
required to organize an activity in their community focused first on the recreational nature of
the activity and then on its tourism aspect. Indeed, economic spin-offs were only listed in 5 th
position among the benefits of the Congress.
It would appear, as suggests Durrett (2008) in his writings on festivals, that the Congress
allowed the Peninsula’s Acadian population to demonstrate its resilience in that it faced its
economic and social challenges by showing, through the WAC, that it stands strong and
proud. There is no doubt in our minds that the benefits of World Acadian Congress will be
sustainable and open the door to other social or economic activities which will promote the
region’s overall development.
It is interesting to note that respondents perceived positive impacts more so for the
community than for themselves. This altruism was also evident with regards to negative
impacts, where respondents gave top billing to the efforts made by their fellow citizens who
were involved as volunteer.
The survey undertaken after the World Acadian Congress provided a better understanding of
the impacts of a major event in a rural setting where activities took place over a large
territory. It would be interesting to examine the social impacts in more detail in a rural setting
where activities would be closer together in time and space. Organizers of the next WAC,
which will be held simultaneously in another region of New Brunswick (Madawaska-
Victoria, or north-western NB), Maine (USA) and Québec (Témiscouata) in 2014, should
repeat this type of survey to determine their social success and try to see if any evolution is
showing up since 2009!
Those organizers would also be well advised to follow the 2009 approach of consulting the
public to establish the community programming as well as communicating with members of
the community throughout the process. The initial idea of organizing activities for residents of
the host community first and foremost, while ensuring that visitors (tourists) still experience
quality and hospitality, probably prompted more people to get involved in the congress in one
way or another.
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www.pch.gc.ca/progs

Analysis and classification of wellness hotels in Austria
Ivo Ponocny, Dagmar Lund-Durlacher
MODUL University Vienna, Am Kahlenberg 1, 1190 Wien, Austria
dagmar.lund-durlacher@modul.ac.at
ivo.ponocny@modul.ac.at
Abstract
Austrian wellness hotel web pages have been analyzed on the basis of a random sample of
134 hotels enumerated in the Relax Wellness Guide. Dominant features were found to be
mountainous surroundings, being operated by independents and promoting non-wellness
activities such as skiing as well. Surprisingly many enterprises focus on families as the target
population, especially in mountainous areas. Quite often there is no particular distinguished
wellness specialization, but wellness is taken as an add-on to other options or activities.
Correspondingly, wellness offers are much closer tied to beauty offers than to genuine
medical treatments, which allow discriminating between a “soft” and “hard” profile, whereby
the former emphasizes relaxing and feeling well and the latter more specific health-related
treatments. Alternative medicine is applied in almost half of the hotels, with a strong tendency
that hotels which offer alternative medicine offer beauty treatments as well. However,
sophisticated concepts of wellness or characteristic profiles are lacking in most cases.
Background
Wellness is a worldwide trend which in the year 2010 led to around 900 health and wellness
hotels in Austria. There are 28 thermal baths with 6.75 billion visitors per year as well as 200
private hospitals and rehabilitation centers. About 12 percent of all tourists in Austria make
health-oriented holidays (ABA Invest in Austria).
Wellness offers in Austria differ widely and there is no clear categorization for the consumer
of what to expect from the variety of wellness hotels. Being still a young concept, health and
wellness tourism lacks commonly recognized definitions and categorizations. Inspired by a
study of Mueller and Lanz-Kaufmann (Müller, Lanz-Kaufmann 2001), which analyzed the
wellness hotel market in Switzerland and revealed four types of wellness hotels there, the
need for investigating the wellness supply in Austria was seen by the researchers.
Research question
The aim of the project is to discover and define different categories of the health and wellness
accommodation sector by analyzing health and wellness establishments in Austria with a
predefined set of criteria which can be used for classification of the health and wellness
supply market.
Characteristics of interest are formal ones such as hotel category, location, ownership, price,
size, properties and general hotel facilities as well as the core marketing concept and the
target groups addressed explicitly or implicitly. The main focus of interest lies on the health
and wellness facilities which are advertised and on the detailed list of health and wellness
offers (treatments, therapies, packages, trainings, courses, retail areas). Another area of
inquiry refers to the promised effects of the wellness supply offered (such as mitigation or
improvement, relaxation, spiritual experience, beauty), and to the promises connected with
this supply. The fundamental concept behind the orientation of the treatments shall be
assessed and analyzed in the context of available natural resources, unique selling position

and other characteristics of the hotels, delivering a detailed picture of similarities and
differences across the Austrian wellness sector. Further interest lies on the relationship
between scientific and alternative medicine. Finally, the hotel descriptions are analyzed
referring to the sustainability aspect. The presence of an explicit focus on sustainability (e.g.
in the mission statement) is evaluated as well as the documentation of tangible evidence of
sustainable behavior.
Based on the analyses, it was expected to find certain types of hotels together with a set of
descriptors for each of these types of accommodation, or to conclude that the Austrian
wellness sector cannot be segmented into types satisfyingly because of a lack of distinguished
hotel profiles.
Research design
A sample of 134 Austrian hotels was randomly drawn from the Relax Wellness Guide website
(http://relax-guide.com/), which is an online compilation of wellness hotels that currently
contains 900 hotels in Austria and is believed to constitute a very reliable and exhaustive
sampling frame. The data collection was carried out by students who attended a course on
health and wellness tourism, whereby a data entry sheet was provided which contains a total
of 183 characteristics to be filled in using the information from the websites. The catalogue of
characteristics was formed by a priori reasoning according to the research question (such as
location, hotel category etc.) as well as by text analytical procedures applied to the hotels’
homepages.
Results
Generally speaking, the analysis shows that – in spite of the differences in the offers – the
various possible properties of the wellness hotels are rather individualistically combined,
without strong partitions into different types and without overarching, stable sets of common
characteristics. However, some remarkable relationships could be observed.
Formal characteristics
Regarding the hotel category, there is much homogeneity resulting in a vast majority of 4 star
hotels (81%) or 4 star superior (5%), followed by 3 star (9%) and 5 star hotels (3%). The most
contributing state by far is Tyrol (52 hotels), followed by other mountainous areas such as
Carinthia, Salzburg and Styria. In the total sample, there are 65% of hotels in a mountainous
surrounding, in contrast to only 5 in a city centre. Again 65 % are year-round hotels, the rest
are mainly 2-season hotels. The typical wellness hotel is family/independently-operated
(81%), 12% are operated and owned by a hotel chain. Price levels are moderate: two third
have been classified as mid-market (between 80 and 300 EUR room rate/double occ.), a sixth
as economy and another sixth as luxury.
The size of the hotels speaking in terms of room numbers was difficult to be assessed because
in half of the cases there was no information given on the homepages. From those hotels
where the room numbers are known it can be concluded that there is a highly significant (p <
0.001) relationship between size of the hotel and how it is run (Cramer’s V = 0.532), but still
far from being deterministic: 24 % of the large hotels (more than 100 rooms) are run by
independents, but 86 % of the smaller hotels (
Table 1).

Table 1: Size of hotel and operator
Familyoperated
No Yes Total
Size 100 16 5 21
Total 26 38 64
A similar relationship can be found between operator and seasonality (p = 0.005, V = 0.245),
with a clear but again non-deterministic tendency of seasonal hotels to be family-operated
(Table 2). There is a clearly visible connection between type of ownership and price level. A
cluster analytical classification according to seasonality, size and type of ownership suggests
to segment the set of hotels in 1) small family owned hotels with a large seasonality share, 2)
large year-round hotels run by chains and 3) small, family owned but also whole-year open
hotels. On the other hand, except for the number of stars the price level is not visibly related
to size, seasonality or ownership.
Table 2: Operator and seasonality
Familyoperated
No Yes Total
Seasonality no 38 49 87
yes 9 38 47
Total 47 87 134
Location and surroundings
The vast majority of Austrian wellness hotels lie in mountainous areas (70%), whereby in 9
cases there are mountainous surroundings as well as a lake (which is coded as “mountainous”
in

Figure 1). Many of the hotels take advantage of the natural resources, the most important of
them being the possibility to ski (48 %) and the availability of thermal water or hot springs
(18%). Only 41 % of hotels do not make use of any of these two benefits. Also many thermal
hotels lie in mountainous areas, but not as many as for hotels where there is no natural hot
water available.

Figure 1: Number of hotels in different surroundings
Surrounding
region of
the hotel
Table 3: Thermal springs and surroundings
Thermal
spring
no yes Total
City centre 4 1 5
Suburb 3 0 3
Mountainous
area
77 13 90
Lake/River 14 2 16
Countryside 9 8 17
Total 107 24 131
Not surprisingly, skiing possibilities are strongly related to mountainous surrounding, where
57% of the hotels praise alpine sport options on their homepages. At the same time, there is
also increased seasonality in mountainous surroundings and accordingly as well for skiingoffering
hotels. Skiing promotion is particularly popular in family-owned seasonal hotels
(71%), but less popular in chain-owned, year-round hotels (26%; in the other types the share
is about 50:50, which creates in a significant relationship between skiing focus and operator, p
= 0.002). This reflects the fact that in mountainous areas family-owned hotels dominate much
more clearly (71%) than in other regions (53%), which stresses the importance of seasonal
family-operated mountainous skiing hotels in the Austrian wellness sector. The centrality of
this combination is not only supported by cluster analytical considerations but also by
configuration frequency analysis: In fact, 23 hotels show all 4 properties literally, whereas 16
show none of them which forms a clearly significant type (expected value for having all 4
properties under independence assumption would be 9.5, p < 0.001).
Unlike the promotion of skiing activities, the availability of thermal water is not visibly linked
with any of the other structural characteristics as mentioned thus far.

Target groups
As shown in Figure 2, the most frequently directly addressed target populations are families
and couples. Correlation structure together with multidimensional scaling (Figure 3) suggests
to group the strategies into single/couples/wellness, business/conferences/50+ and families.
The vertical dimension might be interpreted as tranquility, the horizontal one as
representativeness. The correlations between the targeting families and other groups are very
small indicating that addressing families is independent from addressing the other targets.
There is in general no visible tendency to specialize on particular groups exclusively.
Figure 2: Target groups
A remarkable dominance of family orientation can be noted which is striking because the
classical wellness hotel would not be expected to focus on families. A context analysis of web
pages, on the other hand, reveals that many of the hotels seem to emphasize feeling well and
relaxing more than undergoing distinguished treatments, and the wellness section is not
central there but one among many others. In fact, hotels which target families offer
significantly less items from a pre-defined list of medical treatments (0.6 instead of 1.0,
Mann-Whitney p = 0.04, one-tailed), whereas there are no statistically relevant differences
regarding wellness or beauty treatments, courses, trainings or promoted activities.
Figure 3: Configuration of target groups in a two-dimensional space
What can be observed in the data is that families are particularly targeted in mountainous
areas (especially Salzburg, the Tyrol and Carinthia), whereas there is hardly any business
orientation in family-operated hotels (3 out of 64 (!) family-operated, 10 out of 36 other).
Similarly, family-owners seem to concentrate less on seminars and conferences. Most
interestingly, there seems to be no direct relationship between being family-run and focusing

on families. Furthermore, the availability of thermal water is no predictor for any of the
targeting strategies, neither is the size or the price level.
Broadness of wellness offers
The broadness of wellness offers was assessed by a sum score mapping how many treatments
of a pre-defined list are offered per hotel. The list was generated by a priori-reasoning as well
as by extracting and aggregating frequently mentioned treatments such as classical or Asian
massages, hot stone treatments, baths, lymph drainage, and similar. Analyzing bivariate
relationships, price level is the most marked variable to predict the broadness of offers
(moderate relationship), followed by type of ownership. Not surprisingly, higher price level
corresponds to a broader range of wellness offers. Most interestingly, all other variables
considered by now do not play an important role regarding the broadness, especially not the
availability of thermal water, and neither the addressed target group nor the size of the hotel.
A multivariate consideration reveals a particular interaction: narrow offers are typical for
hotels which are the perfect anti-type to the mountainous seasonal family-operated skiing
hotel as discussed above, which means they are frequently found in year-round hotels which
are neither family-operated nor in the mountains and not promoting skiing.
Judging from the websites, the most popular wellness offers are – apart from the more or less
ubiquitous baths or packages – Asian and classical massages, lymph drainage (all between 25
and 31 %) and hot stone treatments (14 %). Many features such as acupuncture are only
offered by very few hotels, producing an extensive list of treatments which are found in at
least one of the hotels under consideration. However, cluster analytic and factor analytic
investigation could not reveal strong characteristic profiles or typical treatment combinations;
rather the composition of offers seems idiosyncratic or, to put it bluntly, looks somewhat
arbitrary.
Broadness of beauty offers
Similarly to the broadness of wellness offers, a characteristic for the broadness of beauty
offers (facials, manicure, pedicure and similar) was defined and computed. As the most
striking result, the broadness of wellness and beauty offers show an extremely large
correlation (Spearman correlation � = 0.63, p < 0.001). This might not necessarily be due
to the real treatment situation–it probably reflects to some part the general thoroughness of
the hotel’s homepage, as well. Whatsoever, the relationship to price level is similar strong
as the one of broadness of wellness offers. There is again and even slightly closer a
connection to the mountainous seasonal family-operated skiing hotel type: generally
speaking, the more characteristics of a hotel match this type, the more beauty treatments
are offered by the websites.
The most popular beauty features are facial treatments (47 %), followed by manicure (33
%) and pedicure (31 %). Manicure and pedicure are highly interrelated (Cramer’s V =
0.950), but with much weaker links to facial treatments (V = 0.424 or 0.380, resp.).
Structure of offers
Analyzing the structure of offers emphasizes the impression that wellness often appears as
an add-on, as one feature additionally provided. For the analysis, the numbers of items
from certain pre-defined target lists were evaluated per hotel, whereby there were separate
lists for wellness treatments, beauty treatments, medical treatments, educational courses,
training courses and promoted activities (such as sports outside the hotel). The largest
correlation was between beauty and wellness treatments (Spearman correlation � = 0.63,
p < 0.001), whereas numbers of wellness and medical treatments only showed � = 0.28 (p
= 0.001). The mere size of the hotel (operationalized by the number of rooms) didn’t seem

to have an influence on these correlations and can be ruled out as relevant confounder.
The factor analytical structure (Table 4) based on two components (with 57 % explained
variance) splits these variables into one group stressing wellness, beauty and promoted
activities, and one stressing medical treatments and educational courses. Training courses
somehow range in between.
Table 4: Factorial structure of offers
Factor loadings
Factor Factor
1 2
Wellness
treatments
0.78 0.24
Beauty treatments 0.83 0.11
Medical treatments 0.09 0.71
Educational
courses
-0.05 0.79
Training courses 0.49 0.47
Promoted activities 0.62 -0.22
A multidimensional scaling visualization (based on z-standardized values) points out the
similarity between wellness and beauty in the sample very drastically, in a two-dimensional
mapping of the 6 characteristics the numbers of wellness and beauty offers are immediate
neighbors to each other, whereas the distance between wellness and medical offers is much
larger (Table 5). An illustrative example may be the presence of nutrition courses which
correlates moderately with the number of medical treatments (� = 0.231, p = 0.007) but close
to zero with the number of wellness or beauty treatments.
Table 5: Configuration of offers in a two-dimensional space
Indeed, the contrast between wellness/beauty/activities vs. medical treatments/educational
courses as indicated by factor analysis can be related to other characteristics of the hotels. A
linear regression analysis identified three predictors for a wide offer of “soft” applications
(wellness and beauty area): being family-operated, promoting skiing and being expensive
(adjusted r² = 0.13, p < 0.001;
Table 6). Accordingly, broadness of wellness and beauty offers is specific for family-operated
hotels which promote other activities such as skiing as well – and which have high room rates.

Table 6: Predictors for the number of "soft" treatments
Coefficients
Predictor
pvalu
Unstandardized Standardized e
Familyoperated
1.60 0.17 0.03
Skiing 1.73 0.19 0.02
Price 1.87 0.24 0.01
The number of medical treatments and educational courses (“hard” treatments), on the other
hand, could be significantly predicted by 5 characteristics (adjusted r² = 0.32, p < 0.001;
Table 7). Medical orientation is found in large hotels which specialize on meeting the needs
of older people rather than on families or couples, and is typical for hotels with thermal water.
Table 7: Predictors for the number of "hard" treatments
Coefficients
Predictor Unstandardized Standardized p-value
Couples targeted -0.66 -0.21 0.03
50+ targeted 1.05 0.30 0.01
Families targeted -0.59 -0.19 0.05
Thermal water 1.04 0.28 0.01
Number of rooms 0.48 0.26 0.02
Regarding the particular wellness offers per hotel, no common pattern could be found which
would indicate different sophisticated philosophies. An inspection of the web pages shows
that the majority of hotels do not profile themselves with an individual wellness concept, so
the wellness focus is seldom used to create a distinguished USP. As already mentioned above,
in many cases wellness is treated as synonym for relaxing and feeling well.
This is further demonstrated by an analysis of the promised effect of the treatments offered. It
is clearly seen that relaxation, beauty and general health (vitality, fitness, refreshing,
strengthening the immune system) are the most widespread effects by far, whereas specific
health programs, educational efforts or spiritual approaches play, in comparison, a marginal
role (Table 8).
Table 8: Promised effects
Aim/Promise Percentage
Relaxation 29
Spiritual/Mental health 5
Harmony between body and soul 10
Health in general 24
Specific health treatments 7
Change of behavior or thinking 4
Beauty 29

Purification 11
Application of alternative medicine
Many of the treatments involve procedures which have to be subsumed under the notion
“alternative medicine”, whereby every approach is subsumed here for which a scientific
confirmation of the effectiveness is not documented (in contrast to the so-called “evidencebased
medicine”). These offers can be classified into two categories: 1) treatments following
an approach which would in principle be consistent with a natural science point of view but
without effect control studies acknowledged by the scientific community (such as certain
lymph drainages or detoxifications), and 2) treatments with a background exceeding natural
science approaches, such as traditional Asian concepts involving the diagnosis of energy
balances or similar. In the sample of 134 hotels, 75 (56 %) do not promote any kind of
alternative medicine on the homepage, 17 only type 1), 16 type 2) and 26 hotels both types.
So if type 1) is applied, the probability that also type 2) is applied is doubled (Cramer’s V =
0.432, p < 0.001).
In general, the broader the offer, the more alternative medicine is contained. All Mann &
Whitney-tests comparing the broadness of wellness/beauty offers between hotels applying/not
applying alternative medicine result in p-values smaller than 0.001. As another example, there
is a marked positive correlation (r = 0.345, p < 0.001) between the availability of classic and
Asian massage offers.
However, the presence of alternative medicine is hardly predictable by any other of the
characteristics considered by now, so it seems to be a stand-alone characteristic completely
independent of any other assessed property of the hotels – but for two exceptions: The one is
the price, the more expensive, the more alternative medicine of type 1 (V = 0.325, p = 0.001;
Table 9). As the most striking observation, there is hardly any cheap hotel offering type 1
treatments. Additionally, this only holds for type 1), type 2) is not visibly related to the price
level (V = 0.067, p = 0.75).
Table 9: Price level and type 1-treatments
Type 1
offered
Price
level no yes Total
Economy 21 1 22
Mid- 56 30 86
market
Luxury 9 12 21
Total 86 43 129
The other exception is the presence of a beauty focus. If there is one, this raises the
probability that alternative medicine is applied drastically. This statements holds for both of
its types (Type 1: V = 0.31, p < 0.001, Type 2: V = 0.26, p = 0.002). The presence of a beauty
focus obviously corresponds to less confinement to evidence-based procedures (Table 10).
Table 10: Beauty treatments and alternative medicine
Type 1
Type 2
Beauty offered
offered
treatments no yes Total no yes Total
no 51 10 61 50 11 61

yes 40 33 73 42 31 73
Total 91 43 134 92 42 134
Sustainability
Sustainability issues were addressed only by a small minority of hotels (8 of 134) which
makes it impossible to go into thorough analysis. However, the data indicate by no means that
larger or more expensive hotels would show more sensibility for sustainability on their web
pages (descriptively speaking, the few hotels which do are mainly cheaper ones). Even if
sustainability topics are mentioned explicitly, there is no elaborate concept published; mostly
only allusions such as “regional orientation” or “according to ecological guidelines” are
found, clear-cut information like “growing in-house vegetables” and “recycling” is quite rare.
Conclusion
Analyzing the structure of the Austrian wellness hotels shows that the market is rather
heterogeneous with rarely clearly positioned wellness hotels. Wellness offers appear as an
additionally provided feature by hotels which otherwise position themselves on other
dimensions. Referring to Austria’s geographical situation, family operated mountainous
skiing hotels play a major role in the Austrian wellness sector. Related to that fact are the
main target groups of the wellness hotels which are couples and surprisingly families which
are focused by many hotels in addition to the classical wellness target groups. Many hotels
seem to mainly emphasize on relaxation where the wellness offer is not central to the guests.
Analyses show that wellness offers can be split in two groups, one focusing on wellness,
beauty and other leisure activities, the other stressing medical treatments and educational
courses. The broadness of the wellness and beauty offers is strongly related to the price level
whereas again no clear patterns of specific wellness and beauty treatments could be
discovered. It seems that wellness hotels do not have a clear strategy for their offered
wellness portfolio but rather combine offers arbitrarily or according to availability of
therapists. It is also obvious that offers are following certain trends and range from numerous
Asian massages and treatments to lymph drainage and reflexology. Only a few hotels
specialize on local treatments which are based on Austrian traditional healing approaches.
There are exemptions which strongly refer to local and regional resources, but they are few.
Most of the wellness hotels offer a broad mix of therapies stemming from different cultural
backgrounds. Based on the findings it can be said that there are many opportunities for
wellness hotels to clearly position themselves with a focused offer taking into account the
local and regional resources not only in their wellness as well as F & B offer but also in their
hotel concept such as architecture and design. Wellness suppliers have to be aware that often
their wellness supply is only an add-on to other attraction factors and therefore have to be
carefully integrated in the overall strategy and concept of the hotel.
References
ABA Invest in Austria: Health Tourism retrieved on 15.3.2010 from
http://www.aba.gv.at/EN/Sectors/WellnessTourism/Health+Tourism.aspx
Cohen, M. and Bodeker, G. (2008). Understanding the Global Spa Industry: Spa
Management. Oxford: Elsevier.
Bushell R., Sheldon, P.J. (2009). Wellness and Tourism. Mind, Body, Spirit, Place. New
York: Cognizant.
Smith, M. and Kelly C. (2006). Wellness Tourism. Tourism Recreation Research. Vol. 31(1),
2006: 1-4
Smith, M., Puczko L. (2009). Health and Wellness Tourism. Oxford: Elsevier.

Mueller H. and Lanz-Kaufmann E. (2001). Wellness Tourism: Market analysis of a special
health tourism segment and implications for the hotel industry. Journal of Vacation
Marketing. 7 (1): 5-17

Forming groups of European destinations based on bednight statistics
- using factor analysis and multidimensional scaling techniques
Carl Marcussen
Centre for Regional and Tourism Research, Bornholm
Denmark
marcussen@crt.dk
www.crt.dk
Abstract
This paper uses applies a technique called multidimensional scaling (MDS) to illustrate how
European destinations are positioned in relation to each other. The basis for doing so is
bednight statistics from Eurostat for the period 1998 to 2009 for 33 European destinations
(countries, nations). For each destination bednights are registered in four categories: domestic
hotel guests, foreign hotel guests, domestic guests at other types of accommodations, and
foreign guests at other types of accommodation. With bednights on a monthly basis, this
makes a data matrix with 12*12*4=576 cases. The variables are the destinations, up to 28 of
them, when combining a few of them. Months or quarters are dummy-variables, and so are
the guest type, and type of accommodation. A series of MDS diagrams are shown. Factor
analysis is used to form groups of destinations, which are also visible in the MDS diagrams.
The European destinations for international visitors may be grouped by major language
spheres.
Keywords: Factor analysis; multidimensional scaling; destinations; competitors.
Introduction
This paper applies a technique called multidimensional scaling (MDS) to illustrate how
European destinations are positioned in relation to each other. The data which will form the
basis for the MDS analyses are bednight statistics for 33 European destinations, i.e. EU27,
EFTA4 plus Turkey and Croatia. The statistics are from Eurostat and cover the period 1998-
2009. The data are the monthly bednights at all commercial accommodations, i.e. both hotels
and other types of collective accommodations. For each of these two main groups of
accommodations, the statistics are recorded for residents and for non-residents.
The purpose of this paper is to visualize how European destinations are positioned in relation
to each other and how destinations can be grouped based on bednight statistics.
Research questions:
1. Based on time series of bednight statistics, which destinations are somewhat similar,
and how can this be illustrated, using a multidimensional scaling technique?
2. Based on bednight statistics, which destinations can be grouped, using factor analysis?
Literature Review
Readers are assumed to be familiar with factor analysis. However, the basics both about factor
analysis and multidimensional scaling (MDS) sometimes referred to as Principal Component
Analysis (CPA), can be read in Green & Tull (1978). Factor analysis forms groups of
variables which are correlated with each other, whereas the resulting principal components
(factors) are uncorrelated. In statistical programs such as SPSS / PASW (Neulman & Heiser
2009), factor analysis is in the dimension reduction category.

The term multidimensional scaling (MDS) was coined by Torgerson in the early 1950’s
(Torgerson 1952). The technique started with metric MDS, i.e. based on interval or ratio
scaled data. Later on non-metric MDS was developed, based on rank-order scales (Kruskal
1964), which became and remains popular within psychometrics.
Since the late 1970’s more than 30 travel and tourism journal articles have used MDS. One of
these, Mazanec (1995), used bednight statistics for European cities, as a basis for visualizing
how these presumably competing cities were positioned in relation to each other. This will
also be done in this study, although the destinations here will be countries rather than cities.
The incumbent MDS procedure from the late 1970’s is called ALSCAL, an Alternating Least
Squares approach to Scaling (Young et al. 1978). Later on a more effective MDS algorithm
has been implemented in the SPSS / PASW Categories procedure called PROXSCAL
(Meulman & Heiser 2009), Proximity Scaling, from the late 1990’s in SPSS Categories 10
and onwards. A few tourism or travel related journal articles have appeared, explicitly
applying PROXSCAL (Ahmed & Miller 2007; Wöber 2007; Wolk & Wöber 2008; Burns
2009).
Methdology and Data
MDS is capable of visualizing – typically in a two dimensional diagram – how multiple
variables are related. The diagram is referred to as the common space. Each variable is
represented in the MDS diagram by a dot, referred to as an object point. Closely related
variables are placed close together in the MDS diagram and vice versa. Factor analysis is
capable of forming groups of variables. Presumably, variables which are grouped together by
the factor analysis will be placed close together in the MDS diagram(s).
The data used in this study are bednight statistics for European destinations at the country
level according to Eurostat. These are reported for different types of accommodation. Hotel
and similar accommodations form the main category. There are three other types of
accommodation in Eurostat, and they will here be called “other” under one. So there will be
two main groups of accommodation. There are only to source markets in the Eurostat data,
namely bednights by domestic and non-domestic visitors (foreigners).
The bednight statics are reported in Eurostat on a monthly basis, and annually of course. The
monthly numbers have been used to capture seasonal variations. A 12 year period 1998-2009
has been selected. For some countries data is missing for some years. In place of missing data
the corresponding numbers for the (corresponding month of the) preceding year or the
following year have been used, or the average between the preceding and the following year,
if both of those were available.
With monthly data for a 12 year period, for hotels and for other commercial accommodations,
and for residents and non-residents in both categories, this makes 12*12*4=576 records in a
data matrix. The 33 destinations are variables, columns, in the data matrix. Additional
variables (dummy-variables) indicate if the type of accommodation is hotels or not, the
visitors are residents or not. Furthermore dummy variables indicate the month and quarter of
visit, and there is a variable for the year. – Figure 1 shows the bednights per destination in
1998, 2009 and in average for all the years.

Figure 4 Bednights in commercial accommodations per year in Europe 1998-2009
Source: Based on Eurostat. Own elaboration.
Figure 1 shows that Italy, Spain, Germany, France and the United Kingdom are the five
largest destinations in Europe based on all bednights (hotels plus other commercial
accommodations). Figure 2 shows the seasonal pattern for overnight stays at commercial
accommodations in Europe (EU27, EFTA4 plus Turkey and Croatia).
Figure 5 Bednights by month: Season – all of Europe – all years under one 1998-2009
Source: Based on Eurostat.

Figure 3 shows the split of bednights on international and domestic visitors by destination, for
all types of commercial accommodations under one. August and July are the busiest months.
Figure 6 Split of bednights on international and domestic visitors, by destination in
Europe 2009
Source: Based on Eurostat.
Figure 4 shows the split of bednights by type of accommodation.
Figure 7 Split of bednights on hotels and other types of accommodations, by destination
in Europe 2009
Source: Based on Eurostat.
Table 1 shows that hotels and similar establishments accounted for 69% of the registered
bednights for the period 1998-2009 in average, other commercial/collective accommodations
31%.

Table 11 Split of bednights in Europe 2009 by source and type of accommodation
2009
(%) Domestic International Total
Hotels 37,3 31,9 69,2
Other 20,4 10,4 30,8
Total 57,7 42,3 100,0
Source: Based on data from Eurostat supplemented by own elaborations.
Note: Total is 2444 million bednights.
Results
In figure 5 there are 32 object points, i.e. 28 destinations or combinations of destinations plus
a pair of object points indicating seasons (the vertical axis), and another pair indicating a
domestic-international dimension (the horizontal axis). The rather few bednights in
Lichtenstein has been added to those of Switzerland. The three Baltic states of Estonia,
Latvia, and Lithuania have been combined here, so have Belgium and Luxembourg, and the
two destinations outside of the EU/EFTA areas Turkey and Croatia. The reason for the two
latter combinations is that Luxembourg and Croatia would appear as a separate factor, if no
combining was undertaken, which would not be convenient here.
Figure 8 Position of European Destinations – based on all collective accommodations –
1998-2009 – including seasons and origin markets
Source: Based on data from Eurostat supplemented by own elaborations.

Note: Objects: 32. Proximities: 496 ((32*(32-1)/2). Normalized Raw Stress: 0.0316.
N=576. Dispersion Accounted For: 1-0.0316=0.9684. PROXSCAL has been applied.
In Figure 6 the 28 destinations are shown without the supplementary object points. Stress is
very low in both Figure 5 and Figure 6, but lower in Figure 6 than in Figure 5 because there
are fewer object points in Figure 6 than in Figure 5. One minus normalized raw stress is
dispersion accounted for, which is very high in all MDS diagrams shown here. There appears
to be some groupings of the destinations. A factor analysis, the result of which is shown in the
left part of Table 2, indicates that there are three groups of destinations. The three groups are
labelled as follows:
1. The hot or generally international destinations.
2. The cool destinations.
3. Destinations dominated by domestic visitors.
The three factors account for 85% of the total variation in bednight statistics, of which factor
one 39%, factor two 24%, and factor three 22%.
Figure 9 Position of European Destinations – based on bednights of all visitors
Source: Based on data from Eurostat supplemented by own elaborations.
Note: Objects: 28. Proximities: 378 ((28*(28-1)/2). Normalized Raw Stress: 0.0141.
N=576. Dispersion Accounted For: 0.9859. PROXSCAL has been applied.

In Figure 7 the included bednights are those for international visitors only. Under this
condition, many neighbouring destinations are positioned next to each other, for example
Denmark, Sweden, Norway, and somewhat to the west Iceland. The alpine destinations
Austria and Switzerland are positioned next to each other, and so are Netherlands and
Belgium, France and Italy, Germany and the Czech Republic, Ireland and the United
Kingdom. There is a rim of Mediterranean destinations in the top left corner of Figure 7.
Many Polish people work in the British Isles. In recent years additional air links have been
established between these destinations.
Figure 10 Position of European Destinations – international visitors only, all types of
accommodation
Source: Based on data from Eurostat supplemented by own elaborations.
Note: Objects: 28. Proximities: 378 ((28*(28-1)/2). Normalized Raw Stress: 0.0232.
N=288. Dispersion Accounted For: 0.9768. PROXSCAL has been applied.
A second factor analysis was undertaken (see the right part of Table 2), based on international
(non-domestic) bednights only. The results indicated that there are also three groups of
destinations for international visitors. These are:
1. The English sphere, around the British Isles, and countries with English as first foreign
language
2. The German language sphere, mostly with countries bordering Germany, or business
partners
3. Other European destinations: Latin (French, Italian), Flemish, and Scandinavian.

Group one account for 37% of the variation in international (non-domestic) bednights in
Europe, group two 28%, and group three 26%, i.e. 91% in total, cf. Table 2. - With half as
many observations (N) in Figure 7, than in Figure 6, stress is a little higher in Figure 7 than in
Figure 6.
Table 12 Result of two factor analyses, one with all visitors, and one with non-residents
only
Conclusion
Three multidimensional scaling (MDS) diagrams were presented. The first one included 32
dots, object points, representing 28 separate destinations, plus four additional object points
indicating foreign vs. domestic guests, and summer versus winter season. Of Europe’s five
largest destinations by number of bednight (Italy, Spain Germany, France and the United
Kingdom) Spain is most oriented towards the international markets. Destinations such as
Belgium, Denmark, Netherland and Poland are generally summer destinations, while others
such as Switzerland and Austria have dual peak seasons.
A second MDS diagram based on all bednights, i.e. both domestic and international visitors,
showed (with the help of a first factor analysis) that three main groups of European
destinations can be identified. The first group is the hot or internationally oriented
destinations including most of the Mediterranean destinations plus some destinations mostly
oriented towards the international markets. The second group are cooler destinations in
middle or northern Europe. The third group of European destinations are those with large
domestic markets, or mainly domestic markets.
A third MDS diagram included only the bednights by international (non-domestic) visitors.
With the help of a second factor analysis three groups of destinations for international visitors
were identified. The first group with the United Kingdom and Spain as the largest destinations
have English either as a first language or English as a first foreign language. The second
group of destinations for international visitors included Germany and other German speaking
destinations, and other destinations familiar with the German language. The third group

included the rest of the European destinations, including the three Scandinavian countries, the
population of which are able to understand each other’s languages, Dutch/Flemish, and the
Latin languages French (France, Belgium, Luxembourg) and Italian.
MDS has many applications, and grouping of destinations is one of them. MDS can be
supported by factor analysis, which is helpful in the interpretation of the MDS diagrams.
Proximity – nearness or distance – between the variables in the original data set and in the
resulting diagrams are central in MDS analyses. – Neighbouring countries are typically top
ranking foreign destinations. Thus nearness and easy access (low costs in terms of time and
money) plays a role in tourists’ choice of destination. So do climate, be it for a summer or a
winter holiday, resulting in short summer seasons in northern Europe, or longer and more sun
safe holidays in southern Europe. Also the ability to be understood well at the holiday or
business destination and an element of cultural overlap clearly plays a role in destination
choice.
References
Ahmed, N., Miller, H. J. (2007). Time–space transformations of geographic space for
exploring, analyzing and visualizing transportation systems. Journal of Transport
Geography, 15(1), 2-17.
Burns, M. C., Roca, J., Moix, M. (2008). The spatial implications of the functional proximity
deriving from air passenger flows between European metropolitan urban regions,
GeoJournal, 71 (1), pp. 37-52, available online.
Green, P. E., Tull, D. S. (1978). Research for Marketing Decisions, 4th ed.. New Jersey:
Prentice-Hall.
Kruskal, J. B. (1964). Nonmetric multidimensional scaling: A numerical method.
Psychometrika, 29, 115–129.
Mazanec, J.A. (1995). Competition among European tourist cities: a comparative analysis
with multidimensional scaling and self-organizing maps. Tourism Economics, 1 (3), 283-
302.
Meulman, J. J., Heiser, W. J. (2009). Multidimensional Scaling (PROXSCAL), in PASW
Categories 18, chapter seven, pp. 67-81, SPSS, Inc..
Torgerson, W. S. (1952). Multidimensional scaling: I. Theory and method. Psychometrika,
17, 401-419.
Wolk, A., Wöber, K. (2008). A comprehensive study of info needs of city travellers in
Europe. Journal of Information Technology and Tourism, 10(2), 119-131.
Wöber, K. (2007). Similarities in Information Search of City Break Travelers — A Web
Usage Mining Exercise, pp. 77-86. In: Information and Communication Technologies in
Tourism 2007, Proceedings of the International Conference in Ljubljana, Slovenia. Edited
by: Marianna Sigala, Luisa Mich, Jamie Murphy. Springer. – Available at
books.google.com.
Young, F. W., Takane, Y., Lewyckyj, R. (1978). ALSCAL: A nonmetric multidimensional
scaling program with several individual difference options. Behavior Research Methods
and Instrumentation, 10, 451-453. (Also in Journal of Marketing Research, 1978, 15,
612-615 and in American Statistician, 1980, 34, 117-118).

Measurement of Tourism-oriented Aspects of Quality of Life
Gábor Michalkó
Geographical Research Institute, Hungarian Academy of Sciences
Hungary
michalko@iif.hu
Johanna Giczi
Central Statistical Office
Hungary
johanna_giczi@yahoo.co.uk
Tamara Rátz
Kodolányi János University of Applied Sciences
Hungary
tratz@uranos.kodolanyi.hu
Abstract
A society’s and individuals’ quality of life has long been in the focus of social science
research. The subjective aspect of one’s quality of life is usually assessed through a person’s
perceived satisfaction with their own life. In comparison, the indicators and methodological
approaches used by researchers trying to objectively measure quality of life are more varied
and complex. However, both the correct identification of the factors influencing objective
quality of life and the longitudinal evaluation of quality of life on the local level have
remained a serious challenge.
The paper presents the results of a study carried out by the HAS Geographical Research
Institute in co-operation with the Kodolányi János University of Applied Sciences that aims to
provide deeper understanding of tourism-oriented quality of life in Hungary. Although the
research raised a large number of new questions as well, in this paper we discuss the
development mechanisms of an indicator system that may fit within the currently used system
of social indicators and may provide useful information on the interrelationship of tourism
and quality of life. The development of the indicator system includes the delineation of the
research area, the creation of the related dimensions and sub-dimensions, and finally the
identification of indicators within the sub-dimensions. The indicator system is based on data
available at the Hungarian Central Statistical Office, derived from regular data collection
methods. Due to the obvious symbiosis of health and quality of life, a special emphasis is put
on measuring tourism-oriented quality of life factors at Hungarian health tourism destinations.
Introduction
The concept of quality of life – in our understanding: happiness – has been a subject of
thinking since millennia past (Aristotle 1997). In spite of this, scientific research of the topic
only started in the second half of the twentieth century (Fekete 2006). Although we may find
references to the responsibility of politics in Aristotle's Ethics of Nicomachus, it was not
before the 1960s that the improvement of the quality of life of any society being the duty of
wielders of power became political evidence (Kopp & Skrabski 2008). Post-industrial
societies gradually recognised that it was not enough to ensure access to goods (guaranteeing
consumption and level of subsistence), it is essential that the citizens are able to live their
everyday life in a positive way (Royo 2007). Satisfaction with one’s life is crucial, since the
negative mental state of those who are dissatisfied – who are experiencing a deep gulf

etween their actual and expected living conditions – may lead to a deterioration of their
physical health (Kopp & Pikó 2006). The overall social consequence of the resulting illness
(loss of productivity, replacement, medication, etc.) will be a heavy burden imposed on state-,
local government- and household budget. It is no coincidence that research in Hungary related
to quality of life almost invariably focuses on health-oriented issues (Kopp & Kovács 2006).
No matter if it is mental or physical health that is examined, its status will be affected by
whether leisure time is spent travelling: levels of mental and physical health are affected
indirectly by leaving the everyday paths of movement behind. Utilising the ever-increasing
range of offers of medical tourism can contribute directly to preserving, even restoring mental
and physical fitness levels (Richards 1999, Neal et al. 2007).
If, based on the literature, we accept that there is a relationship between tourism and quality of
life, then it is justified to expect a method for measuring the qualities of this relationship. For
this reason, the present study aims at laying the theoretical and methodological foundations
for the development of an index which can be used to measure the impact of a person’s
involvement in (or exclusion from) tourism on their quality of life. Given the government
demand as set out in the current Hungarian National Tourism Strategy (2005) for
optimalization of the impact of tourism on quality of life (especially in relation to society,
cultural heritage and natural environment), the statistical assessment of changes is considered
desirable, even on the municipal level.
This study offers a short summary of the theoretical and methodological literature discussing
the relationship of quality of life and tourism. The authors explore the methodological
foundations of selected definitions, thereby producing the set of indicators which, by fitting
into the framework of social indicator systems, are capable of measuring the relationship
between tourism and quality of life. This set of indicators will later provide the basis for the
index measuring the relationship between tourism and quality of life.
As indicated above, a close link is evident between quality of life and health. In order to be
able to show the relationship of this link to tourism, the study examines aspects of quality of
life in the population of settlements that are involved in wellness tourism.
Subjective well-being as a basis of study
Subjective well-being research has difficulties in defining the concept. Although subjective
well-being, happiness and life satisfaction may be treated as synonymous categories, certain
distinctions can be made between these concepts. Following definitions of the concepts
introduced by Lengyel and Janky (2003), differences may best be understood if we accept the
notion that people associate personal happiness rather with their personal micro-surroundings:
family, children, or social relationships - while life satisfaction is seen as something of a
broader concept, related to work, institutions and live history. Other than the clarification of
concepts, subjective assessment of well-being has another cornerstone: its apriori experience.
When examining the relationship between objective and subjective well-being one may find it
convenient to extend these concepts in such a way that the former is associated with material
prosperity, and the latter is paired to individual happiness; for this reason the majority of
studies on subjective well-being have focused on the relationship between these two
phenomena (e.g. Molnár & Kapitány 2006). This relationship can not be avoided when
investigating the connection of tourism and subjective well-being, even though – as also
stated in the introduction – the primary aim of our study is not the demonstration of the
discrepancy between objective and subjective well-being.

Social indicator systems
Social indicators may be grouped under different criteria. The grouping is primarily
determined by what phenomenon the indicators are used to represent. Horn (1993) has these
indicators grouped according to the following criteria:
A. Objective type:
1. Univariate approach: based on a single variable time series (for example, the
number of guest-nights at the town)
2. Multivariate "simple" approach: the formation of a combined index from
heterogeneous indicators (e.g. the distribution of foreign tourists visiting Hungary,
by nationality)
3. Multivariate "complex" approach: based on a complex approach of a socioeconomic
phenomenon, combining a variety of aspects (e.g., changes in long-term
trends of domestic tourism)
B. Derived, or subjective, type: according to Horn's theory, these indicators do not directly
measure the social phenomenon, but use the so-called substitute (proxy) indicators for that
purpose. These derived or inherited social indicators are based on individual perception of
living conditions, or subjective assessment of social facts
An objective-subjective distinction of social indicators is important because the models of
social indicators can be distinguished according to the preference for the type of indicators
they use to describe social phenomena. The summary below displays how, according to these
criteria, a separate index for tourism is used in existing models of social indicators, and how
the topic of tourism is linked with that of quality of life (Bukodi 2003).
The emergence of tourism in social indicator models
Some models use both descriptive and analytical approach at the same time. The resourcebased
(Scandinavian) model is strictly descriptive in nature. Primarily intended to describe
how all kinds of resources – financial, economic, related to way of living (health, social
network, education) – are distributed along different grouping criteria, it reveals in an
analytical framework the main reasons why social differences manifested in living conditions
exist. The Swedish model uses a relatively large group of objective indicators for each of
these reasons to try to describe living conditions of the affected population.
The approach with the set of social indicators called quality of life took root when scientists
set out to study individual and social well-being– and the question arose whether it was
sufficient to assess only objective living conditions, or there was also a need to examine these
objective circumstances from the individual’s point of view (as it was alluded to earlier, when
defining subjective well-being). The function of social indicators in the ‘quality of life'
approach to the model was to measure the gap between aspirations and reality.
According to the methodological foundations of the component model developed by English
researchers (also called the English model), social phenomena marked by the "living
conditions" concept can be divided into components (e.g. employment, household, health
status), and these components can be studied by statistical tools separately. Application of the
Component (or English) model has a double aim: on the one hand it provides a cross-sectional
social map of the time given, and on the other hand, it displays the nature and direction of
temporal changes regarding certain social phenomena 51 (Bukodi 2001).
51 A description of these models can be found in more detail in: Bukodi Erzsébet: Társadalmi jelzőszámok –
Elméletek és megközelítések, Szociológiai Szemle 2001/2. 35–57 o.

All models mentioned above contain some sort of component involving lifestyle or leisure
time that includes a few basic indicators related to tourism:
1. In the leisure and recreation group of the resource-based Scandinavian model we have
"the number and ratio of participants on holidays and vacation during the past year”
2. In the German model called the “Quality of life” (QOL), leisure time is paired with
media consumption
3. The English component-based approach works with the lifestyle category.
However marginally, the effect on quality of life created by tourism and travel is therefore
present in all social indicator models.
Examining the link between tourism and quality of life
Methodological dilemmas and the question of database
One can examine the link between tourism and quality of life from two aspects. First, we can
look at the individual's relationship to tourism (and the nature of involvement); second, we
can study the way that participation in the tourism sector influences the individual's subjective
well-being; we may call this the personal perception. This subject has already been dealt with
in several studies (e.g. Neal et al 2004, Michalkó et al 2009).
There is, however, a possible area of analysis arising from the assumption that people living at
frequented tourist destinations are happier than those living at areas less frequented by
tourists. This hypothesis could be justified by a specific study only, which would require
questioning an appropriate number of inhabitants of both popular and unpopular tourist
destinations about how happy they are. Existing research results on "happiness" or "subjective
well-being” used neither the kind of sampling method nor the sort of database that would be
appropriate for our research on the relationship to be investigated. What existing research may
support is only a kind of aggregate data: we may formulate some claims on individual
happiness and its correlations with various elements of life, but only on a national, possibly
regional level, and strictly along standard socio-demographic characteristics (gender, age,
education, settlement type and economic activity).
Another possible direction of research is to deduce the happiness of the inhabitants of a
settlement from the urban characteristics of their home town, and from the socio-demographic
indices of their population. In other words, we may try to measure subjective well-being at the
level of objective data, naming such an indicator system "objective quality of life". Of course
we are aware that these indicators are also influenced by a number of other mechanisms, and
that in many cases, the causal relationships may become juxtaposed. In spite of this we shall
make the attempt to either confirm or deny our hypothesis.
A further important aspect is that our model must have such a set of indicators that are easily
produced from the existing databases, thus eliminating the need for special or expensive data
surveys. According to this criterion we used the Hungarian Central Statistical Office (HCSO)
Time Use Survey 1999/2000 database and the HCSO TSTAR 2000 database for our research.
Determinants of subjective well-being
Using the theoretical basis, first we identified those areas and the range of indicators which do
affect subjective well-being of the individual. As mentioned earlier, people associate
subjective well-being or happiness with their personal micro-habitat primarily (Janky &
Lengyel 2003). Other literature (Lelkes 2003, Alesina et al 2001) show us that some factors
clearly affect the feeling of happiness. Based on the data of the HCSO Time Use Survey

1999/2000, Table 1. presents the means of scores given assessing individual happiness along
certain socio-demographic characteristics (on a scale of 1-4, where 1 = very unhappy, 4 =
very happy).
Pairing (operationalizing) aspects of micro-habitat with socio-demographic characteristics, we
may draw the following conclusions:
• Looking at age groups, going from younger to older, less and less respondents
considered themselves happy.
• Looking at marital status, the happiest are the married and the single (in the latter case
the appropriate age effect shall also be considered), while the widowed and the
divorced are the least happy.
• In the case of education, the rule seems to be that the more educated people are, the
happier they admit to be.
• Economic activity results show that the happiest are those on maternity leave and
students (again, assuming the age effect), as well as employed people and those having
a job besides pension; and the least happy are the disabled pensioners, those on social
benefit and the unemployed.

Table 1. Assessment of individual happiness along certain socio-demographic
characteristics, 1999/2000, mean
At
settlements
Mean At settlements concerned
concerned in in wellness
tourism tourism
Age group
14-19 years 3.04 3.03 3.07
20-29 years 3.00 3.01 3.01
30-39 years 2.94 2.96 2.94
40-49 years 2.86 2.86 2.86
50-59 years 2.81 2.8 2.82
60-69 years 2.80 2.81 2.8
70-84 years
Family status
2.78 2.81 2.81
Single 2.95 2.97 2.99
Married 2.94 2.94 2.93
Widowed 2.70 2.68 2.71
Divorced
Education
2.66 2.66 2.69
Less than primary school 2.68 2.72 2.63
Primary school 2.83 2.82 2.85
Uncompleted secondary school 2.89 2.89 2.85
Secondary school 2.97 2.99 2.96
Postsecondary school 2.98 2.96 3.05
College, university
Economic activity
3.01 3.04 3.08
Active income earning 2.96 2.97 2.97
Retired, with employment 2.91 2.95 2.99
Retired 2.79 2.81 2.81
Disabled pensioner 2.61 2.53 2.61
Maternity leave 3.05 3.01 2.97
Unemployed 2.73 2.76 2.73
Social benefit 2.53 2.4 2.21
Housewife 2.97 3.02 2.96
Student 3.06 3.05 3.06
Other dependent 2.76 2.77 2.84
Other inactive 2.8 2.82 3
Note: The question asked in the questionnaire: “All in all, what is your well-being
nowadays?” Answer: on a 1-4 scale, where 1 = very unhappy, 2 = unhappy, 3 = happy, 4 =
very happy.
Source: Time Use Survey 1999/2000. HCSO. Own calculations.

However, according to Table 1, it appears that inhabitants of settlements involved in
"tourism" or "wellness tourism" do not differ significantly from the national average in
assessing their personal happiness (53% of subjects in our sample were living at a settlement
involved in tourism; 23% lived at a wellness tourism destination). This appears to
demonstrate that micro-habitat factors affect the individual's subjective well-being more than
their macro-habitat.
Defining the indicator of “objective welfare of settlement”
Beyond a simple analysis of the available database, we are trying to determine the factors that
impact (individual) perception of happiness. Since our ultimate goal is to set up a ranking
among settlements in Hungary in terms of happiness of their inhabitants, we must first
determine the range of variables that influence subjective well-being. In order to do the same
for objective well-being, we must define those indices that will clearly have an impact on
subjective well-being at the individual level as well as at the municipal level. In other words,
if we find, for example, that moving into a new home has a positive impact on the individual's
subjective well-being, then our municipal level indicator measuring the construction of new
housing will receive a higher weight in our index for objective well-being.
Table 2 summarises the indicators used as explanatory variables in our model.
Number Dimensions affecting perceived Indicators affecting perceived
subjective well-being
subjective well-being
1. Socio-demographic indicators Age
2. Marital status
3. Highest level of education
4. Economic activity
5. Urban characteristics (facilities) Railway station
6. Long-distance bus station
7. Post Office/P.O.B, postal agencies
8. Bank
9. Market
10. Pharmacy
11. Old persons’ home
12. GP
13. Kindergarten
14. Primary school
15. Library
16. Tourism exists in the settlement
17. City status
Note: socio-demographic characteristics are from HCSO Time Use Survey 1999/2000, source
of local settlement features from database TSTAR CSO 2002
The dependent variable of our logistic regression model is a binary variable that is created
from a previous model, which had earlier been prepared to measure "happiness" on a fourlevel
scale 52 .
52 This was a question in the questionnaire: values of the dependent variable were created by aggregation. 1=
happy; 0=unhappy

As some of the settlement characteristics were not significant in explaining the dependent
variable, over a number of steps we dropped them from the model (one by one), hence
increasing the explanatory power of the model.
After omitting variables that did not fit in the model , the final equation became:
Happiness=b0+b1*agegroup+b2*familystat+b3*educat+b4*econact+b5*market+b6*GP+b7
*nursery+b8*library.
3.4. Measuring the impact of tourism on subjective well-being
In order to set up the equation, we need to find those settlements first that play an important
role in tourism. According to the classical approach, a settlement’s role in tourism is assessed
by the number of „guest nights” (Michalkó 2007). Therefore, the total number of guest nights
is the key indicator of tourism in our study. Settlements registering even a single guest night
are therefore considered "tourism-affected" settlements.
In addition, our analysis distinguished "wellness tourism-affected" settlements. This group
included all settlements that possessed some sort of medical or thermal spa or cave bath.
Results
Settlement-level approach: creation of a “happiness index” on the settlement level
In addition to assessing the factors that influence individual happiness, we would like to see
what kind of hierarchy can be established among settlements, when we look at the happiness
of the people who live there. In the model presented previously we were using variables
affecting subjective happiness that would apply on a settlement level also.
Why is this level of abstraction needed? It is easy to see that no ranking can be established
among settlements if we only consider individual happiness of their inhabitants; not unless we
also use a database that includes enough related data for each and every settlement. Such
database does not exist unfortunately, therefore we must tackle the problem differently.
Variables of the regression model on the database of answers on individual happiness are
“translated” into a settlement level, and are then weighted with the odds ratios from that
model. We can establish a ranking among the settlements then by simply averaging values
from the weighting.
Based on the HCSO TSTAR database, as settlement-level equivalents of variables in the
regression model, we used the indicators summarised in Table 3.
Table 3. Equivalents of determinants of subjective well-being on the settlement level
Number. Socio-demographic characteristics Settlement level indicators
1.
influencing the individual’s subjective
well-being
Age Proportion of the age group within the
population of the town
2. Marital status Ratio of the population of given family status
within the population of the town
3. Highest level of education Proportion of population of a given education
level within the population of the town
4. Economic activity Ratio of population of given economic
activity within the population of the town

Since the TSTAR database does not have the detail of data that we previously used in our
model, in the case of the variable for economic activity we applied the following aggregation:
TSTAR categories TUS categories
Employed → Pensioner, also active wage earner
Unemployment → Unemployment benefit
Pensioner → Pensioner, disabled pensioner
Inactive wage earner → Maternity leave, social benefit
Dependent → Housewife, other dependents, other inactive
Student → Students, children under school age
Since settlement characteristics did not play a major role in explaining happiness, the only
indicators we used in the following model (Table 4) were socio-demographic.
Table 4. Results of the regression model
Sig. Exp(B)
Age group, Reference category: 60 years
and older
15-29 years 0.011 1.815
30-39 years 0.583 0.897
40-59 years 0.013 0.705
Marital status. reference category: single
Married 0.000 3.316
Widowed 0.171 1.287
Divorced 0.485 0.877
Education, Reference category: school,
apprenticeship, without graduation
Elementary School: 8 or less classes 0.083
completed
0.759
Elementary School, 8 classes completed 0.146 0.834
Baccalaureate 0.000 1.763
Baccalaureate & postsec. 0.011 1.978
Degree 0.000 2.433
Economic activity, Reference category:
active wage earner
Unemployed 0.000 0.322
Pensioner 0.000 0.455
Inactive wage earner 0.003 0.490
Dependent 0.030 0.594
Student 0.003 2.300
Constant 0.000 4.107

The exclusion of settlement characteristics slightly reduced the explanatory power of the
model. The results show that the „trends” described in the previous model have not changed:
it is only the odds ratios of the new model that show a difference.
Definition of a ranking among Hungarian settlements, as a function of perceived
subjective well-being of their inhabitants
The socio-demographic variables we used in our model are coming from the 2001 Census
database, as summarized on a settlement level. The HCSO TUS data only contain answers
from subjects aged 14 years or older; accordingly, we ignored TSTAR Census data related to
population younger than 15 years.
To determine the index, following categories of variables as set in the model, we first
calculate the percentage of population to that of each settlement, as defined by the given
indicator. Each category of indicators will then have an odds ratio from the above model (in
case of the reference category the odds ratio will be a 1). We must then calculate an average
from each value thus obtained.
Figure 1. Hungarian settlements with the highest quality of life
The result are shown in Figure 1 which displays the hundred happiest Hungarian settlements.
It is clear from the figure that most (83%) of these settlements are located in Central Hungary
and the Danube region, while the ratio of happy towns and villages in East Hungary is
significantly lower (17%). Regarding the regional concentration of the settlements in the
sample, areas of higher density are the Budapest Agglomeration, the Lake Balaton region, the
Hungarian-Austrian border region, and around the mountains of Mátra and Bükk, all being
key recreation areas in the country. Considering the above settlements’ role in tourism, 71 of

the hundred happiest settlements registered overnight tourist demand, and 16 of the 71 are
involved in mainly domestic spa and health tourism.
Summary and conclusions
Keeping track of changes in the quality of life is not a task normally taken up by official
statistical data collection surveys. This is probably explained by the fact that the basic data
these studies ought to start with - namely: the question „how are you today”, or „how satisfied
are you with your life?” – will invariably give a body of information that is not exact enough
to serve as the foundation for a methodologically correct evaluation. Nevertheless, from time
to time the surveys of the Hungarian Central Statistical Office do have, as part of their
attempts to measure quality of life, a few questions pertaining to the topic.
As quality of life is a function of a great number of factors, the role played out by these has
been in the centre of interest of scientists representing various disciplines. Hungarian research
is centred upon aspects of quality of life that are related to health – we know much less about
how leisure travel, for example, contributes to the happiness of the Hungarian citizen. Within
this circle of issues, tourism research must look at how direct involvement in leisure travel
change the perceived quality of life, and to what extent living in a tourist destination does the
same.
Starting from the social indicator system, the present study aims at revealing those Hungarian
towns and villages that show the highest indicators of quality of life. Supported by the 2001
Census and the 2000 TUS survey, using an index given by mathematical-statistical methods it
presents the one hundred settlements in Hungary with the happiest citizens. Spatial
distribution of these settlements shows a geographical correlation with distinguished holiday
districts.
Acknowledgements
The survey forming the basis of this study was supported by the OTKA (K67573)
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Managing Cost, Revenue and Yield in the Tourism Wellness Industry
Patrizia Modica
Department of Economics and Business Studies, School of Economics
University of Cagliari
Viale S. Ignazio 17, 09123 Cagliari
Italy
modica@unica.it
Elisa Scanu
PhD School of Management and Accounting
University of Cagliari
Viale S. Ignazio 17, 09123 Cagliari
Italy
Abstract
The tourism wellness industry is a rapidly growing sector facing a number of challenges in
today’s fast-paced world, where people are looking for solutions to their wellness needs.
Management of this demand requires the implementation of a robust strategy in order to
maximise profitability and customer experience. This study considers the application of yield
management as a suitable approach, which is tested in this case in day spas as part of the
wellness industry. The viability of yield management in this field is investigated using a case
study approach, considering particularly the conditions required, and whether this managerial
method can generate significant benefits.
Keywords: Tourism wellness industry; Spas; Yield management; Pricing policies
Introduction
A healthy lifestyle plays an important role in the culture of individuals. Having a good
appearance, a good state of health, and a sporty lifestyle are personal desires that lead to
specific actions and behaviours. This is in contrast to attracting and opposite forces that lead
to unhealthy choices, for example, bad food or overeating, a sedentary lifestyle, or excessive
drinking. Healthy behaviours are generally prevalent in developed societies and this is
reflected in a sense of personal harmony with the environment. The need for wellbeing is
widespread and stimulates people to express a demand for health and wellness products. This
demand tends to accompany a person in everyday life – at home and away, at work, during
free time and in leisure moments. A combination of health, wellness and tourism can naturally
contribute to relaxation, exploration, socialisation, a sense of self-worth (McIntosh et al.
1984) and, moreover, quality of life (Bushell et al. 2009).
The wellness industry has emerged and grown in recent decades around the world (Erfurt-
Cooper et al. 2009, Smith et al. 2009), providing services for both resident and non-resident
customers. These services are provided by spas, gyms, beauty salons and adventure or
sporting travel organisations, among others. In the tourism wellness sector this industry
attracts different, economically-promising segments of demand. The management of the
demand for tourism wellness products can represent a challenge for entrepreneurs,
shareholders and managers. The tourism wellness industry needs to identify the characteristics
of this demand, which can contribute to the management of costs, revenues and profits, thus
revealing industry performance. The demand for tourism wellness products is generally

variable, unstable and seasonal, with high fixed costs and fixed capacity over the short term
on the supply side – as can be seen in the tourism industry in general (Vanhove 1994). Tourist
products are intangible, perishable, diverse and simultaneous to their production. This
demonstrates the need to manage a limited product and a changeable demand for it.
Yield (or revenue) management is considered a key tool for advantageously using the
resources invested in capacity-constrained firms in the tourism sector, reaching the actual and
potential demand and hence maximising profitability (Modica et al. 2009). It is particularly
seen in airlines, hotels and car rental firms, and, less frequently, in other tourism businesses.
Yield management is a strategic approach that optimises unit of inventory availability and
price, based on consumer behaviour prediction, with the objective of maximising revenues
and profitability, improving services and then customer perceived value (Cross 1997,
Donaghy et al. 1995). Kimes (2000) found evidence that yield management is often
implemented in service organisations as a tactical, rather than strategic, approach, for
example, proposing discounted rates to customers in slow periods outside a coherent strategy.
A set of strategic levers have to be adopted to improve the flow of customer demand and thus
performance, including knowledge of clientele segments, time of reservation, appropriate use
of capacity and a change in prices over time.
Some conditions that are present in the tourism service industry favour the effectiveness of
yield management. Yield management is suitable for those entities managing their constrained
capacity, their perishable products, their variable but predictable demand, their high fixed
costs and their pricing structures (Kimes et al. 1998).
This study involves the application of some aspects of yield management to the wellness
industry, specifically spa firms, and an analysis of the effectiveness of revenue management
strategies in this context. The spa industry seems to possess all the attributes to apply yield
management successfully. Spa businesses present similarities to hotels, airlines, car rental
firms, cruise lines, etc., as regards the conditions mentioned above. Spa pricing policies are
different, since spa treatment price tends to be fixed and has not yet been manipulated with
the sophistication that scientific yield management requires. Differential pricing can be
managed, gaining the opportunities that yield management can provide (Phillips 2005, Nagle
et al. 2006, Reece et al. 2000). Demand levels influence the way treatments are priced.
Moving from fixed to variable prices can permit spas to increase clientele numbers and
purchases, revenues and profits.
For the research, a case study approach was adopted, based on a day spa located in Cagliari on
the southern Sardinian coast. In the provision of spa services in Sardinia, as in many other
parts of the world (Kimes et al. 2009), revenue management techniques are not implemented
to contrast variable demand towards profitability results. To construct the case study, the
management practices of the spa were analysed, considering also occupation, treatment
duration and pricing, through semi-structured interviews with the owner/manager and key
staff members and a questionnaire. During these interviews and through the questionnaire the
current performance and the variables determining that performance were also acquired. The
case study tested the demand for a specific service and the related effects on revenues. This
was followed by a comparison with non-discriminating pricing policies practiced for the same
service and the related demand. As a result, the potential of yield management in improving
customer demand, occupation, revenues and, consequently, profits in the spa industry can be
evaluated.

Method: A Case Study Approach
The aim of this research is to analyse the effectiveness of revenue management in the
wellness industry, particularly in spa firms. For this purpose a case study approach is
appropriate, as this method permits exploration of the use of revenue management, and the
development of recommendations for the management of the wellness industry based on the
findings. A case study is defined as “a study of events within their real life context” (Yin
2009). This research looked at “Beauty Center Valentino”, a prominent day spa located in a
charming villa in the centre of Cagliari, the capital of Sardinia. The case study looked at a
single organisation representative of spa firms around the world and attempts to answer the
following research questions: first, are all the conditions to apply yield management to the
tourism wellness spa industry present?; second, is it possible for yield management to be
implemented and developed into this segment of the market?; and third, can yield
management improve profitability, and improve and maintain customer satisfaction?
To build the case study different types of data were required: capacity characteristics of the
day spa; demand characteristics; available services; cost structure; pricing policies and
revenue performance.
A six step approach was used to collect this data.
1. A conversation with the owner/manager to obtain general information about the spa
and explain the research project.
2. A semi-structured interview with the owner/manager and head receptionist about spa
policies and performance.
3. A questionnaire delivered to the head receptionist to complete regarding the spa’s
performance data and customer typology.
4. A focused interview regarding the cost structure to identify a fair margin product to
discount in February 2010.
5. Further interviews regarding the status of the study.
6. A further focused interview to collect the results, discuss the test, and obtain
information regarding the Italian wellness market.
First Step
The conversation was an opportunity to meet the owner/manager and obtain information
regarding the characteristics of the spa supply (services offered), capacity, pricing policies
and discounting, and customer typology, with particular regard to income, age, gender and
time and price sensitivity. The concept of yield management was explained, as well as the
importance of its implementation in the wellness industry to maximise profits and benefit
customers. It was requested that the spa test a particular discounting policy on a product for a
period of one month. This test is a simplified opportunity to observe the effects of the
implementation of some aspects of yield management in the short-term.
Second and third step
Yin (2009) regards the interview as “one of the most important sources of case study
information”, in particular suggesting the use of semi-structured, or guided, conversations
rather than structured queries, though still following a line of inquiry. Furthermore, the use of
a semi-structured, as opposed to a totally unstructured, interview better suits the addressing of
specific issues (Bryman-Bell 2007) and the acquisition of specific information.

A semi-structured interview was conducted with the owner/manager and head receptionist
regarding personnel policy and the spa’s performance. Information was also gathered on
occupation levels, treatment durations and pricing.
The questionnaire was also explained in detail and then given to the head receptionist to
complete and return at the next meeting to collate quantitative data. The questionnaire was
comprised of two sections. The first section covered the spa’s data for specified periods (a
Monday and Friday between 9:00am and 11:00am, and 1:30pm and 3:30pm in one week in
July, September and November 2009 respectively). The data included the number of
treatment rooms, the number of available therapists, the total possible hours to be sold, the
number of clients, and information regarding performance at those times. The second section
dealt with the clients: gender, age, residence, their time and price sensitivities, day of
reservation, attendance, and preferred treatments.
Fourth step
In the fourth step information was gathered regarding the products’ cost structure (revenues,
direct expenses – labour, professional products and supplies – and treatment contribution),
and then a product to which a discount could be applied was identified. This information
gathering approach is modelled on the Uniform System of Financial Reporting for Spas,
developed in 2005 by Schmidgall, which provides a uniform system for spas around the world
to accurately and efficiently manage and control their accounts. The identified product was
advertised on day spa Valentino’s website, and a notice put in each of the treatment rooms
and at reception.
Fifth step
On 1 st February 2010 the study test began. Further meetings were then held with the
owner/manager and the head receptionist to find out about the test’s progress and to conduct a
comparison of the spa’s performance in the same month of the previous year.
Sixth step
In the final step a further focused interview was held with the owner/manager to collect the
test results and discuss the process. In order to consider the case study in a larger context,
information was also gathered regarding the Italian wellness market, particularly
characteristics of competitors and their performances.
Findings
Day spa Valentino started its activity in 1984. It was originally located in a small premises in
Cagliari with a total capacity of 4 treatment rooms and 3 therapists. The business expanded in
1998 to its current premises, due to an increase in clientele numbers, and to offer services in a
larger, more comfortable environment, avoiding lengthy appointment waiting times. The new
premises has a fixed capacity of 12 treatment rooms, each available from 9:00am to 8:00pm,
Monday to Saturday. The number of therapists changes throughout the year, with an increase
in spring/summer, and a decrease in autumn/winter. Services offered vary from facial and
body treatments, to different types of massage, sauna, solarium and make-up.
In discussion with the owner/manager, a number of best practice competitors were identified,
all of which are based in mainland Italy and are the top day spas in the country. Day spa
Valentino is a well-regarded spa and considered one of the most prominent day spas in
Sardinia. Information about the competitors revealed that in the Italian market few spas apply
discounted pricing policies, instead using research into products, services, techniques and

methodologies, and educational travel (workshops and seminars) to maintain and grow their
businesses, as does the owner/manager of day spa Valentino. The owner/manager also
reported that in her opinion the day spa industry in Italy is in a good state of health due to the
tendency of owners to also undertake the roles of manager and therapist, their competencies,
creativity and innovation in this field, and the propensity of Italian women to spend time and
money on maintaining and improving their appearance.
The case study findings can be subdivided into the following sections.
1. Demand data.
2. Pricing policies.
3. Cost structure.
4. Performance data.
Demand data
The following tables show the customer demand details for the three months specified in the
study – July, September and November 2009.
Table 1 Total customers: male/female segmentation
9:00-
11:00
Monday
1:30-
3:30
JULY SEPTEMBER NOVEMBER
Male Female Male Female Male Female
/ 100% / 100% / 100%
10% 90% 16.7% 83.3% / 100%
Friday
9:00-
11:00
1:30-
3:30
/ 100%
23.1% 76.9%
/
/
100%
100%
60% 40%
12.5% 87.5%
Table 2 Total customers: resident/non-resident segmentation
9:00-
11:00
Monday
1:30-
3.30
Friday
9:00-
11:00
1:30-
3:30
JULY SEPTEMBER NOVEMBER
Resident Nonresident
Resident Nonresident
Resident Nonresident
100% 0% 100% 0% 100% 0%
100% 0% 100% 0% 100% 0%
100% 0% 100% 0% 100% 0%
77% 23% 84.6% 15.4% 100% 0%

Table 3 Attendance
Monday
9:00-
11:00
1:30-
3:30
9:00-
11:00
Friday
1:30-
3:30
Day spa Valentino’s customers tend to be local residents, female, predictable in terms of
reservation time and arrival, and aged around forty, their preferred services being body
treatments, nails and waxing. This demographic changes in summer when more tourists
demand spa services. Resident customers tend to have a high level of disposable income, visit
the spa frequently, and can be both time and price sensitive.
Table 4 Female time and price sensitive customers
Monday
9:00-
11:00
1:30-
3.30
JULY SEPTEMBER NOVEMBER
Time Price Time Price Time Price
0% 50% 0% 0% 100% 0%
22% 100% 20% 80% 57% 57%
Friday
9:00-
11:00
1:30-
3:30
50%
30%
100%
100%
0%
38.5
100%
100%
0%
42.9%
50%
28.6
%
Table 5 Male time and price sensitive customers
Monday
Friday
JULY SEPTEMBER NOVEMBER
Show
s
Noshows
9:00-
11:00
1:30-
3.30
9:00-
11:00
Cancella
tions
Shows Noshows
Cancella
tions
JULY SEPTEMBER NOVEMBER
Time Price Time Price Time Price
/ / / / / /
0% 100% 0% 0% / /
/ / / / 0%
Show
s
Noshows
100% 0% 0% 100% 0% 0% 100% 0% 0%
100% 0% 0% 100% 0% 0% 100% 0% 0%
1:30- 0% 100% / / 100% 0%
3:30
The number of customers varies throughout the year, with a higher number in spring and
summer, and fewer in autumn and winter. Of the months for which data was collected, July
experienced the highest number of customers, with a lower number in September, and the
fewest in November. The number of customers also varies per day and per hour. For the days
66.7
%
Cancell
ations
100% 0% 0% 100% 0% 0% 80% 0% 20%
100% 0% 0% 100% 0% 0% 100% 0% 0%

and times the data was collected, Friday experienced more customers than Monday, and
1:30pm to 3:30pm saw more customers than 9:00am to 11:00am.
The owner/manager reported that she was unsatisfied with the demand levels, but this was
likely due to her additional role in marketing and promoting services, whilst also acting as
owner, manager and therapist, and the extra time required for this, as well as the therapists’
lack of understanding and participation in the marketing and promotion of the spa. She also
felt that the local clientele demographic was responsible, with women over the age of fifty
having more disposable income but less tendency to visit the spa, and women aged thirty to
forty having the motivation, but a lower level of disposable income.
The case study revealed differences in the demand data (see Table 11 in 3.4). February is a
winter month and, accordingly, demand is typically low at day spa Valentino during this
month. The introduction of a discounted product as part of the study prompted an increase in
demand for that product throughout the month. Week one of February 2010 saw three times
as many sales of the specified product as the corresponding week in 2009, week two, six
times as many, week three, five times as many, and week four, four times as many. In 2009
for the specified product the customer typology was 100% female, 100% resident with an
average age of forty. During the test period the typology changed, with 4.5% male clients,
9.1% non-resident and an average age of forty. Customers who bought the products during the
case study test period were, predominantly, price-sensitive, reporting that they purchased the
product in direct response to the discounted rate, with only 20% of these customers having
tried the product before. Both in 2009 and 2010 the customers were frequent visitors to the
spa.
Table 6 February 2009: Customer demand details for the specified product at a fixed
price
Ma
Non-
Female Resident
le Resident
Reservation - Reservation
Time Price
Walk
More than 1 -Less than 1
sensitive sensitive
-in Shows
week week
No- Cancel
shows -lations
I
0% 100% 100%
week
0% 100% 100% 0% 100% 0% 100% 0% 0%
II
0% 100% 100%
week
0% 0% 100% 0% 100% 0% 100% 0% 0%
III
0% 100% 100%
week
0% 0% 100% 0% 100% 0% 100% 0% 0%
IV
0% 100% 100%
week
0% 0% 100% 0% 100% 0% 0% 0% 100%
Table 7 February 2010: Customer demand details for the specified product at a
discounted price
Ma Femal
le e
Resident Non-
Resident
Reservation - Reservation -
Time Price
Walk NoCancel- More than 1 Less than 1 Shows
sensitive sensitive
-in showslations week week
I
0% 100% 100%
week
0% 25% 75% 0% 100% 0% 75% 0% 25%
II
0% 100% 100%
week
0% 33.3% 66.7% 0% 100% 0% 100% 0% 0%
III
week
25
% 75% 75% 25% 0% 75% 0% 100% 0% 100% 0% 0%
IV
0% 100% 87.5%
week
12.5%% 12.5% 62.5% 0% 100% 0% 75% 0% 25%

Although day spas, including Valentino, don’t tend to segment or analyse their market data,
the historical demand data regarding time-variable and predictable demand gathered in this
case study demonstrates that segmentation is possible, therefore satisfying the necessary
criteria for applying yield management.
Pricing policies
It was discovered that day spa Valentino uses a fixed pricing policy for all of its products and
services, except for one body treatment, which is offered at a discounted rate between October
and January each year. This practice of implementing a fixed pricing policy is frequent in the
international spa wellness industry, which does not favour yield management as it requires a
variable pricing policy to enable its implementation.
Cost structure
The following pie charts show the cost structure for some treatments offered at day spa
Valentino before the test took place in February 2010.
PROFESSIONAL PRODUCTS 30.00%
SALARIES AND WAGES 13.62%
SUPPLIES 2.00%
PROFESSIONAL PRODUCTS 4.80%
SALARIES AND WAGES 21.80%
CONTRIBUTION 71.40%
Figure 1 Cost structure for facial- percentage Figure 2 Cost structure for massage -
percentage on revenue on revenue
SALARIES AND W AGES 48.47%
SUPPLIES 0.50%
CONTRIBUTION 29.80%
SUPPLIES 0.73%
CONTRIBUTION 55.80%
PROFESSIONAL PRODUCTS 21.00%
SALARIES AND WAGES 36.35%
PROFESSIONAL PRODUCTS 7.60%
CONTRIBUTION 47.30%
SUPPLIES 8.75%
Figure 3 Cost structure for manicure – percentage Figure 4 Cost structure for waxing
- percentage on revenue on revenue
The pie charts below show the cost structure for the case study product, a Damascan Rose
Scrub and Massage, at a fixed price and at the discounted price. The data shows a high
treatment contribution by each service studied. This is consistent with yield management
which is suitable for businesses with high fixed costs as the treatment contribution can be
used to cover the remaining costs.

SALA RIES AN D W AGES 18.17%
PROFESSIO NAL PRODU CTS 6.33%
SUPPLIES 0.50%
CO NTRIBUTIO N 75.00%
Figure 5 Cost structure for Damascan Rose Scrub and Massage at a fixed-price –
percentage on revenue
S A L A R IE S A N D W A G E S 1 8 .1 7 %
P R O F E S S IO N A L P R O D U C T S 6 .3 3 %
S U P P L IE S 0 .5 0 %
C O N T R IB U T IO N 3 8 .3 3 %
A L L O W A N C E S 3 6 .6 7 %
Figure 6 Cost structure for Damascan Rose Scrub and Massage at a discounted price –
percentage on revenue
Performance data
Spas can measure performance by calculating the number of customers, the average spend per
guest, the occupancy rate, or the revenue per available treatment hour (RevPath). The
following table shows day spa Valentino’s average spend per guest, calculated as a percentage
change from month to specified month in the study.
Table 8 Average spend per guest rate of change
Mond
ay
Frida
y
9:00-
11:00
1:30-3.30
9:00-
11:00
1:30-3:30
July/September September/Nov
ember
-20.00% 30.07% -3.90%
-44.71% -21.86% +1.31%
November/July
400.00% -56.00% -54.54%
3.81% 66.08% -42%
In order to calculate day spa Valentino’s performance in July, September and November
2009, two measures were used: occupancy rate (treatment rooms occupied/available);
RevPath. The occupancy rate measures treatment room supply efficiency, that is the capacity
of the spa to sell its units. Based on the results the capacity of the spa is not well-utilised, with
a consistently low occupancy rate, which surpasses 50% only in the busiest month of July,
and the lowest rate on the Monday tested in September. The owner/manager explained that
this occupancy rate is due to a number of the treatment rooms being sole-use, for example, the
solarium and the sauna, with only seven treatment rooms available for multi-use purposes.
Another important measure is the RevPath, which measures revenue per available treatment

hour and “combines information from the average customer expenditure and treatment room
use to provide a measure of flow of revenue (…) and to indicate how effectively a spa is using
its productive capacity” (Kimes 2009). This measure is complementary to the occupancy rate
as it also considers revenues. A manager’s purpose is not only to increase occupancy. Indeed,
an indiscriminate discounting policy can increase the number of treatment rooms occupied yet
have little influence on revenues.
The following tables show day spa Valentino’s occupancy rate; RevPath during the three
months studied, shown as a percentage based on the highest RevPath level achieved on the
Monday in July from 1:30pm to 3:30pm.
Table 9 Day spa Valentino’s occupancy rate in 2009
Monday
9:00-
11:00
Friday
9:00-
11:00
Monday
1:30-
3:30
Friday
1:30-
3:30
JULY SEPTEMBER NOVEMBER
8% 6% 8%
17% 17% 16%
42% 17% 33%
58% 42% 50%
spa to be unsatisfactory, though she
believes the clientele base of the spa
industry will increase significantly in
the coming decade, with men, and
women in their twenties becoming
regular spa users.
The performance data generated by the
case study is shown in the table below.
Table 10 Day spa Valentino’s
RevPath in 2009
Monday
9:00-
11:00
Friday
9:00-
11:00
Monday
1:30-
3:30
Friday
1:30-
3:30
The owner/manager gave information on
the personnel policy at day spa
Valentino, which can affect the RevPath.
For example, in the summer months
customers are more likely to visit the spa
in the afternoon and visit the beach in the
mornings, so the spa has fewer therapists
working at these quieter times. She also
reported difficulties in increasing the
number of therapists whilst demand
levels are low. The owner/manager was
also surprised at the performance data
figures, despite having a general feel for
the performance of the spa and having
full capacity in the multi-use treatment
rooms at some points during the week.
She considered the performance of the
JULY SEPTEMBER NOVEMBER
27.64% 31.58% 13.90%
6.33% 31.58% 13.92%
100% 33.17% 30.26%
59.1% 57.00% 58.30%

Table 11 Treatment and revenue rate of change for February 2009 and February 2010
February 2009/2010
WEEK
1
WEEK
2
WEEK
3
WEEK 4
2009/2010 Treatments 200% 500% 400% >300%
2009/2010 Revenue 128% 356% 280% >204%
As can be seen, there is a dramatic increase in revenues (up 356% in week two) and the
number of treatments demanded (up 500% in week two) during the case study (as shown in
3.1). The owner/manager was positive about the possibility of improving revenues and
customer demand using discounted pricing policies, and was very satisfied with the results.
She does believe, however, that the results could be improved still further with increased
marketing and promotion of the discounted service.
Concluding Remarks
Personal interest in health and wellbeing has grown in recent years and is expected to further
increase in the coming decades. People’s lifestyles are constrained by a fast pace of life and
this is in contrast to a natural inclination towards slower living, which represents a challenge
for the wellness industry. The demand for wellness, including from spa services, health
services, and sports and fitness services, needs to be met with appropriate marketing and
management strategies in order to maximise the potential of this sector. This study has
considered yield management as a possible approach to managing this sector more efficiently
and profitably, in this case testing the theory on day spas. Day spa Valentino, located in a
popular tourist destination, allowed the testing of a discounted pricing policy as a part of yield
management techniques. A case study approach was used, with semi-structured interviews
and a questionnaire addressed to the day spa management. Characteristics and baseline
performance for 2009 were acquired, together with demand data and the services cost
structure. A fair margin discounted product was tested in February 2010 and considerable
results were attained. The clientele of the day spa demonstrated an appreciation of the benefits
of the discounted service and their price sensitivity led to a significant increase in sales in
February 2010, with a number of first-time purchasers of the product, despite all the
customers being frequent visitors to the spa. The owner/manager was very satisfied with the
results and has since introduced a number of discounted packages on other products offered
by the spa, encouraging customers to purchase products in bulk, purchase more products and
try services they have not previously bought. The new pricing policy has shown immediate
results with an exceptionally high amount of total revenue in February compared to the other
months studied.
The effects of this simplified application of yield management are worth considering with
regards to the wellness industry as a whole. The strength of yield management in improving
customer demand is evident from the study and this has the potential to be carried over into
other areas of the industry. The dimensions of some spas around the world can create
difficulties in implementing the complexities of an information system as yield management
requires, as the necessary competencies and investment may not be present. However, the
sophistication of yield management can be high requiring the application of information
systems or “in a more limited way with an intelligently developed and applied set of pricing
and organisational practices” (Anderson et al. 2007).
The spa wellness industry has so far been constrained within a fixed price strategy model,
whilst managing a fixed capacity with perishable products, losing the manoeuvrability

equired to fully reach its profitability potential. As the spa wellness industry is currently
considered the fastest growing tourism sector industry in the world (Haden 2007), it is
essential that it begins to seriously consider the implementation of yield management
strategies in order to maximise profitability and customer experience.
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Measurement of the Economic Impacts of Health Tourism Development in
Hungary
Margit Mundruczó
College for Modern Business Studies
Hungary
mundruczo.gyorgyne@mutf.hu
Introduction
Nowadays the health tourism is one of the most dynamic sub-sector of tourism. There are
many reasons for this both on demand and on supply side. The key demand drivers of tourism
are variables such as wellness, beauty, harmony of body and soul, and recently the growing
needs for medical tourism. These demand trends have pushed the owners of traditional
thermal bath and spa hotels to start the development tourism services and facilities based on
the thermal water sources.
There are two major financial support sources of Hungarian health tourism development:
1. Government funding – Széchenyi Development Program (replaced by the New
Hungary Development Plan since 2007). In 2001 the Hungarian Government
established the Széchenyi Tourism Development Program with 115M Euro (31bn
HUF, 1 euro = 270 HUF) to support spa and wellness/medical hotel development. The
objective of the development program was to utilize the tourist development multiplier
effect and level out the regional development differences between tourism
destinations.
2. EU funding. In 2004 Hungary has joined the EU and established the National
Development Program (NDP) to define the national development objectives and
establish supporting financial funding to development project aligned with those
objectives. A major component of this program is the funding of health tourism
developments.
In the first phase of the National Development Program (NDP1 - 2004-2006) 2,7% of all EU
financial support (113M Euro = 30,5bn HUF) was dedicated to the tourism related programs.
The 2 nd phase of the plan (NDP2 – 2007-2013) provides 4% of all EU funding to the tourism
related program, part of which is health tourism program. In 2007-2008, 270M Euro (73bn
HUF) were awarded to 278 projects. The major objective of EU support was to improve lower
developed regions through attraction and accommodation development. (ÖTM, 2008)
In order to monitor the development projects objectives and results achieved, the government
monitoring system provides few simple tourism performance indicators. (MTA-RKK, Raffay
et al) However the noted volume of tourism funding and the nature of tourism developments
require more complex measurement of the economic impacts.
The author of this article has first conducted an economic impact research study in 2004
focusing on 11 Széchenyi Program projects in 11 cities to examine the local economic
impacts of health tourism development (Munduczó et al, 2005).
Later in 2009, on request of the Research Institute of the State Audit Office, Hungary the
author conducted a detailed study of the economic impact of 10 tourism related projects (4
spas, 4 wellness hotels and 2 cultural and natural attractions) in 7 cities. This study is
currently being finalized.

These two research studies together cover 6 of the 7 statistical planning regions of Hungary.
The main objectives of the research studies were:
• examine the local economic impacts of tourism investments financially supported by
the government or EU to measure their multiplier impacts.
• introduce the operational characteristics and local/national impacts of the new tourism
investments (e.g.: new jobs created, growth of operational revenue, growth of local
and central budget revenue generated by the new health tourism projects).
• introduce quantitative indicators of the demand and its structure with seasonal
characteristics
• understand the perception of locals and entrepreneurs about the tourism investments
• estimate the economic impacts of health tourism development at national level.
Research methods
Both research studies have relied on the same approach and methodology. This included the
following components:
• Collect relevant statistical data (desk information) on tourism projects prior to and
after developments such as:
o Capacity and tourist flow of collective accommodation at the examined
destinations.
o Number of tourism enterprises at the examined cities/towns
o Growth of own tax revenue (inc. Tourism taxes) of local government
These data were obtained from the Central Statistical Office, Hungary.
• Information and statistical data produced by primary research such as
o Investment data of health development projects
� Projected, actual investment values
� Characteristics of construction
� Share of import
o Estimated/projected investment values of indirect and induced tourism
investment in the following 4-5 years.
• Operational data
o Number of new jobs generated by health tourism investments
o Operational revenue of new units
o Quantitative demand indicators of new developments, seasonility and structure
of tourist flow
o Local and central budget taxes paid by new health tourism
The primary research was based on focused statistical data request (data sheets designed
specifically for the studies) and interviews with local government representatives and unit
managers.
While the approach and methodology was the same in the two studies, there were some
unique factors and the research timeframe and project macro-environments were different.
Next we present a short summary of the studies with key characteristics.
• 2004 research study
o Scope: 11 health tourism projects, financially supported by Széchenyi
Program.
o Research timeframe: base year of 2001 and first full operational year in 2004
o Széchenyi Program was the only tourism development program in Hungary in
the research timeframe

o The macro and micro environment remained the same during the research
timeframe
o Examined development projects completed and operations started at nearly the
same time
o The studied project investment value was over 15% of total project investment
value, which allowed for estimation of national impacts.
• 2009 research study
o Scope: 10 tourism projects, out of which 4 financially supported by Széchenyi
Program and 6 projects financially supported by EU Regional Operational
Program (ROP).
o Research timeframe: 8-year timeframe with different project start and end
dates (2004-2008).
o The 2008-2009 economic crisis impacted 6 EU supported projects’ first
operational data.
Major findings
This section will present the major findings of the two studies. First the focus will be on the
investment multiplier, than on the operational impacts of health tourism project (from
employment impacts, through revenue impacts demand indicators and taxation).
Investment multiplier
Both studies focused on analyzing the impacts of the investments in generating further
investments and calculated the investment multipliers for the projects in focus.
2004 research study major findings:
• Tourism investment multiplier value of 2,7 based on indirect and induced investments
– 11 projects with 77,8M Euro (21bn HUF) investment generated additional 118,5M
Euro (32bn HUF) investment, altogether 196,3M Euro (53bn HUF) investment over 5
year period.
• 100 HUF government financial support of health tourism development generated 550-
500 HUF private capital investments in tourism over the 5 years.
• The induced and indirect investments were primarily in accommodation development
(e.g. wellness hotel near the spas, pensions) and spa/thermal bath developments
further enhancing facilities and services.
2004 research study - investment multiplier
(data in 1000 HUF)
22 620 000 ; 43%
9 700 000 ; 18%
Actual investment value (2001-2003)
Indirect Investment value (2001-2003)
Induced investment value (2004-2006)
(Source: Research study, 2004)
20 935 016 ; 39%

2009 research study major findings:
• Tourism investment multiplier value of 1,49 based on indirect and induced
investments. Spa and aqua park investment multiplier of 2,4, wellness hotel multiplier
of 0,33, other attraction multiplier of 2,66.
• Out of the studied projects, the highest investment multiplier value belonged to St.
Gotthard Spa, located on the Hungarian-Austrian border. The high multiplier value
may be explained by the fact that the city did not have active tourism until recently.
This spa project was the first step in building of the city tourism infrastructure, which
was soon followed by multiple city projects.
• Indirect investments related to cultural and natural attraction developments (e.g.
accommodation) were found to be minimal, however the induced impacts (e.g. aqua
park) still generate a high multiplier value.
2009 research study - investment multiplier
(data in 1000 HUF)
12 238 000;
39%
6 428 350;
21%
Actual investment value (2001-2008)
Indirect investment value (2002-2008)
Induced investment value (2003-2012)
(Source: Research study, 2009)|
12 536 001;
40%
Major conclusions:
• Spa and aqua park investments have high investment multiplier values (between 2,4
and 2,7). These facilities have also fulfilled tourism attraction functions.
• Wellness hotel developments have a low investment multiplier value. This may be
attributed to the fact that these hotels provide services in-house and do not generate
other tourism investments outside the unit.
• Due to the increased business risks, the economic crisis decreased the multiplier
values of the tourism investments.
Operational impacts of health tourism projects
Operational impacts were identified based on the last full operational year of each unit (base
year) and the first year of full operation after the project completed.
In case of the 2004 research, 2001 was the common base year for all projects and 2004 was
the first full operational year.
In case of the 2009 study, the base year and first full operational year were different project
by project. The wellness hotel projects with EU financial support (4 units) have had only 1-2
years of operation at the time of the study. It is well known that the first years of new hotel
operations are introductory years with lower prices, lower occupancy rates as compared to
later years. This is further impacted by the economic crisis started in 2008 Q4.
Next we will look at the employment impacts, the operational revenue impacts, the
quantitative demand indicators, taxation and local economy impacts of the tourism projects.

Employment impacts
During our analysis of employment generation impacts of health tourism projects we relied on
the following data:
• Average number of full time employees in units
• Number of part time employees in units
• Number of employees (full time and part time) at the outsource partners e.g.: fast
food restaurant within the thermal bath unit, security services, gardening, etc.
Major findings:
• In the 2004 research study, 457 new full time jobs and 690 part time jobs had been
generated by the examined health tourism projects. In the project applications, the
projected new positions totaled only 387. The majority of these projects were thermal
bath/aqua parks (10), and a few small wellness/spa hotels (3). Two spas have had
small hotels too.
The investment required per one new full time employee was 166,7k (thousand) Euro
(45 million HUF) - without part-time employees. This indicator would have been
much lower with the calculation of the number of part-time employees.
The government’s subsidy on average was 59,3k Euro (16 million HUF) per new job.
• In 2009 research study, 363 new full time jobs had been created for employees by the
tourism projects in focus. Interestingly, relatively few outsource jobs were offered for
employees within the health tourism units. The numbers of part-time employees were
65, mainly trainees, waiters/waitresses and hostesses.
The investments required per one new full time job in the case of thermal bath/aquapark
was 111k Euro (30M HUF) on average. In the case of middle size wellness hotels
this indicator was between 133-159k Euro (36-43M HUF), and 56-74k Euro (15-20M
HUF) of small hotels. We can state that the larger the hotel capacity, the larger the
investment costs of job creation.
The financial subsidy provided by the government or EU for job creation in the case of
thermal bath/aqua park was between 52-122k Euro (14-33M HUF), the private
investors of wellness hotels received 11-33k Euro (3-9M HUF) for established new
workplace.
The next graph shows the job creation impact of 11 health tourism projects from the 2004
study:
2500
2000
1500
1000
500
0
Be fore proje ct
inve s tm e nt
(Source: Research study, 2004)
Employe e s in 11 proje cts
Afte r proje ct
inve s tm e nt
Outs ource
In fa cility

Operational revenue of health tourism projects
The revenue of unit operations depends by large on the size of the unit, the types of core
businesses, the market segments and market opportunity of the unit.
The operational revenue is one of the most important basic business performance indicators in
the view of the economic impact. Partly because it is the source of costs and expenses (e.g.
payroll related direct expenses paid to the central budget) and certain local taxes directly
based on the operational revenue (e.g.: local operational tax). It’s growth also shows the
business success of the examined tourism property.
In the 2004 research study, 3 new health tourism projects were examined out of 11
developments. The other projects were renovation of existing services for a higher service
level, enlargement (more pools inside and/or outside) of the unit, development of medical
treatment facilities and wellness facilities.
Major findings of 2004 research study:
• The total operational revenue of 11 examined health tourism projects increased by
130% (with an extra of 3,35bn HUF) compared to the base year’s operational revenue.
• We could see a synergy effect of the new health tourism developments. It means that
the new developments have not reduced the operational revenue of their competitors,
thus they have resulted an extra tourism demand for the region. The yield of wellness
and spa hotel is much higher than the yield of thermal bath and aqua park. It is due to
the daily expenditure of visitors.
• Operational revenues per one new full time employee was 24k Euro (6,6M HUF)
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
-
(Source: Research study, 2004)
Operational revenue in 11 facitities
(data in 1000 HUF)
2001 2004
Major findings of 2009 research study:
• Despite that the majority (7 out of 8 projects) of the examined health tourism projects
were new developments they generated 4,8 M Euro (1,3bn HUF) extra operational
revenue – at the price level of the first full operational year.
• The operational revenue per one full time employee was 13,7k Euro (3,7m HUF). The
lower labor productivity indicator is due to lower discretional income of Hungarians
and the economic recession mentioned earlier.

• The examined wellness hotels were strongly influenced by the economic crises started
in 2008.
Quantitative demand indicators
Quantitative demand indicators are commonly used in market analysis. The main indicators
are the following: number of visitors (in thermal bath/aqua park), number of tourist arrivals at
accommodation (in hotels), number of tourist nights (in hotels). These indicators with the
actual prices directly influence the operational revenue and the occupancy rate of hotels. In
the case of thermal bath and aqua park we use the number of visitors, in the case of hotels the
best volume indicator is the number of tourist nights.
Below we explain the key volume demand indicators of the examined units.
The 2004 research study finding may be summarized as follows:
• The number of visitors of the examined 11 projects in the first full operational year
was higher with 60% (+ 2,16M HUF) compare to the base year (2001).
• The market share of domestic visitors out of total number of visitors were 70%
• The new health tourism developments reduced the seasonal fluctuations of tourism
demand.
• The thermal baths and aqua parks are very popular attractions among the locals.
80% of the examined cities’ population had already visited the new health tourism
units and 50% of the local visitors regularly attend the thermal bath. Most of the
primary and secondary schools’ students have their gymnastic class in the
swimming pool of the thermal bath.
• The health tourism developments of Széchenyi Program resulted 10 million extra
domestic visitor numbers yearly.
We present the findings of 2009 research study:
• Debrecen Aquaticum has shown the greatest volume and the most dynamic
increase since their opening. This unit provides 60% of the total visitor numbers of
the examined 4 thermal bath/aqua parks. It caused by the size of tourism
development and its attractiveness.
• The examined 4 new wellness hotels with conference facilities (618 room of total
room capacity) provided 60,000 tourist nights in the first full operation year. The
room occupancy rate was relatively high between 32-40% on yearly.
• MICE (Meeting, Incentive, Conference, Event) market segment provides the major
demand driver with 40% of total tourist nights generated, while the market share of
foreign tourists was relatively low (between 10-30%).
Taxation
As with all enterprises, health tourism enterprises pay various direct and indirect taxes. The
direct tourism taxes paid are local operational tax (if the enterprise has an operating profit),
property tax, and other taxes, etc. Indirect taxes paid to the central budget excl. VAT are
mainly payroll related expenses: income tax, social insurance, employee tax, employer tax,
etc.)
There are three important taxes paid by hotels: operational tax which is a few percent of the
net revenue, real estate tax, and the most important, the tourism tax which amounts to 0.9 –
1.3 Euro (250-350 HUF) per night /tourist. The latter is to be paid by tourists, however, due to
the price competition between hotels often undertaken by the hotel.

We present the direct tax revenues (excl. VAT) of health tourism projects based on the 2009
research data:
• Research data shows that local tax revenues of the examined projects depend on the
projects’ specifics and their ownership. Most thermal bath and aqua parks in Hungary
are city government owned, thus during the first years of operation they are usually
exempt from local taxes. However later this local operational tax is a large
• On average, about 20% of the net revenue of health tourism project are paid as a direct
taxes. (The 2004 study showed the same data.) Based on the studied projects, 5-10%
of thermal bath and aqua park revenues and 12-25% of hotel revenues are paid to the
local governments.
• The amount of local tax revenues of particularly small city governments, are greatly
influenced by the examined tourism facilities. The examined 4 new wellness hotels
generated 110M Euro (30bn HUF) local tax for the city governments. The local tax
paid by the examined thermal bath and aqua parks (with the same investment value)
was only 55% of the wellness hotels’ local taxes.
The impacts of health tourism development on the local economy
Health tourism development has significant impacts the local economy both directly and
indirectly. Direct impact includes local tax revenues and job creation; indirect effects are the
multiplier effect of the investment, the development of the city as a tourism destination and
the associated increased visits of tourist. Further direct effects are increased local tax revenues
and increased scope of activity and prosperity of local businesses. Below, through the results
of the 2009 study, we will show you these direct effects in three different size cities in
different regions of the country. These cities are:
• Debrecen (located in North Hungary), population of 206,000, new aqua park
development (2003)
• Szentgotthárd (located in West Hungary), population of 9,000, new thermal bath and
aqua park development (2007)
• Tiszafüred (located in Lake Tisza region), population of 11,000, new wellness hotel
development (2007)
Accommodation capacity and demand volume
As it was mentioned earlier the accommodation capacity and the number tourist arrivals at
commercial accommodation expresses the size tourism at the visited destination. Below we
illustrate the impact of health tourism development in three examined cities, namely:
Debrecen, Szentgotthárd and Tiszafüred.
Total number of available beds Total number of tourist nights spent
(accommodation supply side)
(accommodation demand side)
Debrecen. In early 2000 the commercial accommodation capacity stagnated in Debrecen. Due
to the higher level of quality accommodation development, the number of hotel rooms
increased but it did not translate to a bed capacity increase. Partly as a result of the
introduction of the aqua park, hotel utilization increased until 2006. Hotels provide 2/3 of total
commercial accommodation nights. Since 2006, accommodation utilization slightly declined
due to a decrease in foreign tourist. This trend fits with the experience in Hajdú-Bihar County
where Debrecen is located. Both the capacity and quality of commercial accommodation
satisfies the need, which explains the low number of bed & breakfast accommodation.

Total number of available beds
(accommodation supply side)
8 000
7 000
6 000
5 000
4 000
3 000
2 000
1 000
0
Debrecen
2001 2002 2003 2004 2005 2006 2007 2008
Magán szállás férőhely
Egyéb ker. férőhely
Szállodai férőhely
Total number of tourist nights spent
(accommodation demand side)
450 000
400 000
350 000
300 000
250 000
200 000
150 000
100 000
50 000
0
Debrecen
2001 2002 2003 2004 2005 2006 2007 2008
Magán szálláshelyi vendég éjsz.
Egyéb ker. vendég éjsz.
Belföldi száll. vendég éjsz.
Külföldi száll. vendég éjsz.
Szentgotthárd: the city’s accommodation capacity increased due to the building of smaller
hotels and pensions as an indirect effect of the examined health investment. This also effected
the influx foreign tourist nights. This is the likely explanation of the continued growth of
tourism in Szentgotthárd through 2008.
500
450
400
350
300
250
200
150
100
50
0
Szentgotthárd
2001 2002 2003 2004 2005 2006 2007 2008
Magán szállás férőhely
Egyéb ker. férőhely
Szállodai férőhely
25 000
20 000
15 000
10 000
5 000
0
Szentgotthárd
2001 2002 2003 2004 2005 2006 2007 2008
Magán szálláshelyi vendég éjsz.
Egyéb ker. vendég éjsz.
Belföldi száll. vendég éjsz.
Külföldi száll. vendég éjsz.
Tiszafüred: until the opening the Hotel Tisza Balneum, there was no hotel in town. In 2008,
guest nights influx increased significantly due to the new 4 star wellness & conference hotel.
This private hotel investment stimulated other commercial accommodation utilization and
demand for bed & breakfast accommodation.
4000
3500
3000
2500
2000
1500
1000
500
0
Tiszafüred
2001 2002 2003 2004 2005 2006 2007 2008
Magán szállás férőhely
Egyéb ker. férőhely
Szállodai férőhely
80 000
70 000
60 000
50 000
40 000
30 000
20 000
10 000
0
Tiszafüred
2001 2002 2003 2004 2005 2006 2007 2008
Magán szálláshelyi vendég éjsz.
Egyéb ker. vendég éjsz.
Belföldi száll. vendég éjsz.
Külföldi száll. vendég éjsz.

Local tax revenue generated by tourism
Tourism related local tax revenue
Debrecen
Comments
Debrecen
The tourism related tax revenue of city
700 000
government started to increase from the
600 000
second year of the new aqua park operation
500 000
due to the indirect investment multiplier effect
400 000
Idegenforgalmi váll. Iparűzési adója (000) (e.g.: hotel investments). The graph shows that
Idegenforgami adó utáni állami támogatás ('000)
300 000
Idegenforgalmi adó (000)
the tourism enterprises pay a significant
200 000
amount of local operational tax.
100 000
0
1 2 3 4 5 6 7 8
Szentgotthárd
18 000
16 000
14 000
12 000
10 000
8 000
6 000
4 000
2 000
Tiszafüred
0
40 000
35 000
30 000
25 000
20 000
15 000
10 000
5 000
0
Szentgotthárd
2001 2002 2003 2004 2005 2006 2007 2008
Tiszafüred
2001 2002 2003 2004 2005 2006 2007 2008
Ideg enforga lm i v áll. Iparűz és i adója (000 )
Ideg enforga mi a dó u táni állam i támogatá s
(' 000)
Ideg enforga lm i adó (000)
Ideg enforga lm i v áll. Iparűz és i adója (000 )
Ideg enforga mi a dó u táni állam i támogatá s
(' 000)
Ideg enforga lm i adó (000)
Tourism related tax data are available from
2006. The graph shows a dynamic growth of
local tourism tax revenue and government
subsidy based on the actual tourist nights in
the city’s accommodation.
Hotel Tisza Balneum has influenced the
city’s tourism tax revenue significantly,
resulted by the increased tourist nights and
by the government subsidy based on the
actual tourist nights.
Conclusion: The tourism indicators show that the examined health tourism developments have
increased the volume and the level of tourism infrastructure, they have influenced the growth
of tourism demand, and resulted significant surplus tax revenue for the city government.
Summary
• The studies found that the investment multiplier largely depends on the type of
development (attraction, aqua park, accommodation, etc). Other factors include the
ratio of financial support and private capital, the tourism potential of the region and
the macro economic environment and general tourism trends. Spa/aqua park health
tourism development investments have an investment multiplier of 2,4-2.7. In the case
of accommodation developments the investment multiplier was found to be 0,37 in a
time of economic crisis.

• Our analysis showed that new job generation as a KPI to measure the impacts of
tourism developments have important shortcomings, which makes it’s calculation
more difficult. In the case of the number of newly created jobs one needs to take into
account the outsourcing of services – the additional jobs generated outside the unit at
service partners.
• In the case of the studied projects we found that the investment cost of creating a new
job is 110k – 150k Euro (~30-40M HUF), in case of small hotels this value was 55k –
66k Euro (15-18M HUF). The financial support per new job was found to be in the
range of 11k-55k Euro (3-15M HUF).
• Both studies found that 1 unit of health tourism financial support generated altogether
6 unit of investment.
• The highest profit generation was found in hotel developments. Hotels also generated
the highest revenue and tax payments.
• Tourism units pay 15-24% of their revenue to the central budget and the local
government. Local governments receive ~20% of all taxes paid by the units.
• When analyzing the local government revenues, we found that over the study
timeframes, the tourism related revenue increased consistently which was still further
increased by the tourism tax.
• The studied tourism development projects generated dynamic tourism developments in
the host cities (which yielded significant local government revenue increase).
• Tourism activity in general is sensitive to the macro-economic environment. This was
confirmed by our analysis: in 2006 the Hungarian Government introduced fiscal
restrictions and later in 2008 Q4 the world economic crisis further depressed the
economic environment. Unemployment increased, companies cut back on spending
and events. As a result new hotels experienced a fall in guest nights, which further
increased the difficulties of the introductory years.
• The dynamic increase of tourism and tourism related revenues at the host cities clearly
show the indirect impacts of tourism development projects.
References:
Medlik, S – Ingram, H (2000): The Business of Hotels, BH Fourth Edition
Mundruczó Györgyné – Szennyessy Judit (2005): A Széchenyi Terv egészségturisztikai
beruházásainak gazdasági hatásai. Turizmus Bulletin IX. évfolyam 3. szám
Mundruczó Györgyné (2010): A támogatott turisztikai beruházások gazdasági hatásai.
Résztanulmány, ÁSZKUT
Raffay et al (2007): A ROP Program intézkedések hatékonyságjavítását célzó értékelő
tanulmány. Kutatási zárójelentés.
Tribe, J (1999): The Economic of Leisure and Tourism, Butterworth-Heinemann, 2 nd Edition
www.ksh.hu, Regionális adatok, 2001-2008
www.otm.hu EU-ROP pályázati adatok

Famous spas in Budapest facing the challenges of change
Andrea Nemes
Tourism Competence Center, CUB
Hungary
andrea.nemes@uni-corvinus.hu
Abstract
This paper aims at presenting the famous historical spas life cycle in Budapest in the last
years. It seeks to broach the issue of one type of the heritage of historical monuments, the spas
in Budapest and their usage in the tourism market. The paper is intended to provide an
overview of the famous historical spas, and to analyse its services in a competitive and
changing environment. The article also includes empirical findings on guest’s surveys and
interviews with the management of the spas.
Design/ methodology /approach - Comparative case studies were elaborated for the most
famous historical spas in Budapest based on secondary and primary sources. The data consists
of statistics, interviews and other documents.
Findings - Nowadays it seems to be the only way for the management of the spas in Budapest
to make innovations and improve the level of their services, and focusing not only to the
Hungarian but to the international market.
It summarizes the basic information’s, and previews ongoing innovations to the state of the art
level, to take into consideration the life cycle of the area and the products.
Keywords: national heritage conservation, competitiveness, spa tourism, product
development, life cycle of destinations, Budapest, Hungary.
Introduction
Nowadays the basic conditions of tourism and the health awareness of tourist and inhabitants
of spa cities and towns are changing. Due to economic difficulties, in view of changing travel
behaviour towards shorter and less holidays, health awareness, and strong individualization as
well as increasing quality awareness of the customers, it becomes clear that tourist
destinations face an even more difficult situation. It is the case in the spa cities and spa towns
too. Change in tourist destinations is driven by various events, institutions or actors, which
exert pressure or indicate new directions (Beritelli & Reinhold 2010). From the other hand the
changing health care system in Hungary require new conformation from the spa cities and
towns with the new planed regulation on the health mobility within the European Union.
Health tourism is one of the most visibly and rapidly developing product of domestic tourism
and is currently one of the world’s most innovative business sectors. Within the tourism sector
the development of health tourism can significantly enhance the number of guest, guest-nights
and the actual spending of guests. The spa city of Budapest has a special character and plays a
special role in this context. The development of health tourism and spas in Budapest seems to
be a good combination for wellness and cure purposes based on thermal water.
The definition of a tourism product is most often understood as a tourism destination in the
tourism literature, and looked through a tourism area life cycle point of view. In this study the

City of Budapest is seen as a tourist destination, and the famous spas in Budapest are the
tourism products.
First change, competition and the concept of area life cycle and product life cycle will be
presented as a theoretical foundation, followed by a short overview of the spa heritage in
Budapest and the specific characteristic of the product. In addition four famous historical spas
in Budapest, namely the Gellért Spa, the Széchenyi Spa, the Lukács Spa and the Rudas Spa
will be presented separately according to the empirical case studies of these four spas in
Budapest. The selected case study research method has several methodological limitations
(Yin, 2003), namely limited rigor, and limited potential for generalization. To weaken the
limitations we analyze each case both separately and in cross-case comparison. The case
study reflects national context with nowadays political, economic and cultural settings.
In the process interviews were conducted with managers of spas and questionnaires were
filled out by guests visiting the spas which provided the basic data for the results shown in the
article.
Thus, the article aims at responding to the following questions: What challenges do the
management of the spas in Budapest have to face nowadays. Which role has an area and a
product life cycle model in this context?
Literature Research
In our global world economy every district (settlement, region) is forced to compete with
other districts in order to gain economic advantage over them. They are endeavouring to
provide the most favourable conditions for business corporations, industrial establishments,
consortiums, scientific research centres, investors, tourists, conventions and conferences, in
order to increase the number of jobs, income, to boost commerce, investments, and growth.
(Kotler/Raider/Rein, 1994, p. 24) „In countries with a market economy the communities
themselves are markets. In consequence they must find ways to market their resources in a
way to benefit from a competitive advantage in order to establish new companies and thus
survive economically.” (Blakely, 1989, p. 57)
The trends mentioned above sharpen the competition between individual settlements and
regions, which is realised on different levels and fields throughout Europe, consequently in
Hungary as well. Settlements and regions are competing with each other at an ever increasing
rate as economic zones; residential areas; locations for work, shopping, and recreation; and
finally holiday resort areas. (Horner, 1991, p. 394) Economic factors can only achieve success
for settlements and regions when they are coupled with social and cultural factors. The extent
to which this is influenced and formed by the communities becomes part of the settlement and
regional marketing concept. Besides the economic strength, the standard of living in the
settlements and regions must also be improved, in order to make them attractive industrial,
commercial, and recreational areas (Nemes, 2010, 11.).
The Hungarian settlements and regions need innovative development and promotion concept
to take advantage of the global competition and change for residence to encourage economic
growth. The increasing attractiveness of settlements and regions, the boosting of the image
and thus the development of a unique profile is only possible through the integrated
assessment and proper handling of the needs of the participants (Nemes, 2010, 11.)

The phenomenon “change” is associated with many different notions from various research
traditions and steams of management research (Baumöl, 2008). Pettigrew (1990) consider
change as a dynamic process. Lewin (1951) see change as a linear input-to-output model and
suggested a three-step model of change. There is no single dominant theory in the change
management literature upon which academics agree (Baumöl, 2008). Regarding a tourist
destination over a longer period, a life cycle can be determined, which ranges from an
investigation and development phase of a destination to a consolidation and stagnation phase.
Achieving this point, a new phase of revival can follow in the case of successful repositioning
and new market-product combination.
The product life cycle model is one of the most famous theoretical models in the research of
marketing and strategic management (Goncalves & Aguas, 1997, 1; Mercer 1993, 269).
According to Holloway and Robinson (1995, 79) the model is also applicable to the tourism
product. In the literature the often presented product life cycle has four stages: introduction
followed by growth, maturity and decline stages (e.g. Goncalves & Aguas, 1997, 13; Kotler,
2000, 304) or introduction, growth, competitive turbulence, maturity and decline (Wilson
1995, 167). Sometimes the product development stage is added to the life cycle (e.g. Kotler,
Bowen & Makens, 1999, 304-306). The stages of the product life cycle are identified points in
the sales history. The life cycle curve finds strong theoretical support from Rogers’s
innovation adoption theory (Rogers, 1995).
At the introduction stage, a new product is introduced to the market. The price of the product
tends to be high and sales volume will be low. Usually, the profits are negative or low,
because of the low sales and heavy promotion expenses (Kotler, 2003, 330.). In the growth
stage, the sales curve is rapidly rising (Norgan, 1994). There are a growing number of
customers, an early majority following early adopters. New competitors enter the market,
attracted by the opportunities for large volumes and profits. They introduce new product
features. The prices remain or fall slightly and the promotional expenditures are maintained at
the same level or are slightly raised (Kotler, 2003, 332.).
In the competitive turbulence stage, the cumulative sales penetration approaches market
capacity and the rate of the sales is decelerating, although primary demand is still growing.
The target group is now the majority of the market and the competitive climate becomes more
aggressive (Wilson, 1995; Lambing, 1993.). At some point, sales growth will slow down, and
the product will enter a stage of maturity. This stage normally has the longest duration. The
slowdown rate of the sales growth impacts on declining numbers of competitors (Kotler,
2003, 333.). At the decline stage, the saturation level of the market has occurred and absolute
sales of the product decline. Because of the overcapacity in the industry, there is a strong
competitive warfare, which is manifested in several promotion battles using price competition
and advertising. As sales and profits decline further, companies withdraw from the market
(Kotler, 2003, 337; McNamee, 1988.).
The most widely known application of Product Life Cycle in the tourism field is the tourist
area life cycle (Butler, 1980). In the literature, very often the concept tourist product life cycle
is used, although writers refer to Butler’s model (see e.g. Goncalves & Aguas, 1997). Butler’s
(1980) tourist area life cycle model includes six stages: exploration, involvement,
development, consolidation, stagnation and decline or rejuvenation. The model applies the
product life cycle concept compensating sales by the amount of visitors. Visitors will come to
an area in small numbers initially, restricted by lack of access, facilities, and local knowledge.
As facilities are provided and awareness grows, the amount of visitors increases. Familiarity

of the area will also grow by marketing efforts and development facilities. Eventually, the rate
of increase in visitor numbers will decline as the levels of carrying capacity are reached. With
new or improved attractions the rejuvenation may occur, instead of the decline stage with
small interest among vacationers. (Butler, 1980, 6-9.)
TALC has been critiqued and developed (Haywood; 1998, 273-285; Puczkó & Rátz, 2005,
41.). Buhalis (2000, 105) has expanded the life cycle theory by describing typical features in
destination, and economical, social and environmental impacts of tourism on the destination
area at different life cycle stages. He also differentiates the supply and demand curves of the
destination. He suggested a destination life cycle model with five stages: introduction, growth,
maturity, saturation and decline.
Innovations in the product of the spas in Budapest were generated by the international and
Hungarian tourism market and by the inhabitants at the beginning of 2000. Therefore in this
study, the maturity, the saturation and the decline stage is important. Following Buhalis
(2000), the saturation stage is used in this study between the maturity and decline stages. This
approach is helpful when utilising qualitative features like attitudes of locals. In interpreting
the life cycle, it is important to understand that the boundaries of stages are not clear and
different stages can appear partly at the same time. There can also be features typical for
different stages at the same life cycle stage (Berry, 2001.).
In this study, a combination of the product life cycle and the destination life cycle theories is
used and the following stages of the life cycle are applied: product development, introduction,
growth, maturity, saturation and decline or new growth (see Hakulinen, Komppula &
Saraniemi 2007). Thus, a general view of a life cycle of the spas in Budapest product is
generated. The life cycle stages are based on the foregoing literature, particularly the division
by Buhalis (2000). The context of stages applies e.g. features proposed by Buhalis (2000),
Kauppila (1995), Butler (1980) Kotler et al. (1999), Cohen (1972), Plog (1974; 2001), Thurot
(1973, in Pearce, 1995), Strapp (1988), Rogers (1995) and Doxey (1975, in Järviluoma,
1993).
The underlying prerequisite for a successful tourist product development is a continuous
service system development, which involves continual development of the strategy
(Edvardsson et.al 2000). So the “augmented tourist product” (mentioned by e.g. Middleton
and Clarke 2001, see also Kotler et. al 1999, and Lumsdon 1997) in this case is the spa
product in Budapest itself, its reputation and image.
The research methodology
The research has covered the four most important spas in Budapest, namely the Széchenyi
Spa, the Gellért Spa, the Lukács Spa and the Rudas Spa, which belong to the municipality of
Budapest as an owner and to the Budapest Healing Baths and Hot Springs Co. Ltd. (Budapest
Gyógyfürdői és Hévizei Zrt.), as a management company, owed by the municipality of
Budapest.
In the study both qualitative and quantitative techniques were used in order to illustrate the
product life cycle and the needed fields for innovation and quality improvement.
The data consists interviews with visitors, who are already visited the spas and interviews
with managers of the Budapest Healing Baths and Hot Springs Co. Ltd. (Budapest
Gyógyfürdői és Hévizei Zrt.).

More than 400 interviews were made with the visitors in the 4 spas at the end of last year, in
November and December 2009. In choosing interviews with the managers, we focused on the
following two levels: the central management office of the spas as a head quarter and the
management level of the different spas, namely the Széchenyi Spa, the Gellért Spa, the
Lukács Spa and the Rudas Spa.
The description of the spas and tourism in Budapest are based on secondary data sources. For
the illustration of the life cycle we have used statistical data.
Spa heritage in Hungary and in Budapest
The Carpathian Basin, with Hungary at its centre, is one of the biggest sedimentary basins in
the world and has an extensive geothermal system. The main geothermal reservoir systems in
Hungary are the Mesozoic carbonate-karstic basement rocks and the Pliocene-Upper
Pannonian porous sedimentary formations. Their wells produce water that is mostly in the
low-to-medium temperature range (30-100 ºC) (Árpási, 2003, 371-377). According to
different assessments of its geothermal resources (Boldizsár, 1967; Bobok et al., 1988),
Hungary has the biggest underground thermal water reserves and low-to-medium enthalpy
geothermal potential in Europe.
Geothermal gradient in Hungary is 5ºC/100 m as average, which is about one and half times
as high as the worldwide average. The mean temperature is about 10ºC on the surface and
with the geothermal gradient the rock temperature is 60ºC at the depth of 1 km and 110ºC at
the depth of 2 km together with the water contained by them. The geothermal gradient is
higher than the countrywide average in the southern part of the Transdanubian region and in
the Lowland, while it is lower in the Kisalföld region and in the hilly areas of the country.
In Hungary the wells and springs of higher than 30ºC wellhead water temperature are
considered as geothermal springs, thermal water. Waters of such temperature can be explored
on the 70 % of the area of the country from the known geological formations.
Since ancient times, springs have been surrounded by a respect, usually attributed to holy
sites. Water, as a revitalising element, has been revered since antiquity. Though medical
science has endeavoured to discover empirical sources of diseases and methods of healing, an
uninterrupted interest in natural healing effects of water remanded. Through prehistoric times,
healing practices were passed along from generation to generation.
Hungary’s spa culture has a long history in Budapest, where people have been bathing in the
thermal baths for nearly 2000 years. Excavated remains of bath houses in Budapest show that
the Romans used the thermal springs. The next stage of development of our baths was brought
along by the Turkish occupation. Community buildings were built on the healing waters,
bearing a particular style, and incorporating a culture of individual bathing. The third period
in the history of Budapest bathing culture occurred during the Age of Enlightenment. As early
as in the first half of the 1700s, one can find early studies about the usefulness of the Buda hot
spring. In 1772, a decree was issued by Maria Theresia, Queen of Hungary and Empress of
Austria to have all mineral water analysed and recorded in a list at the expense of the
Treasury. In the early 1930s, Budapest, as the capital possessing the most healing thermal
water springs in the world, was awarded the title “Spa City”.
Among the best known Budapest baths are the Gellért Baths, the Széchenyi Bath, the Lukács
Bath and the Rudas Bath where our research was made. In the following the short description

of the case studies will be presented. In 1990 the former ownership of the baths was
transferred to local governments except the Rudas baths which were considered public
monuments and remained in state ownership, but the Metropolitan Local Government
retained their use free-of-charge. These properties are managed by the Budapest Gyógyfürdői
és Hévizei Zrt. which owner is the Metropolitan Local Government.
In Hungary, health care is based on a compulsory and comprehensive social insurance
scheme. Health services are financed by the National Health Insurance Administration in our
country. Nowadays health resorts and spas offer a new spa product in the form of health
tourism. The sustainable development of spas will be achieved by implementing local
development strategies, which have been formulated according to development tendencies of
the domestic spa market.
In accordance with current legal regulation, nine kinds of various bath treatments can be
obtained by medical prescription, for the purpose of rehabilitation in these four thermal baths:
thermal healing pool, thermal tub-bath, mud package, weight bath, carbonic acid bath,
medical healing massage, underwater water-beam massage, underwater healing gymnastics in
groups and complex healing bath facilities. Thermal bath therapies can be ordered by
physicians specialising in rheumatology, physiotherapy and rehabilitation of the organs of
locomotion.
The Gellért Bath
We can find records about the springs spurting up on the territory of the Bath from as early a
date as the 15 th century. These springs were favoured and used by the Turks as well. The
Gellért Thermal Bath and Hotel was built in secession style in 1918 and was expanded in
1927 by the wave-bath and in 1934 by the effervescent bath. The modernization followed, the
different pools were renovated and equipped with a state-of the art water filtering and
circulation device. The bath offers complex bath facilities, daytime, outpatient hospital.
The water is hot spring water with calcium, magnesium and hydrogen-carbonate as well as
sulphate-chloride, also containing sodium and fluoride ions. Therapeutic is suggested for
degenerative joint diseases, spinal deformity, chronic and sub-acute arthritis, discus hernia,
neuralgia, vasoconstriction, circulatory disturbances and inhalation for the chronic diseases of
respiratory organs.
The bath has 3 parts, the man part, the women part and a swimming pool part, with whirlpool,
sitting pool, wave pool, adventure pool, children’s pool and thermal baths. The water
temperature is between 26 – 36 ºC. All together 83 people are working in the bath.
There are some tasks which are centralized in the central office, the finance and the human
research activities. The centralization has advantage, but many disadvantages too. The
important decisions will be made at the central level and not at the bath level, which need
more time. Nowadays the bath provides medical, wellness and medical wellness services too,
to be able to expand the guest circle. In the frame of the new Hungary Development Plan
2007 investment in the value of 1.5 billion Hungarian forint was made.
Both, the domestic and the international market are important for the bath. The guests are
mostly satisfied with the product and with the services. There are some fields which have to
be developed. These are the level of services and the foreign language knowledge of the
personal.

The Széchenyi Bath
The Széchenyi Thermal Bath in one of the largest spa complexes in Europe which was built in
1913. The bath was expanded in 1927 with a public bathing department for gentlemen and
ladies and a beach site. In the middle of the 1960s, a daytime hospital was built. The
reconstruction of the pools of the swimming section was completed in 1999. Further
reconstructions and product innovations were made during the last years.
The water of the bath contains calcium, magnesium, hydro-carbonate, sodium and sulphate,
with a significant content in fluoride and metaboric acid. Therapeutic is suggested for
degenerative joint diseases, chronic and sub-acute arthritis.
The bath has a swimming pool with water filtering and circulation device, adventure pool, and
thermal sitting pool, group thermal bath with adventure pool and group stream-baths. The
water temperature is between 27 – 38 ºC.
The tasks of marketing finance, controlling and administration are centralised, the bath is
responsible for the daily operation. The bath provides daily hospital, medical and wellness
services. There are two main target audience, the domestic and the international markets. In
the frame of the different investment plans 3.5 billion Hungarian forint was invested into the
renovation of the bath and the development of services. The guests are mostly satisfied with
the services. There are some fields which have to be developed. These are the level of
services and the foreign language knowledge of the personal.
The Lukács Bath
In the 12 th century, knights of the order of Saint John engaging in curing the sick settled in the
area of today’s Lukács Bath. The bath operated through the time of Turks but the energy of
the springs were used primary to produce gunpowder and for grinding wheat. The first
department to ensure complex thermal bath facilities, daytime hospital was established in
1979 in the Lukács Thermal Bath. The swimming pools were rebuilt and modernised from
1999 in more phases.
The hot spring water contains calcium, magnesium, hydrogen-carbonate and sulphate,
chloride, sodium and fluoride ions. Therapeutic is suggested for degenerative diseases,
chronic and sub-acute arthritis, spinal deformity, discus hernia, neuralgia and post-accident
rehabilitation. The bath has swimming pools, adventure pool, thermal bath and underwater
traction bath. The Lukács Bath profile is a medical bath.
In three beat between 2005 – 2009 all together 2,7 billion Hungarian forint was invested in the
development of the Lukács bath., which affected the daily hospital, the thermal bath, the sun
suit and the wellness services. The centralisation is the same than in the case of Gellért and
Széchenyi bath. The guest are coming mostly from the domestic market, the bath is not
familiar for the international guests. The guest’s satisfaction is lower in the Lukács bath as in
the Gellért and Széchény bath.
The Rudas Spa
The centrepiece of the bath today, the Turkish bath, was built during the 16 th century in the
period of the Turkish occupation. Below the 10 m diameter dome, sustained by 8 pillars, there
is an octagonal pool. The thermal bath has been visited from 1936 on exclusively by men. The
swimming pool, operating as a therapeutic swimming facility and with a sauna, was built in
1896.

The water is radio-active and contains calcium-magnesium-hydrogen-carbonate, sodium,
sulphate and fluoride ions. Therapeutic is suggested for degenerative joint diseases, chronic
and sub-acute arthritis, discus hernia and neuralgia. The bath has steam pools and swimming
pool. The water temperature is between 16 – 42 ºC.
The bath the similar services as the mentioned 3 baths. The difference is the activity on the
programs for the Jung generation, for example the Cinetrip SParty. The centralisation is the
same than in the Gellért, in the Széchenyi and in the Lukács bath. The domestic and the
international market are equally important for the bath.
As mentioned above in three spas are daily hospitals, in the Gellért bath, in the Széchenyi
bath and in the Lukács bath, which is a separate part in the bath. It determines the profile of
the bath too. Complex therapies are needed and constant doctor attendance. Cooperation with
National Health Service, with the hospitals has to be stronger. Also connections with foreign
(public) health funds can cause an increment in the number of visitors in the future.
Nowadays prevention is important as well, and therefore the bath has to focus not only on the
ill, elder people. The product innovation and the services have to focus on the need of the
inhabitants of Budapest, the domestic and the international market as well.
Results
This research noted measures the historical evolution of the spa market in Budapest and the
curve of demand by the number of guests visiting the most important spas in the capital city
of Hungary in the years 1995 – 2008. We analysed the number of guest arrivals at the public
accommodation in Budapest, to prepare a destination life cycle for the capital city of Hungary
and the number of visitors’ at the most important spas in Budapest to prepare a product life
cycle for the spas. We can see on Figure 1 that the destination life cycle of Budapest is in the
stagnation phase. After an increase from 2002 the guest flow stabilized in the years of 2004-
208.
Figure 1
3000000
2500000
2000000
1500000
1000000
500000
0
Tour i st a r r i v a ls of publ i c a c c omoda t i ons in B uda pe st be t we e n 2 0 0 2 - 2 0 0 9
2002 2003 2004 2005 2006 2007 2008 2009
year s
Source: Central Statistical Office, own illustration
Inter national tour ist ar r ivals
Domestic tour ist ar r ivals
Total

The product life cycle of the spas in Budapest shows (see Figure 2) a decline phase of the
curve which means that the total number of visitors in the four most important spas is
declining. However there is a difference between the different spas.
Figure 2
Source: Budapest Gyógyfürdői és Hévizei Zrt., own illustration
The Széchenyi Spa realizes the highest visitor number between the four spas where the guest
flow is stabile. In figure 1, the life cycle of the area Budapest is illustrated. In figure 2, the life
cycle of Spas in Budapest product is illustrated. We have prepared a shorter and a longer time
row to be able to analyze a longer time square. We have collected the data of the visitors from
the year 1995 which present clear that a product need more innovation and adaptation to the
current market tendencies or the managers has to market the product better to be able to step
into the new growth phase. It is absolute necessary.
Figure 3
3000000
2000000
1000000
Number of visitors
0
Number of vis itors in the different s pas in Budapes t between
2002-2008
Source: Central Statistical Office, own illustration
2002 2003 2004 2005 2006 2007 2008
G ellért S pa S z échenyi S pa
Lukács S pa R udas S pa
Total
3500000
3000000
2500000
2000000
1500000
1000000
500000
Number of visitors in the different spas in
Budapest between 1995-2008
0
1995
1997
1999
2001
2003
years
2005
2007
Gellért Spa
Széchenyi Spa
Lukács Spa
Rudas Spa
Total

Conclusions
In our changing environment the spas in Budapest are facing with problems regarding the
turnover and the guest number which has to be solved. The number of guest is decreasing
instead of big investment which was made in the last period in the spas. Solution should be a
better and more professional marketing activity, the development of unique profile through
proper handling of the needs of participants (inhabitants and tourists), guest oriented
innovation in the services, improvement on the field of human resource and service quality.
The Budapest Healing Baths and Hot Springs Co. Ltd. have to further develop a segmented,
well-branded spa product in Budapest. A strategy would be required for the brand creation.
According to this study, combining a traditional product life cycle and a destination life cycle
is useful. The best results are obtained by using both quantitative and qualitative indicators.
Factors utilised in this study related to tourist, product, competition, destination and tourism
in the area were the most applicable measures in describing a tourist product life cycle.
This study underpins the proposal that customers are often involved with the innovation
process (Alam & Perry, 2002; Belz & Bieger, 2004 in Bieger & Weiner, 2006). As Holloway
& Robinson (1995) stated, new products often are improvements of the old ones. During the
life cycle, the core product changed, being today a need to the prevention.
The main theoretical contribution of this study is the experiment to the application of a
combined life cycle model.
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Rogers, E.M. (1995), Diffusion of Innovation. Fourth edition. New York.

Should Private Healthcare Insurance Providers in the UK Outsource
Surgery?
A Case Study of Hip and Knee Replacements in India
Rina Parmar, Anthony Brown, Olivia Cleevely, Akira Fukutomi, Katharine Hanan,
Eleanor Rowland.
Imperial College London, Business School, South Kensington Campus, London, SW7 2AZ,
United Kingdom
rina.parmar08@ic.ac.uk
Abstract
Objective – To determine the relevant benefits of outsourcing treatment, for both private
health care insurance providers and potential patients in the UK, using a case study of India.
Aims
1. To establish the perceptions of the UK public on private healthcare insurance and their
views on the outsourcing of treatment
2. Perform a cost analysis comparing private healthcare providers in India and in the UK with
respect to hip and knee replacements
3. To determine whether or not outsourcing hip and knee replacements to India would
compromise the quality of treatment the patient receives
4. To measure patient satisfaction of UK citizens getting hip and knee replacements in India
Methodology
Spire Healthcare in the UK was used as a point of comparison to the Apollo Hospitals Group
in India.
- Face-to-face questionnaire survey of 100 people to obtain a sample of public
perceptions to health insurers outsourcing treatment.
- Cost data was compiled from various sources with comparisons made between the two
organisations.
- Fieldwork was carried out in India. Information was collected regarding quality
standards, patient satisfaction and hospital management through interviews with staff
and patients. Comparable data for the UK was obtained from published sources.
Results and Conclusions
People were shown to be price sensitive towards insurance policies. Overall, there was a
willingness to accept outsourcing as a means of reducing premiums. India was shown to have
reduced price mark-ups, lower costs of equipment and medication as well as the lower wages
demanded by staff compared to the UK. Patient satisfaction and quality of care were not
compromised in India, although follow-up care was identified as being unsatisfactory.
Overall it was concluded that there is clear potential for health insurers to outsource elements
of treatment in order to expand their target market.
Keywords: Medical, Tourism, Outsourcing, Private, Healthcare, Insurance, Bupa, Apollo
Introduction
In the current economic climate, many businesses are seeking strategies to reduce costs to
gain a competitive advantage (Aron and Singh, 2005). The healthcare insurance business is

no exception. Already, patients are travelling abroad for treatment such as coronary artery
bypass surgery (CABG) to countries such as India where it costs £3950 (Taj Medical Group,
2008) compared to an English cost of £1700 (Spire Healthcare, 2008). However, it is
uncertain whether this practice could prove beneficial for private healthcare insurance
companies who could potentially provide low-cost packages which included treatment being
outsourced.
It was deemed appropriate to consider hip and knee replacements being carried out both in the
UK and in India to ensure a broad demographic range was considered whilst looking at a
country that was already receiving patients from abroad for medical and surgical treatment.
The objectives of the project were divided into four categories: market determination,
financial savings, patient satisfaction (including cultural issues) and quality of care.
Due to the recent emergence of outsourcing in healthcare, limited published literature is
available, although some US based literature exists.
At present there are no UK insurers that outsource surgery abroad, although there are private
companies such as The Taj Medical Group who specifically focuses on sending UK patients
to India, providing fully inclusive packages and work in partnership with the Indian
Government to help regulate medical tourism, such as offering medical visa’s to patients, as
well as tax incentives to hospitals.
Deloitte found in their Survey of Health Care Consumers (2008) that nearly 40% of US
citizens would travel abroad for treatment, as long as the standard of care was comparable and
the cost was 50% of that in the US. However despite this, it was found that only 3% of
Americans have travelled for treatment. Horowitz and Rosensweig (2007) believe that the
number of Americans travelling for treatment is set to soar, predicting that by 2010 the
number will have increased from 750,000 to 6 million per year.
The Medical Tourism Association Survey conducted in August 2007, shows that India is by
far the cheapest country for the majority of surgical procedures listed. If the quality of care
and patient satisfaction were uncompromised, India would be the most cost effective country
to outsource to.
At present there are various internationally recognised accreditations for the standards of care,
such as the Joint Commission International (JCI) or the International Organization for
Standardization (ISO). Although there is a distinct lack of primary research on the subject,
the quality of care in India appears to be of equal or greater standard than that of the US. For
example, an elective CABG in California has a mortality rate of 2.91% compared to less than
1% for the same operation in Apollo hospitals in India (Milstein and Smith, 2007)
US literature cannot be solely used to predict the success of outsourcing treatment in the UK,
as the UK and US have vastly different health systems. Due to the National Health Service in
the UK, it is likely that far fewer people in the UK would be willing to pay for treatment
compared to people in the US. However, with the rise in medical tourism there is scope for
UK private health insurers to capture a new segment of the healthcare market.
Methodology
Spire and Bupa were selected as examples within the project as they are market leaders for
private healthcare provision in the UK however both Bupa and Spire felt unable to participate

with this research due to the sensitivity of data required and the conflicts between the project
and their overall business plan. As such, data from the UK health insurance market was
collected from published sources.
Apollo Hospitals Group was chosen as an example of foreign hospitals as it is the largest and
most established private hospital group in India, already widely used by UK patients seeking
healthcare abroad. A field research trip was organized to collect accurate primary research
from India in the form of observations and interviews. For consistency, all interviews were
carried out by the same person using a semi-structured, face-to-face format, which were
digitally audio-recorded and transcribed.
Market determination
A face-to-face interviewer-led questionnaire survey was carried out to establish public
perceptions of medical treatment both in the UK and abroad.
This questionnaire had a quantitative focus and consisted of 20 questions. A sample size of
100 participants was selected using a non-randomised, quota-sampling method. It was aimed
to include 10 males and 10 females within each of the five age groups (20-29, 30-39, 40-49,
50-59, and over 60). Age stratification was used, as different age groups often have marked
differences in health service requirements and would therefore have different views
concerning past and future medical care.
Initial piloting of the questionnaire was carried out, of which revisions of the questions were
made prior to implementing the questionnaire across the 100 participants.
Participants were selected on the basis that they lived in the UK and did not currently have
health insurance. The data was collected over three weeks at different times and locations
across London.
The questionnaire responses were coded using an alphanumerical code and entered into
Microsoft Excel. Thematic analysis was carried out on all qualitative data. Quantitative data
was tabulated in order to categorise the responses, and was represented graphically to assist
analysis. Statistical tests (un-paired t-test at 95% significance level) were carried out to
determine any statistical significance between different groups.
Financial savings
An Interview with Apollo’s financial department manager provided information regarding
price mark-ups and the costs of different components of hip or knee replacements
Information regarding the costs for hip replacements in the UK was compiled from two
different sources. Firstly, published accounts from Spire’s own website (Spire Healthcare,
2009) were used for an estimation of hospital running costs. Secondly, information on staff
and equipment costs was gathered from various sources such as Jobsformedical.com (2009)
and NICE (2000). Information from both Spire and Apollo was tabulated to provide a total
cost of treatment. This enabled a cross-comparison between the data from Spire and Apollo,
allowing observations of where savings had been made by Apollo.
Quality of care
Interviews were conducted with orthopaedic surgeons at Apollo to explore their level of
professional experience and to highlight their motivations for working in India. Additionally,
professional profiles of those doctors interviewed were obtained from Apollo’s website.
Quality control managers were also interviewed to determine how Apollo ensures the quality
of treatment provided.

Data regarding levels of training of orthopaedic surgeons in the UK was obtained from
professional profiles accessible from Spire’s own website (Spire Healthcare, 2009).
Data regarding Spire’s surgical success rates were obtained from published data from both
Spire’s own publications and those of external monitoring bodies. Apollo were able to
provide these details directly. The recovery times, infection rates and complication rates from
both Apollo and Spire were compared directly.
Patient satisfaction (including cultural issues)
Three patients, who had previously undergone hip replacements in India, were interviewed
via email and telephone correspondence to determine their satisfaction with treatment
provided and the overall experience of care in India. Semi-structured interviews were
performed.
Data regarding patient satisfaction with treatment received at Spire was collected from Spire’s
website (Spire Healthcare, 2009), the Independent Healthcare Advisory Service (IHAS,
2009), the Welsh Independent Hospitals Association (WIHA, 2009) and the Scottish
Independent Hospitals Association (SIHA, 2009). The published data provided information
on satisfaction with the hospital, staff and willingness to recommend treatment. This data was
then compared with the data from Apollo to highlight discrepancies and allow conclusions to
be drawn.
Results
Market determination
The survey looked at participants’ views on whether they would travel abroad for medical
treatment. On initial questioning (Question 9a) 57% of participants said that they would
either probably or definitely consider travelling abroad for treatment in the future. India was
the most popular non-Western country to be chosen for the participant’s destination with 31%
choosing it as one of their ideal locations. When asked whether they would take out a health
insurance policy where foreign treatment was provided (in question 13a), a slightly lower
proportion suggested they would, with 53% saying that they probably or definitely would take
out cover if premiums were cheaper as a result.
Figure 1- Comparison of overall answers from question 9a and question 13a

However, when comparing answers to questions 9a and 13a (shown in figure 1), there was
less certainty amongst respondents who answered positively to taking out insurance with the
addition of healthcare abroad rather than simply travelling abroad for treatment in general.
‘Definite yes’ responses fell by almost half from 17% to 8% of all responses.
When those willing to travel abroad were further questioned regarding their answer to
question 9a, the answers given fell into one or more of five main themes:
1. Seen as cheaper to have surgery abroad than arrange it privately in the UK (26% of
responses)
2. Quality in other countries is potentially better than the UK (23% of responses)
3. Urgent treatment should be undertaken anywhere in the world that can offer it
fastest (21% of responses)
4. Willing to seek treatment in other countries if not available in the UK (19% of
responses)
5. A belief that certain health conditions receive a standard level of care worldwide
(11% of responses)
The cheaper cost of treatment abroad was the most common factor in decisions to go abroad
for surgery.
Similarly, negative responses to Question 9a were grouped into themes. Four main reasons
were given by those who were disinclined to travelling abroad:
1. Satisfied with the UK healthcare system. This included the NHS and private health
care networks (46% of responses)
2. Negative connotations associated with receiving medical care in a different culture
to that of the UK (24% of responses)
3. Problems associated with follow-up and aftercare after returning from the country
of treatment (10% of responses)
4. Poor perceptions of quality in foreign countries (10% of responses)
5. Other (10% of responses)
The answer most readily given as to why respondents would not travel for medical care was
overwhelmingly due to satisfaction with the UK healthcare system, with it being a factor in
46% of responses.
When asked: “What is the maximum price you would pay per month for private health
insurance?” - 75% of participants would pay a maximum of £50 per month for insurance
covering a broad range of coverage (shown in figure 2).

Figure 2 - Graph showing price willing to pay for insurance
Age Analysis
When asked how much they would be willing to pay for health insurance, 50-59 year olds had
the highest mean of £67.00. Lowest mean price was from the 20-29 age category, at £31.59.
The three oldest age groups had the largest number of ‘definitely no’ responses for
willingness to travel abroad for treatment in the future. The 50-59’s were the least willing to
travel abroad with 60% of individuals answering ‘no’. The 20-29’s and the 30-39’s were the
most inclined to travel abroad with over 70% of individuals in both age categories answering
‘yes’ to the question (either ‘probably’ or ‘definitely’).
The introduction of the concept of treatment abroad reducing the cost of health insurance
premiums did not increase positive responses to travelling for health treatment in any age
group.
Occupation Analysis
The mean price that the executives would be willing to pay was the highest at £75. The next
highest means were amongst the professionals and skilled labourers at around £50. All other
groups fell into a range of around £25-35. Despite the apparent marked difference between the
mean prices that different occupations were prepared to pay, t-test results showed no
significance at the 95% level.
For travelling abroad for treatment the unskilled labourers had the highest proportion of
‘definitely yes’ at 45% with the Executives following closely with 38%. Contrary to this, the
most certain ‘no’s’ were amongst the Admin and Clericals and the Retired individuals. The
student groups were the most uncertain with less than 10% ‘definitely yes’ and no ‘definitely
no’ responses.

Health Issue Analysis
From the sample selected, the group that considered themselves to have current health issues
were generally willing to pay less for a health insurance premium than the healthy
participants, with a mean price of £47.36 in the healthy group, and £39.62 in the group with
health issues.
Health Insurance Analysis
The participants were grouped into those who had previous health insurance, and those who
have never had health insurance. Those with previous insurance appeared to be willing to pay
more for insurance at a mean value of £60.54, compared to £39.21 in those who have never
been insured.
When asked whether they would travel abroad for medical treatment in the future, those that
had previous insurance gave less positive responses, with 47% of responses either ‘probably’
or ‘definitely yes’, compared to 61% in those that had not previously been insured.
Financial savings
From the interview with the Finance Department at Apollo, it is clear that costs are reduced in
several areas which enable the hospital to charge patients on average of £4,000 (Taj Medical
Group, 2009) for a hip replacement compared to the £12,000 charged in the UK.
Apollo claim a price mark-up of treatment of 17-18%. The price mark-up at Apollo is
dependent on the category of room that a patient chooses. It is observed by Apollo that
international patients are those most likely to demand the higher categories of treatment
allowing for higher profit margins (greater than 20% mark-up).
A further explanation of the lower cost of treatment offered in India is accounted for by the
lower wages of professionals throughout India. The Apollo Finance Department claim that a
surgeon would be expected to charge 35-40,000 INR per operation which is equivalent to a
range of approximately £469 - £536. In the UK a surgeon would be expected to charge double
this.
The Apollo Finance Department state how they are able to obtain medicines at one tenth of
the cost of the UK for various different reasons. India’s ability to obtain medicines at such a
low cost is claimed to be due to their proximity to the countries of production and the fact that
they use ‘generic’ brands. In comparison, medicines are sold to the UK with a large profit
margin.
The interview with the Apollo Finance Department provided various details regarding the
equipment, hospital and staff costs. This has been analysed and tabulated in Table 1. The
approximations of actual costs for Spire has been tabulated in Table 2. Spire’s most recent
figures state that they charge patients between £9,680 and £15,230. Using an average price of
£12,455, with costs of £6,131, it is evident that the mark up of treatment is over 103%.

Table 13 – Typical hospital costs for hip replacements at Apollo
Items Costs
Surgeon £500
Anaesthetist £125
Prosthesis £1,205
Assistant surgeon £50
Further
costs
hospital
£675
TOTAL £2,555
Table 14 – Typical hospital costs for hip replacements at Spire
Items Costs
SURGERY COSTS
Surgeon x2
£1,060
(£530/surgeon)
Nurse x2 £408 (£204/nurse)
Anaesthetist £400
Prosthesis £2,000
INPATIENT COSTS
Nurse £1,920
Consultation fees £300
HOSPITAL AND
ADMINISTRATION
FEES
Other associated costs £43
TOTAL £6,131
Quality of care
With respect to treatment provided in India compared to the UK, there appeared to be no
significant difference in levels of medical staff training as all the doctors that we interviewed
had training and/or working experience in either America or the UK. The infection rates and
surgical outcomes at Apollo scored better in all aspects compared to the NHS average, and
many measures were better than Spire (shown in table 3).

Table 3 - Surgical outcomes of Apollo, Spire and the NHS
Measure Apollo Spire NHS average
3 year revision rate - hip replacements 1.17% 0.8% 1.3%
3 year revision rate - knee replacements 0.0% 1.0% 1.3%
Mortality rate - hip replacements 0.0% 3.2% 6.4%
Mortality rate - knee replacements 0.0% 3.6% 6.3%
C. difficile rate (per 1,000 bed days) Nil 0.02 1.56
Wound infection rate - hip replacements 0.6% 0.3% 0.9%
Wound infection rate - knee replacements 0.42% 0.04% 0.5%
Both Apollo and Spire hospitals are regulated by external bodies, ensuring standards are
maintained. In both the UK and India, patients were satisfied with the treatment received.
UK citizens receiving treatment in India are prepared to recommend treatment at Apollo.
However, the follow-up care currently provided by Apollo does not meet the guidelines
recommended by the British Orthopaedic Association (BOA).
Patient satisfaction (including cultural issues)
Interviews with patients revealed that patients sought treatment in India due to the low cost,
high level of expertise in India, previous experience of difficulties within the NHS and long
waiting lists in the NHS. Apollo was specifically chosen by the patients due to the hospital’s
reputation and efficiency with regards to dealing with patients’ needs.
The patients interviewed stated that prior to travelling to Apollo their expectations were
higher than what they initially experienced stating that they were slightly nervous when they
arrived. This was due to the chaotic nature of the hospital when they arrived at 3am. However,
they went on to state that their expectations were met when they had settled in to their private
ward. All staff exceeded their expectations in the service they delivered.
Cultural barriers were not reported at Apollo, there were no language barriers due to the
English speaking policy within the hospital and services such as catering were tailored to the
patient, with a wide range of choices available. When asked if they would advise others to
travel to India they responded positively
As interviews were not possible with patients who have had treatment at Spire, information
from the Independent Advisory Services was used. SIHA who showed that in private
hospitals in Scotland 98% of patients would recommend the hospital to others (Independent
Healthcare Advisory Services, 2008). The WIHA found that the average was closer to 88%
(Independent Healthcare Advisory Services, 2008), whereas the IHAS found that 97% of
people would recommend the hospital that provided their care (Independent Healthcare
Advisory Services, 2008).
Discussion
The survey conducted confirmed that cost was the most common identifiable reason for
influencing discretionary health spending. Although it was theorised that due to the highly
price sensitive nature of health insurance, people willing to pay the least for insurance would
be the most likely to accept treatment abroad due to cost implications, the survey indicated

that people willing to pay slightly more for health insurance were also more likely to view
going abroad for treatment more favourably. Highly positive perceptions of foreign treatment
also gave further evidence that there is a market for outsourced surgery as a component of
health insurance, with only 6% of respondents citing poor quality treatment outside of the UK
as a reason for not travelling for treatment.
There were three main areas which accounted for the large discrepancy between the prices
charged for a hip replacement between Spire and Apollo hospitals. Firstly, the profit margin
at Spire for each procedure was estimated as being five times that of the same procedure in an
Apollo hospital. This is likely to be due to different strategies pursued by each hospital to
attract business and maintain profitability. Secondly, fees for the clinical workers in Indian
hospitals were a fraction of the costs attributed to costs due to the hiring of UK staff. Thirdly,
favourable drug licensing laws in the developing world allow more widespread use of
cheaper, generic drugs. A reduced proximity to global manufacturing centres in the Far East
also leads to cheaper medication and equipment.
Professional training of doctors at Apollo was found to be comparable to the UK, as many of
the staff had direct clinical experience with the NHS or other western medical organisations.
Apollo also have achieved recognition by the JCI which seek to ensure standards of
healthcare in institutions are met and comparable between hospitals in different countries.
Similarly, Spire must comply with the UK’s Care Quality Commission (CQC) to ensure that
standards of patient care remain at the highest levels. One area of concern is the nature of
follow-up care in foreign medical institutions. Geographical separation would make it
difficult to treat long term complications, and it is likely that this aspect will need to remain in
the UK, possibly under the care of a UK partner of the foreign hospital to ensure continuity of
care.
From the data relating to both Apollo and Spire it can be seen that patients are satisfied with
treatment provided by both organisations. Of significant note is that patients appear to be no
less satisfied with treatment provided by Apollo than Spire, or other UK independent
healthcare providers.
Perceived cultural differences have been minimised by stressing importance on pre-journey
communication with the patient to ensure a personalised service, as well as specialist
language and cultural training for all hospital staff. Hospitals are also built to western
standards to ensure patients are treated in a familiar setting. Foreign medical centres do have
to operate in an unstable business climate, with factors such as global war, terrorism and the
effect of economic cycles having a huge impact on their profitability. Reduction in overseas
travel for any reason could be detrimental to their business model; however it is possible that
the potential for cost savings in those that have already decided to pursue private medical
treatment may still result in business potential for these health centres. The continued
economic growth of India may limit the long term applicability of these cost savings as the
economy matures and costs of living and conducting business continue to rise.

Conclusion
Summary of comparison between India and the UK
India UK
Price
£3,575 - £4,750
£9,680 - £15,230
Quality
Quality of staff
Infection rates
Surgical outcomes
Satisfaction
Follow-up care
Strategic
positioning
(Taj Medical Group, 2009)
Monitoring bodies: Joint Commission
International and the International
Organization for Standardisation
Employ high quality doctors with
worldwide training.
C. difficile: nil
Wound infection (Hip) : 0.6%
Wound infection (Knee): 0.42%
Revision Rates (Hip) : 1.17%
Revision Rates (Knee) : 0.00%
Mortality Rates (Hip): 0.00%
Mortality Rates (Knee) : 0.00%
4 of 4 patients would recommend
Apollo to others and would return
themselves for future treatment
Does not meet the BOA recommended
follow-up treatment guidelines
Likely to be positively affected by
recession as people seek cost-cutting
alternatives to expensive treatments in
the UK.
(Spire Healthcare, 2009)
Monitoring bodies: Care Quality
Commission and Independent
health care: national minimum
standards
Employ high quality doctors
with worldwide training.
C. difficile: 0.02 per 1,000
bed days
Wound infection (Hip):
0.30%
Wound infection (Knee) :
0.04%
Revision Rates (Hip) : 0.8%
Revision Rates (Knee) : 1.0%
Mortality Rates (Hip): 3.2%
Mortality Rates (Knee) : 3.6%
85% of patients would
recommend Spire’s services to
others.
Unclear as to whether follow
BOA standards
Likely to be negatively affected
by recession as disposable
incomes are reduced.
Outsourcing surgery has the potential to increase brand equity and market share for insurance
providers in the UK without compromising patient satisfaction or quality of care. However,
the following conditions should be met in order to gain maximum advantage from this
strategic direction:
Create an appropriate pricing strategy
The luxury image associated with private healthcare in the UK may conflict with the
competitive costing approach that outsourcing provides; sub-brands or cash-back systems
may be helpful.
Creating the right package tailored to the individual
Customers should have the option of receiving certain treatments in the UK, with foreign
treatment only for procedures that they would be willing to travel for. A package which
includes flights and accommodation would help maintain brand image by ensuring the whole
experience is of a high standard.
Outsource to an accredited reputable hospital
Independent assurance of quality is essential. However, accreditations are only beneficial if
patients are aware of the existence of these awards and the level of quality they represent.

Continue follow-up care in the UK
Follow-up care is a major concern to both patients and doctors. Insurance companies should
use their established networks of private healthcare providers in order to ensure pre- and post-
operative care is offered in the UK irrespective of where surgery takes place.
Recommendations:
• Questionnaire survey: a larger sample size is required to enable examination of a
greater social demographic range.
• To ensure validity of the cost analysis results, accurate and detailed cost breakdowns
of treatment are required.
• A wider survey of patients who have previously travelled for surgery would be
beneficial.
• Direct comparison of the accreditation systems currently in use in both India and the
UK would ensure that the standard of treatment provided could be accurately
compared.
• Quality of treatment could be further investigated through the analysis of 10 year
revision rates of hip and knee replacements in both the UK and India.
• Increasing the scope of the entire project to include the NHS would confirm whether
the conclusions of the project can be applied to the UK healthcare market in its
entirety.
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Healthcare Advisory Services

HEALTH TOURISM IN IZMIR: POTENTIAL, STRATEGIES AND
SUGGESTIONS
İge Pırnar
Yaşar University, Turkey
ige.pirnar@gmail.com
Onur İçöz
Yaşar University, Turkey
Abstract
Health tourism which includes several branches such as, medical tourism, thermal tourism,
SPA and wellness, aged-tourism, handicapped-tourism,and sports tourism is one of the fastest
growing sub-sectors of the international tourism industry, since it has a constant annual
increase of 20% with a considerable demand potential. This is an original study which
attempts to make a preliminary SWOT analysis of health tourism in Izmir which is considered
as a very suitable type for the regions’ resources. In addition applicable strategies are
predicted for each of the different conditions (like. S/O, W/O, S/T and W/T strategies).
Introduction
Izmir is in excellent location for health tourism due to the unique natural and thermal
resources the area owns. The interest to Izmir’s health tourism potential is increasing
gradually by the fastest growth in private health sector, the increasing number of modern
lodging facilities, very good value-price ratio, high percentage of repeat health guests,
qualified thermal and health service, the good results from thermal treatments, friendliness,
hospitality and tolerance to different cultures.
Health Tourism in General
Health tourism’s definition stated in Erfurt-Cooper & Cooper’s textbook (2009:6) by Ross
(2001) and Tabacchi (2003) is as “any kind of travel to make yourself or a member of your
family healthier” Another resource defines the health and wellness tourism industry together
as “products and services made accessible to people travelling from their place of residence
for health reasons. In addition to conventional healthcare (medical), this definition
encompasses health & wellness, spa tourism, convalescent addiction treatment, retirement
communities, and some alternative health services” (Caribbean Export Development Agency,
2008). It is indicated that health tourism has a huge target potential including visitors with
health problems, visitors who are looking for medical /thermal or spa treatments and visitors
who are trying to preserve and promote their wellness and fitness (Ülker, 1994; Gurkan et. al,
2007:479; Erfurt-Cooper & Cooper, 2009:8). Thus it includes operations and services like;
cosmetic surgery, medical surgery, operations like dental, eye or IVF operations, physical
fitness, spa treatments, beauty care, healthy nutrition and diet issues, relaxation, rehabilitation,
meditation and mental activity (Pırnar, 2007). Thus it involves many segments and the basis
do vary from organization to organization. Eg. “health and wellness tourism market in the
Caribbean can be divided into four segments (Caribbean Export Development Agency, 2008):
(1) medical tourism;
(2) wellness and spas;
(3) nursing and elderly care; and
(4) research and diagnostic services”, and HT8 (or Health Tourism 8) refers to the
industry segments where ht8 is a concept and approach introduced in 2008 by healthCare

cybernetics (an international Health Tourism Sector think and do tank)
(Constantinides,2009:13);
1) Medical Tourism
2) Dental Tourism
3) Spa (and Thalassotherapy) Tourism
4) Wellness and Fitness Tourism
5) Sports Tourism
6) Culinary Tourism
7) Accessible Tourism
8) Assisted Residential Tourism
Typologies of health and wellness tourism vary as does the health, medical and wellness
tourism. “Several scholars do not differentiate between wellness tourism and medical tourism
and subsume wellness-related categories under medical tourism. For instance, one typology
suggests the four medical tourism categories of ‘Illness’ (e.g. medical check-ups, medical
surgery, dental treatment), ‘Wellness’ (e.g. beauty care, spa treatment, yoga, herbal healing),
‘Enhancement’ (e.g. cosmetic surgery) and ‘Reproduction’ (e.g. fertility treatment and birth
tourism) (Voight et. al, 2010:30). As another example, in their textbook typologies of health
and wellness tourism is stated as (Smith & Puckzo, 2009:85): Leisure Spa tourism (e.g.
therapeutic medical, hotel, resort, resting, day spa) Holistic tourism (e.g. retreat, yoga centre)
Medical tourism (e.g. surgery) Spiritual tourism (e.g. pilgrimage, meditation, yoga, retreat,
spiritual quest) Occupational wellness tourism (e.g. life-coaching, recuperation, stress
management)
The global health tourism industry revenuer make up to US$40 billion 2005, US$60 billion in
2006 and is projected to grow at US$ 100 billion in 2012 and US$ 188 billion in 2013
according to different resources (Zoref, 2006; Herrick, 2007:1). The growth is due to; aging
populations, high cost of medical services, shortage of health care professionals and long
waiting periods in developed countries, and, on the other, improved medical technology,
competitive healthcare prices, and rest & relaxation in exotic destinations in developing
countries.
In order to attain customer satisfaction in health tourism, it is important that the supplier does
meet the individual expectations of the patient since each patient may have different
individual expectation some of the individual expectations may be (Edelheit, 2009);
1) the customer looks for less costly treatment / procedure than his/her own country,
2) may be embarrassed to get surgery at home (eg. wants to keep it secret that he/she had
cosmetic surgery)
3) may want privacy during treatment and recovery processes,
4) may look for high standards and level of quality which is unaffordable at home.
The basic expectations for health and wellness tourists do vary a lot, and some may be added
below in addition to the ones stated before (Kaur, 2007:421; Yıldırım, 2005; Pırnar, 2007:35-
38):
• Hygienic environment
• Standardization and quality of the services
• Range of services
• Highly qualified staff ( trained technically as well as in soft skills)
• Value proposition
• Customization

• Service provided within the insurance coverage
• Stability for long periods
• Connectivity
• Availability of different touristic attractions
• Alternative tourism products
• International standard certification
• Low cost / Price advantage
• Extraordinary and unique surgery or treatment methods.
The prices of the health tourism products do vary a lot from region to region and from one
country to another, which creates a very sold the demand for health tourism which makes a
very important differential advantage for the health tourism marketing countries. Table below
shows a range of countries price lists for different health tourism products.
Table 1 - Distribution of medical service fees according to countries($)
USA Paid by Patient USA Insurance Turkey** India Thailand Singapore
Angio $ 98,618 $ 44,268 $ 3,500 $ 11,000 $ 13,000 $ 13,000
Bypass $ 210,842 $ 94,277 $ 12,000 $ 10,000 $ 12,000 $ 20,000
Cardiac $ 274,395 $ 122,969 $ 12,000 $ 9,500 $ 10,500 $ 13,000
valve surgery
Hip surgery $ 75,399 $ 31,485 $ 13,000 $ 9,000 $ 12,000 $ 12,000
Knee surgery $ 69,991 $ 30,358 $ 15,000 $ 8,500 $ 10,000 $ 13,000
Spine $ 108,127 $ 43,576 $ 15,000 $ 5,500 $ 7,000 $ 9,000
Mastectomy $ 40,832 $ 16,833 $ 9,000 $ 7,500 $ 9,000 $ 12,400
Resource: TUSIAD- DEIK (2009). “The Economic Dimension and Other Effects of
Medical Tourism in Terms of Turkey”, TUSIAD_ DEIK Health Tourism Report, Health
Tourism Journal, Sağlık Turizmini Geliştirme Derneği, 2(8):32. (Medical Tourism: Global
Competition in Health Care”, Devon M. Herrick – National Center for Policy Analysis **:
Quoted from TAIK).
Health Tourism in Izmir
Global competitiveness researches indicate that the international tourists looking for
differentiated tourism experiences is increasing rapidly, and health tourism is one of the
fastest growing sub-segments. Taking the Izmir city in consideration, it used to be an
important destination of Turkish tourism though its' been loosing popularity to Antalya and
Istanbul It could be said that the long-term competitiveness of the Izmir’s’ tourism as a global
tourist destination may depend on product innovation and improving access to high value
niche. When the resources and potentials of the region are taken into consideration, the health
tourism seems to be the innovative product which is very suitable for the region. Thus when
Izmir was a candidate for EXPO 2015 the theme selected was “health” since this theme is
very suitable with what the city can offer.
Methodology
In this study, interview technique is preferred. The interview questions were open ended and
structured (see appendix 1) and interviews were held face to face where the replies were
written by the interviewees to the blanks spaces provided under ach specific question. the
population of the study consisted of 22 people who are experts of both Izmir city’s health
tourism potential, medical aspects and tourism industry. The data gathered through qualitative
techniques was analyzed and a SWOT analysis table was derived from answers which
involves a detailed examination of the strengths and weaknesses of the region’s potential, and

the opportunities and threats in the environment within which it belongs. As an addition to
SWOT Analysis table prepared, S/O, W/O, S/T and W/T strategies were also derived and
added adjunct to the analysis table, since they were also included within the interview
questions asked. If applied properly and with the help of contingency plans, SWOT analysis
of health tourism potential of Izmir, may help the development and implementation processes.
SWOT Analysis of Health Tourism in Izmir
A SWOT analysis is a procedure generally carried out before the development of a business
plan. It involves a detailed examination of the strengths and weaknesses of the organization,
and the opportunities and threats in the environment within which it operates. SWOT can
provide an insightful executive summary of the different elements of strategic analysis (Tribe,
2010:118-121). Appropriate strategies are likely to;
• Capitalize and align on opportunities and strengths
• Strengthen, eliminate or transform weaknesses and
• Overcome threats.

Table 2 - SWOT Analysis of Health Tourism in Izmir
Strengths (S)
1. Unique thermal / natural
resources
2. Richness and variety of
thermal resources
3. Suitable climate
4. Modern hospitals
5. Qualified health staff with
necessary academic,
operational and linguistic
skills
6. Transportation
7. Existence of tourist
attractions of national and
international significance
8. City being an industry and
trade center
9. Number of high quality
hotels
10.Society is health
conscious
11. Long coastal zones
12.High awareness and
positive consumer perception
in market
13. Product has potential for
differentiation
14. Availability of unique
and tremendous historical,
cultural and religious
attractions
15. Destination’s location
(near to EU health tourism
demand)
16. Existence of popular IVF
centers, dentistry and eye
care clinics, transplantation
units, etc.
17. Composed of multi
cultural groups
18. Comparatively low cost
19. Value proposition ( Good
price / quality ratio)
20. Support from local
people
21. Complicated surgical
procedures possible at 1/10th
the cost
Weaknesses (W)
1.Lack of coordination
among related organizations
2. Lack of projected plans
3.Lack of destination
management plans
4. Lack of mission, vision
and related strategies for
improvement
5. Need for cooperation
among related establishments
6. Inefficient marketing plans
7. Need for focusing and
effective target marketing
8. Need for accreditation,
standardization and
certification of health service
providers
9. Need for specific designed
health packages
10. Need for cooperation
with foreign insurance
companies
11. Benchmarking and
modern management
applications not utilized
12.Need for linguistic
improvement (2 nd 3 rd foreign
languages requirement for all
staff)
13.Public hospitals lack
necessary infrastructure
14. Research is needed to
figure out the trends,
potential, market
effectiveness etc.
15. Legislation problems
16. Need for an integrated
approach for health tourism
developments

Opportunities (O)
1. Growing global demand
for health tourism (%30
annual increase)
2. Global healthcare is
worlds largest after
retailing, revenue US$ 2.8
trillion
3. Long waiting lines for
some medical treatments
and periods in developed
countries like UK, USA
etc.
4. High prices for health
services in developed
countries
5. Insurance unaffordable
leading to semi insured and
uninsured population – US
6. Limited specialized care
in less developed countries
7. There is a healthcare
crisis in some of the
developed countries where
people cannot afford health
insurance and the
government does not
provide healthcare to a
majority of the population.
8. Health care costs
continuing to rise – Crisis
getting worse with no
solution in sight.
9. Economic crisis makes
low cost products more
demandable especially if
they have a standard
quality
10.Young spa users
increasing in numbers
11. Spas becoming places
to socialize
12. Fitness and wellness
issues are very popular
13. Increased concern in
corporate wellness
14. Increase in the 3 rd age
group who are interested in
health tourism
15. Aging generation in EU
S/O Strategies
1. Expand in existing
markets, penetrate in new
markets by using differential
aspects of the health tourism
product
2. Establishing a brand name
for Izmir’s health tourism
product
3. Establish a unified brand
and image for health tourism
in Izmir.
4. Apply co-branding with
new partnerships
5. Apply successful market
penetration techniques
6. Attract new market
segments (older people,
sportsmen) by using existing
products, well trained staff,
and product differentiation
and by introducing new
products to the whole market
6.Use cultural and heritage
beauties as a differential
image of the region
7.Research about what
region/patients you want to
attract and how you will
market to those patients
8.Make sure for every patient
that comes they have an
amazing experience, - word
of mouth marketing.
9. Promote the quality and
price differentials for
region’s health care product.
10. Integrate the medical and
beauty aspects of spas and
wellness establishments.
W/O Strategies
1.Overcome inefficient
marketing applications by
using opportunities of
growing industry and new
markets,
2.By getting help from
environmental groups and
training try to overcome the
pollution problems
3. By decreasing red tape and
increasing the speed in
beaurocratic activities,
support the technological
improvement in already built
hospitals and health services.
4.Get support for the
construction of specific new
health tourism establishments
5.Increase the specialty
education in medical,
wellness and nursing issues.
6. Improve coordination and
cooperation among related
bodies
7. Focus on niche medical
strengths such as fertility
treatments or regional unique
thermal therapies
8. Provide opportunity for
strategic partnerships or
alliances between
international healthcare
providers, insurance groups,
tour operators and the local
hospitals
9. Establish quality by
certifying investment and
enterprise documentation

16. Increasing interest in
alternative treatments
17. Increasing interest in
staying young and healthy
Threats (T)
1. Competition (especially
when offers better quality/
sophisticated service)
2. Demand for highest
quality, luxury, comfort
3. Wars and conflicts near
the region
4. Terrorist attacks all over
the world
5. Prices dropping in
competitive suppliers
6. Crises related to diseases
like swine flue, etc.
7. Natural deterioration &
pollution in thermal
regions
8. Water pollution, air
pollution, soil pollution
S/T Strategies
1.Keep up with the trends
and satisfy changing
customer demands
2. Market aggressively and
have a strategic marketing
plan.
3. Application of industry
accreditation standards
4.Use new management,
unique product and brand
power, and new partnerships
to match competition’s
increasing power
5.Use product’s differential
advantage, apply marketing
strategies to build brand
loyalty.
6.Offer interesting, tailormade
and unique travel
packages alternatives for
health tourists.
7. Consider ways to package
and promote visitor
experiences to potential
international spa and
wellness visitors
W/T Strategies
1.Special attention should be
given to hygine and quality
issues
3.Use crisis management
tools for overcoming
inconsistent image of the
region
4.Form a consistent message,
to match competitions image
as being better in terms of
quality- value proposition
etc.
5. Use all the combinations
of 8 P’s that is suitable
6. Apply a coordinated
regional policy and
promotional approach to
develop health tourism in
Izmir
7.Establish intra regional
cooperation to enhance
productivity and take
advantage of economies of
scale
Findings and Conclusion
The findings indicated that health tourism is indeed a very suitable tourism sub sector for
Izmir since all respondents mentioned so. There seems to be huge potential since the city
strong points like unique and curable thermal resources, already established health tourism
centers, proper climate that is suitable all year long, unique geography and heritage resources,
base for clustering in health tourism, appropriate infrastructure. The replies on the optimal
usage though showed that the interviewee mostly (only 3 disagreed) believed that though the
city has a huge potential for health tourism to improve, this potential is not utilized fully. The
reasons were stated as;
• The framework of health tourism in Izmir is very narrowly defined
• Most of the existing hotels are not designed specific to health tourism standards
and requirements
• There is a lack of coordination among responsible bodies
• There is a need for common policy regarding the health tourism
• Izmir needs proper positioning, imaging and branding for health tourism.

Many respondents suggested strategies to match these strengths with opportunities. Some
were quite creative strategies which may show an initial path for the practioners S/T
strategies were found to be especially useful in today’s period of economic crisis. The
findings indicated that coordination of related groups, planning, targeted promotion and local
interest are very important for the development of health tourism in the Izmir city. Some of
the weak points mentioned were; lack of focus on planning issues, lack of standardization,
inappropriate promotion and marketing strategies and limited bed capacity. Professional and
centralized marketing and managing of the issue were identified as vulnerable points where a
special focus of attention should be given to. W/O strategies were found to be especially
useful for this process. It was indicated that thus there is a huge potential for the development
of health tourism in Izmir, the resources are not fully utilized and with the application of
proper strategies and measures, it may become one of the important health tourism destination
in the global market.
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APPENDIX 1
Interview Questions
1. May Izmir be regarded as a suitable destination for health and wellness tourism?
2. Do you thing the health and wellness potential of Izmir is utilized in full for health tourism
purposes? If no, why do you think that is?
3. State the;
a. strong points (strengths) of Izmir’s health and wellness tourism
b. weak points (weaknesses) of Izmir’s health and wellness tourism
4. In order to promote and improve the health tourism market in Izmir name the;
a. opportunities
b. threats
taking into consideration the impacts that may come from all the economic, politic, social,
legistlative, cultural and technological external environments.
5. a According to you, what should be the S/O and W/O strategies applicable for Izmir’s
health tourism improvement?
5. b. According to you, what should be the S/T and W/T strategies applicable for Izmir’s
health tourism improvement?

Conscious or trendy? How do fashions and trends influence consumer’s
selection criteria in health-related tourism?
Krisztina Priszinger – Katalin Formádi – Peter Mayer
University of Pannonia
8200 Veszprém, Egyetem u. 10.
priszinger@turizmus.uni-pannon.hu
Abstract
With the raising preferences of being healthy, fit, environmentally sensitive, wellness became
more popular in our societies. This loosely defined term includes desirable ends such as a
dynamic lifestyle, mental and physical harmony, but also the means enabling the achievement
of the ends: services related to spending leisure time and holiday actively. Wellness became a
diversified and a holistic product which might be a key component to a long-term health and
wellness.
Wellness – beside being aimed in everyday life – also constitutes a motivation for a certain
type of tourism: the health and wellness tourist product. This can take various forms,
including both indoor and outdoor activities, taking place in spas, wellness hotels or even in
rural settings. A key trend in Western European destinations, medical wellness can still be
considered as a niche market in Central-and Eastern Europe. Suppliers are mostly underinformed
on the exact content of medical wellness and the needs of medical-wellness tourists.
As a consequence, the actual supply does not fit yet this demand.
On the other hand, we can appoint that the demand for traditional wellness-tourism plays an
important role in this region. Demand for wellness tourism is based on the generally
increasing importance of health-awareness and health-related lifestyle.
The focus of this paper is first, to identify trends and meta-trends in the media that may
influence consumer’s decision making. This part of the research is based on content analysis
of life-style print magazines and home pages. The secondary research is extended with
quantitative research based on a questionnaire carried out among spa visitors in one of the
most known Hungarian spa, in Zalakaros to point out the level of health-consciousness. The
targeted sample size is around 300 visitors. With that we examined whether visiting spas and
spending holidays in wellness hotels are “just” a trendy way of travelling or a healthconscious
step towards a healthier lifestyle. With that the study will examine the level of
health-consciousness from various perspectives. In reference to the actual product consumed
we discuss the facilities used, as well as the individual time spent on wellness services.
Furthermore, we investigate visitors’ decision making paying attention to the selection criteria
they apply as well as the general importance of this criteria in their everyday life.
Meaning of wellness
With the trends towards a greater preference for of being healthy, fit, environmentally
sensitive, wellness became more popular in our societies. Wellness has various meanings for
many people but it refers to the feeling of wholeness and health. Generally wellness is related
to the physical condition of a person as people’s aim is to achieve a good health condition and
minimize the risk of illnesses. Nevertheless wellness goes far beyond physical condition or
health. Certainly it starts with the physical health (doing exercises, cooking healthier,
consuming organic food etc.) but extends to other areas of people’s lives. From a holistic

point of view it means wholeness as all spheres of life come into balance: including the
working time, family- and leisure time.
The terminology of wellness is widely used in everyday life and in professional literatures as
well. Therefore wellness is defined in many different ways by many different people. The
problem arises as the wellness concept is closely related to the terms of health and well-being
– as all follow the same philosophy however the wellness implies a balance of different life
areas. The relationship between the lifestyle and state of health are closely linked - being fit,
not smoking has an impact on our well-being and health condition. Wellness is not the mere
absence of disease, it is rather a proactive, preventive approach designed to achieve the above
mentioned balance, and also a positive approach to environmentally conscious and healthy
living. It is important to note that the good physical condition does not necessarily constitute
an overall state of wellness or vice versa, a person may have an illness but he/she could reach
the balance in his/her life between the working, leisure or emotional dimensions.
Charles Corvin defined wellness “as a multidimensional state of being described the existence
of positive health in an individual as exemplified by quality of life and sense of well-being”
(http://www.definitionofwellness.com). The mentioned multi-dimensions of wellness fall into
broader categories, achieving the balance of all aspects or sub-dimensions. The National
Wellness Institute (Smith-Puczkó, 2009:55) defined wellness also as an active process
through which people become aware of, and make choices towards, a more successful
existence. They advocate a positive, optimistic outlook and a holistic and balanced approach
to life.
Illing (2009) made a differentiation in term of wellness between CEE and US. According to
him, the difference is in the motivation background – CEE people are less interested in
intervention and health-consciousness, they quest the long-term balance of body and/or mind
on one hand, and a quick gratification of their needs on the other hand.
The complexity of wellness has other impacts on everyday life: the health- and environment
conscious lifestyle makes it necessary to adapt new life-coaching “techniques” either by using
professional life-coach services (eg. life-style packages by hotels or using coaching services
or lifestyle consultant) or “learning by experiencing” throughout the person’s own life (eg.
how to deal with everyday stress). It suggests that wellness is a continuum rather than a
specific fixed state (Miller, MTW, 2008).
If we connect the dimensions of wellness to tourism, we find a spectrum of wellness offers
and wellness destinations which focus on the synergy of body-mind-spirit-environment. The
choice is depending on the visitors’ priorities which dimensions they want to experience and
focus during the travel. As Adams stated in 2003 (Smith-Puczkó, 2009:54) wellness is
relative, subjective or perceptual – so in this approach, more of a psychological than a
physical state of wellness is emphasized.
Wellness also constitutes a motivation for a certain type of tourism: the health and wellness
tourist product. This can take various forms, including both indoor and outdoor activities, take
place in spas, wellness hotels or in rural settings. The rapidly growing HWT sector includes
traditional spas, health centres, wellness-hotels and wellness-related accommodations (e.g.
farm accommodations with a focus on natural healing or relaxation). As the sector is
relatively diversified and in Central-Europe spas represent an important element of the
wellness offer, we focused only on the wellness spas.

As consumers intend to slow down, to relax and relieve stress and search for new lifestyle
experiences, which could be achieved by various spa experiences (individual, tailor-made,
intimacy or just simply having fun services etc.). Market trend analysis (Mintel, WTO, ISPA)
strongly points out the boom in the usage of spas worldwide. This is strengthened by the fact
that the awareness of the health benefits of spas increase and target markets become more
inclusive. More active spa-goers are measured and also the proportion of consumers going on
spa holidays is growing.
However, as Erfurt-Cooper and Cooper (2009) summarize, all interpretations of wellness
“have its origin in a natural and holistic approach to health that includes the use of water and
minerals within it”.
Yet more issue to address is the fact that wellness itself became a powerful notion. Due to the
success of using wellness associated with fun and also luxury, it became an effective
marketing tool for other products. The following advertisements exemplify how wellness
became a brand component of various products from other sectors:
“This is
what one
now calls
wellness.”
“Astra—
got
anything
against
it?”
Figure 1. Wellness as a slogan for other sectors Source: Miller, MTW, 2008
“The first
wellness
concept based
on motor oil.”
“We build
your car —
the new Opel
Signum.”
The success behind wellness as an advertising tool is explained by a German advertising
expert Marc Schwieger: “Wellness exudes an irresistible sense of pleasure. Health is
connected with illness, fitness is connected with exertion, well-being sounds too much like a
couch-potato existence. Wellness, on the other hand, sounds dynamic, because it originated in
America” (Formádi-Miller, MTW, 2008). Thus, the use of wellness to market other
prestigious and/or hedonic products further strengthens its positive reception. As a result,
wellness is developing both in its scope and its differentiation.
Methodology
In order to get insight into the actual wellness trends and to unfold from these, the underlying
meta-trends of changing consumer interests we applied content analysis of lifestyle
magazines. We selected all articles which have been, in any form, related to any of the aspects
of wellness (as outlined in table 1.). The sample involved all 2008 issues of the following
Hungarian and international printed and online lifestyle magazines:

Men Women
International
Playboy, Men’s Health
Elle Man
Cosmopolitan
Elle
CKM (online)
Éva, Patika, Nők Lapja Egészség,
Hungarian Deluxe (online)
Vital Magazin
Diéta és fitness
Table 1 Lifestyle magazines analysed
All in all 147 articles have been involved into the analysis. The texts have been carefully read
to identify any wellness-related issues. Major characteristics of discussing wellness were
noticed to create a list of issues. In a second step, these issues were discussed by the authors
to synthesise appearances of emerging trends and meta-trends. Finally, evidence from other
social science research fields (as demography, or the sociology of consumption) were sought
to underpin the outreach of the trends experienced in wellness.
The secondary research is extended with quantitative research based on a questionnaire
carried out among spa visitors in one of the most well known Hungarian spas, in Zalakaros to
point out the level of health-consciousness. The sample size was 330 spa visitors at the Gránit
Health Spa in Zalakaros. The data were collected between the 1st and 9th of May, 2009 based
on a questionnaire. Our main assumption was that the fun water is the more searched for
element for the Hungarian spa-goers rather than the regenerating or healing waters. The
Hungarian wellness spa-goers have not developed complex health-conscious attitude, they are
visiting spas because they seek enjoyment, fun and recreation but not for health reasons. The
importance of health-consciousness could be measured by the number of services used by the
visitors. If spa-goers pay only for the entrance fee and not for using wellness services from the
offer then they seek the entertainment elements only. Simply they visit the spas because it is
trendy and fashionable.
Fashions and trends in the magazines
In the following we unfold a number of meta-trends and trends associated with wellness as
emerging in over mentioned lifestyle magazines, first, to develop our knowledge about the
needs and desires of consumers, and, second, provide insights into possible soft product
development opportunities for the CEE spa sector. In this section we first describe the metatrend
in general, then, second, provide insight into the product development trends based on
the meta-trends, and, third we provide examples for the trends raised.
� Balance. Wellness is more and more (re-)discovered as an approach rather than mere a
set of activities. It is widely argued that wellness should address the lifestyle in general
and not a few days in a year only. The former approach which offered wellness (trips) as
an escape from everyday life is going to be replaced by considering a wellness holiday as
a tool to modify the course of life, to find balance – in all aspects of life. This trend also
involves taking a holistic approach to wellness, which is addressing more or all aspects of
wellness together, as related to each other, as impacting upon each other.
o Work/life balance: This is a widely discussed issue, from daily time management to
the burn-out syndrome. Wellness is seen as a help to learn managing multiple
challenges – both the do-it-yourself practices and the range of professional
consultancy. Bad Blumau, a luxury spa and hotel in Styria, Austria offers several
packages in the name of relaxation in a really de-stressing area (e.g. “Relaxation under
palm trees”, “Feel good”, ‘A woman’s job” or “Time for Two”).

o Body in balance: Formerly the body has been contrasted to the optimal body, as seen
on TV or in movies – young, slim, energetic and sun-tanned. Wellness meant getting
closer to this ideal picture through treatments, exercises and cosmetic products. This is
gradually giving place to a more accepting approach to the body, emphasizing
individual differences, multiple beauty idols, as well the mind/soul/body balance.
Nutrition is central to discourses about the body: instead of eating less, eating
differently – healthy, organic, rich in flavours and experimental, and, in some cases,
even more. Mountain Track, the Super Natural Spa (Canada) is not a fat farm but a fit
farm, offering both physical and nutrition programs to change lifestyle. FitPath is the
spa’s special methodology, which build on active participation of guests. The program
goes on for 3 weeks, with special diet and exercise-programs tailor-made for every
guest.
o Offers for couples: The discourse on wellness does more and more accept the idea that
at the quality of intimate partnership lies at the heart of well-being. A successful and
balanced partnership provides joie-de-vivre through sexual satisfaction, psychological
support, self confidence and security. Wellness should thus provide the opportunity to
enhance the quality of partnerships, with offering both gender-specific, but jointly
consumable services and programmes, but also opportunities to relaxed enjoy each
other and deepen the intimate relationship.
� Masculine emancipation. Metrosexuality is finding its way to the spa. Today’s men do
not have to live a grey, emotion-free life, demonstrating power and rigidness all the time.
Whereas issues like beauty and health, as well visiting spas in general have been seen as
female issues and activities before. Nowadays it is evident that men are targeted
indirectly through the female consumer (as men’s wellness discussed in women’s
magazines), but it is also clear that there is a growing interest among men to understand
the own body and soul, and to tackle – instead of dismiss – the problems faced in
everyday life.
o Men’s beauty: Man taking care of their outfit is a typical metrosexual orientation.
Contemporary cosmetic industry, clothing, etc. offer a range of product lines specially
designed for men. The selection form and the use of men’s products is a topic theme
of both men’s magazines – as a kind of quick guide to a new world. Men’s topics also
emerge in woman’s magazines, as how-to-help-and-guide-him articles. Also, the spa
sector develops more and more special packages for men. A spa is thus not a place to
send wives while men are working hard: it is an oasis for him, as well. Hotel
Loipersdorf Spa and Conference (Austria) offers in their Spa Days For Him package
massage, foot treatment and body pack.
o Men’s health: Health is an emerging issue in men’s magazines. It is now widely
accepted that men face specific health problems – both common minor problems (e.g.
hair or skin problems) and more serious, but yet mass diseases like cardiovascular
problems and the like. Sophisticated health schemes as medical wellness and
especially prevention measures specifically tackle these male issues. DAS GOGERS
Golf –und Spa Hotel’s (Austria) offer contains vitality face treatment and medical
pedicure with herbal bath only for men, which can be completed by one of massages
(like chocolate or golf massage), anti-stress treatments or body peeling.
� Age equality. Modernity is a youth regime. For the first time in history, youth, beauty,
ambiguous, innovativeness and the ability to change became higher valued then age,
experience, secure, determined and the ability to possess. In a fast changing society and
economy adaptation became the life maxima. Youth became the idol – middle-aged and

elderly wanted to look like, to act like and to be accepted like the youth. Although feeling
and looking young is still tempting – and, most probably, always will be – it is loosing its
absolute guidance in consumer trends. In late or post-modernity it is more and more
accepted that every age has its specific joys and pains and that it is an oversimplification
to push the youth-solution forward in all cases. On the contrary, lifestyle magazines
themselves tend to specialize, with some having a distinctively middle-aged character
(e.g. Éva and Nők Lapja) whereas others keep promoting the youth (e.g. Cosmopolitan
and Joy). Although not in CEE yet, in Western Europe and North America some lifestyle
magazines specialized into the 60+ age group (e.g. Zoomers). Also, the problems and
opportunities of each age group are discussed in a new way: first there are no taboos,
second all groups became self-referent. There are as many subsequent trends as age
groups, we only highlight three changes that exemplifies the meta-trend.
o Children spa: Most spas accept children as being important customers. First, because
the notion of children friendly service is got accepted, it is now obvious for everyone
that children have special needs, they’re just different form the adults. Second,
because parents – who make decisions about vacations and pay – consider services for
children the most important decision factor. A special example for babies-childrenfamily
oriented parks is Sonnenthereme in Lutzmannsburg-Frankenau, Austria.
Babyworld and Funny Waters indicators the main target groups of the spa – all
services are centralized on the difference in the needs of babies and kids, e.g. Babypools,
Nursing Cocoon, Children’s Nap Room, Baby Kitchen for the youngest; or
Children’s Sauna, Children’s Playroom, Adventure Pools and Activity Pool for
younger.
o Children health: For some years still health tourism was something for the elderly, the
weak and the ill. Growing health consciousness and development in research brought
widespread knowledge about childhood reasons of adult health problems. Paying
attention to issues like overweight children – a mass problem in advanced societies –
is a good example of this new approach to health. Also, HWT provides solutions for
overweight children – a typical example of addressing new segments with old
products. Czech Podebrady spa offers a special package for overweight children
o Third age: Also called 60+, this has been the number one target group of health
tourism. Whereas age still matters, there are a series of products and services
specifically addressing third age consumers. They do not have to provide performance
as their grandchildren anymore – a range of solutions offers positive experiences for
them.
Conscious or trendy?
In the second part of the research we aimed to demonstrate the effects of the above displayed
trends and metatrends on consumers’ consciousness.
Two-thirds of the interviewed spa-visitors were women, 35.8% were men. The average age of
respondents was 40 years old with a big variance: the oldest respondent was born in 1935,
while the youngest in 1990.

Table 2. Year of birth of the respondents (in %). Source: own research, 2009
More than half of the respondents had secondary education (54.6%) and 40.7% had college or
university degree. The respondents came from various locations: most visitors in our sample
lived in the capital city, Budapest, which is 200 km from Zalakaros (29 spa-visitor) or arrived
from the nearby big cities within 75 km circle such as Nagykanizsa (28 person), Kaposvár (18
person), Zalaegerszeg (15 person).
Surprisingly none of the visitors came alone to the spa: 93.8% visited the spa with families,
6.2% with friends. As the age of children is essential from the used type of services, we
examined that factor as well. A significant portion of spa-goers (half of the family visitors)
had 6 years old or younger children and only 4% had 18 years old or older kids. The average
children age is 7.5 years old: with big variation, as the youngest child was 3 months old, while
the oldest “child” is 32 years old with parents.
Table 3 The age of the children (in %). Source: own research, 2009
One-tenth of the family spa visitors had two kids where the average age of the second child is
10 years old, 4 visitors arrived with 3 kids– at this case the third child is 12,5 years old. Only
8% (25 people) of the interviewed spa-visitors answered to the duration of the spa-visit
question: they stay on average 2 days in the spa (variation between 1 and 6 days, with 1.5
standard deviation) and on the examined day they spent on average 4.5 hours in the spa
(between 1 and 8 hours variation, 2.2 standard deviation).
Generally visitors have experience 4,5 services (with 2,5 st. deviation) during a spa visit. The
list of services includes the 4 various pools so it shows that mainly those used by the visitors.

Table 4. The number of experienced spa services during a spa visit. Source: own
research, 2009
By examining the spa services experienced, 75 % of the visitors declared to use the wellness
pool and 50% use the thermal water/medical pool. No matter what the weather is, the outside
pool is very attractive in all season: 78.2 % of the respondents used in their spa-visit. Using
the pools seems to be obvious in case of a spa visit, but sauna and massage is clearly the most
popular service offered by spas. 49.1% of the 14.2% of the asked spa-visitors had healing
massage and 9.1% of them the wellness massage. The beauty treatments are less frequently
used by the examined spa-goers: only a small percent of the visitors purchased eg. a manicure,
pedicure or facial treatment or body scrub service. We can identify these services belonging to
“balance” metatrend, namely to an elementary level of “work/life balance” and “body in
balance” trends.
As the proportion of families is high among the visitors, the use of the children pool is very
high (57.5%). Among the experience-oriented services, the slides are very popular, 57% of
the visitors used it. We can highlight the “children’s spa” trend in this case, but the services
used by spa-goers of “children’s spa”-area is considerably close – in is confined to pools and
slides, and to playing room.
One-fifth of the visitors used the salt-cave services. In case of other healing elements,
acupuncture or medical treatment are rarely used among the respondents. The basic services
of the examined spa are based on “third age” guest, although the used services are
concentrating only on a few types of them.
All of the services were rated very good on a 1-5 scale according to the scale rating where 1 is
the worst and 5 is the best. All services by the users were rated above 4.3.

Table 5 The experienced spa services (the number of mentions). Source: own
research, 2009
Conclusions
Presently the examined spa (as well, as, most of Hungarian and CEE spas) incorporate only
few of the metatrends and trends, identified above, in their wellness offers. A key
characteristic of these spas is that they concentrate on the physical aspects of wellness such as
equipment variety, water quality and interior design. The underlying spiritual aspects and the
resulting sophistication of the soft service components are not addressed yet. Some of these
are missing completely: there are few gender-specific services and where such exists, these
are offered to women only. Similarly ‘balance” in its wider meaning is rarely discussed. The
most existent trend is that of serving children – these offers however address fun and
experiences, but not health.
However this does not seems to be a disadvantage on current markets as actual visitors do
require trend-related offers. Guests would require more services related to the food and
beverages component of the spas (to have healthier or green food, child friendly menus, good
cafeteria and good selection of wines). Even though it has not been formulated in this way, it
is easy to identify the trend of “body in balance” behind these wishes. As a second group of
missing services, the visitors mentioned the need for more specialized wellness services such
as different massages offers, more sport and fitness services for the younger generation too –
which we linked to the “work/life balance” trend. Families with young children would
require baby services such as babysitting or kindergarten in the spa, playground, according to
“children’s spa”. As contrasted to the few such ideas, the majority of the guests mentioned
different infrastructure items, as more pools, more resting beds with tables – these can’t be
classified to trends.
The research showed that visiting a spa became a trendy way of spending leisure time for lots
of people. The visitors experienced the spa in general (the thermal basin and wellness pools),
with a few wellness services. More complex and multi-layered wellness experiences are rarely
sought of.
Based on the above findings we can draw the conclusion that the development of wellness in
Hungary is mostly media-driven. Neither spa services nor the visitors reflect on the
metatrends and trends identified in life-style media. Thus media coverage is not based on
existing offers but rather envisages the – possible – future of wellness in Central Europe. It

emains an open question when the sharp competition among recently opened spas will force
these establishments to compete on the level of innovative service developments.
Summarizing our issues, we can draw the following inferences:
� According to Illing, Hungarian spa-goers have different motivations behind visiting
spas, than US guests (or even Western-European visitors). Regeneration and
rejuvenation is in focus only among a few visitors, most of them are interested only in
pampering or having fun with friends and/or family.
� The metatrends and trends identified in online and printed magazines are not
commonplaces among Hungarian tourist, neither among spas. Some of the trends are
not present at all (e.g. masculine emancipation), but as it turned out from the research,
spa-goers don’t even miss these services.
� The trends highlighted in magazines are not catching out in present spa-supply, but
they show the future, on one hand in demand, on the other in spa supply. This
induction is underpinned by the growing importance of children and their needs in a
spa.
References
Formádi, K., Miller, J. [2008] Making Tourism Work. Final report to the Leonardo da Vinci
pilot project. University of Pannonia, Veszprém
Erfurt-Cooper, P., Cooper, M. [2009] Health and Wellness Tourism. Spas and Hot Springs.
Aspects of Tourism, edited by Cooper, Ch., Hali, C. M., Timothy, D. J. Channel View
Publications, Bristol
Illing, K. T. [2009] Gesundheitstourismus und Spa-Management Oldenbourg Verlag,
München
Miller, J. Wellness. Educational Material for the Making Tourism Work: An Initiative for the
health and wellness tourism sector. Leonardo da Vinci pilot course, 2006-2008
Smith, M., Puczkó, L. [2009] Health and Wellness Tourism Elsevier, London
Definition of wellness http://www.definitionofwellness.com/
Internet
www.beautifulbreak.com
www.bultins.com
www.blumau.com
www.merchantcircle.com
www.sarvarfurdo.hu
www.sonnentherme.at
www.whynotmenspa.com
www.annabelkarmel.com

FITNESS AND WELLNESS DEMAND AND OFFER DURING A CITY BREAK IN
BARCELONA
The (mis)match of the wellness and fitness offer of Barcelona for Dutch tourists who practice
fitness in their daily life and how Barcelona can develop itself into a wellness destination
Xavier Puertas
Escola Universitaria d'Hoteleria i Turisme
Barcelona
Spain
xavier.puertas@cett.es
Roos Gerritsma
University of InHolland, Amsterdam/Diemen
The Netherlands
roos.gerritsma@inholland.nl
Keywords: fitness, wellness, demand, supply, destination concepts
Dutch demand
Nearly 25% of the Dutch inhabitants practices fitness during their daily life 53 and often use
the wellness facilities offered in their gym. The main focus in this research is the question to
what extent this target group is looking for a fitness and wellness offer during a city break in
Europe, especially in Barcelona. Research has been carried out amongst 334 Dutch fitness
practitioners between the ages of 18 and 45 years old 54 . Sixty two percent of the respondents
visited Barcelona, and 71% of them would like to visit Barcelona again.
The sample consists of three different groups, depending on their monthly membership fee
they pay for their membership per month: budget (>30 euro ), middle (31 – 60 euro) and high
(< 61 euro), 46% use the wellness facilities frequently. There is a significant difference in
the use between men (38%) and women (53%). The more they pay for their membership, the
more often they use wellness facilities: low budget 28% and high budget 85%. Another
significant gender difference turns out to be the fact that women (45%) use wellness facilities
in order to relax, whilst for men this is 33%, men find the recuperation of their muscles more
important (38%) against only 12% of the women. Core values they all share are: taking care
of one’s own health, striving for a tight body and developing muscles.
Sixty nine percent of the respondents has been on a city break at least two times during the
last two years, 11% of them even 4 to 10 times. For approx. Seventy percent think that a city
break consists of 3 to 4 days. Twenty five percent want to pay 300 to 400 euros for such a
trip and 23% is willing to spend 400 to 500 euros for a city break in Europe. Funny enough
the men have a preference to go during the autumn and winter, and the women prefer to go
during spring and summer. Almost 50% brings sports cloths with them on a city break, men
more often than women. When using wellness facilities in the hotel, 75% of them would like
this to be an offer that is all inclusive with the price of their staying. High budget practitioners
(64%) are willing to pay more for fitness and wellness facilities in their hotel and find such an
offer very important, this against 26% of the low budget respondents. Only 9% of the
respondents think of Barcelona as an active and sports city, most of them consider Barcelona
more as a place to wonder around, visit the main attractions and sense its cultural atmosphere.
53 Fitness in The Nederlands 2008-2009, GFK Panel, NRIT Media

Most important criteria when booking a hotel are the price (83%) and location (93%) of the
hotel. Wellness facilities are important for 33% of them (women more than men) and 28% of
them would like to use fitness facilities in their hotel.
The more often respondents are practicing fitness , the more often they would like to get
informed about fitness, wellness and healthy nutrition.
Barcelona wellness and fitness offer
Although Barcelona does not stand out as a wellness tourist destination, it has a significant
potential in this sector that may be able to transform it into an excellent supplement for the
new tourist trends, and specially for Dutch people.
To analyze the wellness and fitness offer of the city, we applied a SWOT analysis to find out
that the most important strengths are the identity of the city, the culture and its climate. In
terms of opportunities for Barcelona the fact that wellness/fitness is an expanding sector
represents an important and an unquestionable added value for tourism industry nowadays.
On the other hand we also find some weaknesses. For example the lack of tradition in
wellness or spas in the city, which limits the use of the actual facilities to a small group of
citizens and to some tourists staying in some specific hotels that are not usually located in the
city centre. Finally the main threats are the typology of city visitors, since at this writing
most of them are are low costs tourists. Furthermore, the increasing competition of other cities
that are already positioned internationally.
An important part of the research results are the proposals and suggestions addressed to
future tourists visiting Barcelona but also to companies willing to meet the needs of these
possible future customers.
New directions for Barcelona?
The following destination concepts will be presented at the TTRA conference:
Mediterranean Wellness
Wellness based on typical and traditional values and products
Wellness de luxe for business travelers
Well-being, fitness and gastronomy

ATTRIBUTES OF HEALTH AND WELLNESS TOURISM UNITS – AN
IMPORTANCE-PERFORMANCE ANALYSIS
Joana Alegria Quintela
University of Aveiro / Dept. of Economics, Management and Industrial Engineering
MA in Tourism Management and Development
Campus Universitário de Santiago . 3810-193 Aveiro, Portugal
joana.quintela@gmail.com
Anabela Gomes Correia
Polytechnic Institute of Setúbal / College of Business and Administration
Campus do IPS, Estefanilha 2914-193 Setúbal, Portugal
Center for Governance and Public Policy Research – University of Aveiro
acorreia@esce.pt
Jjoaquim Gonçalves Antunes
Polytechnic Institute of Viseu / School of Technology
Avenida Coronel José Maria Vale de Andrade
Campus Politécnico . 3504 - 510 Viseu, Portugal
jantunes@dgest.estv.ipv.pt
Abstract
The main objective of this study consists of identifying the attributes that please more and that
are more emphasized by the users of five thermal units and a hotel with Spa situated in a
Portuguese region. The empiric research consisted on the interpretation of surveys
administrated to their users. The model of this study was based on Importance-Performance
Analysis. Through the IPA analysis, we verified that all the attributes are concentrated on the
area of the critical forces, in which the importance and performance attained high levels.
Although, must still be emphasized that “Relation quality / price”, “Quality of complementary
services” and “Geographic localization” are attributes that belong to the area risk/opportunity
and are in its threshold, which means that Health and Wellness Tourism units managers
should concentrate efforts to improve the performance of these attributes because they are
very important to their users.
Keywords: Health, Wellness, Tourism, Attributes, Performance, Satisfaction.
Introduction
The growth of Health and Wellness Tourism in Europe is clear and it is due to a number of
social circumstances, such as the increase of the citizens and to the population oldness and its
lifestyles.
On recognizing the increase of the number of people interested in having leisure times with
quality, becomes evident and necessary that the supply should give special attention to this
question, as an answer to the needs and wishes of consumers, as well as the fulfillment of
their satisfaction levels. This perspective is seen as a determinant factor in what concerns to
the competitiveness which allows the regional development of the inner regions of Portugal,
where this kind of touristic offer can mainly be found.

The study investigates the performance of the main attributes in Health and Wellness units,
located in Viseu, a region in the center of Portugal, well-known by its thermal and touristic
potential.
The purpose of this study is employing the importance-performance analysis (IPA), a
decision-making tool for service management, to assess the performance of the attributes of
Health and Wellness units in Viseu region and analyze the importance those attributes have to
their users.
The Importance-Performance Analysis (IPA) is a technique introduced into the field of
marketing by Martilla and James (1977). Although this research method has been referred
mainly in marketing literature it was initially applied in the automobile sector. But in a short
time the application of this technique was applied to the health sector, banking (Ennew et al.,
1993), hotel industry (Martin, 1995), education and destination tourism (Hudson and
Shephard, 1998).
This technique identifies strengths and weaknesses of brands, products and services by
comparing the two criteria that consumers use in making a choice: the relative importance of
attributes and consumers’ evaluation of the offering in terms of those attributes.
Once the importance and performance of each attribute have been plotted, the resulting IP
space is traditionally divided into four quadrants. The priorities for improving the attributes of
the service are then inferred from the quadrant where each attribute (performance, importance
point) is located.
Unlike SERVQUAL model created by Parasuraman, Zeithaml & Berry, (1994), which is best
described as an absolute performance measure of consumer perceptions of service quality, the
Importance-Performance paradigm also seeks to identify the underlying importance attributed
by consumers to the various quality criteria being assessed (Sampson and Showalter 1999),
constituting a tool for managerial decision making in services.
Several different approaches have been used to undertake Importance-Performance Analysis
(IPA), aka quadrant analysis or gap analysis. Martilla and James (1977) originally suggested
that the positioning of the grid lines is a matter of judgement, because the value of IPA is in
determining relative, rather than absolute, levels of importance. In some applications, the
point where the quadrant grid lines cross (the cross-point) is placed in the centre of the scale
used.
Slack (1991) presented an IPA model that considered a relationship between importance and
performance and theorized that target levels of performance for particular product attributes
should be proportional to the importance of those attributes. In other words, importance is
seen as viewed as a reflection of the relative value of the various quality attributes’ to
consumers. According to Barsky (1995), lower importance ratings are likely to play a lesser
role in affecting overall perceptions, while higher importance ratings are likely to play a more
critical role in determining customer satisfaction. IPA also helps to identify which attributes,
or combinations of the attributes are more influential in repeat purchase behavior and which
have less impact. The information is valuable for the development of marketing strategies in
organizations (Ford et al., 1991). This view is confirmed by Lovelock et al. (1998), who
stated that importance-performance analysis is an especially useful.

The theoretical and practical issues relating to the variations in these components, while
quadrant analysis of some sort appears to be the most common method of inferring priorities
for service improvement in IPA, sometimes some type of gap analysis is also used.
Methods
The methodology used in this study consists of the review of the literature and in the analysis
of statistic data. The statistical analysis was conducted based on the quantitative data from the
survey used for achieving the research objectives.
A modified IPA model was used for a sample of users of the five therms located in Viseu’s
region and a hotel with Spa facilities. These health and wellness units were selected to
investigate the importance of service/product attributes for service providers’ and users’
evaluation of services.
A survey of users of health and wellness units was conducted for measuring and comparing
the perception of these clients about health and wellness units attributes’. Empiric data were
collected during a period of four months.
The survey was applied randomly to the users of the mentioned units that were asked to
complete the questionnaire in person. In order to qualify for the sample, individuals had to be
over the age of 18 years old.
Respondents were also asked to provide importance and performance scores, in two identical
five-point Likert’s scales, for the 15 service attributes identified for health and wellness units.
The instrument was applied for measuring the key variables in the framework including the
perception of service quality, overall satisfaction, and pride in the university. The health and
wellness users were asked about their perceptions with a 5-point rating scale ranging from
“Very Low” to “Very High” on 15 items in the questionnaire (Table 1).
Table 1 – Difference between importance and performance means’.
1 Very Low 5 Very High Non applicable NA
SERVICE / PRODUCT ATTRIBUTES
Quality of attendance 1 2 3 4 5 NA 1 2 3 4 5 NA
Thermal waters’ quality 1 2 3 4 5 NA 1 2 3 4 5 NA
Quality of equipment and public areas 1 2 3 4 5 NA 1 2 3 4 5 NA
Confidence on the received service 1 2 3 4 5 NA 1 2 3 4 5 NA
Quality of the medical consultants 1 2 3 4 5 NA 1 2 3 4 5 NA
Quality of thermal application techniques 1 2 3 4 5 NA 1 2 3 4 5 NA
Variety of treatments 1 2 3 4 5 NA 1 2 3 4 5 NA
Hygiene of the public areas 1 2 3 4 5 NA 1 2 3 4 5 NA
Comfort of the public areas 1 2 3 4 5 NA 1 2 3 4 5 NA
Quality of the complementary services
1 2 3 4 5 NA 1 2 3 4 5 NA
(lodging and animation)
Technical competence of therapists 1 2 3 4 5 NA 1 2 3 4 5 NA
Efficiency and results of the treatments 1 2 3 4 5 NA 1 2 3 4 5 NA
Publicity 1 2 3 4 5 NA 1 2 3 4 5 NA
Geographical location (transportation and
accessibilities)
1 2 3 4 5 NA 1 2 3 4 5 NA

The survey was distributed to 400 users of those units, with a rate of answer in the percentage
of 64,5%, making a total of 268 valid surveys.
´
Results
The gap between importance and performance from both perspectives were also evaluated
using the T-test criteria as shown in Table 2.
After the treatment of the obtained data trough the survey that constitutes the main search
instrument of our empiric study, we can interpret e discuss the results.
Table 2 – Difference of means between the importance and performance levels.
Attributes of the Health and
Wellness Units
Level of
Importance
Mean
Mean
Level of
Performance
Mean
Difference
Imp. –
Perf.
Level of
Significance
(Sig. 2tailed)
Pair 1 Quality of attendance 4,48 4,13 - 0,35 0,000
Pair 2 Thermal waters’
quality
4,54 4,18 - 0,36 0,000
Pair 3 Quality of equipment
and public areas
4,47 4,05 - 0,42 0,000
Pair 4 Confidence on the
received service
4,47 4,12 - 0,35 0,000
Pair 5 Quality of the
medical consultants
4,44 4,16 - 0,28 0,000
Pair 6 Quality of thermal
application
techniques
4,45 4,08 - 0,37 0,000
Pair 7 Variety of treatments 4,40 3,99 - 0,41 0,000
Pair 8 Hygiene of the public
areas
4,52 4,20 - 0,32 0,000
Pair 9 Comfort of the public
areas
4,44 4,07 - 0,37 0,000
Pair Quality of the
10 complementary
services (lodging and
animation)
4,27 3,74 - 0,53 0,000
Pair Technical
11 competence of
therapists
4,45 4,12 - 0,33 0,000
Par 12 Efficiency and results
of the treatments
4,39 4,09 - 0,30 0,000
Pair
13
Publicity
4,02 3,88 . 0,14 0,000
Pair Geographical
14 location
(transportation and
accessibilities)
4,25 3,86 - 0,39 0,000
Pair
15
Quality / price
relation
4,40 3,66 - 0,74 0,000
Test of the
nule (H0)
and
alternative
hypothesis
(H1)
Rejection
of the H0
because the
significance
level is
inferior to
0,05,
prevailing
the H1.

Note: Total of 15 variables. T-test bilateral with a significance level of 0,05; N=268.
Gap (Sat-Imp) difference between the users´ satisfaction about the service and the importance
given to each attribute.
Relatively to IPA analysis, we verify that the 15 attributes considered in the survey are all
concentrated on the area of the critical forces (Figure 1), in which the importance and the
performance attain high levels, calling the attention and motivating the Health and Wellness
units managers’ to profit the competitive advantage. This aspect strengthens what was
previously said about the high level of satisfaction the users have in the conditions and
services offered by those units.
From this analysis must still be emphasized that the “Relation quality / price”, the “Quality of
complementary services (lodging and leisure)” and the “Geographic localization (quality of
transports and accessibilities)” are attributes that, in spite of being in a comfortable situation,
belong to the area risk/opportunity and are in its threshold, which means that the managers of
Health and Wellness Tourism units has to concentrate efforts to improve the performance of
these attributes because they are important to the clients.
Figure 1 – Importance-performance Analysis.
In this sense, the IPA helps to verify that there´s a high evaluation of all the considered
attributes, alerting and incentive the managers of the health and wellness units to take a
competitive advantage, because the attributes are classified with a high level of importance
and performance.

Conclusions and Discussion
In this study, the Importance-Performance attributes of a service quality of health and
wellness units were examined among users. The key results were that users are satisfied with
the attributes of the services and equipments of the units they visited.
However, regarding to the Importance attributes users feel some had lower mean data of some
attributes (i.e. “Relation quality / price”, “Quality of complementary services” and the
“Geographic localization”). These findings may be concluded that health and wellness
managers should give more attention to these attributes that influences the users satisfaction
with the service received during their stay in those units. Moreover, we suggest that these
service attributes would be improved.
This study also was focused on significant factors affecting respondents’ satisfaction with a
service quality in the visited health and wellness units.
The findings of this study could be applied to improve service quality, equipments and
facilities in those private health and wellness, well-known for its touristic potential.
Research limitations/implications
The main limitations of this study are that it was based on a single service industry and that
convenience sampling was used. However, its methodology and results are valid for various
industries in the service sector and provide a solid basis for future research.
The contribution and the value of this study consist in the fact that service managers can
exploit the approach taken by this study to improve service management and attributes of
health and wellness units. The managers have to keep considering the needs and wants of
their users regarding their satisfaction levels and their loyalty, consequently.
Therefore, future research may be needed to examine these proposed variables. From the
findings, solving service problems and improving quality of attributes and services of health
and wellness units are an important task to use all of their potentialities.
References
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Ennew, C. & Binks, M. R. (1999). Impact of Participative Service Relationships on Quality,
Satisfaction and Retention: An Exploratory Study. Journal of Business Research, 46,
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Ford, J. B., Joseph, M. & Joseph, B. (1991). Importance – performance analysis as a strategic
tool for service marketers: the case of service quality perceptions of business students in
New Zealand and the USA. European Journal of Marketing, 27(2), 59- 70.
Hudson, S., Hudson, P. & Miller, G. A. (2004). The Measurement of Service Quality in the
Tour Operating Sector: A Methodological Comparison. Journal of Travel Research,
Vol. 42, February, 305-312.
Lovelock, C., Vandermerwe, S. & Lewis, B. (1998). Services Marketing. A European
Perspective. Prentice-Hall Europe.
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January, 77-9.

Martin, D.W. (1995). An Importance-Performance Analysis of Service Providers´, Perception
of Quality Service in the Hotel Industry. Journal of Hospitality and Leisure Marketing,
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Parasuraman, A., Zeithaml, V.A. & Berry, L. (1994). SERVQUAL: A Multiple-Item Scale for
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A Comparative Analysis of Spa Tourism in Japan and Hungary
Tamara Rátz
Kodolányi János University of Applied Sciences, Hungary
tratz@uranos.kodolanyi.hu
Abstract
Health is an ancient travel and leisure motivation that has inspired people all around the world
to leave their permanent residence and visit far-away destinations for thousand of years.
Although globalisation trends in supply and demand also affect spa and health tourism which
leads to the introduction of novel and exotic treatments and services, health-oriented leisure
and tourism behaviour is still considerably culture-dependent on the one hand, and
economically and environmentally influenced on the other hand. As a consequence of its
richness in geothermal resources and its unique culture, Japan has been able develop a
distinctive path in spa tourism development and wellness. Hungary is also in rich thermal
springs and spa culture also developed for centuries, but the leisure and tourist supply and
demand are highly different in the two countries, due to each countries’ unique cultural,
economic and natural background.
The paper analyses the similarities and differences between health-oriented leisure mobility
and the development characteristics of health tourism in Japan and Hungary, and assesses the
cultural and environmental factors that have shaped development in each country. Based on
secondary literature research, personal observation at Japanese hot springs destinations and
customer attitude analysis based on a mail survey carried out among 150 international visitors
to Japanese spas, questions to be discussed also include health tourism marketing issues, the
range and characteristics of facilities, as well as perceptions and attitudes of foreign and
domestic visitors. In addition, the paper aims to identify the specific factors in Japanese and
Hungarian spa tourism that may prove to be attractive for certain visitor segments in the
respective countries.
Introduction
Japan and Hungary are both listed among the world’s five richest countries in terms of
thermal and medicinal springs. However, this richness is explained by different natural
factors: in Japan it is the widespread volcanic activity that makes the islands of the country
one of the world’s greatest hot spring (onsen) destinations (Kojima and Kawamura 2006),
while Hungary’s favourable position is due to the Carpathian basin’s particularly high
geothermal gradient (Boldizsár 1973).
This paper is based on field research in Japan in spring 2008 supported by the Japan
Foundation Fellowship for Intellectual Research. The major objective of the research project
was to explore and understand the social, economic and environmental aspects of healthoriented
leisure mobility in Japan. The project had a theoretical as well as a practical
approach. Despite the growing significance of Japan both as a country of origin and a
destination of tourism, relatively little research has been undertaken to explore the sociocultural
and economic aspects of Japanese tourists’ behaviour, although interest in the subject
has been growing recently (e.g. Graburn 1983, Creighton 1997, Baláz and Mitsutake 1998,
Hendry and Raveri 2002, Guichard-Anguis and Moon 2009).

Health-oriented leisure and travel mobility in Japan is a relatively under-researched area,
especially in the international literature, so an assessment of the factors affecting Japanese
health-oriented leisure and tourism demand – such as the various cultural and economic
aspects of demand as well as the constraints and the push factors that motivate the Japanese to
choose health-oriented forms of leisure and tourism services – can be a valuable contribution
to the existing tourism research literature.
The development of spa and health tourism in Japan
Bathing in hot springs has been a quintessentially Japanese form of leisure for centuries: the
country’s arguably oldest hot spring, Dogo Onsen has a history stretching back over 1500
years (JNTO 2010). However, the attraction of onsen is about much more than hot water: the
essential components of the modern onsen experience are nutrition, sightseeing, exercise and
relaxation in natural surroundings (Seki and Heilman Brooke 2005). Throughout the
centuries, the interpretation and utilisation of hot springs in Japan has undergone significant
changes. While during the Edo period (1603-1868) travelling to hot springs also represented a
spiritual journey, partly a pilgrimage and partly a way to relax one’s mind, in the Meiji era
(1868-1912) onsen visits became institutionalized events for school and company groups,
with an emphasis on learning (Raveri 2002). In the second part of the 20 th century, as the
popularity of recreation-oriented tourism increased, many traditional onsen were transformed
into large-scale holiday resorts that are today among the most visited destinations in the
country, offering outdoor and indoor communal bathing facilities, hotel spas, as well as
private baths (Chartrungruang and Mitsutake 2007), in addition to supplementary services
such as aromatherapy, foot and hand baths, and a wide range of restaurants and shopping
facilities (Mansfield 2001, Kobayashi 2004). According to the Japan Spa Association, the
country’s 16,000 onsen get over 140 million visits every year, which is an indication of how
many people, especially the elderly, return repeatedly (Ellis 2004).
In recent years, Japanese hot springs have also become a part of the modern medical system,
although the number of facilities offering long-term therapy is still rather small, since medical
insurance rarely covers onsen stays which tend to be relatively short breaks and are typically
regarded as fun trips (Ito 2003). However, the imminent ageing of the country’s population
(Aspalter 2007) is likely to increase the need for enjoyable alternative healthcare solutions
offered by hot springs resorts. Onsen therapy is a type of alternative or complementary
medicine, not directly curing the cause of the disease, but treating the body as a whole, and
assisting in recuperation, rehabilitation and prevention. In addition to the hot springs, the key
elements in Japanese balneotherapy are gases as well as climatic and geographical factors (Ito
2003). An onsen's chemical makeup is one of the key elements of balneotherapy. According
to the 1979 revision of the 1948 Onsen Law, Japan’s hot springs are classified into nine
categories based on water properties (Ueda 2006): simple carbon-dioxide springs, hydrogencarbonate
springs, chloride springs, vitriolic springs, ferrous springs, sulphur springs, acidic
springs, radioactive springs, and simple thermal springs with water temperature over 25ºC.
The development of spa and health tourism in Hungary
Spa tourism based on thermal baths also have a long history in Hungary: the country’s current
supply is built on Roman, Turkish and Austro-Hungarian spa heritage, in addition to modern
developments inspired by Western and Oriental trends (Puczkó and Rátz 2006).
In the territory of Hungary, the first thermal baths were built by the Romans in the 1 st century,
although these ancient spas are only preserved in ruins today as heritage attractions. The
tradition of bathing continued during the 15 th -17 th centuries throughout the country’s 150-

year-long Ottoman occupation: the Turkish baths and the culture of spa visits that Hungarians
adopted are among the positive legacies of this historical period. The Turkish-style heritage
baths of Budapest are today equally popular as leisure facilities for local residents and
heritage attractions for tourists. The third golden age of spa-going in Hungary started in the
19 th century when balneology – the study of the art and science of bathing – became both
popular and scientifically approved. The establishment of the “Balneological Society of the
Countries of the Hungarian Holy Crown” in 1891 (MBE 2004) facilitated scientific cooperation
in balneology, thus resulting in a more effective healing process and contributing to
the development of medical spas around the country. The period’s typically science-oriented
focus on the medicinal values of natural waters significantly affected Hungarian spa tourism
development throughout the 20 th century.
However, political and economic factors have also played a significant role in shaping the
industry. By 1920, due to the Trianon Peace Treaty ending World War I, Hungary lost more
than two thirds of its territory, and the majority of the country’s internationally established
thermal and mineral spas were located behind the newly drawn borders. As a consequence,
the focus of spa tourism development shifted to the exploitation of thermal resources of
Budapest and other destinations within the country. Unfortunately, the outbreak of World War
2 in 1939 interrupted the progress of Hungarian tourism development, and in the newly
established socialist political system spa and health tourism development was mostly limited
to state-controlled social tourism (Lengyel, Puczkó and Rátz 1996).
Hungary is the fifth richest country in thermal and healing waters after Japan, Iceland, France
and Italy. According to the natural healing assets register, Hungary has 1372 thermal wells, of
which 224 are mineralised and 197 medicinal; five medicinal caves, five medicinal mud
sources, one mofetta (a carbon dioxide bath), one natural healing lake (Lake Hévíz), and
altogether 385 spas, of which 65 are classified health spas (Aquaprofit 2007).
In Hungarian tourism, spa and health tourism is a key priority product. The Hungarian
National Tourist Office declared year 2008 the “Year of Waters” including mineral and
thermal waters, putting the field in the focus of the organisation’s domestic and international
marketing efforts. During the last five years, significant capital investment with state support
has been realised in spa and health tourism, resulting in the development of new spas and
wellness centres as well as the necessary tourism suprastructure (hospitality services).
Research methods
During the fellowship period in Japan, both secondary and primary research methods were
used to analyse the role of hot springs in Japanese tourism, the characteristics of supply and
demand, the factors influencing the development of supply and demand, and to compare the
characteristics of tourism based on thermal resources in Japan and in Hungary.
Secondary research methods included the collection and analysis of literature sources on
Japanese tourism, hot springs, social and economic development, using the Library of the
Japan Foundation in Tokyo, the Library of Sapporo Gakuin University in Sapporo, and the
Library of Hokkaido University in Sapporo. This information was later supplemented by
statistical facts and other sources on Hungarian spa and health tourism.
Primary research, on the one hand, included participant observation in the form of visiting
onsen destinations, baths and spas, at a variety of locations around Japan (Toyako, Jozankei,
Sapporo, Hakone, Kawaguchiko, Beppu, Osaka, Tokyo). During these visits, data collection

focused on the following topics: information available on the spot and beforehand (in printed
promotional materials and online), focus and style of promotional messages, use of Japanese
and foreign language(s) in communication, architectural styles of onsen destinations, range of
services available, type of customers (age, gender, nationality), behaviour of customers.
In addition, a set of qualitative surveys were carried out in order to better understand foreign
spa tourists’ experiences and attitudes: 30 foreign backpackers were interviewed in the visited
hot springs destinations (between the age of 18 and 50, representing 9 countries), and a mail
survey was conducted on virtualtourist.com with a sample of 150 members who had visited
Japan (an excellent 80% response rate was achieved which may be explained by the website’s
focus on travel and communication as well as the researcher’s active involvement and
presence on the selected site). Both the interviews and the mail survey aimed to investigate
the main motivations of visiting a Japanese bath, the possible differences between the previsit
expectations and the actual experiences, the most positive and most negative aspects of
the onsen experience, and the respondents’ expectations and image of the ideal Japanese
onsen. Among the 120 respondents, 38% did not visit any onsen, for a variety of reasons,
while staying in Japan, 45% were willing to describe their actual onsen experience, and 17%
described in detail the expected ideal onsen experience.
The Japanese onsen experience
Not surprisingly, the central theme of the Japanese onsen experience, almost irrespectively of
the respondents’ nationality, proved to be the enjoyment of the hot waters. Several
respondents mentioned how “relaxing and mind-soothing” bathing was, although some also
pointed out that the high temperatures enjoyed by the Japanese bathers may prove to be
slightly uncomfortable for novice tourists. As one American tourist recalled: “we were told
that a gaijin (foreigner) might have to get out after fifteen minutes or so since the body is not
used to such heat.”
The geographical location and the architecture of the destination are also important elements
of the onsen experience. Onsen ryokan have always been constructed of natural materials,
including timber, paper, bamboo, grass or cloth, in order to form an environment that
encourages “traditional behaviour”, i.e. the personal, relaxing rituals of the Japanese bath
(Altman 2008). While many onsen have been modernized over the last decades – which, in
many cases, has led to replacing the atmospheric, wooden Japanese buildings with large
concrete structures that are less in harmony with the environment, there are many exceptions
where the onsen have been remade in an elegant, traditional Japanese way, with refined
artwork, elegant flower arrangements, impeccable and relatively flexible personal service,
excellent food served in private rooms and small capacity.
In addition to the built environment, the natural surroundings also play a key role in affecting
visitors’ satisfaction. For example, when describing the most positive part of his onsen
experience in Hakone, one respondent emphasised that “the onsen was surrounded by lush
vegetation and you could see the lake of Hakone from where you were bathing”. The image of
the ideal onsen almost exclusively represented an outdoor experience, e.g. “a naturalistic
mountain setting with a lovely view, or if not this, then a view of a garden”, or “set in a great
natural environment such as in the middle of a forest or beside the crashing sea”.
In Japan, gastronomy – with meals generally being included at onsen ryokans – is a key
component of the overall onsen experience. International visitors – particularly to the smaller,
less mass-oriented hot springs – generally appreciate the typical onsen cuisine which,

although unintentionally, represents the key characteristics of the increasingly popular “slow
food” movement. Japanese cuisine has traditionally been based on the principle of
consciously enjoying both the flavours and the presentation of the food, and paying particular
attention to details such as matching the colour of the plate with the colour of the food, or the
type and timing of each course served, relative to the previous course. However, high quality
food as part of the typical onsen experience was only mentioned by repeat customers who
have already enjoyed the culinary delights available at a traditional onsen ryokan, which
suggests an incomplete pre-visit image of first time bathers.
The main difference between Japanese and international visitors’ perceptions of onsen visits
is related to the nature of the experience. While in domestic Japanese tourism hot springs are
mostly seen as relaxation-, pleasure- or health-oriented destinations, most Western tourists
staying at hot springs were more inspired by culture- and heritage-related motivations than by
health reasons, since, in the words of a Canadian tourist: “What is more Japanese than
onsen?” Several respondents emphasised that their main motivation to visit an onsen was to
“experience Japanese life more”, that nobody “can or should go to Japan without visiting an
onsen since it is such a big part of their culture and traditions”, and that bathing in the hot
springs “is one of the most interesting and special experiences of a visit to Japan”. It shall be
noted that Japan has changed significantly in the last fifty years, and the socio-economic and
cultural changes are reflected in many aspects of the reality experienced by visitors, including
architecture (traditional Japanese thatch-roofed wooden buildings have mostly disappeared) or
consumer habits (the ubiquity of shopping facilities is overwhelming). Many international
leisure visitors who come to Japan to see a unique culture that is significantly different from
their own may feel slightly disappointed by the thoroughly modernized and Westernized
country, or even by the seemingly harmonious coexistence of Western lifestyle and the
widespread manifestations of traditional cultural heritage. Modern Japan is an overdeveloped
country where, to a surprisingly large extent, the tourist milieu (Michalkó and Rátz 2008),
particularly in the metropolitan areas, is composed of concrete high-rise buildings, neon signs,
and generally nondescript architecture, so the traditional hot springs are among the few places
left in Japan that have retained what Westerners perceive as traditional Japan. Consequently,
visiting an onsen is one opportunity for international travellers to get in touch with the socalled
“real Japan” and “authentic Japanese culture”.
However, throughout the country, there are many well-developed onsen towns catering for
large numbers of mostly domestic tourists that have already lost their traditional atmosphere.
As one respondent described an onsen in Hakone: “the onsen was more like a very large gym
pool, with a wall to separate the men from the women.” Since most foreign visitors expect the
Japanese onsen to “look as natural as possible rather than like swimming pools, use natural
rock and have traditional Japanese style plants around it”, they are more likely to be
attracted by the so-called “hidden” hot springs (Neff 1995), with just one or a few
establishments, catering for a much smaller number and generally more discriminative
visitors. Yet, although these “hidden” onsen are able to offer a rural, fairly natural, quiet
atmosphere, both physical and cultural access may be a challenge for international visitors.
While mass-oriented resorts are usually easily accessible by the country’s extensive railway
network, most small onsen require guests to have their own transportation. Language
difficulties pose a similar problem: particularly finding information and establishing contact
in any other language than Japanese may be difficult, since on the spot, the helpfulness of the
hosts usually overcome language barriers. However, while Japan is generally a touristfriendly
country, the reserved attitude of the Japanese may lead to a deliberate Japanese-only
marketing communication policy in more upmarket onsen ryokan, in order to maintain the

exclusivity of the place by excluding simply curious Westerners with little or no affiliation to
Japanese culture, thus ensuring the satisfaction of their traditional clientele. As one
respondent from Singapore said: “onsen ryokan is Japanese centred. You'd need to speak
Japanese and some ryokan will only accept guests introduced through sister hotels”.
The traditional Japanese aesthetics represented by the “hidden” hot springs draws many
foreigners, but also domestic visitors are motivated by the relaxing and nostalgic atmosphere
promised by such establishments. In one of the most densely populated countries in the world,
where the majority of the population live in crowded urban areas, hot springs breaks may help
restore the equilibrium between the social and the personal. In addition, within the
contradictory framework of the Japanese tourism industry that aims to internationalize its
supply and preserve the vanishing cultural traditions, domestic tourism enjoys an increasing
popularity, since travelling to rural areas is perceived by many domestic visitors as a reunion
with Japanese identity (Creighton 1997). Thus, it is also the “real Japan” what many domestic
visitors seek during their holidays, a concept similar to foreign tourists’ perceptions in terms
of being pre-Western, pre-industrialised and non-urban, but also acknowledged by the
Japanese as a place located in the past.
As indicated by the survey results (and confirmed by e.g. Tsukada 2003, Kojima and
Kawamura 2006), foreigners typically perceive an onsen visit as a pleasurable experience
because of the warm, soothing water, but also some sort of a cultural challenge since there are
strict rules to learn and follow. Although a thorough description of the basics of Japanese
bathing etiquette is included in practically any information or promotional material, including
guidebooks, websites, and even the onsen changing rooms (all very vigorously emphasising
the correct rules, e.g. not taking soap into the tub, really washing yourself well, taking off
jewellery beforehand, bathing without swimsuit, separate pools for men and women, not
taking the little towel into the water), first time visitors may still experience discomfort as one
American respondent described: “Another interesting detail I nearly missed was not knowing
that I had to shower & wash my body with soap before entering the large bath. […] Lastly,
when I was done with my late night bath I thought it was polite to drain all of the water out of
the tub so the person who follows me would not bath in my water. I learned from the ryokan
manager that I should not have drained the tub of its water. She was very polite to me and
understood that I was not very keen on their bathing etiquette. I felt pretty silly after the whole
experience....like an American idiot.” Consequently, it is easy to develop a preconception of
an onsen visit as some sort of cultural test as opposed to the relaxing physical experience it
actually is. The difference in tone is particularly sharp in comparison with marketing
messages of spas in Hungary (and elsewhere outside Japan), which generally focus on the
pleasantness of the experience and the variety of services, treatments, not on expected
behaviour.
Obviously, many international visitors to Japan are simply not interested in an onsen
experience. For some, the reason is the separation of men and women: “My wife and I have
visited Japan three times and lived there for more than two years, but we have not gone to
onsen. Since most onsen are for males only or females only, we would not be together. Since
we are not highly fluent in Japanese, we would not be able to socialize with those around us.”
The lack of interest or an unfavourable attitude towards hot springs may also stems from
intimidation: the further out of the tourist areas they get, the less likely they will find Englishspeakers
and the more likely they will be confused about what is expected of them (Kojima
and Kawamura 2006). As one respondent explained: “I travelled by myself and didn't feel
going into such an onsen by myself as I didn't exactly know whether men and women would be

separated and I don't like being stared at”. Although the bathing rules are not particularly
complex, being naked among strangers make many Western tourists uncomfortable,
especially as they tend to stand out in a predominantly Japanese crowd. “It can be awkward
when the Japanese stare at a foreigner in an onsen. I know my mother (when she visited as a
tourist for two weeks) was very uncomfortable about this and not keen to do this again.”
In addition, there are also many behavioural rules and little flexibility in traditional onsen
accommodation; for example, it is rather unusual for Japanese onsen ryokan to accept guests
travelling alone, which, from an international visitor’s point of view, this is slightly in contrast
with the separate bathing principle, and again, does not make the overall experience easier for
foreigners. However, recently there has been some gradual change in terms of rules and
flexibility among ryokan owners, partly as a concession to international visitors, but mostly to
accommodate a younger, well-travelled Japanese clientele (Altman 2008).
Discussion and conclusions
Spa and health tourism development has a long history both in Japan and in Hungary,
although as opposed to the national character of the Japanese development, Hungary’s spa
heritage is based on a multicultural tradition including Roman, Turkish, and Austrian customs
and practices. Spa towns are among the most popular domestic tourist destinations in both
countries, but spa and health resources and facilities are also featured in the countries’
international tourism marketing communication, although to a different extent (health and
wellness tourism is marketed by the Hungarian National Tourist Office as a priority product
of key importance, while the role of hot springs seems to be secondary compared to the
country’s cultural heritage in Japanese international marketing). Although Hungarian and
Japanese spas are equally able to offer both wellness and health benefits, the majority of
customers are motivated by the leisure and relaxation aspects of the product (Aquaprofit
2007, IBS 2007).
However, the medical orientation of spas is traditionally much stronger in Hungary than in
Japan, despite the scientific acknowledgement of the medical benefits of the Japanese onsen.
Similarly to other Central European health tourism destinations, Hungarian spas offer a wide
range of therapeutic treatments, although the several weeks long, physician-prescribed cures
that were so typical throughout the 19 th -20 th centuries, and particularly in the socialist period,
are slowly disappearing, mainly due to the financial transformation of the healthcare system.
In the last decade, spa and health tourism trends in Hungary have included the growing
popularity of wellness facilities and treatments, and extensive construction of wellness hotels
and spa centres around the country, even at locations with spectacular natural attractions (such
as e.g. the natural thermal lake of Hévíz or the travertine mound of Egerszalók). This
construction-oriented development is in contrast with the main Japanese trends where the aim
is to create an onsen experience that is as natural as possible. (Although a parallel type of
development, the creation of so-called “super spas, the best example of which is the Oedo-
Onsen Monogatari hot spring theme park in Tokyo, is also present in Japan as well)
(Talmadge 2006).
The Japanese incoming tourist market is a relatively small segment in Hungarian tourism, but
with exceptionally high potential. Product effectiveness and efficiency in Hungarian tourism
targeting the Japanese market depend on understanding the exact needs and wants of the
target customers, and satisfying these needs by offering products that are distinctive in nature
(and, consequently, are able to stimulate demand to travel to a new destination) and familiar
in quality. The socio-cultural background of potential visitors defines both perceptions of

distinctiveness and expectations of quality standards. The physical environment of Japan and
its richness in geothermal resources determines the local product structure of spa tourism
which is similar in character to Hungary, i.e. spa tourism in both countries is based on thermal
springs). In addition, the actual economic situation of Japan also affects spending power and
consumer behaviour, so it is necessary to use a complex approach when investigating tourist
demand and behaviour.
When considering the potential appeal of Hungarian spas in the Japanese market, it is
important to realise that for Japanese tourists, Hungary is usually not a primary destination,
but part of a Central European tour (HNTO 2006). The fact that Japanese spa tourism is also
based on thermal waters may be considered both an advantage and a disadvantage: incoming
Japanese visitors are familiar with the practice of bathing in hot waters, but Hungarian spas
need to provide a unique selling point in order to make a spa visit an unmissable Hungarian
tourist experience: e.g. heritage spas with unique history and architecture may be attractive for
Japanese customers.
In Japan, young single females have a particularly high travel propensity (IBS 2006), and they
might be interested in wellness and beauty treatments in Hungary, but, as suggested by the
interviews with Asian young female backpackers during the field study, they may also be shy
to enjoy a mixed bathing environment. Senior Japanese citizens also have an increasing travel
propensity, and they may appreciate the health benefits provided by the Hungarian spas,
although the necessary length of stay for medical cures would be much longer than the current
average length of stay of Japanese tourists in Hungary (HNTO 2006). Medical onsen
therapies are not particularly well established in Japan at the moment, and senior travellers
may be rather concerned about foreign customs and behaviour. Consequently, although there
is a positive attitude to and interest in Hungarian spas in the Japanese market, Hungary’s most
important attractions are culture- and heritage based at the moment, and it would require
significant product development and marketing efforts to position Hungary as a major spa and
health tourism destination among Japanese tourists.
Acknowledgements
The survey forming the basis of this study was supported by the OTKA (K67573)
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Does tourism really contribute to our quality of life? A tourism
destination residents’ perspective
Renda, Ana
ESGHT, University of Algarve, Portugal
arenda@ualg.pt
Júlio Mendes
Faculty of Economics, University of Algarve, Portugal
Patrícia do Valle
Faculty of Economics, University of Algarve, Portugal
Abstract
The increasing importance and complexity of tourism activity confers new dimensions and
therefore new challenges to places. Thus local governments are even more responsible for a
sustainable development planning that lead to satisfy tourists’ expectations and to improve the
residents’ quality of life.
However, despite the planning efforts and widely recognized importance of residents’
attitudes regarding tourism development, the residents’ perspective is often forgotten or
undervalued.
The present investigation adopts the residents’ point of view by analyzing the importance of
the perceived tourism impacts in the assessment of their own quality of life and well-being.
This paper results from the literature review on quality of life and tourism areas and proposes
a preliminary theoretical model that will be subsequently tested through the study of the
municipality of Loulé, located in the Algarve, one of the most internationally well-known
Portuguese destinations, by applying a structured questionnaire to a sample of residents.
Keywords: Residents; Perception; Tourism Impacts; Quality of Life; Well-Being; Tourism
Development.
Introduction
Tourism has become increasing important as an economic activity and as a social
phenomenon. It is also an interesting holistic and integrated research area. Its importance and
complexity requires a destination effort to adequate the supply to the tourists’ desires and
motivations especially once tourists are increasingly demanding and experienced.
At a time when more and more people travel looking for remarkable experiences,
differentiation tends to be the most successful strategy in order to guarantee the competitive
advantage in tourism. Sustainable development planning is one of the key points to achieve
this.
Nowadays there is an increasing awareness of tourism development impact on tourism
destinations. As Jurowski (2004) argues, the quality of life of the residents in a community is
affected by the consequences of tourism. This reinforces the idea of Allen et al. (1988) that

the residents must be willing partners in the process and their attitudes toward tourism as the
perceptions of its impact on the community should be continuously evaluated.
Governments have the responsibility to satisfy both the expectations and desires of tourists,
and to improve the quality of life of residents. However, despite the planning efforts, the
widely recognized importance of residents’ attitudes to tourism development and the concern
about their quality of life and well-being, the residents’ perspective is often forgotten or
undervalued. Only recently, the studies of quality of life and happiness within nations have
increased but, in general, these studies have been conduct from the perspective of decisionmakers
and not from the community ones.
This study adopts the resident’s point of view by analyzing the importance of the perceived
tourism impacts in the assessment of their own quality of life, a topic insufficiently studied in
the tourism area. The study has the purpose of creating a model to analyze the relationship
between residents’ perception of tourism impacts and the perception of their own quality of
life. It is crucial to understand if residents feel tourism as important for their own quality of
life or, on contrary if they value other dimensions related with everyday life even without
tourism. This research will be based on a case study, specifically examining the perceptions of
a sample of residents of the eleven parishes of the municipality of Loulé, located in the
Algarve tourism destination.
For a better understanding of the study this paper describes the geographic study area and
characterizes generically his host community in terms of demographic, social, economical and
cultural aspects. It provides a background to the research by outlining the benefits and costs
associated to tourism development, residents’ attitudes towards tourism and some of the key
theories and concepts associated.
Study area
The Algarve, one of the most internationally well-known Portuguese destinations, is located
in the south of Portugal and it is a traditionally sun and beach destination since the 60’s and
more recently it stands out internationally as a very popular golf destination. As stated in the
National Strategic Plan for Tourism (ME, 2006:6), the “proposal for the country will focus on
the key factors that differentiate Portugal from other competing destinations – Climate and
light”, “History, culture and tradition”, Hospitality” and Concentrated diversity” and on
elements that bring value to Portugal in the context of tourists’ options – “Modern
authenticity”, Safety and Competitive quality”. The Algarve, has also these performance
features which can be important tools to develop the region as an excellence destination.
The municipality of Loulé is centrally located in the Algarve tourism destination. It entails
geographic diversity and socio-cultural, economic and environmental differences as for
example the very different stages of tourism development in the eleven parishes.
The Litoral, seaside presents plenty of natural resources and tourist attractions and it is the
region that gives visibility to the Algarve destination. This area has a big human density and a
great diversity of accommodation, restaurants and all kind of tourist supplies. The population
works mainly in the tertiary sector and generally is characterized by particular social cultural
elements, some of them very traditional and a marked culture of acceptance and integration.
In this area live daily those natives and other people of various nationalities and cultures,
some of which began as tourists and after that have become residents due the features of the
region and the attractiveness of a quality of life lifestyle. Coexist even immigrants from

Africa (mainly Cape Verde, Angola and Mozambique) that have for years voted the Algarve
and the municipality of Loulé as their “port of refuge and work” and immigrants from eastern
and Brazil who that also come to this region, attracted by employment opportunities.
The emerging Barrocal, located between the seaside and the low mountain range, is gradually
changing its traditional activities to tourism. However, this area still has agriculture and
livestock practices mainly of subsistence and in some cases as an economic complement of
working in the tertiary sector. Many residents work in Loulé and Faro cities or on the Algarve
coast (especially in the tourism industry). This area is characterized by a village lifestyle,
marked by traditional practices which coexist in some moments, with new experiences
resulting from the presence of some tourists and foreign residents and from the proximity to
the coast.
Finally Serra, the low mountain range with very few residents and almost unexplored tourism
is a territory in desertification due the sparing employment and the more adverse physical
conditions to liveability. This is an isolated territory with a more rugged climate. The main
economic activities in Serra are forestry, livestock (goats, sheep and pigs), and the production
of traditional cheeses, sausages and the highly appreciated spirits from arbutus.
Today, the Algarve tourism destination and the municipality of Loulé face some problems,
among which are tourism seasonality, dependence on outbound markets and consequences of
the initial decades of disorderly developing, without tourism sustainable planning. At this
moment government and private sector are trying to consolidate and develop strategic
touristic products such as Sun and Beach, Meetings and Congresses, Nature Tourism, Golf
and also new tourism areas related to an authentic and unique tourist experience.
With this new reality, it becomes essential to understand how tourism development actually
addresses the residents’ perspective, their interests and opinions and how this development
contributes to the perception of improvements in their quality of life.
Literature review
This paper will discuss some of the main concepts that the literature review so far carried out,
allowing us to identify as the most important to this investigation, among following: tourism
development and tourism destination, residents’ attitudes, tourism impact perception, wellbeing
and quality of life, happiness and life satisfaction.
Therefore the study, in the context of tourism phenomenon and concerning the quality of life
and the well-being, focuses essentially on Psychology, in relation to the topics of perceptions
and attitudes, on tourism, namely on issues like tourism development and tourism industry, on
Tourism Sociology, discussing issues related to social processes, social relations in the host
community and in relation to tourists and to tourism industry and on Tourism Anthropology,
namely socio - cultural changes in host community, processes of change in local identity,
processes of acculturation lifestyles and local experiences.
The issue of quality of life is arousing interest within the economic and political field.
Researchers and stakeholders have begun to realise that a community well-being depends on
the development and it also impacts this development. Relevant efforts to measure quality of
life and well-being have been undertaken. Some focus on the quality of life, while others are
more directly related to happiness. Most of them apply this concept to the national or
international context, as for example The World Health Organization Quality of Life

WHOQOL (WHO 2010), initiated in 1991, the Human Development Index – HDI (HDR –
UNDP 2010), introduced in 1991 or the World Database of Happiness (Veenhoven 2010). In
Portugal we can highlight three studies about municipalities, that are, in general, economic
and political approaches to tourism planning and tourism industry (Ferrão et al. 2004; Manso
et al. 2007).
Since tourism development causes changes in the territories and in host community, it brings
increasing concerns among promoters and academics about sustainability because it is
important to understand those changes. According to the World Tourism Organization (2004),
"Sustainable tourism development entails the environmental, economic and socio-cultural
aspects of tourism development, and a suitable balance between these three dimensions to
guarantee its long-term sustainability.” The involvement of residents in an impact assessment
can be useful to both forecast and appraise its more complex impacts (Dean and Wu 1979).
Moreover, most of the studies show that tourism is seen by many communities as a way to
improve residents’ quality of life and, for that reason many communities encourage tourism
development (Pizam 1978; Gursoy and Rutherford 2004; Andreck et al. 2005; Lindberg et al.
1997; Uriely 2002). However it is also recognized that this activity causes a negative impact
on destinations and among residents, particularly in economical, social and environmental
areas. As Pizam (1978) concludes there is a strong support for the hypothesis that big tourism
concentration causes negative resident attitudes towards tourists and tourism in general.
The tourism sustainable development and his relationship with residents’ attitudes is a subject
of considerable interest for many authors (Allen et al. 1988; Andreck and Vogt 2000;
Carmichael 2000; Gursoy and Rutherford 2004; Jurowski et al. 1997; Ko and Stewart 2002;
Lindberg and Johnson 1997; Perdue et al. 1987). Some of them apply in their studies the
social exchange theory (Homans, 1961) which recognized that people select exchanges after
having assessed the costs and benefits. Most of the results pointed out differences in attitudes
depending on the level of tourism development as well as a variety of other factors can
influence residents’ attitudes towards tourism.
Concerning the Social Exchange Theory and according to Turner (1986) residents who
perceive the actual or potential tourism value and believe that the costs do not exceed the
benefits will favour the exchange and will consequently be supportive of development efforts.
Skidmore (1975) also suggests that individuals will engage in exchanges if the resulting
rewards are valued, the exchange is likely to produce appreciated rewards, the perceived costs
do not exceed perceived rewards and they will consequently be supportive of development
efforts. Pizam (1978) provides also evidences to sustain this position. The same situation is
expressed in Jurowski model (1994) which demonstrates that attitudes towards tourism are
influenced by residents’ perceptions of economic, social, and environmental impacts.
According to the author, these perceptions are influenced by perceived economic gain, by the
level of use of the recreation resource, and by attitudes about humankind’s role in the
preservation of the natural environment.
Several theoretical models based on the social exchange theory have proposed explanations
for variations in resident attitudes toward tourism (Ap, 1992; Jurowski, 1994; Lindberg et al.,
1997). To quote Jurowski et. al. (1997: p.3) “the analysis demonstrate that potential for
economic gain, use of the tourism resources, ecocentric attitude, and attachment to the
community, affect resident perception of the impacts and modify both directly and indirectly,
resident support for tourism”.

The theoretical significance of understanding residents’ attitudes is their connection with
behaviour (Lepp, 2006). Ajzen and Fishbein (1980) explain this connection with their Theory
of Reasoned Action (TRA). TRA is a hierarchical model, which asserts that behaviour is
influenced by behavioural intent, which is influenced by attitudes and subjective norms
(perceived social pressure for a particular behaviour), and both of these are influenced by
beliefs. In a meta-analysis of past research, found widespread support for the validity of TRA.
In the literature there are also frequent references to issues such as tourism development and
its relationship with residents’ attitudes (Butler 1980; Doxey 1976; Perdue et al. 1990). Butler
(1980) described tourism development as a series of stages through which a destination
evolves: exploration, involvement, development, consolidation and stagnation. This idea is
also expressed in Doxey theory (Doxey, 1976) when he said that those residents’ attitudes
varies with the stage of development of the tourist destination. For the author, residents’
attitudes are positive during the initial stages of tourism development but become increasingly
negative as a destination evolves towards stagnation. A possible addendum to this is Lepp’s
(2006) suggestion that, at destinations with no prior knowledge of tourism, initial tourism
development will be met with suspicion, anxiety and fear.
Dogan (1989) also referred to the importance of tourism development level when predicted
that residents’ adjustments will be homogenous in communities where tourism is in its initial
stages of development and, as a destination matures, various adjustments might emerge, some
in conjunction with tourism and some in opposition. The author emphasise that success or
failure of adjustment strategies influences residents’ attitudes.
The residence area proximity in relation to the main tourism area is another important
relationship to understand residents’ attitudes and perceptions (Gursoy and Rutherford 2004;
Jurowski and Gursoy 2004; Lankford 1997; Sheldon and Hoy 1980; Sheldon and Var 1984;
Sheldon and Abenoja 2001). Belisle and Hoy (1980) identify the perceived positive and
negative impacts by residents, considering the hypotheses that perception vary with the
distance a person lives from the tourist zone and with socio-economic status. The authors
conclude that, effectively, the distance affects significantly the perception of tourism impact
but there are small variances in expressed opinions which may indicate that all groups find
some direct and indirect benefits in tourism. They also note that the incipient stage of tourism
development can contribute to a positive attitude toward tourism.
Gursoy et al (2004) explore also the effects of the distance residents live from attractions on
their attitudes toward tourism by a theoretical model based on the social exchange theory
developed. The model, proposes that support is based on residents’ evaluation of both the
perceived benefits/costs and the state of the local economy. The distance between the
residence area and the attraction had a significant effect on how the costs and benefits were
evaluated. The negative relation between the uses of the resource and the perceived benefits
implies that those who live closest to the attraction feel that an increase in the number of
tourists might negatively impact their ability to use it. The nearby residents may be concerned
about losing their ability to use the resource as they used to. They may also be worried about
traffic congestion, crime, litter, noise, and cost of living increases Lankford (1997).
Residents sensitive to environmental issues who lived closest to the area appear to be more
likely to support tourism than the in-between group residents with similar environmental
attitudes. The Jurowski (1994) study determined that ecocentric attitudes positively impacted
support for the cultural and historic tourism but negatively impacted support for other types.
Consequently, close-in residents with stronger ecocentric attitudes may have been more

supportive because of the type of tourism they were evaluating. The results of the Sheldon
and Var (1984) study appears to support this theory as it determined that residents living in
higher density areas are more likely to have positive attitudes toward tourism because they
favoured it over other industries.
The contact frequency with tourists (Akis et al. 1996; Sheldon & Var 1984) and the fact of
working or not in the tourism sector and being economically dependent from it are relevant
linkages to better understand residents’ attitudes. Studies, in generally confirms the existence
of a relationship between an individual’s economic dependency on tourism and their overall
attitude toward tourism (Brunt and Courtney 1999; Pizam 1978), showing that individuals
who are connected to tourism employment are more favourable to his development.
Once the purpose of this study is to determine the effect of tourism impacts perception on
residents’ perceived quality of life it is essential to know how residents most frequently
perceived tourism. The more significant and frequent impacts considered in tourism area (Ap
1992; Akis et al. 1996; Belisle and Hoy 1980; Jurowski 1994), that will be considered in this
study, are the economic, social, cultural and environmental ones, which matches the presented
WTO definition.
The literature review suggests, as main ideas, that tourism is widely perceived as a way to
improve quality of life, such as employment opportunities, however it can have negative
impacts, e.g. by increasing traffic, crime or by changing hosts’ way of life. There is a strong
perception among residents of investments and profitable local businesses but also the
recognition of negative effects such as an increase in the cost of living (Ap and Crompton
1992; Andreck and Vogt 2000; Andreck et al. 2005; Akis et al. 1996; Belisle and Hoy 1980;
Dyer 2007; Gursoy and Rutherford 2004; Jurowski et al. 1997; Perdue et al. 1987).
Another important concept in this study is the one of well-being. Diener (1984) suggests that
there are three hallmarks in subjective well-being area. For the author it is subjective because
it resides within the experience of the individual, it is not just the absence of negative factors
and it includes a global assessment. However, although these hallmarks serve to delimit the
area of study, they are not complete definitions of subjective well-being.
The literature review points out to the need of distinguishing various dimensions of wellbeing,
taking into account their inherent objective and subjective nature. The well-being
domains considered in this study are organized into four groups as Sirgy (2002), Kim(2002)
of various aspects that the residents take into consideration when evaluating their well-being.
First the material well-being including issues like house ownership, stable employment and
income are explored by authors like Andrew and Withey (1976); Campbell et al. (1976);
Cummins (1996). Second the community Well-being that includes aspects related to
community life, integration and social participation Davis et al. (1988). Third the emotional
well being witch explore subjects like the affective component of life, namely love and family
life (Andrews and Withey 1976; Lane 1994) and finally health and safety well-being that
include items such as the absence of sickness or the feeling of security in the residence area
(Andrew and Withey 1976; Brown 1998).
According to the World Health Organization (1994:5) "Quality of life is defined as
individuals' perceptions of their position in life in the context of the culture and value systems
in which they live and in relation to their goals, expectations, standards and concerns.” For

Veenhoven (2005:61) “quality-of-life can be measured by how long and happy people live”.
These definitions provide the crucial dimensions to consider in this study.
On quality of life studies some authors have a general approach to the concept (Cumminis
1996; Diener and Suh 1997; Jurowski 2004) others, like Veenhoven (2005), highlight more
specifically the construct of Happiness, yet others, like Andrew and Withey (1976) focus on
Life Satisfaction. Happiness and Life Satisfaction are two constructs from Quality of life that
will be studied in this research to define the residents’ perceived quality of life. As Sirgy
(2001) points out these constructs, related to Quality of Life, should not be used
indiscriminately. As such, Happiness entails an emotional nature and Life Satisfaction a
cognitive one. The author refers that Life Satisfaction involves self- evaluation of one’s life or
accomplishments against some standard while Veenhoven (2005) defines Happiness as the
degree in which an individual judges the overall quality of life favourably. In other words,
subjective well-being is how well the person likes the life he or she leads.
Methodology
Until now a literature review and an exploratory study based on interviews and participant
observation have been carried out 55 . Since the researcher lives in the study area, it was
possible to use the techniques of participant observation and of informal interviews with
residents. These interviews were not recorded, as the residents do not deal well with the
situation. Only field notes were taken. It was asked to residents, for example, how they felt
about tourism and how they face tourism in their own space, how they accept tourists with
different nationalities and how they perceive the touristic activity impact on their residence
area and on their own quality of life. Very important topics in these interviews were the ones
distinguishing well-being, happiness and life satisfaction and their contribution to the overall
quality of life.
Semi-structured interviews to community leaders parishes’ presidents and local companies
were carried out in order to collect more detailed information and opinions about the parishes
under study and about tourism in the area. This work is still being done so that all leaders and
organizations representing the parishes are interviewed.
A detailed questionnaire design will be made, based on literature review and on this
exploratory study. The aim is to apply a structured questionnaire to a sample of residents in
the municipality of Loulé. Like in many other studies a five-point Likert scale will be used.
Residents will therefore be asked to rate the level of importance and/or satisfaction related to
given factors.
Discussion and conclusions
The exploratory study conducted so far reveals that residents’ tourism impact perceptions and
attitudes towards tourism are, in general, very positive in the municipality of Loulé. Residents
perceive tourism as a positive way to develop their residence area which, in many cases, faces
economic and social problems mainly due to the lack of employment opportunities. This
occurs primarily in rural areas of the municipality where tourism is not present or is in its
early stage of development. The residents’ support of tourism development seems higher as
residents don’t perceive negatively the tourism impact in the residence area. On the contrary
they tend to valorise the economic and social benefits of tourism. There are some indicators
that may reveal an increasing attention by the residents, to environmental factors.
55 This study is part of a PhD research in “Residents’ Perceptions of tourism impacts in their own quality of life”.

These preliminary finding suggests that there are differences of perception among residents
who live in parishes with different tourism development levels. The same occurs for variables
such as nearby residence, contact frequency with tourists, economic dependence from it, and
personal factors such as number of years of residence in the area, nationality and age or
qualifications. However, only after application of the questionnaire will it will be possible to
draw conclusions.
The exploratory study guides us to verify the importance of including the well-being
dimensions in the study, once the most important in the study is to understand the relation
between tourism perception and quality of life perception. Therefore this exploratory research
has proved very important as it allows us to know how residents understand these dimensions
and how they are taken into account when assessing globally the quality of life. Indeed, since
residents tend to associate the quality of life components with more affective or emotional
components (related to happiness concept), or with cognitive ones (linked theoretically to life
satisfaction) it seems sometimes that the relation occurs often without considering the
presence and influence of tourism and its effects but other aspects of daily life.
The literature review so far enabled us to begin the design of a conceptual model including
the four sets of variables that have been mentioned before and their relationships. Thus, the
model will offer the possibility of identifying the moderating effect of the various levels of
tourism development in residents’ perception, taking into account the perception of tourism
impacts, the four well-being dimensions and also the relevance of the quality of life
constructs.
We believe that this study may contribute to the adoption of the residents’ perspective of
quality of life in the context of tourism studies, concerning the well-being dimensions,
happiness and life satisfaction constructs. It may also be a new tool for public sector and
investors and a contribution for a sustainable tourism development.
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Expectations of Health Tourists in Germany – Illusions and Reality
Monika Rulle
Department of Geography and Geology, Ernst-Moritz-Arndt-University Greifswald,
Makarenkostr. 22, 17487 Greifswald, Germany
rulle@uni-greifswald.de
Abstract
Health tourism in Germany was once strongly supported by the social security system. Today,
destinations of health tourism have to attract more than ever the privately paying guests. In a
first step, the paper discusses general questions about modern health tourism. A special focus
was taken on the development of Medical Wellness. With the help of a nationwide
representative telephone survey, Germans were questioned about their interest in health
holidays. In the second step, preferences to different offers and the satisfaction with these
services were researched. In the case study, health tourists in destinations in Mecklenburg-
Western Pomerania were questioned. A comparison between the two surveys reveals much
difference between the mere interest in the offers and the actual use of them. The additional
cluster analysis defined three main target groups: married middle-aged women, younger
unmarried men and persons age 65 plus.
Keywords: health tourism, visitor expectations, customer satisfaction, target groups,
Germany
The situation of health tourism in Germany
The German tradition in health tourism is long and well-known. For centuries, spas were the
centre of tourism activity, however mainly for the well-off people. The situation changed
when in 1957 West Germany passed a law, which made spa treatments part of the regular
benefits of the social security system. As a result of this, slowly the structure of the spas
changed: the once romantic outline of the spas transformed into a setting often dominated by
newly built large scale sanatoriums and clinics (Brittner, Stehle 2000). Simultaneously, the
number of arrivals to spa destinations exploded: in West Germany figures grew from 5.2
million in 1977 to 9.3 million arrivals in 1998. In the German Democratic Republic, spa
treatments were organized stately and the numbers of participants were far lower. After the
reunification much financial support was necessary to develop the infrastructure to be
nationally competitive (Deutscher Bäderverband 1998).
Between 1999 and 2008, the number of arrivals in all German spas grew again from 16.6
million to 19.3 million. However, at the same time, the average number of overnight stays
sank from 6.3 to 5.3. In 1999, the fraction of guests in German spa destination having their
treatments funded by the social security system was only 10.6%, lower than ever (Deutscher
Heilbäderverband 2009).
On the consumer side, the demographic transition with a population growing older fast
created new types of customers in recent years: patients with chronic, but stable diseases like
diabetes as well as persons concerned about their health are searching now increasingly for
medically supervised vacations, paid partially by health insurances or in total privately. Since
the social system pays ever less for spa treatments, new ideas for the destinations become
necessary in order to be attractive for the self-paying guest. In addition, many destinations,
especially in the eastern part of Germany, need to revitalize their offers and infrastructure, as

they have reached the state of consolidation or even stagnation in the Tourism Area Life
Cycle. Health destinations try to re-position their product in order to attract new groups of
visitors. However, they are often insecure about the real needs and expectations of their guest.
Primarily, the study was supposed to define the real interests and needs of the potential health
traveller. In recent years, the broader development of Medical Wellness products seemed to
be a promising innovation in the Germany health tourism market. Secondly, the aim of the
survey was to evaluate the real choice of health tourists as well as their satisfaction with the
offers in health destinations, using the case study of Mecklenburg-Western Pomerania. Last,
the definition of target groups was supposed to help to develop further specific offers for
health promotion and prevention.
Methods
Two methods were combined for this research project to differentiate between the
expectations of the guests and the real use of the offers in the health destinations: first, a
German wide telephone survey among the population age fourteen and above was carried out.
The results lead to a deeper insight into the wishes and expectations of the potential German
health traveller and assessed possible target groups. Secondly, a face-to-face survey in
relevant destinations for health tourism in Mecklenburg-Western Pomerania generated data of
actual health travellers and their expectations towards the destination and their offers. This
combination of similar questionnaires, as far as appropriate, allowed a comparison between
the stated expectations of possible guest groups from the telephone survey and the real
situation in the health destinations.
Telephone survey
In a first step of the survey on German health tourism, the underlying reasons when deciding
for a health vacation were studied. With the help of a nationwide representative telephone
survey, Germans were questioned about their interest in health holidays. The focus was taken
on the privately paid visits, leaving out the far developed market of cure treatments paid by
the health insurances.
The questionnaire was developed at the University of Greifswald in cooperation with the
University of Rostock. The scientific group consisted of one specialist in tourism and two
medical practitioners, one being specialised in Community Medicine, the other in
Complementary Medicine. The survey was taken out through May and June 2008. Chosen
from a random sample, 6,325 calls were conducted, receiving 1,063 full interviews (response
rate: 17%). The sample was weighted according to the criteria “size of household”, “gender”,
“age” and “residence / Bundesland” (German federal state).
At the beginning of the interview, the concept of “health holiday” was defined as a holiday in
which activities and services are used in order to influence the personal state of health in a
positive manner. The questionnaire consisted of 40 questions and was fully standardised.
Most of the questions were closed, with a fixed set of possible answers, though six questions
had hybrid possible answers, giving the respondent the possibility of free answers.
Guests questionnaire
In a second step, the customer satisfaction was analyzed. Between June and November 2008,
the data was generated by face-to-face interviews in numerous health destinations in
Mecklenburg-Western Pomerania such as hotels, rehabilitation clinics, thermal baths or
therapy centres. 2,222 contacts were made, resulting in 904 full interviews (response rate:

40%). Only those guests were included in the survey, who positively answered to the
screening question about the motivation of their vacation being health.
The guests’ expectations about the destinations were questioned regarding the infrastructure
as well as various types of offers. Where applicable, the same set of questions of the
telephone survey and the guest questionnaire was used.
Modern demands in German health tourism
Generally spoken, Germans were questioned about their interest in health holidays. The focus
was taken exclusively on privately paid visits, in contrast to the traditional market of cure
treatments paid by the health insurances. The results of the multifaceted study can only be
shown showcased.
First of all, the participants were questioned whether they were familiar with the phrase
“medical wellness”. Only 21.8% said to have heard of the term before. The fraction of women
being familiar with the term was slightly higher (24.4%) than the group of men (19.1%). All
participants, regardless whether they knew the term medical wellness or not, were
subsequently questioned about what kind of associations they had with the expression. Most
of the associations stated were “wellbeing”, “health” and “medical attendance” (each about
17%). Less often was “cure” (12%), “holiday” (8.4%) and “rehabilitation clinic” (7.9%)
mentioned. Only 15.8% of all participants of the survey said not to have any association with
the concept of medical wellness.
Health tourism in Germany is often seen as a possibility to prolong the season beyond
summertime. In fact, 35.7% of the persons preferred spring for health tourism. Autumn was
mentioned next (26.6%), followed by summertime (18.9%). More than 10.3% said that the
season is of no importance.
The estimation of guests about the total costs of a health vacation are of great importance in
the process of deciding for a vacation. 44.9% of the Germans would prefer to spend less than
100 Euro per day and person including accommodation, meals and treatments. There is a
significant difference between the answers of men and women. 49.8% of the women stated to
spend preferably less than 100 Euro, whereas only 39.4% of the men answered similarly.
However, men were far more often willing to spend between 100 and less than 200 Euro (45.8
%). Only 39.7% of the women wanted to spend this amount. Concerning the expenditures of
200 Euro and more per day, men were also stronger represented than women.
The comparative study in the destination showed an even more specific detail: in
rehabilitations clinics, most of the guests (90%) paid privately less than 100 Euro per day and
person, including accommodation, meals and treatments (77.7 % of all guest even less than 25
Euro). This has to do with the fact, that most of the guests have their main costs covered by
the health insurance companies. Thermal bath and therapy centres showed almost similar
results. In hotels, however, 27.8% of the guests spend less than 100 Euro per day and person,
and further 37.7% spend between 100 and below 150 Euro.
The three most preferred types of accommodation have reached almost the same figures: the
holiday flat, four star hotel and the rehabilitation clinic were stated with 20.7%, 20.3% and
19% as being the most suitable accommodation for a health vacation.

Almost three quarters of all Germans (71.9%) preferred a health vacation lasting eight nights
or longer. 25% of the questioned persons would favour four to seven nights duration, whereas
short time trips to health destinations were only chosen by 3.1% of the Germans.
When repositioning a destination, the infrastructure and set of offers are of great importance.
However, the real expectations of the guests are often unknown and the success is based
rather on intuition than knowledge. Therefore it was an important aspect of the study to find
out which of the offers are attractive enough to be paid fully or partially by the guest. The
study revealed that next to classical massage (33.1%), aqua sports / swimming (29.1%) were
of strong interest for German health tourists. For dancing (21.8%), relaxation techniques
(20.2%) and gymnastic lessons (19.9%) there was also a large readiness stated to pay the offer
completely. However, less than 10% of the respondents wanted to pay for dietary cures. In
general, traditional spa treatments with local remedies or water treatments after Kneipp as
well as modern offers such as Ayurveda and Thalasso therapy were stated to be less attractive.
Additionally, it can be stated that with the rising age of the participant the willingness to pay
offers partially or fully private decreased. This was specially the fact for the offers of dancing,
personal trainer, yoga, Thalasso therapy and hot stone treatments. For established treatments
such as cardiovascular training, gymnastic lessons or Nordic walking, an equal readiness for
payment was found among younger as well as older Germans.
Corresponding preferences were also found in the destinations: only two of 23 treatments
were used by more than half of the guests: the participation of swimming / aqua sports was
68.7%; classical massage was used by 57.7%. Additionally, 15 of the 23 offers in the
questionnaire had been attended by less than 20% of the visitors. These can be stated as of
less importance when developing health offers in a destination. The results cannot be
explained with the occurrence of the services: e.g. treatments with local remedies were
offered in 87.5% of the destinations, however, they were used only by 9.6% of the guests.
Similar results were found with other treatments.
Important for the destinations was the fact that of all users of the different treatments, the
group of “satisfied” or “very satisfied” customers reached always fractions above 80% of all
responses. This revealed a very positive state of health tourism in Mecklenburg-Western
Pomerania.
Special target groups for health destinations
With the help of a two-step-cluster analysis, specific potential visitor groups with similar
interests in health vacations were identified. Sixteen characteristics representing different
expectations were analysed: thirteen of the most important offers for health vacations, the
preferred duration of stay, the preferred type of accommodation and the accepted maximum
cost for a health vacation. Additionally, six socio-demographic factors were taken into
account: gender, age, family status, employment, highest grade of education and net
household income.
The analysis resulted in four clusters. One of them was the group of “males with little interest
in health vacation” and was for obvious reasons neglected. The largest group was the
“married group of women interested in health vacations”. 65.9% of this group were persons
aged 35 to 54. 40% of this cluster were full-time employed and another 32.8% part-time
working. The group correlated highly in their awareness of health. The preferred
accommodation was the four-star-hotel (23.3%) followed by the rehabilitation clinic (20.9%).
The group of people accepting a maximum of below 100 Euro for one day stay including

accommodation, meals and health offers was almost as large as the group accepting more than
100 Euro per day. This cluster took more interest in price reductions funded by the health
insurances than other groups.
The second largest cluster was the group of “younger men interested in health holidays”. A
large fraction of this group (69.5%) was younger than 45 years old and 69.5% of them fully
employed. More than half of the group (56.9%) are unmarried. The group also preferred the
four star-hotels, however, rehabilitation clinics and holiday flats were closely following up. In
relation to the other clusters, this group showed the largest willingness to pay more than 100
Euro per day per accommodation, meals and health offers. Additionally, the younger men
stated a strong interest in additional leisure time activities.
The last identified target group for health vacations was the group of “people age 65 and
above”. About 26% of all respondents were included in this cluster. This group prefers the
rehabilitation clinic as accommodation and, with lesser importance, holiday flats and fourstar-hotels.
The seniors are much cost-conscious preferring not to spend more than 100 Euro
per day including accommodation, meals and treatments. They were lesser interested in
leisure time activities, but emphasized the importance of medical supervision in the
destination as well as at home, after their return from the destination.
Conclusion
After fundamental reductions in the German health tourism market during the mid 1990s, new
strategies for the growing market of self-paying guests needed to be developed. For Germany,
the development in the new market segment of medical wellness appeared to be promising. In
fact, the study validated that the term medical wellness is not yet established in Germany.
However, the survey showed that not having any idea of its meaning does not imply to have
no specific associations. Indeed, the images vary strongly. Using the term for marketing
activities therefore bears many risks. Destinations have to explain their product in advance
very well in order not to invoke associations, which will later not be fulfilled.
The cure business was traditionally a reliable factor in the tourism sector as the guests sent by
the social security system generally have little choice, neither where nor when to take spa
treatments. This lead to constant all-year-around guest numbers in the destinations. However,
the modern self-paying guest follows his preferences. Modern health tourism is supposedly
good functioning as an off-season attraction. However, the study revealed very little interest
in health tourism during the winter time. The preferred seasons are spring and autumn;
seasons of the year, when other offers compete already with the attention of the guests.
To attract large groups of guests, the cost of the complete offers should not exceed 100 Euro
per day including accommodation, meals and treatments. The willingness to pay more private
money is stronger represented among men, however, any offers above 200 Euro in total will
find little acceptance. Additionally, the guests study revealed that a large number of guests in
rehabilitation clinics still spend very little private money. Most of the expenditure is covered
by the social security system. This leaves much room for further development of the privately
paid market in rehabilitation clinics. The guests of the hotels spend far more and can be seen
as a role model for the clinics. Modern rehabilitation clinics already do offer the necessary
infrastructure on a high standard. Additionally, the results of the telephone survey revealed
that the clinics were mentioned next to holiday flats and four star hotels as being most suitable
for a health holiday. The preferred duration of stay of eight or more nights is also a positive

sign for the development of further products in rehabilitation clinics, as lasting medical effects
are understood to be reached through a longer duration of treatment.
The comparison between the telephone and the guest survey revealed similar results
concerning the acceptance of partial or full private payment. Guests are only willing to invest
private money for traditional offers such as classical massage and aqua sports / swimming.
Medical attendance was another offer, both mentioned and also often used in the destination.
Surprisingly for health tourism with a medical impact is the fact, that treatments with local
remedies as well as programmes for a healthy diet seem to be little attractive.
The study revealed that modern health tourism, especially the market segment of medical
wellness, offers far less opportunities for the destinations than widely assumed.
Although there is a large interest in health tourism among Germans, with the findings of the
study certain target groups were identified: the married group of middle aged women
interested in health vacations, younger, unmarried men interested in health holidays and the
people age 65 and above. Each of the group has certain preferences concerning the price of
the vacation, the optimal form of accommodation, and other specific preferences such as
leisure time activities for the group of younger men. The destinations have to decide for
certain target groups in order to optimize their product.
References
Brittner, A.; Stehle, T. (2000). Kurverkehr. Trierer Tourismus Bibliographien (9). Trier.
Deutscher Bäderverband (1998). Jahresbericht. Guetersloh, Floettmann Verlag.
Deutscher Heilbäderverband (2009). Jahresbericht. Guetersloh, Floettmann Verlag.
Rulle, M., Hoffmann, W. & Kraft, K. (2010). Erfolgsstrategien im Gesundheitstourismus.
Analyse zur Erwartung und Zufriedenheit von Gästen. Berlin, Erich Schmidt Verlag.
The author would like to express her thanks to the supporting Ministry of Economics,
Labour and Tourism, Mecklenburg-Western Pomerania, Germany, which financed the study
with resources from the European Regional Development Fund.

Exploring The Relationship Between Meditation Flow Experience and Well-
Being
Tzuhui A. Tseng
Department of Environmental and Cultural Resources
National Hsinchu University of Education, Taiwan
thtseng@mail.nhcue.edu.tw
Ching-Cheng Shen
The Graduate School of Travel Management
National Kaohsiung Hospitality College, Taiwan
Abstract
Well-being is a kind of healthy or happy feeling one has, and is also one’s goal in life.
Through the process of work, leisure activities, exercise, or social interaction, an individual
could bring his potential into use and satisfy his needs, and further develop a sense of
accomplishment and worthiness, and the feeling of happiness. Because leisure experience
could satisfy people’s psychological needs such as recreation, relaxation, self-improvement,
and self reliance, it is an important source of well-being. When people are immersed in leisure
activities, they would go into a devoting state of mind, and enjoy satisfaction of selfrealization
and flow experience of abundant thoughts. Therefore, the effect of flow experience
from leisure activities on well-being is an important research topic.
People in this society are experiencing more and more stress from life and work. Meditation
can provide satisfaction in people’s physical and spiritual needs, and has gradually become an
important part of leisure activities. This study would explored the relationships between
leisure activity flow experience and well-being, use people who participated in meditation
activities as research subject, and collect data through survey interview.
The findings were as the following: 1. On the factor dimension aspect of meditation flow
experience, the Flow State Scale proposed by Jackson and Marsh (1996) was used as
reference, and clarifying goals, instant feedback, balancing skill and challenge, concentrating
on the activity, self-control, changes in sense of time, and self-forming experience were
chosen as measure foundations. 2. On the factor dimension aspect of well-being, the Oxford
Happiness Inventory (OHI) of World Health Organization (WHO) was used as reference, and
seven dimensions including physical, spiritual, environmental, social, self-growth, joyful and
optimistic, and life satisfaction were chosen as measure foundations. 3. As for the meditation
flow experience, “the meditation experience is great”, “having the ability to face meditation
challenges”, “enjoy the meditation experience”, “meditation feels good”, and “clear about
want I want to do” had higher outcomes. 4. On the well-being aspect, “actively to create in
life”, “cherish good fortune” “harvest from everything in life”, “good performance from
work”, and “having hope for the future” showed better results. 5. After analyzing the
relationship between meditation flow experience and well-being by using linear structural
equation, it was clear that meditation flow experience and well-being had significant positive
relations. 6. In leisure flow experience, “concentrating on the activity”, “clarifying goals”,
“instant feedback”, and “self-forming experience” were higher factor dimensions. 8. In wellbeing,
“joyful and optimistic”, “life satisfaction”, “self-growth”, and “environmental” were

higher factor dimensions. From above results, it is clear that meditation flow experience can
provide people with a higher spiritual level of well-being.
Keywords: Meditation, Flow Experience, Well-being
Introduction
After the Industrial Revolution, due to the fast change of science and technology, the social
structure, the cultural system and economic activity's fast vicissitude, creates the greatest
pressure and astatic for human in psychology and the physiology aspects. All sorts difficult
living , such as anxious, phenomena and losing sleep, causes the damage to the health of
human body and mind directly, subsequently produces “the diseases of civilization”, lets the
human live in the pain and is unhappy everyday. The Taiwan suicide mortality rate has
become one of the top ten reasons to cause death in these continues eight years. Using 2007 as
the example, the people died from the suicide as high as 3,933 people, and the pressure was
the principal factors to cause the death. The pressure has become one of the attribute to
threaten the human body and mind and the peace of social (Robinson & Godbey, 1997;
Zuzanek & Smale, 1997; McBride-King & Bachmann, 1999). Because the leisure activity
may enhance individual sense of self determination and the society supports, can adjust the
life pressure effectively (Coleman & Iso-Ahola,1993). Hull(1990) thought that the leisure
activity may promote the positive mood which influences the health. Pargament(1997) also
pointed out that people's intelligence strength and the mind health was the main resource to
relieve the negative effect from the time pressure, included physical and psychological
aspects.
In recent years, “the meditation” in Taiwan becomes one of the leisure activities to relieve the
pressure. The imperial sacrifices repair activity promotes the health and the psychological
balance by sitting still which includes adjusting the body, breathing and heart. Sitting still
may help individual to reduce rigid, make the brain calmer and clearer, achieve tranquilly
dedicated intrinsic wholly-attention, then has the wisdom and develop individual potential,
and truly feel the original main body of individual . Using the self-restraint and the selfcontrol
from the meditation, lets the meditation’s “engages in introspection sees the nature”,
enable the society to become a wise and the creativity beautiful world.
The Meditation is not only one of the religious activities, also can eliminate the pressure from
the life, promote the health and promote the intrinsic virtue of patience, and the meditation is
also an important leisure activity which can let people enjoy the happiness from the
meditation. The core value of leisure activity is to provide people the happy experience, and at
the same time leisure is also the key activities which the populace regulate their life and the
well being is the ultimate objective which the populace always try to achieve. What kind of
experience does the meditation provide to the people? Do those activities experience can
provide people the well-being? The questions above are the key elements whether meditation
can become important health leisure activity to the populace, and they are also the important
topic for this research project.
Literature Review
The meditation flow experience
The meditation flow experience is that when people are doing some kind of activities or the
work, they pay the centralized attention, and completely invest in the situation, and remove
all the other senses which are not related to the activity, is one kind of meditation flow
experience (Csikszentmihalyi, 1990). The meditation flow experience can cause individual to
be immersed in some kind of activity completely, and disregard the other conditions, and this
kind of experience brings the greatest joy to people. After the meditation flow experience

proposed at 1975 by Cskiszentmihaly, it was widely applied in all kind of areas which
included music, school education, the network, the job, the sport, the volunteer, the leisure,
the Trans-Culture research, the daily life, the computer network (browsing) and so on.
In the measurement of meditation flow experience aspect, Jackson & Marsh(1996) proposed
nine construction surfaces which includes clear goal, immediately pay back, the skill and
challenge balanced, the sense of self-control, the sense of time change, self-forming
experience, the loss of self-awareness, the unite of the body and mind, and the total
concentration in the activity. In the networking training environment meditation flow
experience research which proposed by Cation(2000), the surface construction of mediation
can be divided into the immediately payback, the clear goal, the unite of knowledge and
action, the full concentration, the latent control feeling, temporary lost the determination, the
sense of time change, the long distance live feeling, the spontaneous experience and the
positive emotion. This research referred to the meditation flow scale which was applied by
Jackson and Marsh (1996) and Cation(2000), and considered the characteristic of meditation,
and used the seven construction surfaces which included “the clear goal”, “immediately the
payback”, “the skill and challenge balanced”, “the full concentration in the activity”, “the
sense of self-control”, “the sense of time change” and “self-forming experience” to be the
measurement foundation for the meditation flow.
Well-being
Well-being is healthy or the joyful feeling which generally may divide into quality of Life, is
called QOL, mental health and mental development and used the factors above to measure the
well-being. The quality of lives is emphasis on invisible spiritual life level to person's
survival and the development meaning, and defined the subjective welling being as the
cognation and value of the individual to their life satisfaction level. (Diener, Suh, Lucas &
Smith,1999), and mainly used the overall life satisfaction feeling and the specific satisfaction
feeling to be the measurement foundation. The well being in the metal health aspect thought
that a well being person first need to have a healthy mind, and this kind of health usually was
show in people emotion aspect. The related research thought that people's subjective well
being situation was decided by certain time inner product extremely emotion and the passive
emotion balance. If the people experienced more in happy emotion and less in unhappy
emotion, this person could be estimated as a well-being person. The mental development
defined the well being as that the well being was not only about the happiness; moreover also
including reached fully personal potential to achieve the perfection (Ryff,1995). The related
research thought that the subjective well being measurement only limited to people's positive
feeling, but the positive feeling was not equal to positive healthy life, and then proposed that
the psychological well-being, is called PWB.
Method
In order to analyze the influence relation between flow experience and well- being, this
research established linear structure equation pattern which showed as follows: The latent
independent variable for the flow experience (ξ1), latent depends variable for the well being
(η1). The latent independent variable for flow experience (ξ1) included the clear goal (X1),
immediately the payback (X2), the skill and challenge balanced (X3), the full concentration in
the activity (X4), the sense of self-control (X5), the sense of time change (X6) and selfforming
experience (X7) seven items. Latent depends on the variable well being (η1) the
observation variable included the physiology (Y1), the psychology (Y2), the environment
(Y3), the public relations (Y4), the self-growth (Y5), happy optimistic (Y6) and life

satisfaction (Y7) and seven items. The relational graph of meditation flow experience and
well being was shown in Figure 1.
X1 Clear Goal
X2 Immediately payback
X3 Skill and Challenge
balance
X4 Full concentration in the
activity
X5 Sense of self-control
X6 The sense of time
change
X7 Self forming
experience
λ x11
λ x21
λ
λ
x31
x41
λ x51
λ x71
λ x71
flow
experience
ξ1
Well-being
η1
Y1 physiology
Y2 psychology
Y3: Environment
Y4: Public relation
Y5: Self -grow
Y6: Happy optimistic
Y7: Life -satisfaction
Figure 1 The influence relation model of meditation flow experience and well
being
β 11
Results
Participant basic information analysis
Participant basic document analysis result was shown in Table 1. In the gender aspect, the
majority was the female, accounted for 71.6%. The age aspect, the majority was 41~50 year
old, accounted for 30.9%; next was below 20 years old, accounted for 20.0%. The education
level, the majority was the university level, accounted for 51.7%. In the marital status aspect,
single are the most, accounted for 62.0%. The occupation leaves, the most are the students,
accounted for 39.5%; Next was the armed forces Catholicism, accounted for 23.6%.
λ y11
λ y21
λ y31
λ
λ
y41
y51
λ y61
λ
y71

Table 1 Participant information analysis
Variable Sample ( ) Percent (%)
Male 142 28.4
Gender
Age
Education
Marital
Occupation
Female 358 71.6
20 years and below 101 20.0
21~30 123 24.3
31~40 64 12.6
41~50 96 19.0
51~60 93 18.4
61 years and up 29 5.7
Junior high school and below 20 4.0
Senior high school and up 69 13.7
2 years College 79 15.6
University 261 51.7
Graduate school and up 76 15.0
Single 311 62.0
Married no Kid 8 1.6
Married have kid 170 33.9
Other 13 2.6
Public servant 118 23.6
Business 29 5.8
Self-Employment 16 3.2
Service Industry 41 8.2
Housekeeping 20 4.0
Retire 41 8.2
Student 198 39.5
Other 38 7.6
Flow experience
The flow experience analysis result was shown as Table 2, “ The experience from
participating meditation activity is very good ” was the highest, next was “when you faced the
challenge during participating the meditation activity, believed that you have the ability to
meet the challenge, and overcome it”. 3 “Enjoyed the meditation activity experience”. In the
flow experience, the lowest was “Do not need to ponder and then you can make the correct
action”, the next was “You can control the activity when you participate the meditation.
Although the meditation activity had its own difficulty, it is very good experience.

Table 2 Meditation flow activity analysis
Flow experience factors Mean SD.
Clear goal
Immediately
payback
Skill and
Challenge balance
Full
concentration in
the activity
Sense of selfcontrol
The sense of
time change
I know that I want to participate in meditation activity
clearly.
3.6508 0.8744
When I participate in meditation activity, I know what I
suppose to do clearly.
3.7276 0.8322
When I participate in meditation activity, I know I feel very
good.
3.7475 0.7996
When I participate in meditation activity, I know that I have
good performance.
3.1096 0.8441
When I face the challenge when I participate in meditation
activity, I know that I have enough ability to overcome it.
3.8797 0.7540
The challenge which meditation activity brings to me has
same level with my ability.
3.3214 0.8547
I do not need to ponder and I can do the right reaction. 2.8968 0.9274
I participate in meditation activity automatically. 3.3849 1.0022
I pay fully attention when I participate in meditation
activity naturally.
3.4870 0.8285
When I participate in meditation activity, I will pay all my
attention.
3.5964 0.8072
I can control all the activity freely when I am participating
in mediation activity.
3.1016 0.8776
When I participate in meditation activity, I have the ability
to control all the sense of situation.
3.2282 0.8035
I do not feel myself when I am participating in meditation
activity.
2.7440 0.9012
The time past fast when I am participating in meditation
activity.
3.5149 0.8913
The time passing is unusual when I am participating in
meditation activity.
3.6178 0.8466
The experience comes from the meditation activity is very
good.
3.9085 0.7906
Well-being analysis
The well-being analysis result of the meditation activity is shown as Table 3, “I always
thought that the life should be aggressive and create on own initiative” is the highest, next is
“I cherish good fortune and reason”, next is “when I am work, I will pay all the attention on
work”. The lowest well-being item will be “I am a mood stable person”, the next is “my spirit
is healthier and energize, is not easy to feel weary”. The meditation activity will bring more
positive feeling for life and it will be helpful in the work concentration.

Table 3 Well-being analysis result of the meditation activity is shown
Physiology
Psychology
Environment
Public relation
Self-grow
Happy optimistic
Life satisfaction
Well being factor Mean SD.
My body is healthier and less illness. 3.6612 0.7819
I may adjust my mind to improve my immune system. 3.6309 0.8344
I feel more energize and less weary. 3.6247 0.8857
I am a mood stable person 3.4342 0.8727
My body and mind always maintain at the comfortable
condition.
3.7310 0.7880
I can handle the setback and relieve the angry and sad
emotion.
3.6454 0.8270
I can keep my emotion calm and face the matter which
makes me angry.
3.6598 0.8193
I am satisfying the environment which surrounds me. 3.8417 0.7532
I can make the atmosphere of the working environment
peace and harmonious.
3.7146 0.7527
I will not argue with people for little matter. 3.8953 0.7281
I can communicate coordinated with the others, when I
live with others.
3.7556 0.7397
The co-worker and I often hangout, beside the working
period.
3.6440 0.7987
I will pay attention at work, when I am working. 4.0802 0.6778
I can pay attention at work and activity which are
processing during daily life and work.
3.8045 0.7577
I will make all the effort in the work to have good
performance.
3.9539 0.7027
I always thought that the life should be aggressive and
create on own initiative
4.1900 0.6949
I always keep interest and enthusiastic at work and case
daily.
3.9120 0.7466
I feel the hope for the future. 3.9382 0.8080
I can still be optimistic mind in the adverse
circumstance and keep working hard.
3.7454 0.7623
I can understand life’s meaning. 3.8926 0.8036
I can obtain the harvest from the daily life. 3.9861 0.6603
I cherish good fortune and reason 4.1454 0.6811
The relationship between meditation flow and well-being
This study established the relational liner construction model for the meditation activity flow
experience and well being and used the he Lisrel 8.5 software to find the solutions, and the
relational scheme path diagram was shown as Figure 3. The number represented path
coefficient, and the number in the parenthesis represented the T value of the path coefficient
value. In the basic matching moderation examination aspect, basically in the pattern of the
meditation flow experience and well being of factors reached the remarkable standard, the
coefficients are between 0.66 and 0.87, which belonged to good matching moderation scope.
Each construction surface the measurement of T value are all larger than 1.645, and there are
not negative error variations, and the error variation all achieved the remarkable standard,
demonstrated that this pattern basic adaptive is good. In the Matching the moderation aspect,
χ2 value ratio was 2.90, GFI was 0.95, RMSEA was 0.062, AGFI was 0.92, NFI was 0.98,
CFI was 0.99, RMR was 0.046, PGFI was 0.60, and PNFI was 0.72, was showing that the
mode has very good matching moderation.
From Figure 3, we can know that the meditation flow experience to the well being which
influence coefficient was exactly the 0.76, t value was 12.85, achieves the remarkable
standard and demonstrated that the the meditation flow activity experience has positive
influence to the well being. When the flow experience was higher, the well being was going

to be higher too. In the leisure flow experience aspect, the factors of “ the full concentration in
the activity”, “clear goal”, “immediately payback” and “self-forming” have high construction
surface. In the well-being aspect, the factors of “the happy optimistic”, “life satisfaction”, “the
self-growth” and “the environment” have high construction surface. From the analysis above,
we can know that the meditation flow experience provided the populace to have higher level
of well-being.
X1 Clear Goal
X2 Immediately payback
X3 Skill and Challenge
balance
X4 Full concentration in the
activity
X5 Self-Control
X6 Sense of time change
X7 Self-Forming experience
0.80 *
(20.97)
0.77 *
(20.04)
0.73 *
(18.22)
0.84 *
(22.74)
0.70 *
(17.38)
0.71 *
(17.72)
0.74 *
(18.89)
Flow
experience
ξ1
0.73 *
(12.85)
Well-being
Figure 3 The casual relationship between mediation flow experience and wellbeing.
Conclution
People’s living pressure is increasing, so the life well being value is decreasing. Because the
meditation activity can relieve the pressure and it also has the strength to increase people’s
life quality from the mental and spirit aspect, so meditation activity slowly becomes popular
leisure activity to the people. This research used the influence relation between meditation
flow experience and well being to be the research subject, and the finding demonstrated that
higher meditation flow experience has higher well being value. The people who engaged in
meditation activity thought that the meditation activity is very good experience activity,
would bring the more positive outlook for people’s life at the spirit aspect and the finding
showed that the meditation had the ability to reduce the pressure from the daily life and
increase people’s health, and promote the intrinsic self-control, so people can be able to enjoy
the mediation activity which was important leisure activity.
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η1
0.66
0.78 *
(15.04)
0.79 *
(15.18)
0.75 *
(14.46)
0.80 *
(15.18)
0.87 *
(16.26)
0.81 *
(15.28)
Y1 physiology
Y2 psychology
Y3 Environment
Y4 Public relation
Y5 Self-Grow
Y6 Happy optimistic
Y7 Life satisfaction

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Canada, 1981 to 1992. Society and Leisure , 20(1), pp. 73-106.

Segmenration and Positioning Products and Destinations in Health and
Wellness Tourism
Gabriela Cecilia Stanciulescu
Academy of Economic Studies, Bucharest, Romania
gabriela_stanciulescu@yahoo.com, gabriela.stanciulescu@com.ase.ro
Elisabeth Molnar
elis@remtours.ro
Abstract
Purpose. The proposed theme represents a new marketing approach of health and wellness
tourism from the point of view of tourists segments taken into account and the products that
are offered. In this particular case 20 distinct market segments emerged. Based on within
cluster sum of squares the most homogeneous segments were identified . The author was
seeking within cluster sum of squares to be as close to zero as possible indicating a tight
spread around the centroid. In addition she was interested in clusters being as dissimilar to
each other as possible in order to achieve heterogeneity across segments. A distinction when
segmenting a market has to be made between the health and the wellness aspects. Health
tourism refers to those clients with medical conditions who would travel to experience healing
therapies. A person who seeks a wellness travel experience, is generally healthy to start with,
and seeks therapies to maintain his or her well being.
Key words: Segmentation, Spa culture, Benefit based market
Introduction
Increased competition in health and spa tourism has rendered the tasks of market
segmentation, market targeting and product positioning of paramount importance. Companies
may gain sustainable competitive advantage through innovative segmentation of their
markets. Distinct market segmentation provides a vehicle for directing one’s marketing efforts
toward that narrower base of potential customers. The trick to marketing to a narrower base of
customers is figuring out which narrow portion to market to. A market segmentation
procedure that achieves such precision, yet has received scarce attention from marketing
scholars is the benefit-based market segmentation schema.
Benefit-based market segmentation involves segmenting the market for a product based on
the intrinsic value that customers derive from the product. This intrinsic value (benefit) could
take various forms such as snob appeal, perceived quality, or derived economy. This method
of market segmentation is significantly different from other methods of market segmentation.
It seeks to get "inside" the consumer=s cognitive processes and find out what the customer is
feeling about our product, rather than arbitrarily identifying a consumer based on how much
money she makes or where he lives. The underlying principle is that consumers do not seek a
product per se, rather they seek what that product does for them, or the derived benefit. With
benefit-based segmentation, the objective is to identify why the customer is buying the
product, and group customers with similar whys together.
European spa culture has its roots in ancient Babylon where the curative and purifying effects
of water were already acknowledged and early spas developed. Similar developments are also

evident in Ancient Greece and Rome. Spa culture was highly appreciated in Rome where spas
were the centres of leisure activities and socializing. Spa culture slowly spread to central-
Europe, where spas were mainly used as places to socialise and for cleaning purposes. The
use of mineral water, health and hot springs were known also in other cultures like the Mayas
in South-America, the natives in North-America as well as in the Asian cultures where also a
philosophical point of view played a big role in the practice. In the late 19th century, seaside
holidays became fashionable again as the curative effects of mineral water were rediscovered.
The spas became yet again places of social interaction. Switzerland and the
French Riviera established spas and sanatoriums before the world wars. Thalassotherapy
(based on seawater) has become a major investment in France and also elsewhere in Europe
and the USA the development and re-development of spas is noticeable. Since the beginning
of the 21st century, wellness has become a global phenomenon which will most probably
affect the development of tourism markets and the diversification of health related service
provision, as well as will attract new customer segments.
As a word “wellness” is still relatively young. In 1961 an American physician Dr Halbert
Dunn, developed the term as a combination of the words “wellbeing” and “fitness”. Later the
word was adapted in connection with some health related publications.
Wellness concept and wellness tourism is an old traditions. In many ways, this is one of the
most ancient forms of tourism if one considers the scrupulous attention paid to well-being by
Romans and Ottomans, the quests for spiritual enlightenment of muslim pilgrims, or the
medical seaside and spa tourism of the 18th and 19th century European élite.
Health and wellness tourism is now an international trend set by the health conscious
consumers seeking to enhance their well being through their travel experiences. This type of
consumer seeks to look and feel better, to lose weight, to slow the effects of aging, to relieve
pain or discomfort, to manage stress, or to partake in the use of natural supplements like
vitamins and minerals to improve their health. Resorts and hotels are joining the health spa
development craze, although only some resorts are moving into the scope of services
currently offered by destination spas. Likewise, a growing number of day spas are adding
health and wellness programming options.
Wellness is first and foremost a choice to assume responsibility for the quality of your life. It
begins with a conscious decision to shape a healthy lifestyle. Wellness is a mindset, a
predisposition to adopt a series of key principles in varied life areas that lead to high levels of
well-being and life satisfaction. A distinction is made between the health and the wellness
aspects.

HEALTH
TOURISM
Provision of health
facilities utilising the
natural resources of
the country, in
particular mineral
water and climate.
Health tourism
refers to those clients
with medical
conditions who
would travel to
experience
therapies.
healing
SPA TOURISM WELLNESS TOURISM
Spa tourism is widely
acknowledged as a core
element of the health and
wellness movement which
covers a broad spectrum of
holistic, curative and
preventative activities.
Wellness can be defined as a
balanced state of body, spirit and mind,
including such holistic aspects as selfresponsibility,
physical fitness/beauty
care, healthy nutrition, relaxation,
mental activity and environmental
sensitivity as fundamental elements.
Wellness is also viewed as a way of
life, which aims to create a healthy
body, soul and mind though acquired
knowledge and positive interventions.
A person who seeks a wellness travel
experience, is generally healthy to start
with, and seeks therapies to maintain
his or her well being.
Some topics for spa sector:
1. Spa centres are becoming more relevant to today's traveler. More people go to spas to
improve their looks and well-being.
2. Medical spas will provide the prescription for health and wellness ( health treatments,
nutrition and fitness, health and wellness education.
3. Spa experience will become more important in the corporate world. Mixing business with
‘spa’ pleasure, businesses will engage the use of spas to build relationships and motivate
employees.
4. The 'Hamam Spa Concept ' will become more famous in spa sector. Hamam Spas offer a
holistic mind/body/spirit experience similar to experiences normally associated with
resort/hotel/destination and day spas. Treatments will include cultural and social activities in
addition to spa/beauty treatments. However, Hamam has unique concept with traditional
treatments and its special structure.
5. International spa tours will replace international spa treatments. Rather than seeking
specific treatments from specific facilities, the international traveller will seek to sample a
variety of spa experiences within the same destination.
6. Spas will become the primary consideration for many travellers. In recent years the fastest
growing segment of the hospitality industry was hotels with spas.
Spa Tourism encompasses a number of different tourism experiences based on spa facilities
that are specifically set up for clients to use on a daily basis (ie. no accommodation is
provided).
Destination spas – Resorts that offer a specific health program, with a focus on spa
treatments. Clients stay at the facility and are provided with full board.

Resort spas – Sometimes called ‘amenity spas’, the spa treatments are part of a wider range of
recreational activities offered by a resort or hotel. Other fitness and health programs are
available but are optional – the emphasis is on leisure and wellbeing rather than health and
fitness.
Other spa experiences include Cruise Spas (cruise ships set up with spa facilities), Club Spas
(day spas with an emphasis on fitness), Golf Spas and Ski Spas. A very small but growing
segment of the health tourism sector is dental tourism. Obviously this type of health tourism
does carry with it some dangers.
The newest phenomenon is the development of ‘Spa Tourism’, where the emphasis is on
relaxation and beauty treatments. Spa resorts in fact have a long history – travellers have
been attracted to mineral springs, which are often believed to have many healing properties,
since the Roman era. ‘Taking the waters’ became a popular pastime amongst the middle and
upper classes in the 18th and 19th centuries in Britain and Europe. The latest revival in spa
treatments began in the 1980s and continues to be a major sector of the health tourism
industry.
The turn of the century has produced concern about the future of the spa industry in its classic
form as a component of a comprehensive health system; on the other hand, there is talk of a
renaissance in which the spa industry becomes a fixed component of the hotel trade. Spa
hotels, which up till now shared highly similar operational and business conditions, are
worried about heretofore lucrative long-term stays, the loss of interest from the health care
sphere, the loss of the possibility to generalize the results of spa treatment, as well as the loss
of motivation by qualified health care providers. This trend concerns all traditional spa
industry leaders. On the other hand, the spa industry is becoming a component of hotel
services on a global scale. Wellness or spa operations are not missing from any newly opened
“full-service/upscale” hotel, hotel lines are adding spa facilities, and “spa brands” are being
franchised. On one hand traditional spa hotels fear sophisticated competition, while on the
other they could capitalize on the fact that consumers already consider spa services to be
standard offerings and that these consumers have become accustomed to them and are
familiar with individual procedures. The traditional facilities are attempting to set themselves
apart from the competition and maintain a hallmark of exclusivity in various manners such as
employing the appellation of “medical wellness,” certificates, and so on. Nevertheless, they
need to be careful. Following this unprecedented boom the market appears to be saturated and
the tide of services and new ideas is slowing; many trends in tourism are going in a single or
opposite direction.
Health tourism ranges from travel experiences that offer relaxation and promote a general
sense of well-being (eg. health farms and spa resorts) to travel that is for specific medical
reasons (eg. to obtain cosmetic surgery). Most people participate in health tourism for one or
more of the following reasons:lose weight, quit smoking or conquer some other addiction,
become fitter, become less stressed, gain physical flexibility, improve digestion and
circulation, gain a more positive outlook on life, improve their appearance.
Health tourism tends to appeal to the upper end of the market, with many luxury hotels and
resorts tapping into this lucrative market. Clients are generally affluent, female and middle
aged. Most are private clients, although the corporate market is expanding in many areas.

Health resorts became popular during the 1970 and 80s. They were often called ‘health
farms’, because they were located in the countryside (where clients could not be tempted by
nearby shops selling forbidden food). Typically they offered a strict fitness program and
dietary regime (usually vegetarian and no alcohol) so that clients would feel fitter, cleaner and
thinner after a week or so of the treatment. Nowadays, they are more often called ‘health
resorts’, which reflects the emphasis on having a healthy holiday in an attractive setting.
Many facilities and services are offered at health resorts – from horse riding and meditation,
to massage and bushwalking.
Findings, limitations and future research. Based on the study, the paper reveals 20 segments
and several trends that will highly influence this type of tourism. During the course of
implementing this research, several limitations became apparent. First, my data was obtained
late in the season (in the face of severe winters in the local area) and as a result spa tourism
visitation numbers were lower than normal. Sampling errors might have crept in. Second,
there were no past studies available to compare our results across samples or alternate
segmentation models. Use of a cluster analytic model imposes certain limitations on our
findings. First, the data set that is utilized when performing cluster analysis needs to be one of
perfection (Milligan 1980). There is no provision in the cluster analysis procedure for missing
values. Secondly, the need for superior computing power arises when conducting this type of
analysis.
Originality. This study provides an alternative to conjoint analytic models of benefit-based
market segmentation, namely a multivariate cluster analytic model. It will be soon seen that
this model is easy to comprehend, relatively effortless in application, and involves the
managers responsible for product strategy formulation in interpretation of results. The
cooperative efforts of managers and researchers strengthen the validity of results and findings.
Past research has shown that the benefits consumers derive from various product and service
attributes are powerful discriminatory variables for market segmentation (Haley 1968; Wind
1978). However, the large numbers of such models merely confuse and frustrate both
researchers and practitioners.
Prior Research
Past research has shown that the benefits consumers derive from various product and service
attributes are powerful discriminatory variables for market segmentation (Haley 1968; Wind
1978). Traditionally marketing scholars have restricted benefit-based market segmentation
schema to conjoint analytic models (DeSarbo, Oliver, and Rangaswamy 1989; De Soete and
DeSarbo 1991; Green and Krieger 1991; Kamakura 1988; Wittink, Vriens, and Burhenne
1994). There are several two-stage conjoint models in use to facilitate benefit-based market
segmentation. However, the large numbers of such models merely confuse and frustrate both
researchers and practitioners. Consequently, conjoint analytic segmentation models are
largely chosen based on availability of expertise and software, coincidental acquaintance with
scholars or algorithms, or personal preferences. The concern for strengths and weaknesses of
models of choice and the propriety of use of a specific model for a specific application are
often ignored. One can't help but notice the irony of picking an analytic tool to segment
market by derived benefit based on factors other than product attributes and true benefits!
This study provides an alternative to conjoint analytic models of benefit-based market
segmentation, namely a multivariate cluster analytic model. We will soon see that this model
is easy to comprehend, relatively effortless in application, and involves the managers
responsible for product strategy formulation in interpretation of results. The cooperative
efforts of managers and researchers strengthen the validity of results and findings. A cluster

analytic model has several methodological advantages. Firstly, the advantage of not
depending on unreliable individual-level estimates of benefits based on any subjective a
priori segmentation scheme, as often seen in conjoint analytic models founded on Hagerty's
(1985) two-stage procedures. Secondly, conjoint models often suffer from insufficient degrees
of freedom that may lead to incorrect part worth estimates and misclassification of subjects
(Kamakura 1988; Umesh and Mishra 1990). As we will see, a cluster analytic model allows
for ample degrees of freedom provided the sample size is adequate. Thirdly, cluster analytic
models don't face identification problems often witnessed in alternative models that
overparametrize degenerate solution. A related issue thus involves respondent fatigue
associated with conjoint specific data collection procedures. Often the task of attribute
weighting, attribute-level determination, and preference statements and ratings can be
foreboding for most respondents. In a cluster analytic model interval level data is obtained
with relatively negligible respondent burden, further strengthening the validity of results
obtained.
Theoretical Rationale
A cluster analytic model of benefit-based segmentation is concerned with devising a
methodology of segmenting a very large and diverse potential market, through the use of a
statistical algorithm, with the application of very specific benefit-oriented finite variables. In
the search for narrow and specific segments there are three criteria that need to be satisfied,
homogeneity within the segment, and heterogeneity across the segments, and aggregation
throughout segments. Homogeneity within the segment is critical to defining the target
customer. In the case of a benefit-based segmentation scheme, customers that derive the most
similar benefits would be grouped in one segment. For instance, in the leisure and recreation
industry it is a common practice to group customers who have young children and those that
are on a tight budget. In this case, the common desired benefit being sought is economy.
Heterogeneity across the segments allows for the differentiation of segments and consumers.
If two customers have very different needs, such as economy and snob appeal, they would be
grouped in two very heterogeneous segments. By making the segments as heterogeneous as
possible, the company ensures that marketing resources are utilized efficiently. Finally,
aggregation is the process by which customers are grouped together. Segmentation was once
thought of as being a desegregation of customers, on the contrary, the objective is to group
them together for the most effective targeting, not separate them out to be targeted separately.
The process of aggregation is expected to result in market segments that satisfy the
aforementioned twin qualifications of homogeneity within and heterogeneity across segments.
Methodological Rationale and Case Study
The rationale behind the use of cluster analysis ties in very closely to the rationale for market
segmentation. Cluster analysis seeks to organize information about variables so that relatively
homogeneous groups, or clusters, can be formed (Anderson 1984; Dillon and Goldstein 1984;
Lance and Williams 1967). Similar to market segmentation, the clusters that are formed
should be highly internally homogeneous as well as externally heterogeneous as the groups
should be as dissimilar as possible. Cluster analysis, like market segmentation, is also a
gathering process, since responses are grouped together based on likeness of variables
(Joreskog 1977). Cluster analysis performs agglomerative hierarchical clustering of data in
order to classify observations into prima fascia unknown groups. Observations are aggregated
in a stepwise fashion. Each successive step reduces the number of clusters by one. Similarity
and distances are computed based on the scale on which distances are defined and the
methods of linking researchers prescribe (Morrison 1976). In this research, a market in the
leisure and recreation industry is segmented via the use of a computer-based segmentation

procedure using multivariate cluster analysis. Data was collected from a local spa tourism in
the Midwest and cluster analysis was used to create a multivariate model to achieve a very
precise grouping of responses. Findings indicate that the resultant market segments were
clearly identifiable and valid. Results obtained from the study have resulted in strategic
planning initiatives enhancing customer visitation and satisfaction.
A preliminary draft of the data collection instrument was pre-tested with undergraduate
students and the spa tourism management. The final product turned out to be a rather well
formatted and concise questionnaire consisting of 26 items covering a range of topics that
pertained to the spa tourism and strategic issues facing the management of premises. The data
was procured from a convenience-based random sample of tourists at the local spa tourism
destination. Personal interviews in a mall-intercept fashion were conducted. A high response
rate was made possible through personal interviews assuring respondents of anonymity,
stating the contribution of the study in improving their future visits to the spa tourism, and
offering a token incentive for participation in the study. A total of 743 surveys were returned
out of a possible 1100 (response rate 67.55%). Descriptive statistics (the frequencies in our
case) on the sample profile indicate that 56.28% of the people visiting the spa tourism were
female, while 43.44% were male. The largest number (38.16%) of visitors fell between the
ages of 25-39. Twenty-two percent of the visitors make between $100 and $1,000 annually.
The majority of tourists, 51.98% are married, while 37.71% reported being single. People
with children accounted for 57.69% of all visitors, 36.14% had two children (under 18) in
their home. 62.76% of the visitors reside within the county and 45.11% travelled less than 200
km. to get the spa tourism. The typical visitor is a married female, with 2 children, has an
income between $300 and $3,000, and travels less than 200 km to get to the spa tourism.
Table 1 Number of Observations Within Cluster Sum of Squares
Segments Number of Observations Sum of Squares
Cluster 1 20 200.000
Cluster 2 24 240.000
Cluster 3 38 380.000
Cluster 4 25 250.000
Cluster 5 28 28 0.000
Cluster 6 1 10.000
Cluster 7 22 22 0.000
Cluster 8 25 250.000
Cluster 9 11 110.000
Cluster 10 50 500.000
Cluster 11 10 100.000
Cluster 12 31 310.000
Cluster 13 20 200.000
Cluster 14 35 350.000
Cluster 15 20 200.000
Cluster 16 12 120.000
Cluster 17 8 80.875
Cluster 18 27 270.000
Cluster 19 138 138206.174
Cluster 20 176 176216.875

From this survey, we selected several questions that depicted benefits that the spa tourism
visitors might derive from the spa tourism. These selections ultimately became the variables
that were used in the cluster analysis. One of the issues facing the spa tourism was to ascertain
the profitability and feasibility of introducing information programs about environment and
spa benefits, and their coexistence on premises. The concern was to determine if there was a
sizable portion of the market that sought the benefit of viewing the spa tourism as an
interactive opportunity for their general wellbeing. In order to aid the decision making
process, three variables that dealt with income levels, number of persons in the household,
and willingness to support an information program at the spa were analyzed using the
multivariate cluster analytic model. After the cluster analysis was run, a graph or Dendrogram
was produced that graphically depicted the clusters that we were seeking. The next step is
often referred to as 'cutting the Dendrogram' (Johnson and Wichern 1988; Milligan 1980).
Clusters are identified and cut based on a Cut or Amalgamation Statistic provided by the
procedure and researcher judgement (Morrison 1976).
In this particular case 20 distinct market segments emerged. Based on within cluster sum of
squares the most homogeneous segments were identified (Table 1). We were seeking within
cluster sum of squares to be as close to zero as possible indicating a tight spread around the
centroid. In addition we were interested in clusters being as dissimilar to each other as
possible in order to achieve heterogeneity across segments. We use the distances between
cluster centroids to ensure heterogeneity. Although we now have very distinct clusters, or
segments, the task of segmenting the market is far from complete. The final steps that need to
be taken involve the application of the initial variables to the clusters and the decision making
process about what the clusters actually mean. Labels accorded to each segment are largely
based on inputs obtained from spa tourism management. Eventually, based on management
input two feasible segments emerge which seeks the benefits offered by an information
program at the spa premises.
Limitations and Future Research
During the course of implementing this research project several limitations became apparent.
First, our data was obtained late in the season (in the face of severe winters in the local area)
and as a result spa tourism visitation numbers were lower than normal. Sampling errors might
have crept in. Second, there were no past studies available to compare our results across
samples or alternate segmentation models. Use of a cluster analytic model imposes certain
limitations on our findings. First, the data set that is utilized when performing cluster analysis
needs to be one of perfection (Milligan 1980). There is no provision in the cluster analysis
procedure for missing values. Secondly, the need for superior computing power arises when
conducting this type of analysis.
The lack of a direct comparison between conjoint and cluster analysis is a weakness that was
unavoidable in our study. It was not possible to procure the data necessary to perform a
conjoint analysis and the cluster analysis without angering our respondent base. Duplication
of information throughout the sample would have been necessary in order to overcome
validity issues raised by comparing models across two samples. One would always doubt if
results were indeed dissimilar due to differences in models or because of differences in
sample. The need for specialized data to run conjoint - based models further illustrate the ease
with which multivariate cluster analysis can be performed with rather simple data from a
standardized and versatile questionnaire.

In summary, we have presented a statistical model using multivariate cluster analysis as a
possible alternative to the error prone conjoint model of benefit-based market segmentation.
This model, if proven effective, could be applied to other businesses and industries. In the
instance of the case study that was performed several distinctive clusters were obtained. These
clusters exhibited the traits that are desired in market segments B homogeneity within the
segment and heterogeneity across the segments. However, given the very infantile nature of
this type of statistical theory, there is much work to be done in getting to the point where
multivariate cluster analysis is a reliable and accepted method for producing benefit-based
market segments.
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Gulliver in the land of giants?
The opportunities of the Hungarian initiations in the surgical medical
touristic market
Ivett Sziva
Corvinus University of Budapest, Management and Business Administration Doctoral School,
Institute of Business Economics
Fővám tér 8, 1093 Budapest, Hungary
ivett.sziva@uni-corvinus.hu, ivett.sziva@gmail.com
Abstract
Medical tourism seems to be one of the most dynamically growing segments of health
tourism, what is more it is evaluated as “wonder-niche” product by the rest of the destinations
in trouble because of the economic downturn. However lots we hear about the area called
medical or surgical or clinical or health-related tourism, the definitions are not clear, nor the
measurement of the volume. Moreover there are several challenging questions regarding
quality factors of services, management of the seamless process of care, and liability issues in
the area. There are two main aims of the paper. Firstly to give an academic perspective, what
might be useful for the practice about the most challenging questions of surgical medical
tourism, like definition, dimensions of competition, and service process management.
Secondly to map the Hungarian surgical medical touristic market in the framework of an
exploratory research based on content-analysis and experts’ interviews in order to give
recommendations for the development.
Keywords: health tourism, medical tourism, private clinic, public hospital, Hungary
Introduction
The phenomena of traveling abroad for medical treatments is not new, as wealthy patients
from less-developed countries traveled for cure to European and American clinics even in the
19. century. Nowadays the flow of medical tourism became more complex. The successstories
of the top Asian destinations show enormous change in the supply-side, and raise the
question of the changes affecting the demand-side as well. The picture is more tinged if we
have a look on the crowds traveling from the USA to have different (by not all means
cheaper) treatments to other continents, though USA still seems to be the greatest exporter
regarding health-related services (OECD 2009). Among the driving forces of medical tourism
nowadays we can find the overburdened health-care systems, as well as ‘greying’ societies
and celebrity culture or differences in technology and prices, and last but not least, the
blurring in health touristic services, and the need for holistic services. The paper focuses on
the definitional issues, as well as the dimensions of competition in order to map the success
factors of medical touristic services. This kind of summary was essential to give a proper
picture of the Hungarian medical tourism. Hungary has rather strong position in the surgical
medical touristic markets in certain areas, but seems to be a “silent Gulliver” as whole, since
the individual, and isolated players put the country to the map of medical tourism handling
their selling chains successfully, without making great above the line promotions. The aim of
the paper to analyze the definitional issues in the regard of Hungary based on the international
definitions, and to look in the success factors of the Hungarian players in order to give
recommendations for further development.

A border-less product?
Defining and measuring medical tourism
Medical tourism is a dynamically growing segment of health tourism, which commonly
known as including all the forms of traveling for cure and prevention. Health tourism can be
divided to two parts, to wellness and medical tourism. Medical tourism could be further
decomposed: Puczkó - Smith (2008) has broken medical tourism down into therapeutic
tourism (based on natural healing resources), and surgical tourism (mostly traditional Western
medicine is used). The authors point out an important trend of the holistic concept of
wellness, what gains ground in every area of health tourism. The commonly known definition
of medical tourism relates to the surgical tourism defined above, as the point of these overall
definitions is: traveling to abroad to obtain medical services as dental and surgical care
(Deloitte 2008, OECD 2009), but complex packages can be made with alternative treatments
based on natural resources (ESKI 2009, Youngman 2009).
Defining surgical tourism in details is important regarding the confusion of statistics: some of
the experts estimate that 10 million travelers seek for cure abroad, other study (McKinsey
2008) restricts this amount to 85 thousands worldwide. One of the official statistics in the area
is that of OECD (2009), which is based on the balance of payments item called “Healthrelated
travel”, what includes the medical trips with the first motivation of curing, and spatravel
also. According to these official statistics, USA is the largest exporter of health-related
services (2,3 billion USD in 2007), followed by Czech Republic (481 million USD), Turkey
(489 million USD), Belgium, Mexico, Italy and Hungary (211 million USD). Among the
greatest importers (source markets) we face Germany, USA, Netherlands, Canada, Belgium
and Austria. The main question behind the statistics is who can be considered as medical
tourists and how to measure their flow. Taking the exact definition of McKinsey (2008) as a
starting point, and looking into the criticism of that (Youngman 2009) summarized in Table 1,
the following definition could be given, based on the general definition of tourism (travel
lasting more than 24 hours, but less than one year, including touristic services), and taking a
stand on the debate:
Table 1. The characteristics and the dimensions of medical tourism
Dimensions Statement
(McKinsey)
Evaluation (Youngman)
1. Length of stay in hospital Only inpatients In- and outpatients
2. Main motivation Only
travel
for medical Mixed motivations
3. Emergency included No emergency No emergency
4. Expatriates included No expatriates No expatriates
5.Trip to neighboring Excluded Included
countries
6. Type of treatments Western medicine Holistic view, alternative methods
inc.
7. Estimated volume of the 85.000 worldwide 5 millions worldwide (America
market (touristic arrival)
600 ths, Europe 1,75 millions, Asia
2,25 millions)
Medical trips to abroad with the voluntary (main or part) motivation of obtaining medical
health services based on particularly Western medicine, which might include alternative
healing methods as well as outpatient surgeries, but excludes treatments for expatriates and

emergency cases. As the commonly known medical tourism definition overlaps or equals to
that of surgical tourism, so the terms will be used as synonyms in the following.
The dimension of the competition
The features of the medical touristic market
Being medical tourism a promising niche-segment of tourism, newer and newer destinations
appear in the competition, mainly in the most popular outpatient surgeries area, at dental and
cosmetic treatments. Among the commonly known medical-hubs (eg. Asian countries, USA,
Spain, Belgium) other rising European destinations (Cyprus, Czech Republic, Poland, Croatia,
Bulgaria, and Hungary) should be analyzed to get a total picture. An analysis was carried out
(summary can be seen in Appendix 1.) based on studies (Deloitte 2009, ESKI 2009, Medical
Tourism Association 2009), as well as researching the web-appearance of the destinations,
and having experts interview.
Four different segments can be created among the analyzed countries, particularly based on
the factors of the prices, the know-how and the volume of the market. The below expressed
categories can be named as the development phases of medical tourism as well:
• Premium category based on high level know-how: USA and Germany plays in the
first, premium category, where competition is fueled by innovation and high-tech,
with high price-level generally or in certain areas.
• Medium category with permanent patient flow, and professional market behavior:
Spain, Belgium, Cyprus belongs to the second middle-segment, regarding prices and
technology, where strong market-ties, as well as accreditation seems to be important.
High volume of patients flow is assured by the professional seamless service.
• Countries with price-advantage and industrialized medical tourism: Asian countries
can be featured by “industrialized” medical tourism, which is due to the costadvantage,
as well as the powerful state subsidies (investments, marketing). The Asian
countries use their traditional national healing methods for differentiation, what is an
example to be followed.
• Countries with price advantage and bottom-up initiations: The Central European
countries use out their cost-advantage and the historic market contacts. It seems that
isolated initiations are the typical in these countries. Differentiation is really rare
mostly in Central-Europe, what can cause price-competition in the future.
Among the main source market of medical tourism USA, Middle-East, Germany and UK can
be pointed out based on the estimations (McKinsey 2009, Harryono, M. et al. 2006). In these
countries the main driving force is the overburdened healthcare system, or business-type
insurance, excepting Middle-East, where the lack of the highly sophisticated technology is the
main reason. Elective treatments seem to be the most popular products, but orthopedics, as
well as cardiology appears regularly. In addition to price-conditions, the holiday-programs of
the chosen destination is crucial for the British and Americans, in Germany the financing
conditions of the insurance institutions seems to be essential, while Islamic patients have
special cultural needs (e.g. alcohol-free medicines, great rooms to receive lot of visitor). The
summary of the features of the most significant source markets can be seen in Appendix 2.

The quality and management issues
There are only a few researches regarding how the medical tourists make their travel decision,
and what quality actually mean for them, but according to them it can be stated that the
touristic resources are almost as important for tourists as the quality of medical services
(Crompton 2008, McKinsey 2008).
Table 2. The main factors of medical travel decision
Medical factors Touristic factors
� Reputation and skills of the � Reputation as a touristic
doctors
destination
� Results of the medical treatments � Price of the trip
� Price of the treatments
� Developed infrastructure
� Insurance and guarantee
� Cultural closeness
� Follow-up and supporting services � Safety and stability
� Foreign language skills
Responding to the demands’ requirements, the following steps are (or should be) taken by the
medical service suppliers, based on the results of experts’ researches (McKinsey 2008,
Johnson 2010, Youngman 2008) as well as guidelines of concerned institution (AMA 2009).
• Transparency: proper and honest information about the results (number of
complications, unsuccessful cases), policy of guarantees is crucial information
regarding travel decision.
• Quality control - accreditation: A debate lies in the question of accreditation: some
practitioners find it as an unnecessary process, as price and reputation are the key
issues, others think, it is really important regarding marketing and operation
effectiveness.
• International network - seamless services: The key issue regarding medical trips is to
assure the feeling of permanent safety, care, and well-being, so highly personalized
services (transfer, hostess, assistance services, and interpreter) are essential. The
greatest challenge is to solve the pre-travel and the follow-up services in the mother
country, and the opinion of the Hungarian medical facilitator will be expresses in
Chapter 3. It can be seen, that managing the seamless process needs professional
facilitators, though the process of des-intermediation appeared in medical tourism as
well, due to the internet.
• Insurance: Having long-run contacts with the private or public insurance companies
seems to be a driving factor of the success. In the USA several insurance companies
started to introduce mini-mad plans for overseas healthcare. There are governmental
initiations in the UK as well as in Germany to finance publicly those treatments
abroad, which are unsolvable at home. In the EU steps are taken to ease the process of
patients’ mobility, so that the EU-citizens could obtain for publicly financed
treatments in another EU-country. Insurance is an important question regarding
liability issues: there is a shortage in travel insurance including medical services.
The following figure summarizes the factors influencing the success, and the players of
medical tourism, highlighting destination management organizations (DMOs) and the
institutions for cooperation (IFCs, e.g. chambers, research institutions).

Figure 1. The main factors of quality and management of medical tourism
Case study of Hungary
Hungary can be called as the “silent Gulliver” of the medical touristic market, as the country
makes a lot less noise than the others, but the number of the medical touristic arrivals near
those in Asian countries (Youngman 2009). Three main questions arises regarding the
statement: firstly how medical tourism can be defined in the case of Hungary, secondly what
is the structure and volume of the medical touristic market of Hungary and whether making
less noise helps retaining competitiveness, or other steps are needed. Due to the exploratory
nature of the study the qualitative case study methodology was chosen. To assure
triangulation, the information was gained from the following sources: 1. Secondary sources
(studies, articles); 2. Content analysis of the webpages of the service providers; 3. openstructured
interviews with experts from different areas (Hungarian Healthcare Ministry, and
Research Institute, leader of international medical touristic facilitators, private clinics).
Defining medical tourism in Hungary
It is particularly important to differentiate surgical tourism from therapeutic tourism in the
pool of medical tourism in Hungary, as the latest is commonly known even in the touristic
industry as medical tourism related to treatments based on healing or thermal water, and the
surgical part of the product got less or hardly no common interest until the last year. The main
reason for this is that the culture of thermal-water baths is nearly 2000 years old, and the
country is one of the richest areas with medical and thermal water in the world. That is why
the commonly known idea of health tourism is nearly equal to thermal tourism, and however
we can face dynamic development of wellness tourism, the phenomena usually far away from
the international concept of holistic wellness. Thermal tourism was the main focus of the
governmental subsidies, as well as the national communication during the development of
health tourism in the last 10 years. Nowadays the importance of surgical tourism was realized,
and some funds were opened in 2009 (mainly for municipalities) to develop infrastructure,
and the issue got into the focus of the Hungarian National Touristic Office (HNTO) in the
latest years, mainly in dental segment, particularly in Germany. In the surgical medical
touristic market of Hungary it is important to divide the market to private clinics and state
hospitals, regarding the different significance and management issues of the areas.
Summarizing the definitional questions, from the scope of the structure and volume, three
different service-segments are significant in Hungary: I. therapeutic medical touristic market,
II. surgical medical touristic market: 1) operated by private sector, 2) operated by public
sector.

The scope of the medical touristic market and implications
Regarding the success factors of the overall touristic sector highlighted in Figure 1., the state
of the Hungarian touristic sector seems to be good enough to assure basis for medical tourism.
Considering the latest results of Travel & Tourism Competitiveness Index (TTCI, WEF 2009)
Hungary was in the first third part of the ranked 133 countries regarding the rest of the factors
in question. The state of the airport infrastructure should be pointed out, as it got the lowest
score of 3,0 (from7). The bad score can be explained by the fact that there is only one
significant international airport in Hungary, and the frequencies of the airlines were reduced
in the latest years (affecting particularly badly the surgical touristic players).
Therapeutic medical touristic market
Hungary can be evaluated as a Great Power regarding the thermal and healing water resources
as it possesses nearly 1300 thermal springs, among what 300 are used for bathing. The scope
of the healing waters is uniquely wide, and assures cure for orthopedic-, rheumatologic-,
cardiologic-, dermatologic-, and gynecological diseases. The therapeutic touristic market
generated a turnover of 147 million EUR in 2008 (ESKI 2009). Though Hungary has a great
tradition in therapeutic tourism, the question is whether the infrastructure of thermal baths and
spa hotels can keep up with the newest trends demanding traditional therapies in a more
holistic view of well-being. A shocking result of the research of Techniker Krankenkasse
(German health insurer, Mezősi (2009)), investigating the opinions of German travelers raises
serious questions regarding this issue. The rest of tourists (80%) were satisfied with the
amenity services and leisure activities in Hungary but only 50% of them were content with the
therapeutic treatments, and ca. 35% with the medical supervision.
In order to give a picture of the therapeutic touristic infrastructure a content analysis was
done. The random sample (every fifth of the sites) was chosen out from the database of the
HNTO (2010) containing 85 thermal baths, 52 spa hotels and 10 spa hospitals. The analysis
focuses on the features of the medical and wellness facilities of the service providers. All the
analyzed thermal baths possess thermal pool (100%), further on balneo-fiziotherapy are quite
regular (45%) but medical supervision is rare (20%), while complementary wellness services
appear at 45% of the baths, but alternative healing methods are missing. In the spa hotels,
medical services – particularly rehabilitation of orthopedic-, rheumatologic diseases – are
common as well as healing water baths, balneo-fiziotherapeutic treatments, diagnostic
sections, while clinical services appeared at 30% of the hotels. Avarage wellness services (e.g.
sauna, pampering) are regular, while alternative methods (e.g. Ayurveda) are rare. The main
orientation of the analyzed spa hospitals was rehabilitation, angiology, gastroenterology, and
gynecology. Summarizing the results it can be said, that the Hungarian therapeutic touristic
infrastructure is well-developed to serve the mass medical tourism demanded by elderly
patients. In order to meet the needs of the 50+ segment, innovation and up-to-date services, as
well as well-defined atmosphere are needed, and serious specialization should be done to
serve younger people with the need for lifestyle therapies, or cure for special diseases.
Therapeutic tourism is one the key issues of the Hungarian touristic development as well as
promotion with the aim of becoming the “Pannon Healing Power” of Europe according to the
National Health Touristic Strategy (OEFS 2007). However we have great comparative
advantages based on natural resources, the location-based special, innovative treatments are
missing, as well as the up-to-date holistic atmosphere of the spas. That is why, the strategy
gives priority to product-development, R+D and qualification (OEFS 2007). Unique products
could be developed in the area of thermal and healing water, medicinal plants, or the special
area called hypo-therapy. This kind of innovative treatments could mean unique attractiveness
or could be combined with the suitable surgical touristic service to give complex product.

Surgical medical touristic market
There are no exact statistics counting the number and the turnover of the players involved in
surgical medical touristic market, but according to the estimations (ESKI 2009), the private
sector does the bulk of the turnover. First of all the basic information and characteristics of the
market will be described, followed by the analysis of the private and public sector, based on
the success factors of medical services (shown at Figure 1.).
The turnover of the total market (private and public together) is estimated to be around 36-56
billion HUF (1 EUR = 265 HUF), 90% of that is assured by private service providers. Nearly
300-400 thousands surgical tourists arrive at Hungary yearly, and around 50-60% of them is
cured at private clinics. Being Hungary a player in the surgical touristic market can be due to
the hard and isolated work of the private service providers, who build the international
reputation of the Hungarian clinics as a bottom-up process, but the public hospitals take a part
in the surgical tourism as well. As having no proper statistics of the surgical touristic players,
summarizing the main characteristics of the surgical market (can be seen in Table 1) is based
on estimation of the Hungarian Healthcare Research Institution (ESKI 2009) and experts’
interviews.
Table 3. The main characteristics of the Hungarian surgical touristic market
Main products Main source markets Players
Private dentistry (80%), A, CH, D, IR, Ro, n.d. about 600-800
clinics cosmetic-, eye surgery; DK, N, USA clinics, and doctors in
IVF + obesity surgery
border-land, Budapest,
marginal
spa towns.
Public clinics gynecology, cancer-, D, Ro, A, S, UA, n.d. hospitals in
cardio-vascular USA
Budapest, border-land,
treatments, eye surgery.
close to Research
Institutions
Though the public and private players should be analyzed separately in the regard of success-,
and management factors, there are some mutual sources of comparative advantages, what give
the basis for surgical tourism in Hungary:
• Cost-advantage: The costs of medical treatments are definitely low in Hungary, due to
low wages, comparing to those in the developed countries: rest of the treatments (from
heart bypass to spine surgery) cost the 5-15% of the costs of them in the USA. The
prices of the treatments are significantly (by 50-60%) lower than in the USA, but the
difference is great regarding the expenses in Germany, where eye-surgery costs 2782
USD (in Hungary 846 USD), and face-lift costs 9126 USD (in Hungary 4881 EUR)
(ESKI 2009).
• High-skilled staff: “Another thing that many may find surprising is that Hungarian
surgeons are held to much stricter educational standards than those in the U.K. or
U.S.” (Medical Tourism Association 2009). Though the high skills of the doctors
seem to be one of the most important enabling competencies of Hungary,
shortcomings should be pointed out. The Hungarian public hospitals face a great
volume of brain-pipe, because of low wages, and the aging of the health professionals
causing an avarage low foreign-language skill-level as well as lack of service-oriented
view among the public professionals. Widening surgical tourism could be a solution,
as the Hungarian doctors working abroad could be attracted back, or unless while
staying abroad, they could mean important market-ties in the pre-travel as well as in

the follow-up process. Education can hold market-ties as well: thousands of
international students learn medicine in Hungary, and after returning home they can be
the ambassadors of the Hungarian surgical tourism. These kinds of contacts are used
by the private clinics, where the high-level medicine-, language-, and management
skills are given.
• Innovation – R+D: The Hungarian medical science and research have world famous
results in the area of orthopedics (backbone surgery), cardiology (invasive surgery),
improvement of disabled people (Pető-method), or IVF (Kaáli-method). However
these results are known in the circles of medicine and affected patients, with wider
communication, these areas could serve the improvement of the image of the
Hungarian medical professionals.
Surgical tourism in the private sector
Hungary got to the map of surgical tourism due to the private initiations, started by the
dentists in the border-land towns, close to Austria in 1990’s, and dental tourism is still the
most important product as well as trademark of the Hungarian surgical tourism. Since then the
example as well as the market know-how began to spread in the country, and hundreds of
players launched isolated businesses, and international marketing in different areas, without
any cooperation or state subsidy. However the individual initiations work well, the threat of
the new competitors (Bulgaria, Rumania), and the aggressive market-behavior of the older
ones (Czech Republic, Poland) ask for new solutions, as well as governmental support. In
order to get a picture of the market behavior of the private clinics a content-analysis was
carried out. There are no available statistics about the number of clinics involved in the
surgical tourism, so typing the keyword (private clinic, dental-, cosmetic-, eye surgery,
Hungary) in the Google maps seemed to be a good solution to find the individual service
providers. Though problems arose with this solution, as from the hitting list of some
hundreds, only 200 hits were shown, what should be handled as the basic of the sample, from
what every fifth were analyzed in the dimension of transparency, accreditation and seamless
services. The evaluation of success factors in the private sphere based on content-analysis,
and experts’ interviews are as follows.
• Transparency: Transparency seems to be an issue to be developed: the statistics of the
successful / unsuccessful cases appeared only at one service providers, the prices were
missing at the 25% of clinics, as well as the own guarantee.
• Image: The Hungarian dental-, cosmetic-, and eye surgery have great reputation in the
international market, at which industrialized medical tourism could be built out.
• Accreditation: Neither of the Hungarian clinics possess international accreditation,
according to the list of the accreditation institutions (JCI, Tempos, ACHS), and only
15% of the clinics analyzed have TÜV/ISO accreditation, and it means a disadvantage.
According to the leader of medical facilitator, as well as the expert of Healthcare
Ministry, the accreditation is essential for simple reasons: firstly it is a marketing tool
serving comparison, secondly accreditation is the basic requirements of public and the
rest of the private insurance institutions, thirdly without contracts with these
institutions, the industrialized medical tourism ca not be built out. In the near future a
centralized qualification process will be started in the aim of mapping the market, and
assuring unified quality by recommendations, and researching the satisfaction of the
patients as well as broadcasting information about patients’ mobility (ESKI 2009).
However this kind of process is essential, having the accreditation accepted by the
target-market of the service provider is a crucial factor.

• Seamless services: The professional medical facilitators discovered the country in
2004, when Hungary joined the EU, and started to carry out the seamless service in a
great volume (VMFE, 2009). The seamless service is carried out by the rest of the
players in dentistry, what is more, the practice of organizing consulting possibilities in
the mother-country became a best practice in the market (Pollard 2010). Other players
– particularly in the cosmetic surgery – are in difficult situation, as complex diagnosis
are needed, which costs lot in the mother country, so they offer “fam-trips” to assure
the first check-up and the personal contact with the doctors and the country at an
affordable price. The follow-up process seems to be hard to solve: “It is really
difficult, as the doctors in the mother-country are willing to reject to give help to a
returned medical tourist. The solution is to find a Hungarian doctor in the mothercountry
or to take the patient back to Hungary.” (Medical facilitator). According to the
content-analysis only 35% of the clinics analyzed promote supporting services
(transfer, hostess), the complementary services (hotels, flights) appear at the 52% of
the clinics, while 40% of them have international contact (facilitator, consulting
possibility in the source country), and only 10% of them promote their contracts with
international insurances. Regarding these results, it can be said, that the greater or
first-mover players of the market started the seamless process, while the smaller or
newer players in the majority should realize the importance of that.
• Insurance: According to the experts’ interview, there are several clinics in contract
with Italian as well as German insurance institutions. There are good practices of the
private clinics to handle the patients’ mobility. According to the leader of a private
clinic, the process is not easy but can be managed. Firstly they build contacts with the
G.P.-s in the mother country, who make the administration of the authorization
process of the public health insurance company. The patients is cured in Hungary with
the permission of the insurance institutions, the bill is made out for the institutions,
and to make the payment sure, the clinic make an insurance for recovering the debt.
This extra way of security work in all cases, when the public insurance company is in
delay with payment.
• Innovation: Working with the up-to-date technology is crucial in the most competitive
areas (dentistry, cosmetic and eye surgery), and according to the experts’ opinions, the
Hungarian players invest in the newest know-how without sparing pains. Alternative
healing methods are important areas of innovation. Medical herbal treatments have
been already used in the dental surgery, but healing water could serve for plastic
surgery, as well as gynecology, if suitable treatments, with suitable infrastructure
would be assured by the spas. There are good example of cooperation among spa
hotels and private clinics: in Budapest as well as in the border-land towns luxurious
hotels with high-quality spas give location for surgeries and rehabilitation.
Surgical tourism in the public sector
Some public hospitals (no accurate data) started to be involved in the surgical tourism, though
the rest of the leaders of the public clinics find tourism as a way-out from their generally
difficult financial situations. In Hungary the rest of the hospitals are owned by municipalities
or the state, and the Hungarian healthcare systems is financed by centralized public insurance
fees and taxes, but the system suffers from deficit at almost every year since. It is important to
highlight, that one of the major problems, beyond the lack of financial resources, is the
ineffective structure and operation of the hospitals. In 2007 a major structural reform started,
and the overcapacity of the state hospital was partly reduced by cutting the number of acute
beds, and increasing the volume of chronic beds. However the reform was needed, the time
pressure of the process did not let enough scope for finding the optimal volume as well as

financing (OECD 2009/a). That is why there is free capacity at different treatments (e.g.
orthopedics, heart surgery) without enough hospital beds. This unutilized capacity could be
used by the medical tourists, if proper amenity service is built out, and could be the source for
extra turnover for the hospitals, as well as for the staff. It is essential to have a governmental
decision regarding developing surgical tourism in the public-sphere. The healthcare system of
Hungary is under reformation, and newer steps could be expected regarding enhancing the
effectiveness, and the quality. The question is whether the state – as the main owner –
supports the idea of surgical tourism, and starts to pump European Union subsidies to priority
hospitals, with focusing on surgical tourism. The state of the public hospitals regarding the
success-factors of medical tourism is as follows:
• Transparency: There are serious problems regarding transparency, even it is difficult
to define that how many individually financed treatments were made, or how many
doctors made diagnostic analyzes for their own private patients in the hospital. It is
highly significant to make a transparent solution; otherwise there could be a threat for
having waiting lists for the residents, when surgical tourism starts to boom. The issue
of transparency arises in the area of statistics, considering the success of the treatments
as well. The Hungarian public health insurance started to makes statistics about the
failures, to know which points of the healing process should be improved, but they are
not public, neither have we proper information about the amenity services provided by
the hospitals.
• Image: “However there are great results in orthopedics, cardiology the good skills of
our doctors is not communicated widely. That is the reason why Hungarian healthcare
is not on the medical map, it is not the first destination, what came to the mind of an ill
person searching for cure. It is another question that there areas, where prices, and the
word of mouth have their effects.” (The leader of a private clinic).
• Accreditation: As well as in the private sector, accreditation seems to be essential (or
even more essential) in the public sector. That could be the starting point to widen the
contracts with foreign public and private insurance companies.
• Seamless services + insurance: Though we have little information about the marketties
of the public hospitals, the the experts’ interviews show that the international
facilitators reached the public hospitals as well. The foreign public and private
insurance companies also involved in the process. The basic problem is the low
quality of the amenity services, and the lack of service-oriented view of the health
professionals. If the government gives vote for surgical tourism in the public sphere,
these problems could be remedied by the partner-hospital model (isolated wing of
hospitals for medical tourism, using the same infrastructure of the public hospital
(ESKI 2009)), or by cooperation with hotels.
• Innovation: The medical infrastructure of the rest of the hospitals is up-to-date enough
to serve surgical tourism, but there are serious shortcomings regarding the amenity
facilities detailed above.
Conclusion
Hungary got to the map of world-wide medical tourism as a “Happy Dent” destination, since
the 80% of the treatments in the framework of surgical tourism refer to dentistry. Other areas
like cosmetic-, and eye surgery, as well as gynecology, cancer-, cardio-vascular treatments
provided by the public hospitals are in demand. Even the country has world-famous results in
orthopedics (backbone surgery), cardiology (invasive surgery), improvement of disabled
people (Pető-method), or IVF (Kaáli-method), what is not used out because of the capacity
limits of the affected clinics and doctors, and the lack of wider communication. Regarding the
development phases of the medical tourism, the Hungarian service providers are at the stage

of price-advantage segment. Due to the permanent innovation of the private clinics, steps are
taken to the next stage, what can be called “Medium category with permanent patient flow,
and professional market behavior”, while the world-wide famous results could hold the
possibility of getting to the premium category based on high level know-how. In order to
reach these stages, the following steps are recommended:
Stage of medium category with permanent patient flow, and professional market
behavior:
Efforts are made in the area of dental-, surgical-, eye surgery for assuring permanent up-todate
quality, as well as seamless, professional services. In order to have industrialized medical
tourism, and permanent patients-flow, the best practice of seamless services, and crucial
solutions (e.g. pre-travel, follow-up services, travel insurance) should be spread, as well as
joining the accreditation systems of the target-markets. IFCs got great role in this area, by
raising awareness, and controlling the quality. Co-operation with the touristic sector and
getting the well-deserved attention in the national touristic promotion of health tourism, as
well as in the development fund are essentials. The public sector faces several challenging
questions detailed above, where the decision of the government to support the surgical
tourism or not seems to be vital. Without governmental support, the model of “partner
hospital” cannot be carried out, but the surgical tourism can be increased with the help of
hospitals, and assistance services, in the area of outpatient surgery, and rehabilitation.
Differentiating strategy is important regarding the sharpening competition and using
traditional, national healing methods seems to be good example (e.g. in Asia). The cooperation
with the therapeutic touristic service providers could be a solution, in order to make
specialized, high-quality methods and products based on healing water, medicinal plants.
Stage of premium category based on high level know-how
The areas of the distinguished results of the Hungarian medical research assure the possibility
of getting in the circle of the “bests” in the medical touristic market. It is important to
highlight that the rest of the results is reached in international cooperation or thought to
foreign physicians to spread the knowledge of healing. This means that the know-how spreads
quickly, and eliminates the source of the competitiveness. In this perspective, the medical and
pharmaceutical research institutions have a crucial role, to keep moving the wheels of
innovation with new results. Based on the nowadays results, in the area of the unique methods
detailed above, the actual limits of the infrastructural capacity should be lifted. It could
happen even with the help of the private sector, and a high-level price, complex niche-product
should be built out. All the areas in question can have rehabilitation, lifestyle treatments based
on the therapeutic touristic services, what could add the extra possibility of differentiation.
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Appendix 1. The characteristics of the main (or selected) medical touristic destinations
Country Main areas Main characteristic Prices Accredit
(USD) ation
Thailand General and Some first-mover, 1. Dental 1. JCI –
cardiac surgery, prominent hospital with impl. 1600 9 hosp.;
cosmetic surgery, strong communication, USD, 2. 2.
dentistry, strong state subsidies, Facelift Treatme
orthopedics Thai treatments - 2400 USD ntabroad
rehabilitation, low
– 5
prices
hospitals
Singapore General surgery, Strong governmental 1. Dental 1. JCI –
cardiac surgery, support, national impl. 1180 16 hosp.;
ophthalmology, communication, low USD; 2. 2.
orthopedics, prices, Traditional Facelift Treatme
gynecology, Chinese medicine 2700 USD ntabroad
urology
- n.d.
India Cardiac surgery,
orthopedics,
ophthalmology,
alternative
medicine
USA Rare, complex
illnesses,
treatment of
cancer,
cardiology,
neurotic
treatments,
general surgery
Belgium Cardiology,
cosmetic surgery,
transplantation,
dentistry, fertility
treatments
Germany Wide variety for
surgery: from
cosmetic to
spinal,
cardiology,
Spain Gastric bypass,
cosmetic surgery,
dentistry,
orthopedics, IVF
Some prominent
hospital, strong market
contacts and
governmental support,
differentiation: holistic
concept (alternative
methods), extra low
prices
Famous clinics, the
highest technology, and
skills, continuous R+D
Close to main markets
(UK, NL) ,strong
market-contacts, high
quality, low(er) prices,
opened society
Prominent hospitals in
famous destinations,
Advanced technology,
R+D, high skills,
rehabilitation:
spas+health resorts
Ranked as 7. for highest
quality healthcare in
EU (WHO), famous
holiday destination,
cheap touristic infra. –
long stay, returning,
close to main markets
(UK, D, I)
1. Dental
impl. 500
USD; 2.
Facelift
2700 USD
1. Dental
impl. 2800
USD; 2.
Facelift
14.500
USD
1. Dental
impl. 1000
USD; 2.
Facelift
3524 USD
1. Dental
impl. 1188
USD; 2.
Facelift
9126 USD
1. Dental
impl. 1288
USD; 2.
Facelift
7,198 USD
1. JCI –
16 hosp.;
2.
Treatme
ntabroad
- 6
1. JCI –
n.d.
hosp.; 2.
Treatme
ntabroad
- 3
1. JCI –
n.d.
hosp.; 2.
Treatme
nta. -12
1. JCI –
5 hosp.;
2.
Treatme
nta. -5
1. JCI –
17 hosp.;
2.
Treatme
nta. –
over 40
Overall message
High quality, low
price, exotic travel,
great experience in
medical travel -
image made by the
service suppliers, and
facilitator
“Peace of Mind when
Health Really
Matters” – high
quality, low prices,
transparent national
facilitator-system +
strong
communication
“The Global
Healthcare
destination” -
holistic view:
Western medicine +
traditional Indian
treatments
(Ayurveda, Yoga),
governmental
support, med. tourism
on the official
national tours. site
Leading surgeons and
hospitals in the world
with the most up-todate
R+D results –
image built by market
players
Modernity, high
quality, costefficiency
- image
built by market
players
Excellent reputation,
high skills, and hightech,
rehabilitation-
image built by market
players
Medical hub of
Europe, high quality,
low cost - image built
by market players

Country Main areas Main characteristic Prices
(USD)
Cyprus Cosmetic, dental High skills, 1. Dental
surgery,
international training impl. 1671
orthopedics, for doctors, high-tech USD; 2.
cardiology, IVF private centers, Facelift
prominent
destination
vacation 5,343 USD
Czech
Republic
Dental, cosmetic
surgery, IVF,
rehabilitation
Poland Dentistry,
cosmetic surgery,
cardiology,
ophthalmology,
neurology
Croatia Dental, cosmetic
surgery
Bulgaria Dental, cosmetic
surgery, lifestyle
treatments, IVF
Hungary Dental, cosmetic
surgery,
orthopedics,
ophthalmology
High quality, low
prices, close to markets
(D, A), famous spas +
towns
Close to markets (D,
RU, North-Europe),
international training
for doctors, high-tech
private centers, success
in innovation
Low prices, high skills,
starting networking,
traditional image in
vacation tourism
Low cost, some high
quality centers, rest is
under construction, spas
for rehabilitation
High quality centers,
highly skilled staff with
international
experience, first-mover
hubs in Western-
Hungary, unexploited
innovation in
cardiology
1. Dental
impl. 1046
USD; 2.
Facelift
4051 USD
1. Dental
impl. 805
USD; 2.
Facelift
3980 USD
1. Dental
impl. 975
USD; 2.
Facelift
4813 USD
1. Dental
impl. 1166
USD; 2.
Facelift
2659 USD
1. Dental
impl. 882
USD; 2.
Facelift
4885 USD
Accredit
ation
1. JCI –
4 hosp.;
2.
Treatme
nta. – 19
1. JCI –
4 hosp.;
2.
Treatme
nta. – 3
1. JCI –
0 hosp.;
2.
Treatme
nta. –8
1. JCI –
0 hosp.;
2.
Treatme
nta. – 15
1. JCI –
0 hosp.;
2.
Treatme
nta. –0
1. JCI –
0 hosp.;
2.
Treatme
nta. –28
Overall message
“Treasure your health
in Cyprus” – complex
health +vacation
experience,
governmental
support, med. tourism
on the official
national tours. site
High standards, low
prices, and great
natural resources -
image built by market
players
High quality with
international
experience,
innovation, but low
prices - image built
by market players
Complex experience,
low prices
Low prices, complex
experience
“Happy dent” – high
quality, low prices,
complex experience -
- image built by
market players,
governmental support
recently started

Appendix 2. The characteristics of the main source markets
Country Main motivations Popular treatments Popular
USA price-sensitiveness,
complex
treatments+holiday
Middle-
East
highest level
technology
Germany motivation of public
insurance, pricesensitiveness
at
elective treatments
UK motivation of public
insurance, pricesensitiv.
at elective
treatments, hospital
infection, complex
holiday
general surg., cancer
treatm., orthopedics,
heart-bypass,
cosmetic surg.
heart surgery, cancer
treatm., orthopedics,
detox programs
dental treatments,
orthopedics,
cosmetic-, eye
surgery
dental, cosmetic,
orthopedic surgery,
and fertility
treatments
destinations
Asia, Latin-
America,
Middle-East,
inside USA
growing
North-America,
Asia, Europe
Czech Republic,
Hungary, and
Poland
Belgium, Spain,
India, Hungary,
and Cyprus
Nr of outbound
tour. arrivals (2008)
ca. 540 ths.
no overall
estimation: UAE –
100 ths., Saudi
Arabi 200 ths
ca. 272 ths.
ca. 75 ths
(Source: Pollard 2010, Deliotte 2009, McKinsey 2009, Techniker Krankenkasse 2009,
Crompton 2008, Biomedme 2009)

Developing Quality Criteria for Spa and Wellness Hotels: the Case of
Estonia
Heli Tooman
Pärnu College, University of Tartu, Estonia
heli.tooman@ut.ee
Tiina Viin
Pärnu College, University of Tartu, Estonia
Abstract
The objective of this paper is to give an overview of the process of development of the
categorisation system for Estonian spa and wellness hotels. The categorisation system has
been developed on the basis of the experience of several other countries and organizations,
also the results of thorough research, mapping and analysis of Estonian spa hotels and the
services provided. The need for the research arose, on the one hand, by the appearance of
several new hotels to the Estonian hotel market who started to market themselves as a spa
and/or wellness hotel without having sufficient respective services and conditions, and on the
other hand by the growing need to communicate to visitors clear messages concerning the
specific features and quality of spa hotels. There is no common internationally recognised and
accepted categorisation system for spa hotels all over the world but such systems have been
developed and introduced by several countries and organisations.
As the terms ”spa” and ”wellness” have become undefined and unregulated catchwords which
are often misleading, the Estonian Spa Association adopted a decision in 2006 to launch a
project for the development of classification and categorisation criteria for Estonian spa
hotels. The initial survey was conducted in 2006 among all fifteen spa hotels which belong to
the Estonian Spa Association, and the repeat survey was conducted in 2009 among 10 spas.
The purpose of the surveys was to identify objective information as a basis for the
classification of spa hotels and for the development of the respective categorisation system
which follows internationally recognised concepts. The research tasks consisted in thorough
mapping of the services and conditions of Estonian spa hotels, analysis of results and
development of a system for the classification and categorisation of spa hotels. The research
method applied was a survey in the form of a questionnaire. The respective questionnaire was
developed by the Pärnu College of the University of Tartu and the survey was conducted in
cooperation with the Estonian Spa Association.
As a result of the first survey, classification of spa hotels into three categories was suggested:
medical spa hotels, spa hotels and wellness spa hotels. First, the categorisation criteria for
medical spa hotels were developed. By now the system of categories of medical spa hotels has
been implemented. On the basis of the results of the second survey, categorisation criteria will
be developed for spa hotels and wellness spa hotels in 2010. Assessment of conformity with
the respective categorisation criteria will hopefully start in the same year, 2010. A spa hotel
applying for a category has to conform to the categorisation criteria applicable to hotels in
Estonia and in addition also to requirements established to spa facilities and services.
Key words: quality criteria, spa and wellness hotels.

Introduction
Arguments for the need for quality criteria for spa and wellness hotels
Development of spa industry is founded on the interest people have had since the earliest
times in mineral springs that differed from ordinary springs in their appearance, taste and
temperature. The essential framework of spa industry is based mainly on the use of natural
resources and healthy climate with an important contribution from medical care and a
comprehensive approach to therapeutic stays. More recently, increasing popularity of the
wellness concept has acted to stimulate leisure-based health concept and health tourism. At
the heart of the wellness concept lies the WHO definition of health as “a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity”.
The concept of spa and wellness hotels and notions of health tourism have been in the
forefront of this process, with the development of gyms, saunas, fun pools and wellness
centres following. But also contradictionary trends have been highlighted. On the other hand,
a growing global leisure-based health orientation has become incorporated into a selfconscious
fitness lifestyle. But at the same time in a number of countries there has been a
reduction of social financial support for rehabilitation and treatments in medical spas, as a
result of which traditional European health resorts such as spas and sanatoriums faced a crisis
in the later 1990s (Hall, Brown, 2006; Nahrstedt, 2004).
Over the past years the health tourism, spa and wellness sector has experienced enormous
growth. More and more individuals opt for the unconventional treatments and the popularity
of health and wellness products promises to increase even further. Theories abound as to the
reasons for this exponential growth, many of which cite the anomie of western, capitalist
societies, the breakdown of traditional religions, and the fragmentation of communities.
Concomitant progress in science and medicine has led to better preservation of the body and
increasing absence of disease, yet mental, psychological and emotional problems are often left
untreated. The scarce research available suggests that those who avail themselves of the
plethora of experiences available appear to be not only on a touristic journey of physical
movement, but also on a journey towards greater self-awareness and contentment (Smith,
Puczko 2009). Thousands of new spa and wellness products and services have come to
market, and Pilzer (2007) calls it The New Wellness Revolution, explaining that the majority
of opportunities in wellness still await the individual entrepreneur or health professional.
Today spa visits, health tourism, wellness, beauty and fitness programmes, regenerative,
reconditioning and relaxation stays, are all dynamically growing products and tourist product
packages which, combined with all-inclusive accommodation, catering, entertainment,
sporting and other activities, are responding to the most challenging demands of individual
tourists. The type of client at spas ranges from guests in search of a rest all the way to the
truly ill, including all forms of prevention up to rehabilitation and the treatment of chronic
diseases. Spas are a frequent tourist destination of young and old, singles, families with
children, and recently also a favourite venue for putting on congresses and conferences
(European Spa Industry…; Spas – a further... 2007). Goebel et al (2007) vividly describe the
current situation as follows: The consequence of this significant increase was and still is the
establishment and opening of a myriad of businesses, products and services. Unfortunately,
the lack of standards and uniform criteria is not only limited to non-traditional service
suppliers but concerns almost all aspects of health, spa and wellness tourism. The
consequence of missing quality schemes coupled with outstanding demand led to a
mushrooming of ‘want-to-be’ and ‘try-to-be’ health and wellness providers since set up costs
and entry barriers are low.

There is a lot of confusion in the use of the terms spa and wellness and it often misleads
visitors due to the lack of common concepts. There is a similar confusion concerning spa and
wellness hotels. Addition of the words spa or wellness spa to a hotel name may not always
mean that the hotel really measures up to that. This has made categorisation criteria for spa
hotels very necessary and they have also been developed by different organisations of many
countries. The main purpose of categorisation systems is to organise the market and define the
quality standards of services in order to make the service reliable to the client. How can
quality best be communicated?
The more common European quality systems for spa and wellness hotels
This paper covers more thoroughly only a few main principles and main documents of quality
criteria of European spa and wellness hotels, which have also been taken as a basis for the
development of the categorisation system of Estonian spa hotels. There are, however, many
more of such quality systems both in Europe and on the global scale.
The award of the EUROPESPA-med seal of approval means that the holder meets the
exacting standards of ESPA in terms of general therapy infrastructure, hygiene and safety
(Certified exclellence…; International seal of approval...). The EUROPESPA seal of approval
is designed for spas and health resorts in the classical health care segment as well as centres
specialising in medical wellness whose services include treatment and cures. Health resorts
certified by the European Spas Association are listed in the EUROPESPA directory, which
lists the leading spas in Europe meeting the criteria of the ESPA (EUROPESPA.
International...).
The EUROPESPA wellness quality seal (EUROPESPA wellness...) is specially developed by
the European Spas Association (ESPA). The award of the EUROPESPA wellness quality seal
means the holder meets the exacting standards of ESPA in terms of wellness infrastructure,
wellness service, hygiene and safety. The customer knows that EUROPESPA wellness
certified hotels are fulfilling the international quality standards of the European Spa
Association. The set of criteria contains about 350 audit questions checked through an
announced audit on site and approx. 600 testing points is an anonymous check (mystery test)
made by a professional test person.
The European Audit Institute Wellness & Spa provides certification of wellness hotels in four
categories: for hotels with special wellness and spa offers and wellness ambience; for hotels
with special medical offers and concepts and wellness ambience; for golf hotels with special
wellness and golf concepts and wellness ambience, and for hotels with special thalassic and
spa concepts with wellness. In every category there are 3 grade levels awarded: leading,
premium and quality. The quality certificate of the European Audit Institute Wellness & SPA
is an award not only for the wellness and spa area but for the entire hotel with all its facilities
(Wellness Europe Certificates…).
BISA, the British International Spa Association, has become one of the leading representative
bodies for spa accreditation worldwide. Through its British International Spa Accreditation
scheme, BISA seeks to establish consumer confidence through quality standards in the spa
and health resort industries (BISA. International…; BISA. Accreditation…). First established
in 1998, the Waves of Excellence is an accreditation system developed to indicate that a spa is
offering products and services that the consumer can enjoy with confidence.

The DOSTWELL Wellness Quality Seal is a quality system for wellness-oriented enterprises.
DOSTWELL is an international project co-financed by the European Union – Interreg IIIC
programme. 8 partners from 7 European countries joined together to define wellness on EU
level, to develop a wellness cluster model, set up wellness quality standards, define a wellness
product and promote the concept of wellness water based tourism, as water is the common
element to all regions taking part in this project (DOSTWELL – Quality in Wellness). The
wellness quality seal is oriented towards modern management approach, and spirit of
sustainability also leaves room for and encourages an organisation to keep and further develop
their individuality and distinctive characteristics.
European Wellness & Health Standard (EuWHS) was elaborated by international experts and
specialists of the European Economic Chamber of Trade, Commerce and Industry EEIG
(Brussels) to avoid unfair competition, to protect consumer interests and to contribute to an
improvement of the quality in this specific field. Wellness and health centres the quality of
which complies with the quality criteria as stipulated by the European Wellness and Health
Standard can be certified as quality enterprises (European Wellness and…)
The Fáilte Ireland Spa and Wellness Categorisation Programme sets the criteria for the
categorisation of Ireland’s spas and wellness retreats (The Fáilte Ireland Spa…). Speaking at
the awards ceremony, Tony Lenehan, Fáilte Ireland‘s Head of Industry Standards & Quality
emphasized: “This new categorisation system creates a win-win situation for both operators
and customers. It will help operators to better advertise their services and will aid both
existing and new customers to better understand the variety of spa and wellness offerings
available, make informed choices and find the products that best suit their needs. ”
In each Alpine region country today, there are nationally developed wellness criteria and
initiatives, e.g. Wellfeeling (Switzerland), Well-Vital (Bavaria), Belvita (South Tyrol) and
Best Health Austria (Austria). For a participant of the development and marketing initiative
“Alpine Wellness”, apart from the general wellness basis quality criteria, the minimum
criteria in the area of “alpine character” are obligatory. Furthermore, every alpine wellness
company can distinguish itself by fulfilling additional criteria in the areas of “alpine
indulgence”, “alpine fitness” and “alpine medical wellness”. Alpine Wellness International
was in 2003. (Alpine Wellness…)
The quality concepts and criteria of spa and wellness hotels of also other continents were
examined during the preparation of this study. The following is a brief review of such
concepts. In October 2008, the Singapore Ministry of Trade and Industry appointed CaseTrust
as the accreditation body for the spa and wellness industry (Casetrust for spa and ...). In 2004
the Thailand Ministry of Public Health adopted the Thai spa standards (Ministerial
Announcement...), which defined health and beauty service enterprises, standards for service,
service providers, and principles and methods for inspecting and certifying standards for
health and beauty service enterprises. The basic principles of the quality systems and quality
criteria described in this paper served as an important basis and guidance for the development
of the categorisation system of Estonian spa hotels.
Development of Health, Spa and Wellness tourism in Estonia
National tourism policy and tourism development activities are implemented by the Estonian
Tourist Board, which is a subunit of the Enterprise Estonia Foundation and belongs to the
administrative sphere of the Ministry of Economic Affairs and Communication. In 2006, the
Estonian Parliament adopted the National Development Plan for Tourism for 2007–2013

(Eesti Riiklik… 2006). In 2009, the marketing concept “Introduce Estonia” was developed on
the initiative of Enterprise Estonia to establish the manner and ways in which Estonia is to be
marketed. Presenting Estonia as a travel destination includes four main topics that are most
important to the country: cultural holiday, city holiday, nature holiday and wellness holiday
(“Introduce Estonia” brand manual 2009). Presenting Estonia as a wellness holiday
destination – if there were a competition for selecting the spa kingdom of the world, Estonia
could easily snatch that title (Instructions for focus topic of wellness holiday 2009). Estonia is
a spa paradise – with an impressive number of spas considering its small territory and
population.
Estonia has long traditions and experience from more than 170 years in the development of
resort, health and spa tourism. The relatively favourite geographic position, the sea, beautiful
natural sandy beaches and local natural resources, particularly curative mud but also mineral
waters have been the main preconditions for the birth and development of resorts, particularly
health resorts in Estonia. A number of new spa hotels were built in 2000–2008 in different
regions of Estonia and these have been the main and significant tourism products outside
Tallinn which have attracted visitors all the year round in Estonia.
In 2009, 1.38 million foreign tourists stayed overnight at the accommodation establishments
of Estonia (-3,9% compared to 2008). The number of nights spent was 2.74 million (-6,5%
compared to 2008). Foreign overnights on both holiday and business trips decreased (by 5%
and 4 %) , whereas overnights on other trips (incl. spa and health treatment trips) decreased
by 13%. The economic crisis which started in 2008 has had a negative effect on all tourism
sectors, including on spa tourism, and the quality of the services offered and communication
of appropriate marketing messages to potential visitors have become much more important
than earlier (Estonian Tourism Statistics…).
Through different times, the objectives of the Estonian Spa Association have been to develop
and provide high-quality health resort and rehabilitation treatment and spa services. In the
course of that time the competition in the spa hotel market has dramatically increased and
therefore it has become increasingly important to communicate clear messages concerning the
specific characteristics and quality standards of hotels. In 2006 the Estonian Spa Association
adopted a decision to launch a project for the development of classification and categorisation
criteria for Estonian spa hotels, and the Pärnu College of the University of Tartu is involved in
the project as a partner.
Research Design
The objectives of the first survey were to obtain an objective overview of the current situation
of the capacities, services, volumes and conditions of the spa hotels which are members of the
Estonian Spa Association and of the situation in the market. As only medical spas belonged to
the Estonian Spa Association during the planning and conduction of the survey, the objective
was to use the results of the survey as a basis for the development of classification and
categorisation criteria for Estonian spa hotels according to international models bearing in
mind medical spa hotels. A survey in the form of a questionnaire was used as the research
method. The long questionnaire of the survey consisted of four parts: general characterisation
of the organisation, infrastructure, clients and staff of spa hotels. Each part in its turn
consisted of related questions and detailed subquestions. The sample of the survey consisted
of all 15 spa hotels which belonged to the Estonian Spa Association in 2006. The survey was
conducted in the period from 17 April to 27 May 2006 and responses were received from all
spa hotels included in the sample.

The statistics obtained from the survey have been adjusted to make the results unambiguous.
The analysis of information on the volumes of services, rooms and the staff was based on the
description „volume per 100 beds“, which made it possible to make the analysis of the
information more understandable than „volume per bed“, in which case the figures would
have been very low and difficult to analyse. The statistics were analysed with the MS Excel
spreadsheet and the results were presented in the research report in the generalised form, i.e.
no indicators of any spa hotel were presented separately (Eesti Spa Liidu spaahotellide…
2006). The survey gave very detailed information on the rooms and the services provided by
spa hotels.
On the basis of the results of the first survey, the respective materials of several countries and
organisations and client surveys conducted earlier in spa hotels, the conception of the
classification of Estonian spa hotels and the draft categorisation system of medical spas were
developed by the end of 2006 (Spaahotellide kategooriad... 2006). In the course of 2007 the
categorisation criteria were tested and appropriate additions were made. Unlike the hotel
categorisation criteria applied in Estonia, the categorisation criteria for medical spas include
increasingly more so-called soft criteria (criteria related to the staff and quality of service).
Medical spas have to ensure an appointment of an attending physician to each client, if
necessary, the number of places for therapeutic procedures per 100 beds is 10 in the case of
one and two stars, 13 in the case of three and four stars and 15 in the case of five stars, i.e. not
less than 13 different clients should be able to receive therapeutic procedures at the same time
in a three-star spa hotel. A three-star hotel should have as a minimum 3 physicians per 100
beds. The opening hours of therapeutic services should be not less than nine hours six hours in
three-star spa hotels.
The Estonian Spa Association, which until 2009 only acted as an umbrella organisation for
medical spas, has extended its membership to other spa and wellness spa hotels. Stage 2 of
implementation of the spa hotel categorisation system was started – development of
categorisation criteria for spa and wellness spa hotels. A new survey was planned and
conducted in cooperation with the Pärnu College of the University of Tartu. The objectives of
the second survey were to obtain an objective overview of the current situation of the
capacities, services, volumes and conditions of the hotels which market themselves as spa
hotels or wellness spa hotels.
A survey in the form of a questionnaire was used as the research method. The sizeable
questionnaire which was, however, different in many respects from the questionnaire of the
first survey, made it possible to thoroughly map the spa and wellness spa hotels. The main
differences from the first survey were the absence of the section on medical services (spa and
wellness spa hotels have no license for the provision of rehabilitation treatment services and
no doctors among their staff) and a great emphasis on the holistic approach to the provision of
services (incl. the volumes, diversity, size and conformity of rooms, personal service, etc.)
and formation of the ambience, which are characteristic of the wellness concept.
The sample of the survey consisted of 10 spa hotels which market themselves as spa or
wellness spa hotels. The survey was conducted in the period from 01.12 to 31.12.2009. The
final analysis of the results of the survey will be completed in February 2010 and the
preparation of categorisation criteria for spa and wellness spa hotels is going on at the same
time and will hopefully be completed with their approval and implementation by the end of
2010. A common characteristic feature of the spa hotels which responded to the survey was

that more than 60% of the visitors are at the age of 26–45 and have come on a holiday and
relaxation trip. This indicator is considerably different from the visitors of medical spas where
76% of the visitors were older than 45 years.
On the basis of the results of the first survey, the Pärnu College of the University of Tartu
made proposals to the Estonian Spa Association for the classification of spas and the draft
categorisation criteria for medical spas. By the end of 2008 the categorisation criteria were
approved with a few additions after testing the categorisation criteria for medical spas, the
quality system was completed and the first medical spas were accredited. By the beginning of
2010 the respective categories were awarded to nine Estonian medical spas on the basis of the
medical spa categorisation criteria. Spa hotels use the same rating system as hotels and apply
stars for classification purposes. Stars are used in design alongside the logo of the Estonian
Spa Association.
The system was designed to inform clients of the range and nature of services available. The
fact that the services meet the criteria of the system – and the extent to which they meet them
– is a sign of quality that clients can be guided by in visiting Estonian spas. The quality
criteria (Tabel 1) set out the range of services offered and the requirements for premises, staff
and quality of service. (Spaahotellide kategooriad… 2006; Categories of Spa hotels and
classification…).
The Estonian Spa Association has adopted the proposals made on the basis of the research
concerning the categories of spa hotels, which are the following:
• Category 1. Medical spa hotel is a recognised hotel licensed to provide outpatient
medical care that specialises primarily in various rehabilitation, dietary and medical
spa services.
• Category 2. Spa / wellness spa hotel is a recognised hotel that specialises in various
care, relaxation and other spa services. Such hotels are not required to hold a license
for provision of outpatient medical care. Treatment services are not offered and the
spa services have a relaxing and invigorating nature. Note: The concept of wellness
spa calls for very high quality and level of service, personal service, a varied selection
of spa services and focus on relevant target groups, which means that only hotels that
meet four-star requirements can apply to become wellness spas.
• Category 3. Medical wellness spa hotel is a higher ranked hotel that offers both
medical and wellness spa services. A combination of different categories of spa hotels
is possible if a hotel wants to develop itself as a higher ranked medical wellness spa.

Table 1 Sample of the Classification Requirements for the Medical Spa Category
Requirement * ** *** **** *****
1.1. The licence to provide X X X X X
specialised outpatient medical care
6.2. Separate reception for treatment
and spa services
X X X
7.1. Reception by the attending
doctor is quaranteed for every client
if necessary
X X X X X
7.2. Treatment places per 100 bed 10 10 13 13 15
7.5. Swimming pool (at least 25 m
long)
X X
7.7. Availability of spa services X X X
8.1. Special diet therapy menu X X X X X
11. Number of different types of
saunas
1 1 2 3 3
In all categories, the classification (stars) the hotel is applying for is granted if the
classification requirements for hotels and spas of the relevant category have been met. The
following documents were prepared in the process of development of categorisation criteria:
Classification Requirements for the Medical Spa Category, Statutes of the Spa Hotel
Classification Committee, and Classification Procedure (Categories of spa hotels and
classification...). The Spa Hotel Classification Committee is the committee created by the
management board of Estonian Spa Association (ESPAL) whose task is to determine the
categories of spa hotels and develop relevant classification requirements and their
amendments, to decide on granting and removing classifications and to organise all other
work required for maintaining a functioning classification system. A committee includes the
representatives of the Estonian Spa Association, Estonian Hotel and Restaurant Association
and the Estonian Association of Travel Agents. Application for a category is voluntary.
Implementation of the system of categories of Estonian spa hotels contributes to the
organisation of the market and to the communication of clear and reliable messages to
potential visitors.
Conclusions
Fast development of the spa and wellness sector can be regarded as a phenomenon of the
beginning of the 21. century. There are different reasons for this, including increased health
awareness of people which has led to a very fast development of spa and wellness products
and services. No newly opened full service or upscale hotel is without wellness or spa
services, and almost all hotels are adding spa facilities and services. On the one hand,
traditional spa hotels fear sophisticated competition, while on the other hand they could
capitalize on the fact that consumers already consider spa services to be standard offerings
and that these consumers have been accustomed to them and are familiar with individual
procedures.
Estonian spas have traditionally been medical spas but numerous new spa hotels have been
opened during the last decade which do not provide medical services but offer various
invigorating and relaxing procedures. In some of the hotels which have come to the market
the number of the respective services is very limited, however, and the quality standards are
questionable. As health tourism and spa business are very important aspects of the Estonian

tourism sector for the state as these are tourism products which attract visitors all the year
round, it was also necessary to take steps to ensure the adequacy and reliability of the quality
messages of Estonian spas both in the domestic and foreign markets.
One important step in that direction was the process initiated by the Estonian Spa Association
for the creation of a system for the classification and categorisation of spas. The
categorisation criteria for medical spas, which have been implemented by now, were
developed based on the experience of several countries and organisations, thorough research
conducted in the course of the process, and results of several client satisfaction surveys
conducted among earlier spa guests. By the beginning of 2010 the second survey has reached
the final stage; categorisation criteria for spas and wellness spas are being prepared on the
basis of its results to hopefully implement them in the course of 2010.
Several shortcomings were found in the course of the surveys and pointed out in the report of
the research project and also at the training days for spa staffs and at team meetings in the
course of the project. Quality is no doubt one of the most important keywords and
requirements of tourism today, including health tourism. We can state that without quality we
cannot talk about healthy business and healthy tourists in the context of health, spa and
wellness tourism. The categorisation system of Estonian medical, spa and wellness spa hotels
is an important tool for the self-determination of Estonian spa hotels and in their efforts to be
among the best of their category.
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HINY PACKAGE

Tourists’ satisfaction, leisure involvement and health benefit of special interest
tourism: health and well-being tourism
Ching-Cheng Shen
The Graduate School of Travel Management. National Kaohsiung Hospitality College,
Taiwan
sccheng1202@hotmail.com
Tzuhui A. Tseng
Department of Environmental and Cultural Resources. National Hsinchu University of
Education, Taiwan
thtseng@mail.nhcue.edu.tw
Abstract
Due to the increasing stress from life and work, it has become an important issue for modern
people to release stress and pursuit health in everyday life and leisure time. This has boosted
the development of health and well-being tourism activities. Taitung County is located at the
east side of Taiwan. It neighbors the Pacific Ocean, and is a beautiful and vigorous
environment with green mountains, rushing water, and fresh air. It has been promoted as the
spiritual homeland of Taiwan, and is a good place to develop health and well-being tourism.
To raise its unique attraction in tourism activities, special interest tourism has become more
and more favored by the general public. Da-Muo Yijin Kung is a special kung-fu
Bodhidharma (Da-Muo) created to enhance health and prevent sickness through a series of
exercises. Therefore, how to integrate health and well-being into special interest tourism, in
order to create a unique attraction of health and well-being tourism is a subject that is worth
looking into. This study took the relationship among satisfaction, behavior involvement, and
health effectiveness of special interest health and well-being tourism activities as research
topic, and chose visitors who were at Jing-Mei Villa in Taitung County to learn Da-Muo Yijin
Kung as research subjects. Through survey interviews and empirical analysis, the findings
were as following: 1. On the satisfaction aspect of special interest health and well-being
tourism activities, fresh air, healthy food, Ganoderma tea, owner’s warm hospitality, dining
procedure and moving meditation were the higher scored factors. 2. For health effectiveness,
improve physical health, enhance resistance against disease and delay ageing were the higher
scored factors. 3. On the aspect of behavior involvement, learning devotion and earnestness,
learning time and frequency were the higher scored factors. 4. Through factor analysis, factor
dimensions extracted from satisfaction of special interest health and well-being tourism
activities included health tourism, learning activities of Da-Muo Yijin Kung, healthy diet,
healthy environment, and healthy product; factor dimensions of health effectiveness included
health and self-confidence. 5. To analyze the relationships among satisfaction, behavior
involvement, and health effectiveness of special interest health and well-being tourism
activities, this study developed a linear structural equation, and the result showed: satisfaction
had positive relation to behavior involvement and health effectiveness; behavior involvement
had positive relation to health effectiveness; behavior involvement was and intervening
variable for satisfaction to influence health effectiveness. 6. On the satisfaction aspect of
tourism activities, the learning activities of Da-Muo Yijin Kung and health tourism were
important factor dimensions; on the health effectiveness aspect, health and self-confidence
were both important factor dimensions. The above result showed that by integrating special

interest activity and health and well-being tourism, it truly can form a unique attraction,
deepen visitor’s satisfaction, and create a valuable health tourism experience for visitors.
Keywords: Special interest tourism, well-being, heath, Jing-Mei Villa, Da-Muo Yijin Kung
Introduction
The rapid development of urbanization and industrialization had increased the stress on
everyday life, and as a result, affected people’s health and well-being. Therefore, the need in
activities that could release stress and enhance health is very urgent. Countryside tourism has
leisure tourism and stress relief functions, and has become an important leisure activity for
people pursuing a healthy life. This boosted the development of health and well-being
tourism. In addition, with the arrival of an aging society and the awareness of a healthy living,
maintaining a healthy life has become a trend in the modern world. From healthy diet, leisure
activities and constant exercise to the establishment of resorts focusing on health and wellbeing,
all indicated people’s attention to their welfare. Public’s concept on health has changed
from getting treatments from hospital and clinics to the idea of preventive medicine, using a
more natural method to maintain the health of body, mind and spirit. It is to not only pursuing
physical health, but further seek environmental and mental health, and eventually protect and
maintain the health of both body and mind.
Due to the competitiveness in the public tourism market and the diverse tourism needs people
have nowadays, tourism businesses have been gradually focusing on minority markets and
come up with special interest tourism, or theme tours, that’s made specifically for tourists’
special needs. Opaschowski (2001) stated that tourism in the 21 Century is like buying a piece
of paradise. Tourism business is an experience industry, and consumers are willing to spend
money to experience a different kind of happiness. They are looking for a kind of enjoyment,
atmosphere, and beauty, finding different sensory stimulation and experience. Therefore,
there is a growing population in Special Interest Tourism (SIT).
Jing-Mei Villa is located in the eastern park of Taiwan. It is a beautiful and vigorous
environment with green mountains, rushing water, and fresh air. Nearby scenic attractions
include Yuan-Sen Applied Botanic Garden, Chu-Lu Ranch, Hong-Ye Hot Spring, Little
Huang-Shan, and Shan-Yuan Beach. The owner of Jing-Mei Villa felt people’s need of health
and well-being. He adopted Da-Muo Yijin Kung into the activities and paired it with healthy
diets and beautiful leisure environment, and developed a health and well-being tourism for
people to maintain their health while in leisure activity. This study has based on the concept
of eat healthy and play happy to explore the relationship among tourists’ satisfaction, leisure
involvement and health benefit on the product and service of health and well-being tourism, in
order to provide associated industry some insight when managing this type of special interest
tourism.
Literature Review
Satisfaction
Leisure satisfaction is the psychological result one has after a leisure experience. Bulltena &
Klessing (1969) thought leisure activity satisfaction was decided by the level of coincidence
of one’s expectation and actual experience. Leisure Satisfaction is to what degree an
individual is currently satisfied with their leisure experiences and activities (Beard & Ragheb,
1980). Oliver (1981) indicated whether consumer is satisfied or not comes from the
comparison of their expectation and actual purchase result. Fonell (1992) stated satisfaction is
a reflection of consumer’s overall feeling of like or dislike after they accepted the service (or

used the product). This study combined Bed and Breakfast with specially themed activities,
recreation and healthy diet, therefore, choose health and well-being tourism, health and wellbeing
activities, healthy diets, healthy environment, and health products as the five
dimensions to measure satisfaction.
Leisure Involvement
Leisure involvement is when tourists are interested in leisure activities, sense their value and
importance, and further willing to involve in them. Rothschild (1984) and Havitz & Dimanche
(1999) considered leisure involvement as unobservable state of motivation, arousal or interest
toward a recreational activity, tourist location, or associated recreation facility and product. It
is evoked by particular stimulus or situation and has drive properties. As for the measurement
of leisure involvement, scholars indicated it should include social psychology and behavioral
dimensions (Gunter & Gunter, 1980; Kim et al., 1997). Csikszentmihayi (1975) measured
chess player’s leisure involvement by their competition frequency, time spent on it, and
number of associated books owned. Stone (1984) defined leisure involvement as the time and
effort one spent on participating in a leisure activity. Kim, Scott, & Crompton (1997) also
pointed out that participation frequency, money spent, travel mileage, skill, equipment owned,
associated books, and number of association participated could all be used to measure leisure
involvement. By integrating above literatures, this study would use time invested and level of
seriousness to measure leisure involvement.
Health Benefit
Healthy means there are no signs and symptoms of any kinds of illness. The appearance of
signs and symptoms represented the decrease of certain physiological function, and often
needs applicable treatments to recover to the original healthy state. Basic prevention is very
important to maintain healthy. This is to practice special protection method to promote one’s
health or prevent certain illness before it happens and damages body functions. This often
includes physical and psychological, and emotional health. Basic prevention can also be
categorized into health promotion and disease prevention, also called specific protection.
Health promotion is an approach behavior, it uses actualizing tendency as guidance, direct
individual to maintain or enhance health, actualize and have positive attitude, and indicates
one can actively create new positive behaviors. Health associated elements such as education,
environment and support are also combined to create activates that help promote a healthy
life, and its purpose is to let people have better control over their own health.
Benefit is achieving a goal, which includes goals achieved by participating in leisure
activities, and the participants believe that the leisure activity can help them reach that goal
(Ajzen, 1991). Leisure benefit is the subjective feeling of improvement and satisfaction one
has during and after participating in leisure activities. Bammel and Burrus-Bammel (1982)
proposed six benefits of leisure, which included physiological benefits, social benefits,
relaxation benefits, education benefits, psychological benefits, and aesthetic benefits. Because
this study’s theme is health and well-being tourism, health and leisure benefits need to be
considered. Therefore, survey items including health, relaxation, anti-aging, sense of
accomplishment, and body shaping are used to measure health benefit.
Da-Muo Yijin Kung
Yijinjing is a traditional Chinese Kung-Fu Bodhidharma (Da-Muo) created to enhance health
and prevent sickness through a series of exercises. There are thirteen movements in this
exercise. The basic purpose of Yijinjing is to turn flaccid and frail sinews and tendons into
strong and sturdy ones. The movements of Yijinjing are at once vigorous and gentle. Their

performance calls for a unity of will and strength, by using one’s will to direct the exertion of
muscular strength. It is coordinated with breathing. Better muscles and tendons mean better
health and shape, more resistance, flexibility, and endurance. Yijinjing can interact with both
physical and psychological levels. It can be enhanced if one can practice with the following
four tips: (1) Practice with perseverance and patience; (2) Watch what one eats, be sure to
have a balanced nutrition; (3) Have a regulated everyday schedule; (4) Have a peace of mind,
do not impose, do not have too many desires.
Research Framework
Research Framework
The goal of this study is to explore the relationship among people’s satisfaction, leisure
involvement and health benefit of health and well-being tourism, analyze whether if the
increase of satisfaction would result in tourists’ leisure involvement, and whether if leisure
involvement would promote health benefit. The research framework of this study is shown in
Figure 1.
Product
Satisfaction
H1
Leisure
Involvement
H2
Health
Benefit
H3
Figure 1 - Research Framework
Hypothesis
Iso-Ahola & Weissinger (1984) mentioned leisure experience associated leisure dispositions
would ease the health dimension created by stress. Hull (1990) proposed leisure activities
would promote positive mind set and affect health. In addition, in serious leisure activities, the
stronger the leisure commitment, the higher the leisure benefit (Stebbins, 1982). Therefore,
this study’s research hypothesis included the following:
H1: Product satisfaction has positive effect on leisure involvement.
H2: Product satisfaction has positive effect on health benefit.
H3: Leisure involvement has positive effect on health benefit.
Surveying
The variables measured in this study included satisfaction, leisure involvement, and health
benefit. The five factor dimensions of satisfaction were health and well-being tourism, health
and well-being activities, healthy diets, healthy environment, and health products. The
dimensions of leisure involvement were invested time and seriousness. Health benefits
included health, relaxation, anti-aging, sense of accomplishment, and body shaping. The
above items would be measured using Likert’s five-point scale. The subjects of this study
were people staying at Jing-Mei Villa and practicing Da-Muo Yijin Kung; random sampling
were used and 78 questionnaire were distributed and all 78 of them were collected, effective
return rate was 100%.

Analysis
Product and Service Satisfaction Analysis
The analysis of product and service satisfaction is shown in Table 1. Results showed the top 6
most satisfaction items were fresh air, healthy food, Ganoderma tea, owner’s warm
hospitality, dining procedure, and moving meditation. Satisfactions for other leisure activities
were relatively lower.
Factor analysis for product and service was done by using KMO statistics and its value is
0.560, and Sphericity test Chi-Square value is 0.342.97, both reached significant level. Five
factors were extracted from product and service dimension through factor analysis, and the
accumulated explained variance was 75.818%. Factor one included item such as Eastern
Coastal Trip, and was named health and well-being tourism, with an explained value of
19.21% and reliability analysis Cronbach α value of 0.7399. Factor two included moving
meditation and sitting meditation so it was named as heath and well-being activity, and its
explained value was 17.476% and reliability analysis Cronbach α value was 0.8792. Factor
three included healthy food and dining procedure, therefore, it was named as healthy diet. Its
explained value was 15.981% and reliability analysis Cronbach α value was 0.8911. Factor
four included fresh air and visual landscape, which is related more to the environment,
therefore, it is named as healthy environment. Its explained value was 14.117% and reliability
analysis Cronbach α value was 0.6611. Factor five was Ganoderma tea which is a health
product, so this factor was named health product, and its explained value was 9.033%
Table 1 - Satisfaction analysis of produce and service
Dimension Product and Mean Standard Factor Eigenvalue Explained
Service Factor
Deviation Loading
Variance
Health and Eastern Coastal
well-being Trip
4.0972 0.5607 0.815 2.305 19.210
tourism Guan-Shan Water
Park Trip
3.8750 0.6700 0.807
Hong-Ye Hot
Spring Trip
3.9583 0.6377 0.593
Owner’s warm
hospitality
4.5000 0.5566 0.575
Yuan-Sen Botanic
Garden Trip
3.7222 0.8088 0.913
Heath and Moving Meditation 4.5000 0.6920 0.914 2.097 17.476
well-being Sitting Meditation
activity
4.4722 0.7501 0.879
Healthy diet Healthy Food 4.5556 0.5787 0.924 1.918 15.981
Dining procedure 4.5000 0.6051 0.915
Healthy Fresh air 4.5972 0.5731 0.792 1.694 14.117
environment Visual Landscape 4.2778 0.6548 0.747
Health
products
Ganoderma tea 4.5278 0.5807 0.85 1.084 9.033
Leisure Involvement
Analysis of student’s leisure involvement is shown in Table 2. The result indicated that their
involvement is above average, with the highest score in seriousness level, followed by
practice time and frequency.

Table 2 – Learning Commitment Analysis
Commitment Mean Standard
Deviation
1. Regular practicing time 3.6389 0.6566
2. Practice time and frequency 3.7083 0.5919
3. Level of seriousness 3.8750 0.5551
Health Benefit Analysis
Student’s health benefit analysis is shown in Table 3. It showed that promote health was the
highest, next were enhance immunity and delay aging and then release stress. This
demonstrated the importance of preventing aging. From visitors’ health benefit item KMO
analysis, its value was 0.720, and Sphericity test Chi-Square value was 148.033, both reached
significant level. Two factors were extracted from health benefit items, and the accumulated
explained variance was 65.807%. Factor included enhance immunity, delay aging, promote
health and release stress, therefore, it is named as health. Its explained value of 42.767% and
reliability analysis Cronbach α value is 0.7849. Factor 2 included sense of accomplishment
and body shaping, and because beauty is related with confidence, this factor was named
confidence, and its explained value is 23.040% and reliability analysis Cronbach α value is
0.670.
Table 3 – Health Benefit Analysis
Dimension Health Benefit Mean Standard Factor
Deviation Loading
Health Enhance
Immunity
4.4167 0.7268 .875
Delay Aging 4.4028 0.8164 .859
Promote Health 4.5278 0.5300 .690
Release Stress 4.3333 0.6500 .597
Confidence Sense of
Accomplishment
3.7639 0.7598 .953
Body Shaping 4.1528 0.8164 .608
Eigenvalue Explained
Variance
2.566 42.767
1.382 23.040
The relationship of satisfaction, leisure involvement, and health benefit
The special interest tourism model of this study regarding the relationship of satisfaction,
leisure involvement, and health benefit is shown in Figure 2 by using Lisrel 8.5. The numbers
represent path coefficient, and the ones in parentheses represent T value of path coefficient.
From figure 2, it is learned that model basic goodness-of-fit test all reached significant level
besides health product of satisfaction dimension, and T value of all the dimensions were
larger then 1.645 with no negative deficiency variances and all deficiency variances reached
significant level, which showed the basic good goodness-of-fit of this model is good. As for
model goodness-of-fit, χ 2 value is 1.14, RMSEA=0.042, NFI=0.82, NNFI= 0.93, GFI=0.92,
AGFI=0.85, PGFI=0.52, PNFI=0.57, RMR=0.065, CFI=0.95, IFI=0.96, which showed the
good goodness-of-fit of this model is good.
Based on figure 2, the influence coefficient of satisfaction toward leisure involvement is 0.27,
t value is 1.65 and both reached significant level, which indicated satisfaction has positive
significant effect over leisure involvement, and when satisfaction is higher, leisure
involvement is higher; therefore, hypothesis H1 stands. The influence coefficient of
satisfaction toward health benefit is 0.66, t value is 2.98 and both reached significant level,
which indicated satisfaction has positive significant effect over health benefit, and when

satisfaction is higher, health benefit is higher; therefore, hypothesis H2 stands. The influence
coefficient of leisure involvement toward health benefit is 0.31, t value is 1.73 and both
reached significant level, which indicated leisure involvement has positive significant effect
over health benefit, and when leisure involvement is higher, health benefit is higher;
therefore, hypothesis H3 stands. There are two paths for satisfaction to affect health benefit.
One is satisfaction’s direct effect over health benefit of 0.66, and the other is satisfaction’s
indirect effect over health benefit through leisure involvement of 0.084; satisfaction’s overall
effect over health benefit is 0.74, which indicated leisure involvement’s mediating effect of
satisfaction over health benefit does exist.
As for the observed variables in tourism activity satisfaction, the learning activity of Da-Muo
Yijin Kung is the most important factor dimension, and next is health and well-being tourism
and healthy environment, which showed the combination of health and well-being activity
and tourism is the core of health and well-being tourism. In leisure involvement, practice time
and frequency and level of seriousness are both important factor dimensions, which showed
Da-Muo Yijin Kung needs devotion and practice. In health benefit, health and confidence are
both important factor dimensions, which showed having a healthy mind and body makes
people more confident.
X1: Health and Wellbeing
Tourism
X2: Health and Wellbeing
Activity
X3: Healthy Diet
X4: Healthy
Environment
X5: Health Products
Y1: Regular
practicing time
Y2: Practice time and
frequency
Y3: Level of
seriousness
0.40 *
(3.02)
0.67 *
(4.23)
0.34 *
(2.60)
0.37 *
(2.84)
0.14
(1.05)
0.85
0.92 *
(8.45)
0.70 *
(6.76)
Product
Satisfaction
0.27 *
(1.69)
Leisure
Involvement
0.66 *
(2.98)
0.33 *
(1.73)
Health
Benefit
Y4: Health
Y5: Confidence
Figure 2 – Satisfaction, leisure involvement and health benefit of special interest tourism
model
Conclusion and Suggestions
With the increasing stress in life and work, and the arrival of an aging society, health and
well-being tourism has gradually become a trend. This study choose health and well-being
tourism as research topic, and the result showed that health and well-being activity is the core
of this special interest tourism, and create its uniqueness and attraction. As for health benefit,
people are paying more and more attention on the concept of prevention medicine, using
natural method to maintain the health of body, mind and spirit. For better health, they also
continually put in time to participate in health and well-being tourism activities. When the
0.64
0.65 *
(3.27)

higher the tourists satisfaction in these activities, the more involved they get, and the higher
health benefit they would gain. From the results of this study, by combining special interest
activates and health and well-being tourism could form a unique attraction, deepen tourists’
satisfaction, and create the value of health and well-being tourism.
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25, pp.251-272.
Stone, R. N.(1984). The marketing characteristics of involvement. Advances in Consumer
Research, 3, 355-365.

Implementation of a model of a sustainable wellbeing destination – case
Savonlinna town
Anja Tuohino
University of Eastern Finland, Centre for Tourism Studies
anja.tuohino@uef.fi
Abstract
A conceptual model of destination competitiveness was presented by Ritchie and Crouch in
2003. The model is based on a comparative and competitive advantage concept including
several attributes of a destination. These are the global environment, the competitive micro
environment, core resources and attractions, supporting factors and resources, destination
policy, planning and development, destination management, and qualifying and amplifying
determinants.
The model has been further developed by Sheldon and Park (2009) to be more readily
applicable in the wellness tourism context. Sheldon and Park note that the model is crucial to
identify the contributing factors and resources for wellness tourism because it would not be
possible to develop wellness products if the destination cannot provide basic infrastructure
and guarantee access to the area.
In this paper the model of Sheldon and Park is tested in the Savonlinna region in Finland in
the context of wellbeing tourism. As early as in the 1860s the region of Savonlinna was a
popular holiday resort on Lake Saimaa, attracting visitors from as far afield as St. Petersburg
to experience its spa facilities. Today the old historical spa image of Savonlinna is more or
less a thing of the past and the current tourism image is based on the Opera Festival and the
resources of its lakeland scenery. The recreational use of spas has replaced the traditional spa
culture.
The data for the paper were gathered by interviewing tourism professionals and developers
during autumn 2009. In total 14 people were interviewed. The data are supplemented by a
survey of tourism resources in Savonlinna region. The analysis presented in the paper was
done during the summer 2010 and is based on both interviews and a survey of resources.
Introduction
Destinations can be viewed from two perspectives; destination attractiveness is evaluated
from the tourist’s perspective and destination competitiveness from the perspective of the
destination itself. According to Buhalis (2000, p.97) “destinations are amalgams of tourism
products, offering an integrated experience to consumers, and are consumed under the brand
name of the destination (p.98)”. He continues by citing Hall (2000) and Davidson and
Maitland (1997) that “traditionally, destinations are regarded as well-defined geographical
areas, such as a country, an island or a town”.
While assessing a destination’s competitiveness it can be evaluated with regard to its
economic, political, socio-cultural, technological and environmental competitiveness. (see
Ritchie & Crouch 2003/2005). Ritchie and Crouch presented their own refined conceptual
model of destination competitiveness in 2003. This is based on a comparative and competitive
advantage concept including several attributes of a destination. These are the global
environment, the competitive micro environment, the core resources and attractions,

supporting factors and resources, destination policy, planning and development, destination
management, and qualifying and amplifying determinants. Comparative advantages include
human resources, physical, knowledge and capital resources, infrastructure and cultural and
historical resources. Competitive advantages on the other hand include effectiveness,
efficiency, maintenance and auditing. As core resources and attractors they listed e.g.
physiography and climate, culture and history, mix of activities, special events and
entertainment, while supporting factors and resources include infrastructure, hospitality,
enterprises and facilitating resources. Destination management includes among others
marketing, quality of services, information and research, human resource development and
visitor management. Destination policy, planning and development include visions, branding,
positioning, monitoring and evaluation, while location, safety, cost value, image and carrying
capacity are seen as qualifying and amplifying determinants.
The model by Ritchie and Crouch includes many key elements which are important for
competition between tourist destinations. Cracolici and Nijkamp point out that “...achieving a
good performance and position in the tourism market depends on the capability of a
destination area to manage and organize its resources according to an economic logic driven
by competitiveness strategies”. (Cracolici & Nijkamp 2008, 338.)
The model by Ritchie and Crouch has been further developed by Sheldon and Park (2009) to
be more readily applicable in the wellness tourism context. Sheldon and Park noted that the
model is crucial to identify the supporting factors and resources for wellness tourism because
it would not be possible to develop wellness products if the destination cannot provide basic
infrastructure and guarantee access to the area. According to them (ibid. p. 100) “destinations
can no longer be passive and allow themselves to naturally adapt, but must strategically plan
for this market and identify their competitive advantage. Identification of wellness resources
and products, and strategic positioning in the market are critical to success”
From the resource point of view, the attractions are of vital importance. The built-up and
natural physical environment of a destination, its local culture and community spirit can be
considered as the core resources in tourism. The attractiveness of a destination can be
considered from different angles, among them nature and landscape, culture, history, facilities
for engaging in various hobbies, and accessibility. However, the resource itself is not a
product. Rather, existing resources are the necessary precondition for the creation of a travel
experience that can be turned into a saleable tourism product (Middleton with Clarke 2001,
Middleton 1997, Järviluoma 1994).
Concepts of wellness and wellbeing are quite widely used, for example, in the health,
wellbeing and tourism sectors. The concepts are sometimes used synonymously, but there are
differences in content and meaning. Especially in the Finnish context, the terms are used
interchangeably and this inconsistent use has caused considerable confusion. In this paper, the
term of wellbeing is used instead of wellness. The reason for this is that in Finnish one term
“hyvinvointi” is used render what in English is rendered as wellness and wellbeing. (see Konu
et al. 2010.)
A model of a sustainable wellbeing destination
As mentioned earlier, Sheldon and Park (2009) developed their model (see Figure 1) to be
more readily applicable in the wellness/wellbeing tourism context. In the model of Crouch
and Ritchie (2003/2005) branding, awareness and image are situated among qualifying and
amplifying determinants. Sheldon and Park (2009) argue that these branding efforts should be

situated at the point at which the core resources of wellness tourism are identified. They
explain this by stating that the wellness resources connected with culture and cultural
elements of the host community are a crucial part of the identity/brand of a destination.
Sheldon and Park (2009) locate wellness destination policy and planning in the third stage.
The reason for this is that in their view wellness tourism cannot be sustainable if it has no
clear vision, goals and positioning on the market. Further, Conlin and Baum (2003) argue that
public policymakers and private sector decision-makers need to recognize the human
resources in indispensable component of successful sustainable tourism development.
According to them, human resources have to be part of the overall planning instead of an
operational consideration. Baum’s comprehensive model calls for consideration of the five
areas of tourism - environment, tourism and labour markets, tourism and education, human
resource practises in the industry and tourism and the community in a comprehensive,
integrated and cohesive manner. (Conlin and Baum, 1994, 2003.)
The planning stage is followed by destination development and management. In this stage it is
guaranteed that the wellness products offered and provided are of high quality. To realize this,
the stage includes elements such as training and education of personnel (human resources)
and opportunities to join certification programmes. (Sheldon and Park, 2009).

Sustainable Wellness Tourism Destination
Wellness Destination Development and Management
Human resource, training, education, certification programs, building
associations among and between the wellness industry and public sector
Wellness Destination Policy and Planning
Vision, goals, private-public sectors’ collaborated planning and
development of policy, monitoring/evaluation measures of wellness
experiences and sustainability
Core Wellness Resources and Attractions
Unique wellness destination features: natural and cultural resources,
traditional healing/therapeutic/wellness resources
Supporting Factors & Resources for Wellness Tourism
Infrastructure, superstructure, residents’ hospitality, and knowledge of
healing practices, destination atmosphere (a sense of place)
Figure 1. A model of sustainable wellness destination (Sheldon & Park, 2009, adapted
from Ritchie and Crouch, 2002).
This paper aims to implement the model by Sheldon and Park by examining an urban
destination, Savonlinna town, and its surroundings from the perspective of competitiveness in
the context of wellbeing tourism. Geographically Savonlinna town is located in the Eastern
part of Finland, in the centre of Lake Saimaa (see Figure 2).
Considering tourism in general, Savonlinna has good basic infrastructure and its accessibility
is relatively good. The town is about 340 kilometres from the capital Helsinki by road and
about four hours away by train (see Figure 2). Savonlinna Airport is located about 20
kilometres outside the city, and the journey to Helsinki takes 40–60 minutes by plane.
Savonlinna is built on a chain of islands located throughout a number of large lakes. The lake
environment is a key asset for Savonlinna town.

Figure 2. The location of Savonlinna town.
By interviewing local developers and entrepreneurs the aim is to ascertain how local actors
perceive the current situation and positioning of Savonlinna in the wellbeing tourism context.
Do they see any future potential for wellbeing tourism? Given the many discussions at local
level on Savonlinna’s prospects in wellbeing tourism, the meaning of the paper is to find
whether Savonlinna can be seen as a sustainable wellbeing destination in the future.
Methodology and data gathering
The data for the paper were gathered by interviewing tourism professionals and developers.
The interviews were conducted on between 15 September 2009 and 21 December 2009. In
total 14 interviews were conducted. The interviews took from 23 minutes to 78 minutes. All
interviews were taped and later transcribed. Interviewees were local wellbeing entrepreneurs,
regional developers and project managers in wellbeing-related projects. Regional developers
represented the public sector.
The analysis presented in the paper was done during in summer 2010 and is based on both
interviews and a survey of resources. The survey of resources is based on both written and
observational material. The supplementary documentary data also includes material from a
bachelor´s thesis intended to survey the internet availability of wellness products in the
province of South Savo.
The interviews were a part of the Nordic Wellbeing project implemented in Savonlinna
region. The main objective of the project will be the creation of a customer-driven Nordic
wellbeing concept around Nordic resources based on unique values in the Nordic countries,
anchored in nature, outdoor life, cleanliness, health image and the values of the northern
hemisphere. The thematic interviews included questions about the unique selling points of the
region, cooperation and networking as well as resources used in wellbeing tourism
development.
Savonlinna as a Sustainable Wellbeing Tourism Destination in Finnish context
Wellbeing can be connected to a certain extent to supporting factors and resources.
Savonlinna’s infrastructure and facilities are suitable for the wellbeing sector, as the main
hotels in the town and its surroundings have a long history as rehabilitation centres. Because
of this, the knowledge of healing practices is good, likewise the knowledge of the use of
natural resources such as the water element.

In tourism marketing Savonlinna has been described as the liveliest and most vibrant
summertime town in Finland. Savonlinna and its surroundings are among our country’s most
popular holiday regions. The lake scenery of Saimaa offers a perfect setting for a cultural, spa,
beach, activity or city holiday – or for a combination of these. Various distinctive boutiques,
idyllic cafes and high-class restaurants, offering friendly service and warm hospitality, add to
the unrivalled charming atmosphere of the Savonlinna region (www.savonlinnatravel.com).
Finnish wellbeing tourism focuses mainly on nature, peace and quietness, activities and also
some cultural offerings (Kangas & Tuohino 2008, Finnish Tourist Board 2008a). This also
applies to Savonlinna. The natural core resources are unspoiled natural environment including
forests, lakes and other waterways, hills and extensive areas of wilderness. In Savonlinna
region are is also four distinct seasons to be exploited in different tourism products. Finnish
wellbeing innovations are generally internationally well known. Sauna and Nordic walking
have notably raised their profile as generally known Finnish products (Finnish Tourist Board
2008a). Both activities are well represented in Savonlinna region. The town has a long history
as a spa tourism destination.
As early as in the 1860s the region of Savonlinna was a popular holiday resort on Lake
Saimaa, attracting visitors from as far afield as St. Petersburg to experience its spa facilities
(Hirn & Markkanen 1987). The spa and casino were built in 1896. In 1898, the casino was
extended. The old spa was destroyed by fire in 1962. Today the Spahotel Casino is in
recreational use and offers wide range of summer activities. However, the old historical spa
image of Savonlinna is more or less a thing of the past and the current tourism image is based
on the Opera Festival and the resources of its lakeland scenery. The recreational use of spas
has replaced the traditional spa culture.
In the vicinity of Savonlinna town there are Linnansaari and Kolovesi aquatic national parks
in year-round use. The nature experiences are supported by high quality self-catering cottage
and hotel accommodation and restaurant and sauna facilities. The municipalities of Kerimäki
and Punkaharju strengthen the image of Savonlinna region as a wellbeing destination due to
two significant rehabilitation centres located in these municipalities.
In surveying the wellbeing companies and their offerings in the Internet Mahkonen (2008)
found 19 companies providing wellbeing tourism services in South Savo province. These
companies have altogether only 56 saleable products in the Internet. Only two of the 19
companies were located in Savonlinna town. In Hook’s survey (2008) only four
wellness/wellbeing products were found in Savonlinna.
Wellbeing tourism is one product theme earmarked for development in the Finnish national
tourism strategy published by the Ministry of Trade and Industry (Finnish Tourist Board
2008a). This led to the development of ‘Development strategy for Finnish wellbeing tourism
in international markets, 2009-2013’ in 2008. As the Finnish wellbeing tourism strategy is
quite new, its implementation is still ongoing. There are plans to develop more comprehensive
wellbeing tourism products and services for foreign markets. The vision for Finnish wellbeing
tourism by the Finnish Tourist Board (2008a) is: “Finland is known as a country that can
offer wellbeing, rest, and relaxation. Its wellbeing offering is clearly defined. The offering has
been put together in a manner that is marketable and follows sustainable development. It
comprises packages or modules that are easy to purchase and internationally known.
Wellbeing tourism is a year-round activity that can extend the tourism season in Finland”.

On the regional level, the tourism development strategy of the Province of South Savo and the
strategy of Savonlinna town give the guidelines for wellbeing tourism development. In both
strategies wellbeing is seen as one of the main strategic foci in the region. The lakemilieu and
cultural heritage are in a strong position in strategy and visions. In practice the development
work in the region is just beginning.
In Finland there are so far no official associations in the wellbeing sector or governmental
organizations promoting co-operation between the wellbeing industry and the public sector.
However, the government provides support for social holidays that frequently take place in
wellness or wellbeing facilities. In addition, there are rehabilitation programmes for war
veterans (Aho, 2007). As mentioned earlier, Savonlinna and its surrounding municipalities are
decidedly competent in the rehabilitation sector.
There are ongoing actions implementing the Finnish Wellbeing Strategy. One of the aims is to
create standardised products on international wellness markets. In the process new kinds of
cooperation and cooperation models between the wellness industry and public sector are
likely to take shape. In Savonlinna region there are at present no known activities for the
implementation of wellbeing strategy.
In Finland there is a fairly good education system in place for service personnel in the
wellbeing sector. In addition, a new full-time degree programme in Experience and Wellness
Management has started up (Haaga-Helia 2010). In Turku University of Applied Sciences
there is ongoing a project entitled Innovations and Learning in Spa Management (Turku
University of Applied Sciences 2010). In Savonlinna there are several educational options in
the wellbeing sector as all levels of education from vocational school to university are well
represented in the town.
Attributes describing Savonlinna as a wellbeing tourism destination
Figure 3 shows the attributes interviewees associated with Savonlinna town. Above all, Lake
Saimaa, the lake environment, lake scenery or water elements were mentioned by every
interviewee. In addition cultural attractions like the medieval castle of Olavinlinna, the
Retretti Art Centre and the Opera Festival were mentioned.
While examining the supporting factors the interviewees mentioned the ideal location of
Savonlinna as a key asset. The accessibility from St. Petersburg and the Helsinki metropolitan
region were likewise considered important. The potential for attraction tourists from Russia
also emerged. Other supporting factors mentioned were mainly connected to natural resources
and infrastructures, e.g. forests, rocks, islands, steam boats, self-catering cottages and chalets.
The Savonlinna spirit was also mentioned by some respondents.
Core resources and attractions also included lakes and aquatic environment, national parks
and cultural attractions. Natural resources were seen as a core resource, while the main
attractions mentioned were Olavinlinna castle, the Retretti Art Centre, the Opera Festival and,
of course, lakes. In addition the local people and businesses were seen as unique selling points
of Savonlinna. When asked about added value for the region, the respondents mentioned
attributes like national parks, local services and hospitality, genuine people, authentic way of
life, variety and attractiveness. On the other hand, it was also mentioned that the town is an
underachiever compared to the resources available.

The role and actions of Savonlinna town and Savonlinna Region Federation of Municipalities
were highly appreciated in connection with wellbeing destination policy and planning. The
planning and policy in the region are guided by national, regional and local tourism strategies.
At present Savonlinna has its own tourism development and town planning projects in the city
centre. Projects also include planning activities for new spa and wellbeing facilities.
Destination development and management received only few comments. The strong role of
town and regional policymakers was mentioned as well as the importance of Savonlinna
Travel Ltd. Educational resources were also mentioned by some.
-
Wellbeing Destination Development and Management
- competent human resources available, excellent educational and training resources
- Savonlinna Travel Ltd.
Wellbeing Destination Policy and Planning
- cooperation between municipalities, town and Savonlinna Region Federation of Municipalities
- strong role of town in tourism planning and policy
- strong actors in the region (Savonlinna Travel ltd, Savonlinna Region, Centre for Expertise, Centre
for Tourism Studies in the University of Eastern Finland)
- Locomotive actor is missing at present
Core Wellbeing Resources and Attractions
- unique lake environment, Saimaa lake, Saimaa scenery, beautiful lake landscape
- natural and cultural resources
- resources connected to lakes
- strong culture and history (Opera festivals, Retretti Art Centre, Olavinlinna medieval castle)
- ideal for active nature-based tourism
- unique living environment for both habitants, workers and tourists
- Traditional healing/therapeutic/wellbeing resources
- local people, businesses, hospitality
- good old history
- certain kind of exoticism
- competent and capable businesses (e.g. SaimaaHoliday)
- Old historical spa and casino
Supporting Factors and Resources for Wellbeing Tourism
- geographical location close to Russian border and St. Petersburg
- good accessibility by air, road and rail from capital area
- ideal location on the shores of Saimaa, on the island
- charming small town
- historical steam boats
- forests, rocks, islands, aquatic environment
- Kolovesi and Linnasaari National parks
- variety of accommodations (hotels, cottages, etc.)
- knowledge of healing and rehabilitation practices
- vital lake environment
Figure 3. Savonlinna as a sustainable tourism destination
- interaction between man and nature
- Municipality of Kerimäki with a wooden church
- Municipality of Punkaharju with a ridge and history related Russian Tsar
Figure 3. Savonlinna as a sustainable tourism destination. Attributes listed by
interviewees.

Conclusion and discussion
The aim of the paper is to test the model by Sheldon and Park in Savonlinna by examining an
urban destination, Savonlinna town and its surroundings from the perspective of
competitiveness in the context of wellbeing tourism. The overall finding of the interviews is
that Savonlinna was perceived as a destination product. In addition there was much discussion
on Savonlinna’s assets for wellbeing tourism. However, the interviewees pointed out that in
practice there is still much to be done to achieve the status for Savonlinna town of a
sustainable wellbeing tourism destination. At the moment, such status is more in the minds of
respondents than on a tangible, practical level. As noted earlier in the case of one
rehabilitation centre (see Tuohino & Kangas 2008) one of the greatest challenges for
wellbeing tourism is opportunity. Currently the wellbeing segment in Savonlinna region is
still limited and fragmentary.
Lakes were seen as the town’s main resource. However, the use of lakes in the wellbeing
context was difficult for the interviewees to envisage. Among the interviewees there was a
strong vision of wellbeing tourism development around the lakes but the main question was
how in practice to exploit lakes in tourism product development.
For some reason, none of the interviewees mentioned the strategies while describing the
frameworks of Savonlinna in the wellbeing context in spite of existing national, regional and
local tourism development strategies giving the guidelines. In general it was apparent in the
interviews that the interviewees analyzed Savonlinna as a tourism destination, not as a
wellbeing tourism destination. As one interviewee said “Savonlinna is an underachiever
compared to resources available”.
However, it emerged that the model by Sheldon and Park can indeed be implemented in the
case of Savonlinna and used in evaluating the attributes of the town. According to the
findings presented in this paper there is still a lot of work to be done before Savonlinna can
really be seen as a sustainable wellbeing tourism destination. Therefore this paper presents the
first phase of the process.
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www.savonlinnatravel.com

Polish Spas – in need of a polish?
Eastern and Western European perspectives on spa and health tourism
Sub-theme: Segmentation and positioning products, brands and destinations in health
and wellness tourism
Dorota Ujma
University of Bedfordshire, UK
dorota.ujma@beds.ac.uk
Research paper
This paper aims to explore the ‘ethnocentrically’ divided – and culturally specific
understanding of spa tourism, health tourism and wellness tourism; specifically based on
comparisons between the Central and Eastern European (especially Polish) and Western
perspective.
Drawing on Dann and Liebman Parrinello’s (forthcoming) call to discern, contextualize and
better appreciate research published beyond English-speaking world, Polish and English
literature on health and spa tourism is reviewed and interpreted in combination. It appears that
Polish approaches view spas and health resorts as popular destinations with a number of
protected natural on-site sources (e.g mineral or thermal water), offering contact with nature
resulting in improvements in health and well-being. Polish spas tend to be functional,
utilitarian and regimented in their delivery; where ‘improving health’ is achieved through
basic, traditional treatments, connected with a specific locale. Moreover there is a belief that
just staying within the spa environment is beneficial; that improvements to health and well
being occur simple by “being there”. In contrast to Western facilities both the quality of
facilities together with customer orientated service is not expected to be of a high standard. In
Western Europe the connection with nature and natural resources, along with its perceived
effectiveness of related treatments, is less prevalent and so is of less importance. The
philosophy and customer approach of Western ‘spas’ are often founded in the gentle
encouragement towards healthy living through often exotic and luxury treatments which take
place in random premium settings.
Such differences are not only embedded in the manner in which these types of tourism are
delivered and experienced – but also in the very specific definitions adopted by differing
cultures which are in turn influenced by both semantics and tradition. Whilst in Western
literature spa tourism is seen as a component of health tourism (for example Hall 2003), the
Polish reviews (such as Rydz 2005, Wolski 1970, 1991) indicate that the overlap between the
two may be only partial; resulting in spa tourism covering more types of tourism, not always
related to health alone (Hadzik 2009).
As a result it is suggested that current health tourism definitions should be more sensitive to
cultural variations, and that both Western and Eastern European practitioners be more aware
of the opportunities relating to both location and customer care.
References
Dann, G. M.S. and Liebman Parrinello, G. (Eds.) (Forthcoming) The Sociology of Tourism:
European Contributions, Emerald
Hadzik, A. (2009) Turystyka zdrowotna uzdrowisk (Spa tourism in health resorts),
Wydawnictwo Akademii Wychowania Fizycznego, Katowice.

Hall, M. (2003) Spa and Health Tourism, in S. Hudson, Sport and Adventure Tourism, The
Haworth Hospitality Press, NY, pp. 273- 292
Rydz, E. (Ed.) (2005) Kształtowanie funkcji turystycznych w miejscowościach
uzdrowiskowych (Shaping the role and function of tourism in health resorts), Pomorska
Akademia Pedagogiczna, Słupsk.
Wolski, J. (1970) Turystyka zdrowotna a uzdrowiska europejskich krajów socjalistycznych
(Health tourism and spas in the European socialist countries), Problemy Uzdrowiskowe,
5.
Wolski, J. (1991) Turystyka uzdrowiskowa (Spa tourism), Problemy turystyki (Tourism
Problems / Issues), 1-2.

A strategy based on the traditional health tourism in Central-Europe
and new spa and wellness trends
Policy and strategy document
Várhelyi Tamás
Regional Tourism Knowledge Center, Szolnok, Hungary.
varhelyit@hotmail.com
Torday Judit
Regional Tourism Knowledge Center, Szolnok, Hungary.
Key-words: health tourism, medical spa, traditional spa, knowledge center
Abstract
On the basis of the perceptible developments in tourism and the domestic conditions, health
tourism is considered the most important sector of tourism in Hungary. Due to the effects on
health, life style and on the related products to these, health tourism – in English term: spa
industry- has more significance than just tourism. Understanding these trends and based on
the local traditions, we try to create a spa industry development strategy for Hungary and
Central-Eastern Europe.
Traditional health tourism is thermal water based activity, including spa, long cures, and
health treatments evolved in Central Europe in the 19 th century, partly based on the spa
culture of the Roman Empire. Concerning spa cities the Austrian-Hungarian Monarchy was
market leader in many aspects. In those times such treatments were considered as the most
efficient methods for fighting gastrointestinal problems and rheuma.
In the last decade health, taking care of our body and soul is getting more and more valuable.
In the modern world it is also accompanied with the notion of success: we can become more
successful in our work, surroundings and private life if we can remain healthy, neat and fit.
This is the explanation for a growing need for spa and wellness tourism within the tourism
sector.
Nowadays on the basis of world trends we can talk about producing goods related to the
tourism industry in addition to the traditional travel service and hospitality. Some products
can also be exported, as a matter of fact they can behave similarly as the products of other
export oriented industries. The point here is the export of the innovative services including the
products just like in telecommunication, information technology or health care.
Businesses with billion turnover developed in the spa industry and we might think that by
means of our traditions and of our thermal springs we belong at the forefront of the world. In
reality according to the return of the industry we only take up a place in the middle field and
practically we do not take part in the new trends and export. The reason for this lies mainly in
the insufficiency of the domestic entrepreneurial culture and knowledge. The project carried
out by the Tourism Knowledge Center, sponsored by the Ministry of Economy wished to
change this with the available resources.
Health tourism is also the most important type of tourism for the regions of the Carpathian
Basin. The reason for this lies in sectoral trends, increasing demand, rich traditions and

excellent capabilities. Despite of these, countries of the regions are not among the most
successful countries in Europe. It is obvious that these countries together would be one of the
market leaders, if they can function properly on the market. To support this, we established a
tourism knowledge center, and an innovative tourism cluster. According to it the current
situation could be changed via the following:
• Understanding world trends, benchmarking, development of strategies and action
plans
• Identifying traditions and capabilities in line with current trends and based on the
results, modern product development through organized innovation
• Coordination of innovative, interested, interdisciplinary market players
In order to realistically comprehend the tendencies we have to interpret the circumstances of
the health tourism and emphasize its importance in the international field. This is not always
easy, there can be misunderstandings even concerning the name of the industry. In the English
terminology the spa and wellness industry is used instead of health tourism. In the near future
for that very reason we have to redefine the term ‘health tourism’ and it will be appropriate to
include ‘medical tourism’ into it also.
The transformation of the term ‘spa’, the suppression of water based service can mean a
reshaped business model. In the case of the world’s most profitable health resorts not the
admission price but the therapy fee makes up the most considerable amount of return and by
all means the most profit comes from the treatments. Apparently this world trend will be
effective in Hungary also, we have to prepare for it or rather this can lead to the extreme
increase in the domestic health tourism return.
The quality and diversity of spa waters is a common strength of Centre Europe. Hungary has a
European quality health service in several professions. It has close connections with the
traditional thermal tourism. In health tourism (spa, wellness and medical tourism),
professional basis is getting more significant, and the most dynamic sector being medical
wellness. So it is obvious to use the traditions – with proper innovation it can be successful
tool on the present spa market.
Relative underdevelopment of these countries can be an advantage in the spa world, as less
industrial environment goes well with naturality, it is more capable and attractive for
bioproducts as well. There is more potential for tourism service development requiring large
sites: golf tourism and horse tourism are appropriate subjects for strategy developments in
these regions.
According to the numbers Hungary is not in the first ten European countries and by all means
it is an illusion that we are a ‘superpower of baths’ or even can be one. In spite of this as a
member of the middle field with our great traditions and the possession of considerable
amount of thermal springs we can be more successful than we are now, even double the
present return and significantly increase the profitability which is still very moderate
nowadays. This means the health tourism would not only be the pride of our country, but it
could also be the main sector of the Hungarian economy.
For Europe the general spa trends of the last decade were threats. There were coming from the
US, and allow developing spas without thermal water. Using our traditions and the trends of
medical wellness together, Europe could remain in strong position, and Centre Europe can
increase its market share.

References
The International Spa Association and the Hartman Group: Consumer Report: Spa-Goer and
Non-Spa Goer Perspectives, ISPA, Lexington, 2006.
Várhelyi T., Müller A: Spa tourism and regional development: it can be more successful with
cross-border cooperation. Neighbors and Partners: On the Two Sides of the Border (ed: I.
Süli-Zakar) Debreceni Egyetemi Kossuth Egyetemi Kiadó, 2008. 309-314. p.
SRI International: The Global Spa Economy 2007. Global Spa Summit, New York, 2008.
Cohen, M., Gerard Bodeker: Understanding the global spa industry. Elsevier, 2008.
Várhelyi T: Hungary & Central-Eastern Europe, Global Spa & Wellness Industry Briefing
Papers, p. 23-25, Global Spa Summit, 2009.
Stanton, L.: Research: Global Spa Consumers. Spa business, 2009/3, pp. 32-36.

Australian Wellness Tourism Providers: Definition, Typology and Current
Status
Cornelia Voigt
School of Management, University of South Australia
City West Campus, GPO Box 2471, Adelaide, SA 5001, Australia
Cornelia.Voigt@unisa.edu.au
And
Jennifer Laing
Tourism Research Unit, Monash University
Berwick Campus, PO Box 1071, Narre Warren, VIC 3805, Australia
Jennifer.Laing@BusEco.monash.edu.au
Abstract
This paper provides insight into the current structure of Australian wellness tourism providers,
which is based on a national scoping study investigating supply and demand of Australian
health tourism. A new wellness tourism provider typology consisting of three core categories
is suggested: (1) Beauty Spa Hotel/Resorts, (2) Lifestyle Resorts, and (3) Spiritual Retreats. In
order to build a picture of the structure of the industry, the main body of this paper provides
examples of wellness tourism operators that illustrate each of the wellness tourism provider
categories. This is followed by a discussion of the results of a survey sent to all Australian
wellness tourism providers, demonstrating the nature of services offered by the three core
types of wellness tourism operators. This research contributes to the understanding of
different approaches to developing and delivering wellness tourism, not only within one
country but also in comparison to how wellness tourism is supplied in other countries.
Key words: wellness tourism, Australia, typology, spa, retreat, resort
Introduction
Although there is some evidence that Australia’s Indigenous people have used geothermal
waters for spiritual and medicinal purposes for thousands of years (Lambert, 2008; White,
2009), the Australian wellness and health tourism industry is very young when compared to
its development in Europe and some Asian countries. One reason for this might be that – with
the notable exception of the mineral and hot springs in the Daylesford/Hepburn Springs
region and the Mornington Peninsula in the state of Victoria – Australia does not possess
large deposits of mineral and hot springs that have been the central focus for Europe’s healthseeking
travellers for centuries. Researchers have noted that the term ‘spa’ has distinctly
different meanings in English-speaking countries and continental Europe (Puczkó &
Bacharov, 2006; Williams et al., 1996). Accordingly, the Australian wellness and spa tourism
industry is focused on health promotion and prevention rather than on medical cure or
rehabilitation as traditionally found in European countries (Bennett, King, & Milner, 2004;
Puczkó & Bacharov, 2006; Smith & Puczkó, 2008).
Possibly fuelled by broad socio-cultural and economic factors such as escalating health costs,
an increasing scepticism of orthodox biomedicine on one hand and a growing acceptance of
alternative healing practices on the other, and a rise in the health consciousness of consumers
(Pollock & Williams, 2000; Weiermair & Mathies, 2004) as well as a need to downsize and

simplify one’s life in light of rising stress-levels and the fast pace of everyday life (Douglas,
2007; Smith & Puczkó, 2008), the Australian wellness tourism industry has grown
exponentially in the past decade. For example, Australian spa providers have experienced a
growth rate of 129 percent between 2002 and 2006 (Intelligent Spas, 2006) while more recent
data shows that the number of Australian spa facilities is still expanding despite the global
economic downturn (Intelligent Spas, 2009). Until recently, however, there has been a
“distinct lack of published research on health tourism issues in Australia” (Bennett, King, &
Milner, 2004, p. 122). Previous research has tended to focus narrowly on only one type of
wellness tourism provider or one group of wellness tourist without considering that there
might be a broader range of wellness tourism supply and demand. Consequently, a recent
Australian national scoping study aimed at defining wellness tourism in the Australian context
and investigating supply and demand. This paper focuses on the supply-side and discusses a
newly developed typology of wellness tourism providers. Based on this typology, a nationwide
survey was conducted to establish a profile of all Australian wellness tourism suppliers.
This paper provides an analysis of the services of three distinct core categories of Australian
wellness tourism providers.
A New Typology of Wellness Tourism
Apart from the apparent agreement that wellness tourism is a form of Special Interest Tourism
(SIT) (e.g. Hall, 2003; Letho et al., 2006), existing definitions and typologies vary
extensively. It seems that there is a tension between finding a broad enough typology that
acknowledges a diversity of wellness tourism supply and demand, but that is narrow enough
to enable workable data collection. For instance, very broad wellness tourism typologies such
as the one suggested by Sheldon and Bushell (2009) which includes medical tourism,
sport/fitness, adventure tourism and volunteer tourism activities may be useful in a heuristic
sense, yet are so inclusive that they limit realistic, practical application.
One area of disagreement between scholars is whether wellness tourism subsumes medical
tourism (e.g. Sheldon and Bushell, 2009), or vice-versa (e.g. Bookman & Bookman, 2007), or
alternatively whether wellness and medical tourism are two essentially separate tourism
categories. This paper supports the view that there is a theoretical difference between ‘cure’ or
‘illness’ concepts on one side and the ‘wellness’ concept on the other (Müller & Lanz
Kaufmann, 2001; Nahrstedt, 2004; Voigt, 2008). Whereas medical tourists are illness-oriented
because they primarily travel in order to cure or treat a certain illness or medical condition,
wellness tourists go on vacation in order to maintain or improve their health and well-being
and thus try to reach higher levels of wellness. Consequently, providers catering to those
differing cure- or wellness-driven needs of tourists can thus also be conceptualised as two
distinct sub-segments of health tourism suppliers (Figure 1). However, a wellness tourism
definition and typology that is purely based on this distinction in demand, is still too vague
and difficult to operationalise because tourists can improve their health and well-being in a
vast range of tourism contexts.
Another basis upon which to develop a wellness tourism typology concerns the deliberate
creation of tourist infrastructure that is specifically and primarily designed to enable and
enhance people’s health and well-being. For instance, while the supply of volunteer tourism
might evoke increased well-being of participating tourists, this type of travel is primarily
designed to provide aid for communities or assisting in environmental or cultural preservation
(Brown, 2005; Wearing, 2001). One could argue that the emphasis is the well-being of
communities or the environment rather than the well-being of the tourists. Similarly,
adventure tourism infrastructure is primarily designed to offer extreme physical challenges,

thrills and excitement which sometimes even involves tourists’ taking physical risks that are
dangerous rather than health-promoting.
However, there seems to be infrastructure that is specifically designed to facilitate tourists’
health and well-being. An extensive literature review as well as previous research in the
Australian context (Inside Story, 2007; Voigt, 2009), as well as interviews with key
stakeholders, revealed three distinct core categories of wellness tourism providers. These
three provider groups can be labelled as (1) Beauty Spa Hotels/Resorts; (2) Lifestyle Resorts;
and (3) Spiritual Retreats (Figure 1).
Medical tourism providers cater
to tourists who travel because
they want to treat/cure a medical
condition.
MEDICAL
Tourism Providers
Special Interest
Tourism
HEALTH
Tourism
Overlap
‘Medical Wellness’
1. Medispas
2. Traditional European Spas
3. Therapeutic Recreation and
Rehabilitation
3. s
Figure 1: Typology of Health and Wellness Tourism
Wellness tourism providers cater to
tourists who travel because they
want to maintain or improve their
health.
WELLNESS
Tourism Providers
Beauty Spa
Hotels/Resorts
Lifestyle Resorts
Spiritual Retreats
Before explaining these categories and presenting concrete, illustrative examples in section
4.1, it needs to be acknowledged that there is an overlap between medical and wellness
tourism, creating three additional types of health or ‘Medical Wellness’ tourism suppliers: (1)
So-called ‘Medispas’, where alternative therapies are offered beside medical treatments such
as Botox injections or liposuction and the line between true health promotion and the
correction of physical ‘problems’ or ailments becomes blurred; (2) Traditional European spas
where spa therapies are perceived as mainstream medicine and therefore subsidised by
national health insurance schemes as well as receiving ‘patients’ with physical ailments; (3)
Therapeutic Recreation/Therapeutic Rehabilitation facilities which offer holistic and
alternative wellness therapies and counselling to support people with serious illnesses or to
rehabilitate individuals with addictions or other psychological disorders. The major focus of
this paper, however, lies on the three core categories of wellness tourism providers.
Bringing together the demand as well as the supply side, wellness tourism can be defined as
the sum of all the relationships resulting from a journey by people whose primary motive is to
maintain or promote their health and well-being and who stay at least one night at a facility
that is specifically designed to enable and enhance people’s physical, psychological, spiritual
and/or social well-being (Voigt, 2008).

Methods
To understand the Australian supply-side and structure of wellness tourism, a range of
methods were employed, including secondary data analyses, stakeholder interviews and five
detailed cases studies. The interviews with the stakeholders and the interviews conducted for
the cases studies included site visits in all Australian states with the exception of the Northern
Territory, the Australian Capital Territory and Tasmania. A final method, most relevant for
this paper, consisted of a mail-out survey which was based on an audit of Australian wellness
tourism providers which produced a database of 590 businesses.
Sampling Frame. The definition of wellness tourism applied in this research deliberately
incorporates the limitation of “to stay at least one night at a facility”. Therefore, the main
emphasis during the audit was to achieve as complete a census as possible of businesses that
included or were attached to accommodation facilities. It was assumed that providers with
accommodation would receive a higher proportion of tourists than local residents in
comparison to establishments without accommodation. Nevertheless, a number of day spas
(although less than a census) were also included in our sampling frame, based on an
acknowledgment that some tourists visit these facilities while on vacation. This was important
to gain a broad snapshot of the Australian wellness tourism industry.
The sampling frame was established on the basis of a database of suppliers provided by the
Australian Tourism Data Warehouse (ATDW). The database included all suppliers listed by
the ATDW where the experiences field included ‘health and wellbeing’. The database was
subsequently reviewed by two research team members, with out of scope records removed
(e.g. businesses that provide a spa bath in their rooms but do not offer any other health and
wellness tourism services, or duplicates), which substantially reduced this database. The
database was then crosschecked against other sources, such as Sensis Yellow and White
Pages, online directories (e.g. SpaFinder) and private records of the research team, to include
additional providers in the database.
Survey Instrument. A self-completion mail-out questionnaire was developed that included
questions in regard to the nature of the service offerings; the business profile including year of
establishment, staffing; and promotion strategies and distribution.
Data Collection Procedure. Before the survey was mailed out, each of the 590 wellness
providers was contacted by telephone and the name of an appropriate manager was identified
and recorded in the database. This enabled the research team to produce personalised
introduction letters. These letters, together with a hard copy of the questionnaire and a reply
paid envelope were sent to every wellness provider listed in the newly created supply data
base. A tracking serial number was printed on the reply paid envelope and responses were
recorded in the supply data base. The envelope was then discarded and the serial number was
not attached to individual questionnaire records. Two reminder letters after four and after
eight weeks were posted to non-respondents. A total of 156 responses were received by the
closing date of the survey, representing a response rate of 25 percent.
Data Analysis. The survey data was captured electronically and set up as an SPSS (Version
17) data file. The data was initially inspected through frequency count and cross-tabulation to
check for range validity and logical consistency. After deleting four questionnaires due to
missing data, we had responses from managers of 68 Beauty Spa Hotels/Resorts, 37 Day
Spas, 27 Lifestyle Resorts and 22 Spiritual Retreats. The data set was then analysed by
frequency count, cross-tabulation and the calculation of means.

The actual responses were compared with the data base classifications in regard to location
and wellness tourism provider category. The distribution of business location of the sample
was consistent with the distribution within the supply data base, suggesting that there was no
significant sample bias on the basis of respondent’s business location. A comparison between
the distribution of wellness tourism provider category within the sample and the supply data
base revealed an over-presentation of the beauty spa resort/hotel and the lifestyle resort
categories and an under-representation of the day spa category. The higher non-response rate
among day spa providers might be explained by their major focus on local residents rather
than tourists, so that they may have perceived that the study was not applicable to them.
Results
The Three Core Wellness Tourism Provider Categories
The main focus of Beauty Spa Hotels/Resorts is on body and beauty treatments such as
facials, massages and body wraps. Of the three provider groups, Beauty Spa Hotels/Resorts
are most likely to offer some form of water-based treatment. In this regard, some beauty spa
facilities have an intrinsic geographic advantage as they are based on or around mineral or
thermal pools. Spas that do not have this advantage also offer water-based treatments, for
instance in the form of steam rooms, saunas, whirlpools, hot tubs and wet treatments rooms
(e.g. for baths and hydrotherapy massages such as a Vichy shower). Day spas are very similar
to Beauty Spa Hotels/Resorts, however they do not include or are not attached to
accommodation facilities.
Some beauty spas are managed independently but are still physically located on the premises
of hotel or resort accommodation suppliers. In recent years, many beauty spas have been
added to existing tourism resort properties, considerably increasing their marketing
advantage, revenue per occupied room, occupancy and perceived value for room rate
(Monteson & Singer, 2002). Indeed, it seems that hotel or resort guests nowadays expect fouror
five-star properties to encompass spa facilities.
Based on the discussion with stakeholders and through the audit of wellness tourism provider
service offerings it can be argued that Australian Beauty Spa Hotels/Resorts seem to follow
one out of three different thematic approaches.
In the first approach, spa services, facilities and décor are reminiscent of traditional
European-style spas. One example is the Aqua Day Spa located in the Sheraton Noosa Resort
& Spa in Queensland. A central focus of this establishment is the use of water with an ‘Aqua
Therapy Centre’ including indoor pools with a range of resistance pressure treatments,
submerged water-lounges, a Vichy shower, a steam room and Roman outdoor spas. The décor
consists of Roman-like statues and the tiled floors and walls as well as the crisp, white
uniforms of the staff, reminiscent of doctors’ coveralls evoke the image of a luxurious
sanatorium. The Aqua Day Spa also includes eight treatment room, including a couple’s room
in which only European cosmetic brands (the Swiss La Prairie and the French Thalgo) are
used for the therapies.
In the second approach, the spa theme is strongly based on Asian healing techniques and
philosophies. An example is Shangri-La’s signature spa brand CHI, which was launched only
this year at the Shangri-La Hotel in Sydney. The concept of CHI spas was developed by
recognised specialists and its treatments and products are based on Traditional Chinese
medicine with its concept of ‘chi’ or ‘qi’ which represents the life force or energy flow that
sustains health, well-being and personal vitality. Guests visiting CHI spas fill out a

questionnaire that determines which one of the Chinese Five Elements (metal, water, wood,
fire and earth) they are and allowing the spa services to be tailored accordingly. The
treatments in CHI spas focus on removing blockages of ‘chi’ with movement, stretching and
massages as well as ‘movement of the mind’ through relaxation and meditation. Although
CHI spas strive to incorporate local elements in their interior design, Chinese and Himalayan
artefacts, warm colours and woods, as well as specifically designed, mystical ambient lighting
support the Asian healing concept and make reference to the Himalayan Shangri-La legend, a
place of personal peace, well-being and enchantment.
In the third approach, some Beauty Spa Hotels/Resorts deliberately seek to create a uniquely
Australian theme, thereby often drawing on Indigenous cultural elements and healing
philosophies. The Reef House Day Spa at the Sebel Reef House & Spa in Palm Cove,
Queensland illustrates this approach. In their five treatment rooms, the Reef House Day Spa
offers therapies with Aboriginal names such as ‘Yanko’ (meaning ‘sound of running water’
and is a Vichy shower treatment), ‘Kodo’ massage (meaning ‘melody’ which is based on
Torres Strait Islander massage techniques) or ‘Gapu Yuru’ (meaning ‘water cloud’ which
includes a ritual using hot and chilled stones, a facial, body wrap and exfoliation). They use
the Australian skin care brand Li’Tya (meaning ‘of the earth’) which distributes products that
have been created based on Indigenous knowledge of the therapeutic value of Australian
plants such as lemon myrtle and wild rosella flowers. The interior design incorporates the
surrounding rainforest with an open-air reception and glimpses on the tropical garden and the
use of native timbers, for instance for the handcrafted, leaf-shaped signature massage table
from Melaleuca wood. It should be noted that while some Australian wellness tourism
suppliers and providers build on the advantage of using Indigenous healing traditions in order
to make their services and products more attractive to tourists, those businesses are generally
not owned by Indigenous Australians and employment of Indigenous staff is also rare.
Lifestyle resorts typically entail the participation in a comprehensive program which focuses
on health-promoting behaviour changes in areas such as nutrition, exercise and fitness,
personal goals and counselling and stress management. Lifestyle resorts are what Americans
often call a ‘destination spa’ and as McNeil and Ragin (2004, p. 32) observe: “The sole
purpose of this type of spa is to set guests on a healthier path for life”. Spivack (1998, p. 68),
however, notes that the term ‘spa’ is often avoided by lifestyle resort owners because it is seen
as too closely associated with beauty treatments. Therefore, terms such as ‘health resort’,
‘wellness centre’, ‘fitness retreat’ or ‘health farm’ are more common in this category.
Examples of an Australian lifestyle resort are the two Golden Door lifestyle resort properties.
The original Golden Door resort is located in Willowvale, Queensland’s Gold Coast
hinterland, and opened in 1993. The other resort, the Golden Door Elysia, opened 10 years
later in the Hunter Valley, New South Wales. The two Golden Door properties were
developed in different ways, required different levels of capital investment and therefore offer
different experiences. Whereas the Golden Door in Queensland has a more rustic, closer to
nature feel, Elysia is more elegantly designed and luxurious. The Golden Door became
famous with its 5-14 day health programs that promise long-lasting lifestyle changes. Based
on an extensive health and fitness assessment, Golden Door staff establish personalised
programs to meet the individual needs of each guest. Both Golden Door properties possess
extensive indoor gym facilities, tennis courts, and swimming-pools, and are surrounded by
nature that is the setting for bushwalking activities. An extensive assortment of activities and
seminars is offered, ranging from T’ai Chi, yoga, aquaerobics, water polo, Kung Fu, boxing,
women’s and men’s health, and cooking classes, to detoxification, and alternative healing

therapies such as Feldenkrais, acupuncture, naturopathy and hypnotherapy. Both Golden Door
resorts also include a beauty spa where guests can book beauty treatments at an additional
cost. Program guests have three fixed meal times built into their program structure. The
cuisine offered at the Golden Door consists of low fat, wholesome meals without added salt
and sugar. Furthermore, alcohol, non-herbal teas and coffee are not allowed on the premises
and the resort is a smoking-free zone. Amenities such as television, Internet and telephones
are not offered and the use of mobile phones is discouraged and not permitted outside of the
guest’s room.
The emphasis of Spiritual Retreats is on spiritual development or enlightenment. Spiritual
retreats can be religious or non-religious but always include meditation in various forms.
Many spiritual retreats are based on some specific teachings or philosophy and/or focus on the
study of a specific activity such as yoga, T’ai Chi or Reiki or particular meditation techniques.
Like lifestyle resorts, some spiritual retreats also focus on detoxing and fasting. Here,
however, this often has a distinct spiritual note in terms of ‘purification’ or ‘cleansing’ and
not only in regard to weight loss or getting rid of unhealthy toxins. Additionally, one can also
distinguish ‘non-silent’ and ‘silent’ Spiritual Retreats. In ‘silent’ spiritual retreats, participants
are not allowed to talk to each other the entire time; they are supposed to focus entirely on
their personal spiritual journey. Compared to Beauty Spa Hotel/Resorts and Lifestyle Resorts,
the interior design and facilities of Spiritual Retreats tend to be more basic and participants
often have to share austere rooms and/or bathroom facilities. Guests are also often expected to
participate in housekeeping activities, such as washing the dishes after meals. The food
offered in Spiritual Retreats is often vegetarian or vegan and alcohol is generally not
permitted.
The majority of Australian Spiritual Retreats are based on or influenced by Asian
philosophies and meditation techniques. Examples are the week-end or short monastic retreats
that are regularly organised at the Nan Tien Temple in Wollongong, New South Wales. The
Nan Tien Temple is the largest Buddhist Temple in the Southern hemisphere, run by nuns
from the Fo Guang Shan Buddhist order. The temple complex incorporates two prayer halls
including shrines five Big Buddha statues, 100.000 small Buddha statues, a gong and a drum,
an eight-storey pagoda, a museum, a tea house, a library and a conference centre, all set
amidst landscaped gardens which include a lotus pond. There is also housing for nuns and
monks as well as the ‘Pilgrim Lodge’, where retreat participants and other visitors stay.
Retreat participants, or ‘students’ wear traditional grey, monastic garb during their stay and
men are required to shave their heads for longer retreats. Students are expected to partake in
the normal temple life which also includes morning chanting sessions at 6 a.m. and are also
required to observe ‘Noble Silence’. Vegetarian meals, cooked with food donated to the
temple, are served in the public dining hall. Some Nan Tien Temple retreats provide students
with a theoretical approach to learning and understanding Buddhism whereas others teach
several meditation techniques, including sitting meditation, walking meditation, tea
meditation and T’ai Chi.
Database Analysis
The final data base consisted of 590 service providers, categorised into 201 spa hotel/resorts,
262 day spas, 28 lifestyle resorts, 83 spiritual retreats and 16 hybrids (businesses that could
not be definitely classified on the database information alone).
Thus, the majority of businesses in our database consisted of day spa businesses, even though
there was no intention to achieve a complete Australian census for this wellness provider

category. Of the three core wellness tourism provider categories that include accommodation,
Spa Hotels/Resorts were clearly the majority (35%), followed by Spiritual Retreats (14%) and
Lifestyle Resorts (5%).
The supply of wellness service providers in Australia is distributed differently across the
states. The biggest proportion of all wellness service providers is located in New South Wales
(29%), followed by Victoria (24%) and Queensland (22%), Western Australia (12%), South
Australia (7%), and Tasmania (4%). Only 2% of the businesses are located in the Australian
Capital Territory and 1% in the Northern Territory. Moreover, New South Wales contains the
majority of Spiritual Retreats and Lifestyle resorts, whereas Queensland hosts the highest
proportion of Spa Hotels/Resorts.
Survey Analysis
Business Profile. The basic business profile revealed the proportions of regional versus
metropolitan wellness providers, how long the businesses were operating, their average
number of employees and their distribution channels.
Based on the survey responses, it is also apparent that the majority of wellness providers in
Australia are located in regional areas (72%) rather than in metropolitan areas (28%).
However, there are differences between the types of wellness providers. As expected, day
spas are more likely to be found in metropolitan areas than Spa Hotels/Resorts, Lifestyle
Resorts or Spiritual Retreats (Table 1).
Table 1: Metropolitan versus Regional Distribution of Wellness Tourism Providers and
Day Spas
Wellness Provider Category
Day
Spas
Spa
Hotels/Resorts
Lifestyle
Resorts/Retreats
Spiritual
Retreats
TOTAL
Metropolitan
area
41% 24% 32% 18% 28%
Regional area 59% 76% 68% 82% 72%
The respondents of our survey were asked when their business was established. Almost half
of all businesses (48%) providing wellness services are only five years old or less, which
confirms the youthfulness of the wellness tourism industry in Australia. Of all wellness
tourism provider categories, Spiritual Retreats tend to have been established longer than the
other types (59% of spiritual retreats have been in business for more than 11 years versus 21%
Spa Hotels/Resorts and 16% Lifestyle Resorts).
The size of wellness tourism facilities can differ substantially, which is mirrored by the
number of full-time staff a business employs. Fourteen respondents of our survey only
employed one full-time staff, and only nine businesses employed 20 full-time staff or more.
The highest number of full-time staff employed by a Lifestyle Resort was 105. Table 2 shows
the average number of full-time staff across the different wellness provider categories and
categorised as metropolitan or regional. Lifestyle Resorts tend to employ the highest number
of full-time staff. This is attributed to the fact that they usually provide a range of different
services that require the employment of specialists (e.g. nutritionists, fitness trainers,
beauticians, massage therapists, nurses). Spiritual Retreats tend to employ the lowest number
of full-time staff. In general, wellness service providers employed more staff in regional areas
than in metropolitan areas.

Table 2: Average Number of Employees
Wellness Provider Category
Average Number of
Employees
Day Spas
Spa
Resorts/Hotels
Lifestyle
Resorts
Spiritual
Retreats
Metropolitan area 4.9 9.4 4.6 np*
Regional area 7.9 5.6 18.6 3.9
Total (all areas) 6.7 6.5 13.7 4.0
(*)Not published where sample base is less than 5 cases.
Respondents were asked about the proportion of clients using different distribution channels.
The vast majority of wellness providers rely on the direct-to-consumer business model (Table
3). Only 2% of all wellness service providers use an Internet intermediary and 1% of the
business results from recommendations by government travel centres or visitor information
centres. The telephone seems to be the key direct-to-consumer distribution channel for day
spas and it is also important for the other wellness provider categories. The Internet appears to
be a significant direct-to consumer distribution channel, particularly for Lifestyle Resorts and
Spiritual Retreats. Forty-one percent of Lifestyle Resorts and 66% of Spiritual Retreats
communicate with their customers either via email or via their own Internet booking facility.
Face-to-face contact tends to be more important for Day Spas and Hotel/Resorts Spas than for
Lifestyle Resorts and Spiritual Retreats.
Table 3: Average Proportion of Bookings via Different Distribution Channels
Wellness Provider Category
Day Spas
Spa
Hotels/Resorts
Lifestyle
Resorts
Spiritual
Retreats
TOTAL
Direct from
consumer via:
Phone 72% 55% 42% 20% 52%
Mail - - 3% 3% 1%
In person 17% 14% 5% 10% 13%
Email 7% 17% 31% 39% 20%
Booking
facility on our
Internet site
2% 5% 10% 27% 8%
Internet
consolidator
- 3% 2% 1% 2%
Retail travel agent - - - - -
Government
travel centre/VIC
1% - 1% 1% 1%
Services offered by Wellness Providers. Table 4 shows an overview of the types of services
and facilities provided by each wellness provider category. The table shows that Lifestyle
Resorts are most likely to offer a wide range of movement therapies such as gym classes,
yoga and guided walking or water activities than the other wellness providers. While no
Spiritual Retreat offers gym classes, by far higher proportions of Spiritual Retreats offer
mind-body activities such as yoga, T’ai Chi or Qi Gong or guided walking activities when
compared to Day Spas and Spa Hotels/Resorts.

Table 4: Distribution of Wellness Services by Wellness Provider Category
Wellness Provider Category
Services and Facilities
Day
Spas
Spa
Hotels/Resorts
Lifestyle
Resorts
Spiritual
Retreats
Total
Movement Therapies
Gym classes/private instructor 5% 16% 32% - 14%
Yoga 8% 25% 68% 73% 35%
T’ai Chi or Qi Gong 3% 10% 36% 32% 16%
Guided walking/hiking - 12% 56% 36% 20%
Guided water
activities/gymnastics
3% 4% 24% 5% 7%
Body and Beauty Treatments
Water-based and sweat bathing
treatments
41% 34% 20% - 28%
Swimming Pool(s) 11% 34% 36% 5% 24%
Bath tubs/Jacuzzi/Whirlpool 70% 68% 40% - 54%
Natural geothermal pool(s) - 1% - - 1%
Steam room(s) 22% 28% 24% - 22%
Sauna(s) 22% 35% 40% - 28%
Vichy shower(s) 41% 37% 16% - 29%
Body scrubs & wraps 100% 90% 56% - 74%
Manicure and pedicure 95% 79% 32% - 64%
Facials 100% 94% 56% 5% 76%
Manual Pressure
Massage 100% 100% 88% 45% 90%
Reflexology 43% 34% 52% 9% 36%
Manipulative/adjustment-based 8% 4% 20% - 7%
Nutrition-based services
Specific diet 11% 15% 64% 55% 28%
Weight management 16% 1% 56% - 14%
Cooking classes/diet education - 1% 60% 32% 15%
Detoxing/fasting 11% 1% 52% 18% 14%
Alcohol not allowed 11% 13% 48% 55% 24%
Coffee and non-herbal tea not
allowed
8% 9% 32% 18% 14%
Medical treatments and services
GP or nurse on premise 5% 3% 20% 5% 7%
General health assessment 11% 1% 32% - 9%
Minor cosmetic surgery 14% 3% 4% - 5%
Referral to GP 8% 1% 16% 5% 6%
Meditation 19% 7% 68% 100% 34%
Spiritual or religious studies 5% - 24% 82% 17%
Private Counselling 14% 4% 60% 32% 20%
Group Counselling 5% 0% 28% 18% 9%
Complementary & Alternative
Medicine
24% 9% 60% 18% 22%

As expected, Day Spas and Beauty Spa Hotels/Resorts are more likely to provide beauty body
treatments (i.e. body scrubs and wraps), facials, manicure and pedicure than Lifestyle Resorts
and Spiritual Retreats. In fact, Spiritual Retreats almost never provide body and beauty
treatments.
Lifestyle Resorts are more likely to offer nutrition-based services, general health assessments,
private and group counselling, as well as complementary and alternative therapies (CAM)
than the other categories of wellness service providers. Although only a few respondents
specified what kind of CAM therapies they offer, therapies mentioned included Traditional
Chinese Medicine, Ayurveda, kinesiology, iridology, naturopathy, homeopathy, bachflower
consults, Feldenkrais, Bowen therapy, hypnotherapy, and psychic or crystal healing.
Unsurprisingly, all Spiritual Retreats offered meditation and they were much more likely to
offer meditation and spiritual or religious teachings than all the other types of wellness service
providers. The fact that 19% of Day Spas offered meditation is a surprising result, as a
previous assessment of spa menus did not appear to include such a service. Perhaps
respondents sought to offer visitors a personal meditative state rather than a guided
meditation. This suggests a blurriness between some of these categories of providers that is
worthy of exploration in future research. Although only some respondents specified the type
of meditation they used, different meditation techniques ranged from Vipassana or Buddhist
meditation, Dru meditation, Raja yoga, visualisation, breath awareness, mindfulness,
Holosync, transcendental meditation, sound meditation, chanting mantra, Kirtan Kriya, chakra
meditation, walking meditation, ‘calming the minds/opening the heart’, and ‘loving kindness’.
It also should be noted that 90% of all providers offered massages, making them overall the
most often provided wellness service. Massage therapies and techniques respondents specified
ranged from remedial or deep tissue, relaxation massages, Thai, Swedish,
Balinese/Indonesian, Lomi Lomi, Kodo, Shiatsu, Tibetian energetic massage, sports massage,
hot stone, bamboo, cupping, lymphatic draining, ear candling, pregnancy/pre-natal massage,
and aromatherapy.
Finally, Lifestyle Resorts and Spiritual Retreats are also more likely to offer specific diets
(most often mentioned menus were vegetarian, vegan, raw foods, and/or organic) than Day
Spas and Beauty Spa Hotels/Resorts.
Discussion and Conclusions
This paper started with a discussion of a new typology of wellness tourism providers. It was
argued that existing typologies often tended to be too broad to meaningfully enable the
collection of data and compare different groups of wellness tourists or wellness tourism
providers. However, a too narrow typology would fail to recognise the diversity of
experiences wellness tourism providers offer to tourists.
The results from this research show that the three core groups of wellness providers are
distinctly different from each other, specifically in regard to the kinds of services and facilities
they offer. Despite these differences in service offerings it is nevertheless argued that the three
different core types of wellness tourism providers should not be perceived as completely
separate categories. Instead they can be better portrayed as distributed along a continuum
where there is a gradual distinction between the three types (Figure 2). For instance, some
Lifestyle Resorts put a heavy emphasis on beauty treatments and massages, whereas others
accentuate meditation and breathing techniques or ‘new age’ services such as psychic

eadings. Similarly, Spiritual Retreats can lean more towards Lifestyle Resorts by providing a
range of seminars and discussions about lifestyle issues and a focus on physical movement
such as yoga or meditative walking.
The data reveals that there are many more Beauty Spa Hotels/Resorts in Australia than
Lifestyle Resorts or Spiritual Retreats. The majority of previously existing research has also
focused on beauty spas or on tourists visiting spas and even national and regional destination
advertising materials of Destination Marketing Organisations (DMOs) tend to be dominated
by this hedonic type of wellness provider. Australian DMOs but perhaps also DMOs in other
countries should be aware that wellness tourism includes a broader range of providers than
just Beauty Spa Hotels/Resorts.
Beauty Spa
Hotel/Resort
Services
Lifestyle Resort
Services
Body and Facial Beauty Treatments
e.g. facials, body wraps, body scrubs, hair removal, pedicure
Water-based and Sweat Bathing Treatments
e.g. steam baths, Vichy showers, whirl pools, saunas, hammam
Manual-pressure based therapies
e.g. massages (remedial, Swedish, Thai, Lomi-Lomi, Hot Stone, Shiatsu, etc), reflexology,
acupressure
Manipulative/adjustment-based therapies
e.g. chiropractic, osteopathic
Spiritual Retreat
Services
Only specific forms such as ‘Sweat
Lodges’ or ‘Rebirthing’
Movement Therapies
e.g. swimming, aerobics, dancing, Yoga, Qigong, T’ai Chi,
walking
Energy Therapies & New Age
e.g. Healing Touch, Reiki, crystals, psychic readings
Meditation
e.g. Transcendental, Vipassana, chanting, prayer
Nutrition-based
e.g. cooking classes, weight management, detoxing,
fasting
Counselling & Group Therapies
e.g. stress management, life coaching
Figure 2: Wellness Tourism Provider Service Continuum
Studying & Learning
e.g. Buddhism or Bible class
This research disclosed some interesting overlaps and dissimilarities of wellness tourism
supply in Australia in comparison to other countries. First, as in other countries and regions,
wellness tourism is a phenomenon predominantly relying on domestic tourists rather than on
international tourists (Cooper et al., 1992; Lanz Kaufmann, 2002; Minghetti & Furlan, 2006;

Snoj & Mumel, 2002). Furthermore, relatively high numbers of local residents also visit
wellness tourism providers. Second, as several writers have previously observed (e.g.
Nahrstedt, 2004; Pollock & Williams, 2000; Smith & Puczkó, 2008), wellness tourism is an
increasingly important and growing tourism niche.
Despite the widespread economic crisis, the number of wellness tourism providers has grown.
It could be even argued that the wellness tourism industry may benefit from the financial
crisis as people need an outlet where they can de-stress to be able to cope with their worries.
In addition it can be confirmed that Australian wellness tourism – like its Northern American
counterpart and most Asian countries – focuses on health promotion rather than on medical
cure. Only a small percentage of wellness tourism providers in this study offer conventional
medicinal treatments or structures. Third, the majority of Australian wellness tourism
providers are located in regional areas which supports Smith and Kelly’s observation that
wellness tourism providers are are typically located in settings that are “aesthetically pleasing
[and] environmentally lush” (Smith & Kelly, 2006, p. 15).
Minghetti and Furlan (2006) propose that creating links between the wellness tourism product
and the cultural and natural surrounding area provides a competitive advantage over other
regions offering wellness tourism. In contrast to most European countries or countries such as
Japan, however, the Australian wellness tourism industry does not have the competitive
advantage to draw upon thousands of years-old bathing cultures and corresponding
architectural heritage. The Australian wellness tourism industry is really only a few decades
old. However, some Australian wellness tourism providers have started to incorporate
Indigenous culture in their product offerings, perhaps in part due to a perception that this
provides them with a strong competitive advantage (Sheldon & Park, 2009). While this might
be true, there also might be the danger of exploiting Indigenous knowledge. This is very
critical especially in light of the gross disparity between many health measures of Aboriginal
people relative to these of non-Indigenous Australians. Unfortunately, whereas the health gap
between Indigenous and non-Indigenous people is narrowing in other countries such as the
United States, Canada and New Zealand, it is widening in Australia (Ring & Brown, 2003).
Clearly, there are some unresolved issues that wellness tourism operators need to be aware of
and sensitive to when incorporating Indigenous elements in their business offerings.
An interesting difference between Australian wellness tourism providers and those in other
countries is that not even half of Australian Beauty Spa Hotels/Resorts offer water treatments.
It is often claimed that ‘water’ is the central defining element of spas which clearly does not
seem to be the case in Australia. On the contrary, many spas emphasise that they use water
thoughtfully and sparingly which reflects the increasing water scarcity in Australia. Lavish,
extravagant use of water can be perceived as wasteful and unsustainable by some Australians,
especially in light of extensive government campaigns that ingrain water-saving behaviour in
its citizens.
There seems to be a further difference between Australian and European Spiritual Retreats.
Existing literature tends to focus on European Christian, monastic retreat accommodation
(O'Gorman, 2007; Shackley, 2004) and there are even tourist guide books recommending in
which Christian monasteries and nunneries tourists may stay when travelling through Europe
(Clark, 2008; Wright, 2000). In contrast, Australian Spiritual Retreats are clearly much more
influenced by Eastern religions and philosophies – even when they are promoted as nonreligious
places – and Christian retreat accommodations appear to be rare. If the unique
Australian Spiritual Retreat sector were to be promoted more strongly and embraced by

national and state DMOs, it could potentially become highly appealing to international
tourists. Some international tourists with an interest in Eastern spirituality might feel anxious
or unsafe about travelling to Asian countries, or might be concerned about language barriers.
Therefore, they may perceive Australia as a more appealing destination for visiting Spiritual
Retreats.
In conclusion it can be argued that despite the lack of cultural heritage in wellness tourism
and some ethical difficulties inherent in the integration of Indigenous elements into this
offering, Australia offers an extensive range of wellness services catering to tourists who feel
the need to maintain or promote their health and well-being. Not only are there three distinct
types of wellness tourism providers offering distinctly different clusters of wellness services
and facilities, but Australian wellness tourism providers also seem to successfully blend
American, traditional European and Asian influences, thus creating a unique fusion of
attractive choices for wellness tourists. This, in combination with the general image of
Australians as relaxed, friendly, laid-back and outdoorsy as well as pleasant climatic
conditions which foster active, healthy lifestyles, provide an opportunity for positioning
Australia as a wellness tourism destination. While it is unlikely that international tourists
would be solely drawn to Australia because of its wellness tourism industry – with the
possible exception of the distinctive nature of Spiritual Retreats – wellness tourism offerings
may present an appealing add-on that is in keeping with the general branding of Australia.
Future research is needed that would serve as a validation of the proposed wellness tourism
typology outside the Australian context. More research is also needed to further explore
Lifestyle Resorts and Spiritual Retreats as well as the types of tourists who visit these places.
As previously mentioned, existing research tended to predominantly focus on spa tourists or
spa providers. In addition, this study only included the three core types of wellness tourism
providers without focusing on ‘medical wellness’ providers such as Therapeutic Recreation
Retreats or Medispas in its national census. More research should therefore explore these
‘blends’ of wellness and medical tourism.
Acknowledgements
The Sustainable Tourism Cooperative Research Centre (STCRC), established and supported
under the Australian Government’s Cooperative Research Centres Program, funded this
research. The authors also thank all the participating organisations and interviewees for their
contribution as well as the other researchers who contributed to the wider study: Professor
Graham Brown, Dr Gary Howat, Mr Richard Trembath, Professor Betty Weiler, and Dr
Meredith Wray.
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The Exploration of the Perceived Travel Benefits and the Perceived
Importance and Interests of Wellness Tourism
Among the Older Adults in Taiwan Kaohsiung
Ping Yu
The Graduate Institute of Adult Education, National Kaohsiung Normal University, Taiwan
alrr2007@gmail.com
Janet I-Jane Weng
Department of English, Wenzao Ursuline College of Languages; The Graduate Institute of
Adult Education, National Kaohsiung Normal University, Taiwan.
janetweng@mail.wtuc.edu.tw
Abstract
The purposes of this study are to explore and analyze the potential elderly market of wellness
tourism. By using a questionnaire survey, 596 adults of age 50 and above with various
backgrounds in Kaohsiung, the biggest city in southern Taiwan, are involved in the study. An
effort is made to investigate their perceived travel benefits, their perceived importance of
wellness facilities and services in hotels, and their interests in participation in related
activities. Data were analyzed using the statistical cluster analysis, discriminant analysis, chisquare
test, and the t-test. As a result, the elder travelers were segmented into two relatively
well-defined types in terms of their perceived travel benefits: the active benefits seekers and
the passive benefits seekers. Each type has its own characteristics and interests in
participation on the wellness-related activities. The findings indicate that demographic
background, travel experiences and health condition are different significantly between active
and passive benefits seekers. The active benefits seekers tend to be more interesting in
participating in hotel extended wellness-related activities compared with the passive seekers.
On the other hand, compare to the active benefits seekers, the passive benefits seekers ranked
the hotel health-related services and facilities as more important. The study reveals not only a
new perspective to define the wellness market among Taiwan elderly, but also a new market
which can be focused on. Based on the results, discussions and suggestions are generated for
practitioners and researchers.
Keywords elderly, older adults, travel benefits, wellness tourism, wellness hotel
Introduction
Since the health and wellness are the topics concerned most by the older adults, the wellnessrelated
tour package is one of the most attractive leisure selections for the elderly. Research
showed the elders attached a lot importance for health and leisure. In addition, they liked to
join in travel activities and were interesting in lifelong learning (Smith & Kelly, 2006). Chen
and Wu (2005) identified five motives of overseas travel among the Taiwan elders and the
motivation of “health promotion” is on the top of the list as “show off the fun” is the lowest
one. However, as little research has so far been done about wellness tourism, the knowledge
of this potential market is very insufficient (Smith & Kelly, 2006). Wellness travel is a fairly
new product. To better understand the wellness market for those retired older adults with
more leisure time but limited income resources and physical considerations, the authors
believe that their perception of general travel benefits might have great influences on their
trying the new product. Since travel serves multifunctional needs of the tourists, their
perceived travel benefits should be examined as a group type which reveals more meaning to

the real market. Little research has looking on the elderly market and from this perspective.
The specific goals of the research are to explore the elders’ wellness travel market, to identify
the clusters by perceived travel benefits among the elderly, to analyze the demographic
background, travel experience, and their health perception and behavior in different clusters,
to explore their perceived importance of wellness hotel services and facilities in different
clusters, and to compare the participation interests of extended wellness-related activities of
travel in different clusters.
Literature Review
The focus of the study is on the perceived travel benefits of the older adults for wellness
market and its correlation with some variables of hotel wellness-related services. Thus, the
concepts of wellness tourism, wellness hotel services and facilities, and the characteristics of
travelers for wellness tourism will be discussed.
Definition of Wellness and Wellness Tourism
Halbert Dunn (1959) wrote about a special state of great personal health contentment which
consists of an overall sense of well-being. He used “high-level wellness” to describe the state
which sees human as a harmony of body, spirit and mind and being dependent on their
environment. The term “wellness” was also mentioned by Ardell (1977, 1986), Travis (1984),
Benson & Suart (1992), Greenbert & Dintiman (1997), and Myers, Sweeney & Witner (2005)
in their health-related publications. Hertel (1992) of the German Wellness Association
reviewing the definitions of wellness in USA found it shared certain common characteristics:
lifestyle is of critical importance, self-responsibility for health, the multi-factorial roots of
health as well as the exploitation of our potential for a better quality of life.
In a sense, the wellness tourism can be been seen as a part of the health tourism (Mueller &
Kaufmann, 2001; Harahseh, 2002). The authors borrowed the definition of wellness
developed by Mueller and Kaufmann (2001) who defined wellness tourism as “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” to focus on the related wellness services
and facilities provided by the hotel in the journey.
Definitions of Benefits and Travel Benefits.
The Oxford Dictionary (2003) defines “benefit” as “an advantage or profit gained from
something”. According to Driver, Brown, & Peterson (2001), there are two uses of the word
“benefits”. One is simply the monetary valuation of that gain. The second is referred as “a
change that is viewed to be advantageous—an improvement in condition, or a gain to an
individual, a group, to society, or to another entity”. They also argued “benefits defined as
gains or advantageous changes are thus directly subject to predictive modeling and to testing
for cause and effect relationship.” Since the study focuses more on the intention and attitudes
of elder consumers towards travel and what might be considered as beneficial, the authors
adopt the second concept of the definition. As Driver, Brown, & Peterson (2001) said “the
noneconomic measures are useful in recreation resource management.”
Studies on Benefits Segmentation in Tourism Wellness Market
There are many alternative segmentation criteria suggested in the tourism literature (Forgen,
2005; Kangas & Tuohino, 2007; Smith & Puczkó, 2009), such as demogrphics, geographics,
psychographics, expenditure. and perceived benefits.

The key question in market segmentation is what is the most effective segmentation criterion?
According to Haley (1968), the rationale behind this segmentation approach is that the
benefits identified by the consumers were the basis for the existence of true market segment.
The identified benefits determine the consumers’ behavior more accurately than do other
descriptive variables such as demographic and geographic characteristics. Discussing the
conceptualization of leisure attitude, Iso-Ahola (1980) argued leisure participation is affected
by the intention toward an object. The intention is determined by a person’s attitude of that
object, which is a result of belief of that object. Also, if a person has reason to believe that
participation in a leisure activity will lead to intrinsic rewards, the attitude toward that activity
is highly positive. Wellness pursuit is common among older adults. Thus, it is reasonable to
claim the perception of the travel benefits, comprising of belief and attitude might affect in
certain wellness tourism related intention and behavior which is crucial to understand the
elder market. In addition, several authors have suggested that benefit segmentation is one of
the best segmentation bases (Loker & Perdue, 1992; Morrison, 1996). Ahmed, Barber, and
Astous (1998) claimed that because the benefit segmentation identified the travelers’
motivations and satisfaction of what they want and what they need, it was more appropriate in
defining destination segments and developing marketing strategies. After reviewing several of
the academic publications, Frochot and Morrison (2000) argued that benefit segmentation is
most helpful in designing and modifying facilities and attractions, vacation packages, activity
programming, and service quality measurement.
Several studies focusing on benefit segmentation in Japan and America have revealed
significant differences in some socio-demographic variables (Yannopoulos and Rotenberg,
1999; Jang, Morrison, & O’Leary, 2002). Smith & Puczkó (2009) argued when defining the
targets and targeting strategies and tactics, it is essential to know what benefits exist and
prospective customers may associate with a health trip.
Only a few studies were reported on Taiwanese travelers using benefit sought among travelers
to analyze the market. Fu (2003) studied the motivation/benefits of older travelers in Taiwan
using factor analysis. She found the travel motivation of rest/relaxation, being with families,
feelings of relaxation, and appreciation of the nature were recognized to be the most important
by guests over age of 55. The results were identical with the study by Guinn (1980). Chen &
Wu (2005) studies the motivations of the Taiwanese senior travelers, which is generally
accepted as having a direct relationship with the benefits sought and divided the market into
four segments: “the all-directions seniors”, “ the conservative seniors”, “the active and
optimistic seniors“, and “the knowledge and health seeking seniors”. A recent empirical study
by Chen, Prebesen, & Huan (2008) identified relaxation, pursuing multiple activities,
recreation, and enjoying nature as the top four motivations of wellness travelers
To date, almost no reported research directly using the perception of travel benefits of the
elders to segment the wellness market of the aging population. The study attempts not only to
identify a new market in wellness tourism in terms of the perceived travel benefits of the
elders, but also to understand how the identified clusters are related their ratings of wellness
services and facilities and their interests in participation of the activities provided by the
wellness hotels on an overseas trip.
Research Method
Research Respondents:
Questionnaire survey and purposive sampling method were adopted for the study. 596 elderly
respondents, 227 males and 369 females over age 50, from eleven elderly activity centers

located in different administration districts in Kaohsiung who had international travel
experiences were participated to investigate the wellness tourism market.
Research Instruments:
The questionnaire of “the Perceived Travel Benefits Scale for Elderly” consists of 25 travel
benefit-related questions in 5-point Likert scale. The questionnaire is derived from Fu (2003)
who edited the scales of Jang, Morrison, and O’Leary (2002) and Arimond and Elfessi (2001).
Yu and Fu (2008) revised it and using 596 elder respondents for factor analysis and obtained
6 benefit factors: Family gathering and relationship enhancement, nature appreciation,
experiencing life, escape and relaxation, cultural understanding, and social interaction which
match Fu (2003) factor structure and explain 70.1 % of the variance in total. The
Cronbach’sαfor each factor and the total score are between .70 to .97 and show good
reliability.
After a well review of the definition of wellness, Mueller and Kaufmann (2001) revealed
important service categories in wellness tourism in hotel industry. They are: body/physical
fitness/ beauty care, relaxation: rest/mediation, health: nutrition/diet, mind: mental
activity/education, environmental sensitivity, and social contacts. In addition, to arouse
participants’ self-responsibility for wellness is essential for the services. In the study, to
investigate the elder market, questionnaires of “ the Perceived Importance of Wellness
Facilities in the Hotel (PIWFH; 11 questions in 3- point Likert scale)” and “Participation
Interests in Extended Wellness Activities (PIEWA; a checklist of 16 items) were derived from
the above Mueller and Kaufmann’s wellness market analysis framework to measure the
elders’ perceived importance and interests in wellness hotel and the extended services of
wellness activities. Using 596 elder respondents for reliability analysis obtained Cronbach’s
α= .873 for the PIWFH and Cronbach’s α =.743 for PIWAT. In addition, questions of
demographic factors, travel experiences, and health related behaviors were also included in
the questionnaire.
Data Processing
Cluster analysis was used to identify the groups of people who had similar travel benefit
perception among the elderly. Then, t-test and chi-square were applied to describe the
differences in their demographic backgrounds, travel experiences, health behaviors, their
perceived importance of hotel services, as well as their interests of the wellness activities
between the identified clusters.
Findings and Discussions
Two Identified Clusters: Active Benefits Seekers and Passive Benefits Seekers
The study used both hierarchical and non-hierarchical cluster analysis methods. Since the
hierarchical cluster analysis can only process less than 100 cases, about 10% of the samples
were randomly selected from the 596 cases and analyzed using the hierarchical method. The
tree diagrams and agglomeration step tables favored a two-cluster group solution. To further
determine the cluster solution, the next step cluster analysis and k-means were used which reconfirmed
the two-group solution. Also, a discrimination analysis was used to check the
cluster solutions with all variables (6 perceived travel benefit factors) used to create the
cluster, and the two-cluster solution was clearly confirmed. With a success rate of 96.5% and
above for each cluster and 97.3% for total clusters, the allocation was virtually perfect.
The elderly traveler cluster groups were named by comparing the mean values of the 6 major
travel benefit factors in each cluster groups to find out the characteristics that differ

significantly from each other. There were only 2 cluster groups identified, the means of all 6
benefit factors in “cluster 1” were all significantly higher than those in “cluster 2”. Therefore,
the elderly in “cluster 1” were named as “Active Benefits Seekers”; on the other hand, those
in “cluster 2” were named as “Passive Benefits Seekers”. The percentage of population in
type of active benefits seekers (n=395; 66.3%) is higher than the passive benefits seekers
(n=201; 33.7%).
Table 1: The perceived travel benefits between active and passive benefits seekers
1. Family gathering and
relationship
enhancement
Cluster
(n=395)
I Cluster II (n=201)
Active
Passive
benefits seeker benefits seeker t-value p
M SD M SD
21.31 (2.27) 17.64 (2.43) 18.37 .000
2. nature appreciation 20.59 (2.17) 16.53 (2.28) 21.54 .000
3. experiencing life 11.96 (1.77) 9.69 (2.06) 13.85 .000
4. escape and relaxation 17.27 (3.07) 14.14 (2.73) 12.96 .000
5. cultural understanding 11.82 (1.68) 9.15 (1.65) 19.05 .000
6. social interaction 15.78 (2.07) 12.53 (2.06) 18.68 .000
Description of the Demographic Background of two Clusters
To understand the background differences of elderly travelers in two clusters, both t-test and
chi-square were applied. The results show that there are significant differences on the
variables of age, education level, and discretionary income between active benefits seekers
and passive benefits seekers. However, there is no significant difference on gender and
occupations before retirement between two groups.
Compared to the passive benefits seekers, the active benefits seekers is younger with higher
educational level and have higher discretionary monthly income than the passive benefits
seekers. The passive benefits seekers are comparatively much older with lower educational
level and tend to have less discretionary monthly income. The details of demographic
background between active benefits seekers and passive benefits seekers are as Table 2.

Table 2. Demographic Background by Clusters
Demographic background
age
education
Discretionary
income
(NT$)
Active
benefits
seekers
(N=395)
Passive
benefits
seekers
(N=201)
50~54 70 17.7% 22 10.9% 92 15.4%
55~59 56 14.2% 23 11.4% 79 13.3%
60~64 65 16.5% 32 15.9% 97 16.3%
65~69 78 19.7% 34 16.9% 112 18.8%
70~74 79 20.0% 49 24.4% 128 21.5%
75 and above 47 11.9% 41 20.4% 8 14.8%
Elementary
59 14.9% 46 22.9% 105 17.6%
and below
Middle school 70 17.7% 40 19.9% 110 18.5%
High school 104 26.3% 61 30.3% 165 27.7%
Junior college 38 9.6% 15 7.5% 53 8.9%
College and
university
104 26.3% 38 18.9% 142 23.8%
Graduate
school
20 5.1% 1 0.5% 21 3.5%
20000 and
174 44.1% 117 58.2% 291 48.8%
below
20,001~40,000 98 24.8% 53 26.4% 151 25.3%
40001~60,000 61 15.4% 16 8.0% 77 12.9%
60,001~80,000 48 12.2% 10 5.0% 58 9.7%
80,001 and
above
14 3.5% 6 2.5% 19 3.2%
Total (N=596) Chi-
square p
13.012 .023
17.558 .004
18.887 .001
The findings of travel experiences among senior tourists between two clusters show that the
differences are significant in almost all related variables including times of overseas travel,
last travel date, and travel destination, except their travel companion. Compared to the
passive benefits seekers, the active benefits seekers tend to travel more often and the date is
more recent. Northeast Asia, including Japan and Korea, is their favorite destination of the
last travel and they also travel more to those countries outside of Asia.
On the other hand, among the passive benefits seekers, the times of overseas travel are
comparatively fewer. Also, 45.8% of their last travel date is three years ago. The top three
destinations of their last travel are China (37.3%), Southeast Asia (29.4%), and Northeast
Asia (25.9%). The details are as Table 3.

Table 3 Cross-table of Background of Travel Experiences by Clusters
Background of travel
experience
No. of
times of
overseas
travel
Last travel
date
Destination
of last
travel
Active benefits
seekers
(N=395)
Passive
benefits
seekers
(N=201)
1 78 19.7% 56 27.9% 134 22.5%
2-3 105 26.6% 65 32.3% 170 28.5%
4-6 74 18.7% 36 17.9% 110 18.5%
7-9 35 8.9% 19 9.5% 54 9.1%
10 and above 103 26.1% 25 12.4% 128 21.5%
Within 1 year 147 37.2% 46 22.9% 193 32.4%
1-2 years ago 105 26.6% 42 20.9% 147 24.7%
2-3 years ago 56 14.2% 21 10.4% 77 12.9%
3 years ago 87 22.0% 92 45.8% 179 30.0%
Southeast Asia 99 25.1% 59 29.4% 158 26.5%
Northeast Asia 128 32.4% 52 25.9% 180 30.2%
China 94 23.8% 75 37.3% 169 28.4%
North
America
27 6.8% 9 4.5% 36 6.0%
Europe 33 8.4% 4 2.0% 37 6.2%
New Zealand
and Australia
14 3.5% 2 1.0% 16 2.7%
Total (N=596) Χ 2 P
17.086 .002
36.638 .000
24.533 .000
Regarding the self report health and related behavior between two clusters, the active benefits
seekers are healthier than the passive benefits seekers (Table 4). In general, compare to the
passive benefits seekers, those who perceived higher travel benefits tend to be younger, with
higher education level, and more spending power. Also, they travel more often and the time
is more recent. They are healthier and keep a better health habits. The above findings indicate
the relationships between perception of travel benefits with their travel behavior and health.
Table 4 Means and t-Value of Health-Related Variables between Clusters
Health perception and
behavior
Active
benefits
seekers
(N=395)
Passive
benefits
seekers
(N=201)
t-value P
1. Perception of health
condition
1.94 2.32 5.464 .000
2. Engagement in leisure
activities
1.30 1.52 4.464 .000
3. Health check 1.49 1.64 2.904 .005
4. Pay attention to
health-related
knowledge
1.23 1.42 4.161 .000
5. Pay attention to
healthy living habits
1.16 1.36 4.628 .000
Perceived Importance of Wellness-related Hotel Services and Facilities
The elderly tourists were asked to assess the importance of the hotel’s wellness services and
facilities. The hotel services of “sports facilities”, “bath, sauna, steam” and “activities of
learning courses” are perceived as the top three items for both groups. To understand the
differences of perceived importance between the active and passive benefits seekers, the t-test

was applied. The finding shows only four variables are statistically significant, including
activities of learning courses (mean=1.89, 2.02, t=2.416, p=.0.16), atmosphere of calmness or
relaxation (mean=1.31, 1.45, t=2.720, p=.007), non-smoking area/room (mean=1.30, 1.41,
t=2.018, p=.044), and information of health related topics (mean=1.51, 1.63, t=2.384,
p=.018). The passive benefits seekers attach more importance to the above services. It reveals
that among elder travelers, those perceived less travel benefits might be the major target group
for the wellness services and facilities provided by the hotels.
Participation Interests in Extended Wellness-Related Activities
Among the extended wellness-related activities provided by the hotels, the top three activities
of interests for active benefits seekers are “Cultural programs (e.g. music, arts)”, “Hiking or
bicycling with tour guide”, and “Massage” and for passive benefits seekers are “Cultural
programs (e.g. music, arts)”, “Hiking or bicycling with tour guide”, and “Organic food/living
food diet”. There are five items having a significant difference (p .05) in the count of
participation interest between two groups, which are “hiking or bicycling with tour guide”
(χ 2 =6.577, p=.010), “Yoga, meditation, relaxation activities”(χ 2 =12.979, p=.000), “Massage”
(χ 2 =10.656, p=.001), “Special recipe” χ 2 =9.291, p=.002 , and “Low calorie
diet” χ 2 =16.838, p=.000 . As a result, the percentages of these five activities are
significantly higher in active benefits seekers than the passive benefits seekers.
Conclusions and Suggestions
1. Two clusters are identified as “active benefits seekers” and “passive benefits seekers” by
the elders’ perceived travel benefits. The demographic characteristics, health perception and
travel behaviors in each type are distinct. It indicates the importance of using “benefits” for
elder’s travel market segmentation. Compare to the passive benefits seekers, those who
perceived higher travel benefits tend to be younger, with higher education level, and more
spending power. Also, they travel more often and the time is more recent. They are healthier
and keep a better health habits. These findings reveal positive relationships between
perception of travel benefits and their travel behavior and health.
2. As almost all elders perceived the hotel wellness services and facilities to be somewhat
important to very important, the passive benefits seekers valued more about learning course
activities, atmosphere of calmness or relaxation, non-smoking area/room, and information of
health related topics, in comparison with the active benefits seekers. This may be resulted
from their related demographic background, travel experiences and health behavior. It needs
further research. The top three services and facilities for all elders are sports facilities,
bath/sauna/steam, and activities of learning courses. The findings are similar to the empirical
study by Meuller & Kaufmann (2001) and Tsai & Wu (2005). It is recommended the wellness
hotel operators and marketers to have these services and facilities as the basic requirements in
their infrastructure of the wellness hotels and passive benefits seekers should be the major
target group.
3. The wellness tourism providers should also include “Cultural programs (e.g. music, arts)”,
“Hiking or bicycling with tour guide”, and “Massage” and “Organic food/living food diet”
which are on the top list for elders for their interest of participation. However, compared to
the passive benefits seekers, the active seekers should be the target group for the extended
wellness activities. They have more intentions in joining almost all the wellness activities
provided by the hotels. The differences are especially significant on “Hiking or Bicycling
with Tour Guide”, “Yoga, Meditation, Relaxation Activities”, “Massage”, “Special Recipe”,
and “Low Calorie Diet”.

4. Travel benefit perception reflects the expectation and intention of travel behavior. The
participation interests in extended wellness activities reflect higher intention in involving in
wellness services than the perceived importance of the hotel services. Iso-Ahola (1980)
mentioned of active and passive leisure participation. The active and passive travel benefits
seekers maybe the best indicators of the active and passive wellness travel participation for
the elders.
The distinct characteristics and wellness travel interests of the active and passive benefits
seekers suggest that the benefit segmentation of elder travelers is a useful strategy in
developing wellness market; thus, the operators and the marketers of wellness tourism have to
understand the characteristics of these two types of benefits seekers and their preferred
benefits. When the active benefits seekers are more interested in participation in extended
wellness activities, it is reasonable to infer that to increase the perception or the awareness of
travel benefits of the elders might broaden the market.
5. The hotel operators and marketers are recommended to promote different benefits for
different benefits seekers. To the active seekers, the “ nature appreciation ”, “cultural
understanding”, and “escape and relaxation” are perceived as the most important benefits. On
the other hand, the passive benefits seekers stressed more on the benefits of “family gathering
and relationship enhancement”, “appreciation of the nature”, and “social interaction”. The
marketers can match their marketing strategies with the mentioned benefits to further
motivate different benefits seekers in participating of more health related activities in the
wellness tourism. Especially, as the potential of active benefits seekers in wellness market is
higher, the hotel operators and marketers can promote the market by matching the right
benefits and offer more in-depth, diverse, and learning activities to satisfy their needs.
Therefore, it is necessary for the professionals in wellness market to understand the intention,
demands, and attitudes of the older people and incorporate the wellness knowledge into their
program design and implementation, and be capable of facilitating the elders’ awareness of
wellness travel benefits.
6. To better prepare the market, more detailed information need to be obtained regarding the
specific needs, preferences, and the ways of engaging wellness activities in travel of the
passive and active benefits seekers. Furthermore, the stability of the typology of active
benefits seekers vs. passive benefits should be further tested. As the two-types of benefits
seekers are confirmed within the elder travelers in Kaohsiung, Taiwan, more empirical studies
are needed to verify the two types, as well as its relationship with other wellness related
attitudes and behavior in the future.
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Unpulished manuscript.

Destination Image in the Context of Wellness Travel
Andreas H. Zins
Institute for Tourism and Leisure Studies
University of Economics and Business, Vienna, Austria
andreas.zins@wu.ac.at
Abstract
This study tries to give an answer to the question whether the images of destinations differ
across different travel contexts (wellness vs. sun & beach) and wellness and non-wellness
travelers respectively. This objective is demonstrated by considering two sets of destinations:
European and Asian countries which are specializing to a varying degree in wellness tourism.
In addition, the conceptualization of destination image follows the direction of an ‘overall
composite and gestalt impression’ summarized by Keaveney and Hunt (1992) which requires
also an adequate holistic measurement process. For this purpose the procedure outlined by
Tapachai and Waryszak (2000) for developing so-called proxy benefit prototypes for
describing the product category of a destination is replicated. Meaningful practical results
could be elaborated by profiling destination images of ten different countries from the
perspective of the above mentioned traveler segments. Plots from MDS and consecutive
property fitting procedures assisted in visualizing the results and competitive relations.
Keywords: Category-based processing, MDS, free-elicitation, consumption values
Introduction and Background
Repeatedly tourism scholars are reviewing scientific work related to destination image and its
measurement (Echtner and Ritchie 1993; Jenkins 1999; Gallarza, Saura and Garcia 2002; Pike
2002, 2007; Tasci, Gartner and Cavusgil 2007). Steve Pike’s review of about 260 articles on
destination image studies of the past 35 years confirms a rapidly increasing field of interest.
However, both of his analyses (Pike 2002, 2007) come to the conclusion that qualitative
methods are scarcely used and moreover that most of the studies are lacking a specific travel
context. Echtner and Ritchie (1993) strongly recommended using a combination of structured
and unstructured methods to completely capture destination images consisting of attributebased,
holistic, functional, psychological, unique and common characteristics. Many of the
more recent publications focused on the interrelationship between functional (cognitive) and
psychological (emotional, affective) aspects of destination images. Moreover, the discrepancy
between the mainstream conceptualization of the image construct and a matching
measurement carefully addressed by Keaveney and Hunt (1992) is not overcome
automatically. Similarly, the issue of travel context, particularly relevant when conceiving the
market as partitioned into segments, has not been considered appropriately for the
measurement of destination images.
Particular concerns have been raised as to the conceptualization and an appropriate
measurement of destination image. Concept definitions for the image construct exist almost as
many scholars deal with this issue. Many of these definitions are quite broad appealing to
ideas and impressions, beliefs and thoughts and emotional reflections about a particular
destination (e.g. Hunt 1975, Lawson and Bond-Bovy 1977, Crompton 1979, Dichter 1985,
Reynolds 1985, Tasci and Kozak 2006). In contrast, others explicitly narrow the concept to
associations or components (e.g. Hosany, Ekinci and Uysal 2007, Gartner 1993). However, in

summary or as a commonly accepted bottom line, image comprises not only facts but also
fantasy, not only objective reality but also subjective inference, truth and conjecture,
observation and evaluation.
One of the few exceptions for using a qualitative approach which is embedded in a concise
conceptual framework is Tapachai and Waryszak’s (2000) work on the role of beneficial
image for destination selection. They base their approach on the category-based image
processing theory discussed by Keaveney and Hunt (1992) extensively. Keaveney and Hunt
(1992: 167) argue that the “lion’s share of store image research did not capture store image
empirically”. This caveat of mainly attribute-intensive research approaches for supposedly
measuring synergistic and gestalt nature images does not seem to be relevant in the domain of
retailing but also in the area of destinations (Echtner and Ritchie 1993, Pike 2002, 2007).
The discrepancy between concept definition and measurement is fuelled particularly in view
of the rival mid-level theories of piecemeal processing (Fiske 1982) and category-based
processing (Fiske and Pavelchak 1984, Sujan 1985). Piecemeal processing assumes that
consumers evaluate product attributes each time anew when they are encountered (exposure,
presentation). Evaluations are made independently of the presence of other attributes. And
finally, judgments are formed by combining these isolated elements. This type of processing
and information integration is deemed to be effortful, however, ignores prior experience with
other instances of the same category (inferences, conclusions). By contrast, category-based
processing supposes that incoming information is immediately compared with previously
defined categories based on ‘family resemblance’. Categorization of items evolves and
depends on the degree of match of cues within the category. A successful match invokes the
relevant ‘schema’ in memory. A schema is made of salient attributes, importance of attributes,
relationships among attributes, evaluative conclusions, context, and the sequence of events.
Basically, a copying mechanism is triggered where the generic schema is adopted to a specific
instance together with the affect inherent. If a category match fails completely and the
involvement level is sufficiently high the consumer will engage in a more effortful processing
style and will probably come up with a new category in memory. However, if the incoming
information about a stimulus fits the existing category it is evaluated as ‘typical’ and is
deemed to be best remembered. Otherwise, if mildly discrepant information is encountered
modifications to the existing category have to be made. Yet, it is assumed that these deviating
or differential information cues are quickly forgotten. As a consequence, it is strongly
recommended to adapt measurement techniques to these basic assumptions about information
and categorization processing routines.
Hence, this study tries to give an answer to the question whether the images of destinations
differ across different travel contexts (wellness vs. sun & beach). In addition, the
conceptualization follows the direction of an ‘overall composite and gestalt impression’
summarized by Keaveney and Hunt (1992) which requires also an adequate holistic
measurement process. In this respect, the current study is a replication of Tapachai and
Waryszak’s (2000) attempt with four major extensions: 1. The process for developing the socalled
proxy-prototypes for destinations is based on travelers with and without prior
destination visits. 2. The main study is not administered in a class-room situation but with
travelers of various source markets at a destination which has both main offers: sun and beach
and wellness. 3. The study differentiates between two different travel contexts: sun and beach
versus wellness and 4. To generate useful results for strategic marketing the study investigates
the destination image of more than one country.

Research methods
First, data on beneficial image components were collected in two different settings: 1. from
about 100 travelers at home (Austria in this case) for the destinations Thailand and Hungary
splitting the sample into a 2 by 2 roster: travel context and previous visits. Travel context was
either a wellness trip or a seaside/lakeside vacation. The task was to elicit reasons why they
would travel to the given destination in a completely open format. To consider contextual
differences half of the sample was told to having decided for a sun & beach (sea or lake) trip;
the other half decided for a wellness travel. 2. from about 60 travelers in Thailand
differentiating between wellness and other types of tourists. Applying this kind of item
generating approach it is possible to elaborate on differences in category descriptions about
destinations travelers bear in mind when choosing travel destinations.
Second, to address the focal area of concern – the dominance of piecemeal or attribute based
image measurement – this study followed the line of thought of the middle level theory of
category-based processing. Once, consumers are capable of assigning a new stimulus to an
already known category she or he infers existing knowledge and schemata about the category
which is held in memory for an exemplar or prototype (Fiske and Pavelchak 1984). Tapachai
and Waryszak (1990) developed so-called proxy prototypes for a destination (Thailand and
USA) splitting them along five different value domains initially developed by Sheth, Newman
and Gross (1991). Their model assumes that consumers associate benefits of consumption
values with a product or service which can be condensed into a five-dimensional array:
functional, social, emotional, epistemic, and conditional. For the current study the following
destination proxy prototypes (see Table 1) have been developed from the Step 1 data
collection and grouped along the five consumptions values. Respondents were invited to give
their comments and remarks on the category descriptions. Coding of the consent, partial
consent or disagreement with the prototype descriptions followed the procedure outline by
Tapachai and Waryszak (2000).
Table 1 Proxy prototypes for destination images split into five dimensions
Dimension Proxy prototype
Functional Thailand is generally known as a vacation destination with beautiful
scenery, many attractions and a constant warm climate. I associate it
with healthy and country-specific food, cheap shopping opportunities as
well as with outstanding sea water quality (colours) and beach quality. I
immediately combine it with family friendly services and authentic spa
and wellness services.
Emotional Thailand is well-known for exotic, relaxing and pampering holidays.
The country offers romantic, calm and vacations in a safe environment.
Local people are open-minded and share an outstanding friendliness
paired with an exceptional hospitality.
Social Thailand is highly recommended by friends and relatives. Many visitors
come back again and again. It is a destination where you can meet
people of every age and have plenty of parties.
Epistemic Thailand is a country to go for its very different culture. It is known for
a rich variety of traditions. Holidays in the country can easily be
combined with city visits to learn a lot about its cultural heritage.
Conditional For me, Thailand is a destination which is easily accessible and offering
good value-for-money. There are always a lot of offers and attractive
deals. Holidays there mean low incidental expenses.

Third, these proxy prototypes were embedded in a larger paper-and-pencil questionnaire
which was administered among real travellers to Portoroz, Slovenia (527 overnight tourists
from Slovenia, Croatia, Italy, Germany, Austria, Scandinavia). Tourists were invited to
answer in one of the following language versions: English, German, Italian and Slovenian.
The sample was split into two halves: one sub-sample had to reflect on five Asian destinations
(Thailand, Malaysia, Indonesia, Vietnam, Maldives); the other sub-sample dealt with five
European destinations with access to the sea (Slovenia, Italy, Croatia, Bulgaria, Montenegro).
The destinations were selected on the basis of current and/or near-future competitive
relationships in the wellness market. Even though the terms wellness and health tourism do
not share a global and unique definition the phenomenon of a widely increasing tourism
demand with a strong emphasis on physical and mental balance is generally recognized
(Bushell and Sheldon 2009, Smith and Puczko 2009). The investigation of destination images
in the context of two very different traditions of spa and wellness trends (Europe and Asia)
appeared to be challenging and insightful.
Although the open-ended task of collecting elements of the destinations’ images revealed a
number of common (congruent) arguments for Hungary and Thailand, the content analysis
lead to the assumption that two different sub-categories of destination prototypes exist For the
main study (considering only countries with traditional sun and beach tourism), though, the
proxy prototypes were held constant for each of the ten countries involved expecting stated
partial or full objection where applicable. However, based on the insights gained from the
preparatory studies it was deemed not meaningful to project and visualize all ten destinations
in one common competitive map. Finally, to capture contextual effects (wellness vs. sun and
beach), travellers interviewed for the main study are segmented by their propensity to engage
in wellness activities for the current trip or in a wellness travel in the future.
Results
The sample generated from overnight tourists at the selected beach resort in Slovenia was
stratified by nationalities. The given quotas prioritized the top ranked nations, however the
shares are not meant to be proportional to the official statistics. Consequently, the averages
reported here cannot be taken as a valid picture for the average tourism demand for the region.
In contrast, this convenience sample serves the purpose of contrasting mainly two different
traveller segments. These two segments are defined a priori by their affinity towards wellness
travelling. If the current trip was self-rated as a wellness or beauty stay (out of a list of 15 predefined
main travel purposes) or if the respondent stated that she or he generally prefers
staying at wellness resorts or hotels with spa facilities or at some place where spa activities
are consumed, this traveller was classified into the “high affinity or wellness traveller group”,
otherwise into a “low or no affinity segment”. Hence, 62% of the respondents could be
assigned into the group of wellness travellers.
Since the total sample was split into two questionnaire versions (incorporating different sets
of destinations) the structural differences and similarities of the sub-samples are analyzed
first. No significant differences are detected in terms of nationality. Overall, there are 29%
Slovenian tourists, 25% from Austria and Germany, 22% from Italy and 24% other
nationalities. No differences in educational level and gender can be reported. On average,
respondents followed 14 years of formal education: 31% up to 12 years; two thirds up to 15
years; and one third even more. The Asian sub-sample appears to be slightly older (2.5 years
on average). However, significant differences across nationalities and wellness affinity turned
out: Among Slovenian tourists only 50% can be identified as highly interested in wellness
travel. Italian respondents rank highest with a share of 72% compared to 62% on average.

Austrian and German travellers seem to be interested more than average in wellness trips
(67%). This segment appears to appeal more female travellers with 67% share which is a
regular phenomenon in the wellness travel market. No age differences between these two
segments turned out. On average, 37% are at the age below 30 years, 40% in the bracket of 30
to 49 years and 23% belong to the cohort of 50+.
The accommodation chosen for the current trip can be taken as a proxy for preference
differentials in general: 57% of wellness travellers chose hotels whereas the share among nonwellness
travellers is only 39%. The non-wellness segment prefers more private
accommodation, campsites, and non-paid forms (secondary homes, stays with friends or
relatives). A good majority (60%) of the wellness inclined segment can be found in 4-star
hotels compared to 53% in the non-wellness group. The following Table 2 visualizes the
different main purposes of travel as stated by the different respondent groups. Overall, there
are not too many differences except for culture, culinary and curative stays driving the
wellness segment significantly more. The apparent stronger emphasis on recreational
purposes for the wellness segment is not sufficient to be significant.
After having inspected the socio-demographic background and basic travel profile of the two
travel segments the focus changes to investigate the destination experiences and near-future
plans together with the association of destinations with wellness trips. Table 3 gives insights
into these three perspectives. Whereas some differences in prior destination experience are
mainly due to the sample structure (Austria, Germany, Italy) the wellness segment appears to
represent the more travel active travel population. This materializes in the higher rate of past
visits to Hungary and Slovakia and particularly for the Asian destinations: Thailand,
Maldives, China, Japan, India, Indonesia, Vietnam, Philippines, Malaysia and Singapore.
Another perspective is covered by the travel plans looking 5 years ahead. Similarly, some
destinations are favoured through domestic tourism. Higher intentions are revealed by the
wellness segment for Croatia and Hungary and for all Asian countries presented in the
questionnaire. Among the countries most preferred in this region are Maldives (43%),
Thailand (38%), and Malaysia (33%). The differentials between non-wellness and wellness
travellers, though, can be seen as a first sign of competitive advantage for the latter market
segment. The relative difference is highest for Thailand, Philippines and Indonesia (almost
double) followed by Malaysia, India and Vietnam.

Table 2 Main travel purpose of the current trip by wellness segments
Main purpose of this trip
Non-Wellness
traveller
Wellness
traveller
City break 41% 42% 483
Culture tour 28% 40% 474 a)
Multi-destination trip (organised or individual) 27% 34% 486
Activity-packed holiday with lots of exercise/sports 23% 23% 476
Recreational holiday in the sense of relaxing, with little 57% 64% 491
exercise/sports
Curative stay (recommended or prescribed by doctor) 5% 15% 478 a)
Wellness/beauty stay 0% 36% 476
Visit to an event 17% 18% 473
Visiting relatives/friends 27% 20% 483
Private stay in connection with business/fair/congress 9% 10% 479
Hiking/mountain climbing holiday 10% 11% 478
Cycling/ mountain biking holiday 13% 11% 475
Seaside holiday 77% 80% 504
Culinary tour 28% 37% 471 a)
Wine tour 15% 20% 474
Note: a) Chi² statistic significant at < .05.
Another, more focused, approach to measure the perceived suitability of a destination for
wellness trips was taken be the related question of which country the respondents would
recommend for a wellness trip (third column of Table 3). Again, domestic countries are
somehow positively biased from the nationalities represented in the sample. However,
Hungary shows the strongest appeal among the remaining European destinations. For the
Asian countries, the relative differences are highest for Thailand followed by the Philippines,
Maldives, Malaysia and Indonesia. Finally, an open-ended question allowed for suggesting
additional destinations for wellness trips not mentioned in the closed list of countries. Spain,
France and USA ranked on top of these additional destinations favoured by the wellness
segment. Turkey was mentioned almost as frequently as France however did not qualify for a
specific segment. In contrast, Greece has the same frequency as Turkey but is more often
recommended as a wellness destination from the perspective of non-wellness travellers.
Before going on to the results of the image measurement itself it is important to check the data
for non-response behaviour. The responses to the destination descriptions (presented along the
5 consumption value dimensions for each the 5 countries) are not as complete as in a typical
“check any given item” response format. Table 4 investigates therefore if some systematic
influences can be detected that help explain the rate of non-response. The first column of
Table 4 shows the average non-response share for each of the 5 countries prescribed (5
European and 5 Asian for the two sub-samples in the order of appearance in the
questionnaire). From the Asian sub-sample it can be clearly seen that no sequence or fatigue
effect can be substantiated. For the European sub-sample this is not so obvious.
n =

Table 3 Past, future and particular wellness trip destinations by wellness segments
Non-wellness travellers Wellness travellers
Past experience
Future 5
years’
plan
Considering
wellness
Past experience
Future 5
years’
plan
Considering
wellness
Austria 70% 44% 18% 86% 56% 42%
Bulgaria 21% 26% 10% 19% 26% 15%
Croatia 79% 49% 18% 77% 56% 30%
Czech Republic 45% 31% 10% 48% 30% 16%
Germany 62% 42% 13% 74% 50% 29%
Hungary 44% 29% 15% 53% 33% 25%
Italy 74% 41% 16% 86% 59% 37%
Montenegro 19% 32% 11% 22% 35% 18%
Slovakia 22% 23% 10% 26% 23% 16%
Slovenia 74% 42% 20% 71% 44% 33%
China 7% 22% 10% 10% 26% 13%
India 6% 22% 11% 10% 31% 17%
Indonesia 3% 17% 11% 8% 31% 19%
Japan 6% 23% 11% 6% 29% 14%
Malaysia 3% 19% 11% 7% 33% 20%
Maldives 5% 29% 15% 11% 43% 28%
Philippines 2% 16% 11% 6% 30% 23%
Singapore 4% 17% 10% 6% 26% 17%
Thailand 7% 20% 13% 16% 38% 28%
Vietnam 3% 16% 8% 6% 25% 13%
However, investigating the effect of non-response further by differentiating by prior visits of
this destination (column 2 and 3 of Table 4) it becomes evident that for 7 out of 10 countries
the refusal of answering is due to a lack of personal experience. Exceptions that apply for the
Maldives, Slovenia and Italy demonstrate that perceptions and associations were more easily
accessible even in the event of no prior personal exposure. A final check, though, should
inspect if the problem of non-response spreads equally across the two segments (columns 4
and 5 of Table 4). In this respect, the proportions for non-response show only for Italy a
significant difference.
Following the coding procedures for the remarks and comments on the presented destination
proxy prototypes documented by Tapachai and Waryszak (2000) these descriptions were
broken down into 31 different attributes (see Table 5) for which agreement (“1”) or
disagreement (“0”) was coded. Differences of frequencies along these 31 attributes are
inspected for the two traveller segments: non-wellness and wellness. Hence, in total, twenty
destination profiles are available for analysis. Overall, it stands out that wellness travellers
have stronger (more frequent) associations with the destinations compared to the non-wellness
segment. This effect becomes more apparent for more familiar countries and applies for
European as well as for Asian destinations. To eliminate this awareness or salience effect the
following analysis refers to deviations from the average difference between non-wellness and
wellness travellers in descending order of strength.

Table 4 Non-response shares for destination images by prior visits and wellness
segments
Non
response:
average
sample
No prior
visit
Prior visit
Non-
wellness
travellers
Wellness
travellers
Slovenia 17% 18% 17% 22% 13%
Italy 28% 38% 26% 35% 23% a)
Croatia 30% 47% 25% a) 31% 29%
Bulgaria 57% 62% 37% a) 59% 55%
Montenegro 51% 57% 26% a) 55% 48%
Thailand 30% 33% 9% a) 37% 26%
Indonesia 44% 46% 22% a) 52% 40%
India 42% 44% 15% a) 47% 38%
Vietnam 52% 54% 27% a) 57% 49%
Maldives 43% 43% 38% 50% 39%
Note: a) Chi² statistic significant at < .05.
Table 5 Image attributes as used by the proxy prototype descriptions and for profiling
destinations
Beautiful scenery Relaxing Meet people of different age
Many attractions Pampering Different culture
Warm climate Romantic Variety of traditions
Healthy food Calm City visits
Country-specific food Safe Cultural heritage
Cheap shopping Open-minded locals Easily accessible
Water quality Friendliness Good value-for-money
Beach quality Hospitality Many offers and deals
Family friendly service Recommended by friends Low incidental expenses
Authentic spa and wellness Many repeat visitors
Exotic Plenty of parties
Note: items in italic were not used in Tapachai and Waryszak’s study (2000)
Slovenia shows a more favourable image within the wellness traveller segment with regard to
“beautiful scenery”, “authentic spa and wellness facilities”, “water quality”, “family
friendliness”, “beach quality” and “many attractions”. Social value facets such as “meeting
people of different age”, “recommended by friends”, “many repeat visitors” and “plenty of
parties” are much less attributed to this destination. Croatia shares stronger associations in
the wellness segment with respect to “relaxing”, “romantic” and “safe” and weaker ones as to
“city visits”, “variety of traditions” and “different cultures”. The wellness travellers see Italy
more linked with “easy access”, “many offers and deals” and “recommended by friends” but
less with “different cultures” and “romantic”. Bulgaria shows a much less pronounced profile
and profile differences among the two traveller segments. Stronger associations by the
wellness segment appear for “recommended by friends” and “relaxing” whereas as weaker
ones for “different cultures”, “city visits” and “variety of traditions”. Similar effects can be
observed for Montenegro. However, different aspects stand out: “beach quality” and “many
offers and deals” are more frequently attached with the destination; “many repeat visitors”
and “recommended by friends” less frequently.

The second sub-sample considered five Asian destinations for which the following image
profile differences can be observed. Thailand is differentiated positively by the wellness
segment by only a few elements: “meet people of different age”, “warm climate” and “many
repeat visitors”, and negatively by “city visits”, “romantic”, “open-minded people”, “calm”
and “cultural heritage”. Indonesia, in turn, exhibits a more favourable image among wellness
travellers with regard to “relaxing”, “hospitality”, “friendliness”, “romantic”, “calm” and
“exotic”; it is less favourable as to “low incidental expenses”, “easily accessible”, “meet
people of different age” and “water quality”. India’s image among wellness travellers appears
more pronounced with respect to “calm”, “open-minded people” and “healthy food” whereas
weaker in terms of “easily accessible”, “low incidental expenses”, “many offers and deals”
and “safe”. Vietnam is seen by the wellness segment more favourable with regard to
“friendliness”, “hospitality”, “romantic” and “calm” but less positive as to “plenty of parties”,
“meet people of different age”, “many repeat visitors” and “water quality”. Finally, the image
profile for the Maldives is stronger among wellness travellers with respect to “easily
accessible”, “many offers and deals” and “cultural heritage” whereas weaker as to “healthy
food”, “country specific food”, “family friendly” and “authentic spa and wellness”.

Figure 1 Image positions of five Asian destinations by non-wellness and wellness
travellers
The final analysis uses the profile data for the selected destinations (2 sets x 5 countries x 2
segments x 31 attributes) to project their associations into a low-dimensional beneficial image
space. This approach was conducted by applying two separate runs of multi-dimensional
scaling procedures (ALSCAL: Young 1987: 32) on the rectangular matrices. A threedimensional
configuration for the Asian data converged with ratios for Kruskal’s Stress at .02
and and R² of .99. The European data had similarly satisfying convergence conditions: Stress
= .01 and R² = .99. The following two Figures 1 and 2 use the coordinates of the 3dimensional
space of the destinations and add the attribute profiles attached to them through a
routine called property fitting calling the C-Match algorithm developed by Cliff (1966; Rroutine
programmed by C. Buchta). Destination labels without suffix represent images held
by non-wellness travellers whereas labels with the suffix “_W” represent those of wellness
travellers.

These MDS-plots help to visualize competitive relationships among the given destinations
and to identify large or small differences among the selected traveller segments. The projected
attribute vectors support finding meaningful shortcut descriptions for the dimensions of the
MDS map. The compound image differentials materialize particularly for Thailand and
Indonesia. Distances along Dimension 1 are relative large compared to the other countries and
can be traced back to attributions of “warm climate” and social benefit aspects. In Dimension
2 only the Maldives are set aside from the other destinations profiling strongly by the
attributes “romantic”, “calm” and “pampering”. Dimension 3 separates again the Maldives
particularly from India and Thailand which is particularly due to the cultural heritage
associated with the latter ones and the outstanding beach and water quality attached to the
former.

Figure 2 Image positions of five European destinations by non-wellness and wellness
travellers
The competitive positions for the European destinations can be summarized as following:
Distances between the two traveller segments are particularly strong along Dimension 1,
however much larger among Slovenia, Croatia and Italy compared to Montenegro and
Bulgaria, both destinations which are rather in an early stage of their tourism life-cycle. Social
aspects (favouring the Bulgarian and Italian image) and “relaxing”, “many attractions”,
“country-specific food” (favouring the Slovenian image by wellness travellers) are profiling
the second dimension. Cultural diversity together with the flavour of romance determines the
stretch along the third dimension setting Croatia distinctly apart from the four other
destinations.
Conclusions and Recommendations
The study aimed at replicating the applicability of the measurement of destination images
through proxy beneficial prototypes in the light of a category-based processing paradigm. The
replication of Tapachai and Waryczak’s (2000) study about Thailand and the USA followed

four lines of extensions. First, the preparation steps of collecting free elicited arguments for
visiting a destination took place with travellers of different age, gender, prior destination
experience and situations (at home vs. at the destination). While the individual salience of
arguments was limited to an average of 4 to 5 the content analysis and categorization into
more abstract benefits resulted in 48 different aspects out of which 31 have been used to
develop benefit proxy prototypes covering the five consumption value domains outlined by
Sheth et al. (1991). Compared to Tapachai and Waryczak’s study using predominantly
students as respondents this study reveals a broader scope in functional, emotional, epistemic
and social aspects, however a narrower perspective of conditional benefits (rather limited to
price and accessibility arguments) which seems rather due to the geographic location between
generating and receiving country. In addition, the preparatory data collection steps did
consider two different contextual views: a) a European – short distance – vs. Asian – long
distance and b) a seaside/lakeside vs. wellness trip purpose. Differentiating by two completely
contrasting geographic regions it became quickly evident that travellers developed at least two
different sub-types of destination categories. However, the specific travel purpose did not
seem to be a sufficient condition that respondents elaborated or referred to a different subtype
of a destination category (Zins and Prompitak 2009).
The second extension to the initial study aimed at testing the proxy prototype instrument for
measuring destination images with ‘real’ travellers. The sample taken in Slovenia served the
purpose to have easy access to travellers of different national backgrounds with a high
propensity to belong to either a segment with a strong preference for sun and beach vacations
or with a strong affinity towards wellness trips. The samples were split into half covering
selected European destinations on the side and Asian destinations on the other. Both samples
shared very similar socio-demographic and travel characteristics which reduced unintended
impacts on the image measurement results.
The third extension dealt with the influence of a particular travel context. While the
preparatory studies stated the main purpose of the fictitious trip explicitly (sun and beach vs.
wellness) the main study investigated the destination images from the perspective of two
different traveller segments (wellness vs. non-wellness). Apart from their general travel
preferences towards wellness and spa activities travellers belonging to this segment
demonstrated straight behavioural differences relevant for tourism marketing: gender,
nationality, accommodation types and quality levels, past and future travel experiences. From
this approach of competitive analysis it can be concluded that Hungary and Croatia – apart
from Austria, Germany and Slovenia – have positioning advantages as wellness destinations
within the wellness segment; much in contrast to other European destinations like Turkey,
Greece or Spain. Among the Asian countries a similar advantage can be observed for
Thailand, the Philippines, and Maldives.
By considering not only one destination but a number of current or potential competitors the
current study made a fourth extension. A contrasting analysis for both traveller segments and
for each of the ten destinations revealed relatively outstanding assets and weaknesses which –
of course – can only be assessed finally by comparing positioning goals of an individual
destination. Yet, it is rather intriguing that the much stronger image associations for Indonesia
and India create some mental obstacles to position Thailand as a wellness destination more
favourably, particularly among wellness travellers.
Assuming that the category-based processing theory holds in the context of destination
competition: what are the consequences for destination marketing managers? Under the

piecemeal hypothesis and an undifferentiated strategy for a given destination it would be
sufficient to emphasize on the attributes which are common to similar countries. In contrast,
under the category-based assumption the destination marketing organization would rather
follow the schemas underlying the relevant destination category. This category seems to be
less distorted by a given travel purpose and more dependent on the geographic distance and
nationality. More relevant however appear to be two other main strategies: differentiation and
niche. While the marketing plans would not differ essentially compared to the undifferentiated
strategy (putting some or relatively strong emphasis on one or several attributes) under the
category-based processing assumption it would have to entail a differentiation on many if not
all aspects to induce the consumer to develop a sub-type. This recommendation is neither
obvious nor apparent from competitive positioning maps commonly generated in marketing
research. Yet, the consequences for developing an appropriate destination marketing strategy
are quite different considering a priori completely different information processes on the
consumer side.
What lessons could be learnt from a methodological point of view? The replication of the
proxy prototype instrument for destination image measurement was successful in general. The
non-response problem was slightly better (average across destinations: 39%) compared to the
students’ sample of Tapachai and Waryszak’s study (2000; 45%). Considering, though, the a
priori selection of only destination novice students the non-response phenomenon in the
current study among travellers without prior visits to the various destinations was exactly the
same. Nevertheless, from comments respondents wrote into the questionnaire it became
evident that many respondents refused any response due to a lack of sufficient knowledge.
This cognitive boundary is difficult to break through where appropriate. Relatively openended,
unaided answers are cognitively more effortful to elaborate and to reveal (orally or in
written). Aided answer formats – often in the form of attribute lists – ease the job however
may introduce biases between long-term, stable cognitions versus those which are constructed
ad hoc.
The experiences of the content analysis and the consecutive coding steps into more abstract
benefit categories which fit into the proposed five consumption value dimensions gave
additional insights into the critical role of the researcher. The split into the functional,
emotional, social, epistemic and conditional dimensions is in many instances artificial and
cuts the rich, contextual and schema-based information delivered by respondents into pieces.
Valuable nuances get lost which are against any comprehensive and more complex
conceptualizations of destination (or brand) images. Measurement instruments slicing the
image concept into lists of attributes where cognitive, affective and maybe conative aspects
are treated separately rather move away from a valid mapping effort.
In this respect, the current attempt has probably also limitations and avenues for further
improvements and refinements. The question of which destinations are competing which each
other: only destinations within a limited geographic distance or only destinations with exactly
the same tourism products? should be addressed by applying different research methods.
Further evidence should be elaborated on how destinations are represented in the consumers’
minds and compared which each other. Repertory grid techniques are among meaningful
options. And, of course, in order to deliver more relevant results for marketing purposes, a
study into competitive relationships among destinations would have to be extended to the
most important generating markets for a specific destination

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What is Tourism in Dental Tourism?
Judit Zoltan and Rico Maggi
Faculty of Economics, University of Lugano, Switzerland
Istituto di ricerche economiche
Via Maderno 24, CP 4361, CH-6904, Lugano, Switzerland
judit.zoltan@usi.ch
Abstract
Dental tourism is an important segment of the growing health tourism industry. Patients
generate relevant tourism revenues for the destination country beyond the direct income of the
dental clinics. This paper illustrates the development of dental tourism in the case of Hungary
based mainly on price competitiveness of treatments. The first part of the paper traces this
development on the base of in-depth interviews with representatives of the sector arriving at
the conclusion that the treatment element still dominates the tourism experience. The question
therefore arises whether a more destination based strategy would allow for a sustainable
future. To respond to this question, the second part of the paper models the experience of the
dental tourist in three phases - get there, stay there and live there – focusing on trip duration,
expenditure and tourists’ activities. Finally, implications for destination marketing strategies
to overcome prospected future decline are discussed.
Introduction
The research is focusing on the tourism components of a specific medical treatment abroad.
Medical tourism captured worldwide attention only in 2006, when medical journals started to
publish papers on the topic, as awareness of the phenomenon in both developing and
industrial countries was increasing (Horowitz, 2007). It became a growing trend, and its
organization, volume and economic impact changed. According to Connell (2006), a medical
tourist is someone who in order to minimize his costs of health care decides to travel abroad,
and becomes a tourist. Statistically speaking this may be true but it is not very useful
analytically as it mixes dental migrants (or commuters) with dental tourists in a strict sense (as
we want to define them in this study) i.e. dental patients who combine the consumption of a
treatment with tourism experience.
The dental tourist’s decision starts with a health problem which creates a more or less urgent
need for an intervention by a dentist. If the price differences among services “at home” and
“abroad” at some perceived quality level are important enough to incite the patient to travel
abroad for the intervention, the dental patient becomes a potential dental tourist who is
choosing a dentist, and – seemingly – in a simultaneous way a destination. However, if the
destination has no touristic value as such for the patient other than being the location of the
more convenient offer for a dental service, we cannot usefully consider this as being dental
tourism. Medical services are dominant in the experience, while tourism spending is not
significant.
Travelers who buy health care abroad usually get a package deal including the treatment, air
transport, transfers and accommodation. Tourism is thus rather a byproduct of packaging, but
creates substantial benefits to the travel industry. Although as will be argued below, the
tourism part is not necessarily sustainable as it depends completely on the price differences of
medical treatment. We will therefore discuss the potential for increasing the tourism value of
dental tourism to the patient and to the destination.

Among the economic factors determining the demand for medical tourism, several
components can be identified; the most important being differences in treatment price, in
national health systems and in conditions of private health insurance. The reduced prices can
compensate for the absence of insurance overall or for some treatments (e.g. cosmetic
surgery). These push factors are well known from UK and USA who are important source
countries of medical tourism in general. Concerning dental treatments, the British national
health system, scarcely funded by tax revenue, results in long, up to half year stays on the
waiting lists, while some treatments are hardly available in some regions. At the same time
UK`s private clinics are offering their treatments at unaffordable prices for many. As far as
the US is concerned, an estimated 50 million of citizens are without health insurance and 120
million without dental coverage which creates and important potential for medical and dental
tourism. To what extent this translates into effective demand depends on the type of
treatment. Bookman and Bookman (2007) claim, that the price elasticity of demand depends
on the importance of the operation less complicated and more available treatments being more
price sensitive. The implication for destinations is that they have to closely observe the
development of relative, all inclusive prices to the patient between the source country and
their own for different kinds of treatments before they ponder about additional tourism
services. Apart from price differences, the necessary elements for the development of medical
tourism (Bookman and Bookman, 2007) are: skilled local human capital, domestic research
and development, developed infrastructure, stable political and regulated legal institutions,
liberalized market economy, available tourist attractions.
Finally, as in general in tourism, good and cheap accessibility (i.e. mostly air transport
services) will enhance the competitiveness of a dental tourism destination. Improved mobility
gives better access to health services for the patients, and allows for a more efficient use of
existing medical capacities. (Österle, 2007)
The Case of Dental Tourism in Hungary
Most of the medical tourism destinations offer dental treatments, but there are some countries,
which are specialized in it. Only estimations are existing, how many people are undertaking
dental tourism worldwide? RevaHelath, an Internet-based database of healthcare providers for
the medical and tourism sector, is estimating the market through online advertising
campaigns, impressions of web searches in the sector. Their numbers are still useful as
indicators, looking at the World and Hungary’s dental market. The leading dental tourism
destination is Mexico, which comes from its closeness to the United States, from where 25%
of the worldwide dental tourist are coming. The second place is shared between India and
Hungary. Hungary is serving more European patients, while India attends Asian patients, and
they share some of the US citizens.

In Table 1. the average prices of each dental treatment at each dental tourism destination are
presented. The last two columns of the table show the prices of the dental treatments in UK
and USA, which are the main sender countries regarding dental tourism. The difference is
considerable in most cases.
Dental migration dates back to the late 1980’s, when border-crossing Austrians have been
visiting Hungarian dentists, because their prices were much cheaper than in Austria and their
work was known to be of high quality. In the 1990`s German and Swiss patients followed this
health migration movement. Around 2003 some dental clinics started to supply incoming
dental tourists with travel arrangements and accommodation, information about the
destination, basing the marketing on price savings and tourism. This became possible with the
presence of the budget airlines, the entry to the European Union in 2004, significantly cheaper
dental prices than in Western countries and the well-known expertise of Hungarian dentists,
which will be discussed later on.
Demand side analysis already exists on the topic, however no study has been conducted on
the supply side; on the organization of dental tourism, the actors involved, their strategies,
how they are structured and co-operate with different partners. How can the two different
sector, tourism and dentistry combine their products?
Through questionnaires the market has been examined by Bünten (2006) and Österle, Balazs,
Delgado (2009). Bünten (2006) was questioning foreign tourists about dental treatments in
three regions of Hungary; a spa destination, a city at the Austrian border and Budapest. Form
the answers of the respondents Bünten (2006) describes three type of dental tourist and their
characteristics at the different destination. Österle, Balazs and Delgado (2009) sent their
questionnaires via the Hungarian Medical Chamber to all registered dentists in the border
regions with Austria and in the capital, Budapest, receiving a 25,34% and 20,65% response
rate from the regions. In their results patients from neighboring countries are more attracted to
the regions in Western Hungary, while patients coming by airplane are preferring the capital,
Budapest, for dental treatment. Both studies found the price-performance ratio the main
reason of the dental trips.
For our study the methodology of in-depth interviews has been chosen, in order to get an
overview of this market from the suppliers involved. Eight experts have been interviewed,
public authorities from the tourism and the dental side and private players (Table 2.).
Additionally two cases of direct evidence have been collected via interview and an
experiment to get a deeper insight on actual price differences and organizational issues.

The demographic profile of the dental tourist coming to Hungary has been built in accordance
with the interviews done. The average age group, country of origin, income status and party
composition are shown in Table 3. For further analysis, it is important to highlight that the
patients are mainly from the lower part of the middle class, with a growth toward the higher
middle income classes. People from low income classes in case of Great-Britain are rather
waiting for the free national health treatments, or do not repair their teeth at all. Patients with
high income tend to do less dental travel, as for them the time is more precious, and they can
afford private dental treatment in their own country.

Dental trips are not penalized by seasonality; patients have teeth problems all year around.
Dental tourism is less likely in the Christmas-New year’s break and in the month of August,
in the seasons of traditional family holidays, both for doctors and patients. Some dental clinics
are also closing for those periods. Most of the arrivals are on Sunday nights, and the first visit
of the dentist on Monday, differently from leisure travelers arriving for weekends. Hence a
partnership with a dental clinic represents a perfect complement to the leisure business with
respect to seasonality and weekly variations. The type of accommodation, where dental tourist
usually stay are 3-star partner hotels, most of the agencies and clinics have agreements with
them in Budapest. Some agencies offer wider scale of accommodation from bed&breakfasts
till 5 star hotels. This is a mutually beneficial partnership, the clinics can provide discounted
rooms to the patients nearby, while the hotels have very high occupancy rate all year around,
saving costs for the marketing and sales department.
The duration of the trip depends on the nature of the dental treatment. In Table 3. the three
most usual durations of dental trips are introduced. All of these require more than the average
stay of a normal tourist in Hungary, which is 2,6 days (Hungarian Central Statistical Office).
The mode of transportation is airplane for 90% of the dental tourists. Hungary and its close
neighbor countries are well-served with budget-airlines, which can keep the price of the
overall experience low.

The main part of the tourists’ expenditure is coming from the dental treatment itself. As an
example, an Italian patient’s cost calculation about his dental trip is presented in Table 4. The
price in his case depended on how many implants it was necessary to install. There are two
solutions, comprehending a different number of implantations from 8 to 16. In Italy the
dentist always suggested “the 16-solution”, the most expensive and also the “easiest” in
technical terms, but also very “destructive” for the patient. The estimated cost was 100.000 €.
In Hungary the dentist offered him the solution with 8 installations and significant savings.
As compared to this extreme example, the average saving is around 50-70% of the price in the
sender country, according to our interviews. Private insurance companies are also saving on
the reimbursement; therefore they encourage their customers for treatments in cheaper
countries. The most required treatments are the implants, bridges, and crowns, because those
are the most expensive and allow bigger savings on the treatments. On average 3-4.000 €
spent on a treatment.
For further evidence, an experiment was conducted using a test person with cosmetic dentistry
problems. An estimate was requested with an x-ray for her treatment in Lugano, Switzerland.
Using the online contact form of dental clinics and agencies in Hungary, the same request was
sent to 15 of them. Treatment type and price, accommodation offers and trip duration were the
main curiosities. 12 answers were returned and the results are presented and compared in
Table 5. There are four possible solutions for the patients’ problem; treatment I refers to a
cheap composite filling, while treatment II, III and IV require a dental laboratory. The
difference in the last three options is the material and the technology used; III and IV are more
expensive, higher quality solutions. Responses showed higher prices from agencies, due to
their commission fee. Packages include the treatment price and the hotel price multiplied with
the number of nights suggested by the clinics. The table confirms that for small scale
treatments it is not worth travelling, while more labor-intensive procedures shows significant
savings even combined with the travel costs. The graph (Figure 1) represents a hypothetical
demand curve for a specific dental treatment and illustrates the potential welfare gain realized
at destination which creates a potential for demand for additional tourism services and
products.

Figure 1 Demand curve using the data from the experiment
In order to analyze the tourism effects of a dental treatment in Hungary, Interview I has been
conducted with the representative of one of the main sender countries. The tourism
representative noted, that in 2007 55.000 Irish tourist visited Hungary, among them almost
10% went for dental treatment. 40% of all Irish dental patients going abroad have chosen a
Hungarian clinic for their treatment. Approximately 5.000 patients spent at least 5 nights in
Hungary.
In line with the Interview I, the tourism factor has not got a significant role in the decision for
having a dental treatment abroad. The clinics can sell their product easier if it is in Budapest,
even if it is a bit more expensive. 80% of the dental tourists are going to Hungary only for the
dental treatment. The other 20% are interested in visiting Budapest in the first place, and
decide after to undertake a treatment during the holiday. So far the Tourism Office of
Hungary did not deal with the dental tourism topic. They are promoting heavily the Spa
culture of Hungary, the curing thermal water, as health tourism. Dental tourism is mainly
motivated by the price advantage not the country itself that is why, the tourism industry is less
interested in it. Even though the opportunity is high to convert patients to normal tourists.

Interview II was with the Chief Dental Officer of Hungary responsible for quality control and
head of dental staff and dental profession in the country. According to him, Hungary’s leading
position is based on its cheaper prices and high quality dental education. The proof of this
high quality education is coming from Israel, which is the only country where dental
education is measured. Israel has one of the highest proportions of dentists to the general
population in the world, with some 7,500 dentists currently practicing and about 300 new
ones joining the profession each year. That is reason, why they have introduced a dental
licensing examination, which is mandatory to complete successfully in order to obtain
recognition as a dentist. Apparently students having obtained their degree in the Semmelweis
University of Hungary, pass this exam with the highest results. In fact each year
approximately 120 international students are enrolled at one of the English language medical
programs at the university. The result of the EU/EEA Dental Complement Authorities Survey
from 2006 can be seen in Figure 2. Hungary has the highest ratio of dentists with the
specialist degree in the European Union. It is due to the fact, that before the political and
economic changes of 1989-1990 it was compulsory to study an additional 3 years in a
specialized filed of dentistry for being allowed to practice.
The remaining interviews confirmed the findings cited. Turning to the tourism related aspects
of the findings we discuss the way of organizing the trip, which will lead to the identification
of a destination based strategy in the next part of the paper.
Patients can organise their dental trips in three different ways. Contacting directly the dental
clinic, using a dental agent abroad, or booking via a dental travel agency.
In the most simple case, the patient contacts the dental clinic directly via internet or phone, in
order to get a quote for his treatment. In this model the patient does not pay the commission to
the agent for organizing the trip. Most of the dental clinics have agreements with partner
hotels, if the patient is asking for help in booking accommodation. The hotel can help them in
spending their free time. Clinics following this model are the least successful in the
international competition, as they have only the presence on the Internet abroad. However
those, which are located in well known spa destinations are receiving many incidental tourist

from Austria and Germany. Especially elderly repeaters, who are spending 2-3 weeks of
holiday there, and during their stay seek out the dental treatment. In this case the dental visit is
the secondary motivation of the patient.
The second possibility is to contact a Dental Travel Agent. In this case the dentistry is
working with several dental travel agents located in the sender countries and mainly expatients
of the clinic. They are representing the tangible aspect before the experience, the
person with whom a patient can talk to and build up trust. The agents are intermediates
between the clinic and the patients, everything is communicated through them, they ask for
the quote and book an appointment for the patients. The accommodation is booked by the
clinics at the destination. In terms of number of dental patients per months, this model proved
to be the most successful one. Though success can be influenced by many other factors, such
as how long they have been treating foreign patients, how big the clinic’s capacity, how many
articles have been written on them in foreign media, not to mention customer satisfaction,
which is the key element of word of mouth marketing.
The third and most advanced way to book a dental holiday is via a Dental Travel Agency. In
sender countries based agencies are responsible for the marketing, providing information,
finding the right dentist for the patients, arranging appointments, communicating between the
two parties, booking hotel, transfer, entertainment, keeping customer service. Some agencies
are also advertising packages, which are containing a specific treatment the hotel for the
number of nights required by the treatment.
It is common, that agencies have contracts with more than one clinic. Smaller dental clinics
can enter into the dental tourism market only by cooperating with travel agencies, which can
take over the organizational tasks acting as an outgoing tour operator.
As the above findings shows, in dental tourism the treatment part dominates the whole
experience of the tourists. Price differences are still significant between sender and receiver
countries, which ensure the continuation of the business as long as prices are not getting
equalized. The tourism part has not yet been exploited enough, which gives scope for
enhancing the experience with more tourism activities. While current strategies focus only on
treatment and hotel elements, the business should develop, as the following part of the study
argues, towards destination based strategies, inspired by integrated tourism experience
models.
Strategy for Dental Tourism
In order to describe a strategy for dental tourism that would take dental tourism closer to
tourism, we apply the “Get there – stay there - live there” model (Croce, Maggi, 2005) which
distinguish these three phases of the tourism experience. The GET THERE phase covers
holiday start-up activities as information gathering ("Virtual Get There") and mobility ("Real
Get There"). STAY THERE regards the satisfaction of basic holiday needs, i.e.
accommodation and food, and LIVE THERE is about the satisfaction of secondary holiday
needs and including all the activities of tourists at destination. The overall experience of a
tourist is integrated among the three phases, but the degree of integration can vary in the
different organizational models.
Dental treatments are the primary motivation of the dental trips. For obvious reasons the
treatment is placed in Stay there phase (see Table 6). Visiting dental clinics constitutes a basic
need of the patients; dental tourism would not be possible without them. The clinic is the

anchor point of the dental tourism experience, much like the business meeting of the
conference is for business tourism.
The challenge for the development of dental tourism lies in the currently dominating focus of
the tour organization on the stay there phase, hence the dental treatment complemented by the
accommodation. Figure 3 shows the three actual dominating organizational models of dental
tourism. While in the first of the three cases illustrated the organizational anchor point (i.e. the
TO) is the clinic, in the other two cases the organization of the experience is in the hand of a
specialized tour operator. When the first model applies, the tourism experience at destination
represents just an accessory, organized eventually by the hotel or the clinic upon request from
the patient. As there is no integration with the destination, the scope of a DMO to target the
market via the TO is very limited and the business will never become more touristic. The
intermediation between the clinic and the patient by a TO, as in the second case in Figure 3,
makes the organization of the experience more efficient and consequently will enlarge the
market. However neither this model includes the tourism experience at the destination in the
dental tourism market. Only the third model where the anchor is again the TO but with direct
access to the destination, i.e. packaging, arranging, offering the whole experience will give
scope for a development of a real dental tourism market. Dental Travel Agencies have the
potential to link effectively DMO-s with the dental industry.

Figure 3 Dental tourism organizational models in the Get there - Stay there - Live there
frame
International competition is growing in Europe, especially in Poland, Turkey, Croatia,
Slovenia, Slovakia, Czech Republic, and for British and Irish patients with lower willingness
to travel, the prices are already a bit lower in Northern Ireland.
So how can Hungary keep its leading position with respect to the eastern competitors which
are sometimes cheaper, but less experienced in this sector? Hungary can beat them at the
moment by guaranteeing its high-quality dental tourism, emphasis on high professional
standards with more agencies, bigger clinics, more doctors, state of the art technology and
language skills. A successful strategy has to contain at least two elements: quality control,
cure of the core product and extension of the tourism experience to the live there phase.
Hungarian dentists need to cooperate in filtering out lower quality clinics and keeping their
good fame facing the foreign competition. Labeling on quality control of dental tourism could
be a strategy in this situation, in which to enter would be a free decision of each clinic. Under
that label all clinics and agencies should satisfy dental requirements for foreign patients.
Besides the usual control of a flawless clinic, ensuring fluent communication towards patients
and help during their stay in Hungary. This could represent their competitive advantage to win
and retain more customers. A recent initiative in this direction is the one of five clinics,
claimed to be the biggest in Hungary, who has decided to form an association of Leading
Hungarian Dental Clinics in 2009. Their efforts concentrate on common marketing and
lobbying for stronger image building in the European Union. Together those clinics generated
20.000 overnight stays in 2007 and 22.000 in 2008.

The country itself could profit much more from the existing dental business with higher
involvement of the tourism offices (DMO’s). Patients could be motivated to extend their stay,
or plan a new trip in the future to visit the country, get in touch with the culture or just simply
spend their time more enjoyably, and when they return talk not just about the treatment but
also about the destination. Possible cooperation with the Tourism Office also in small level,
such as brochures in the waiting room of the dental clinic, would work as a tourist information
point. On higher level, dental tourism should get an important role in thematic marketing of
the county abroad, as it has been decided to dedicate 2011 to the year of Health tourism.
Special dental holiday packages should be created for that occasion, using the dental
professionalism in Hungary to attract more tourism.
The Hungarian competitive advantage will shrink within 2 to 3 years, and possibly, only the
few big players will continue, those which will take part in dental travel association, have
consultancy service in foreign countries, and advertising the most (Interview I).
Making the example of the positioning of dental clinics in Great-Britain and in Hungary, the
National Health System (NHS) today offers free dental services to the British patients, but at
low quality, concerning availability and waiting lists. The British dental clinics offer good
quality services, at high prices. Hungarian dental clinics provide high-quality services for low
prices to Western patients. When the overhead costs will increase in Hungary, the price of the
treatment together with the airplane and accommodation might cost as much as the treatment
in Great-Britain. Hungary will be repositioned into high-quality high price dental tourism
segment. At that point the competitive potential of an integration of the dental service with the
improved tourism product comes into play. While today the primary motivation is the medical
treatment, in the future it would be the tourism experience with the dental treatment as a
byproduct.
According to Pucko and Ràtz (2006) Hungary’s competitiveness is in wellness and city
tourism, while its unique selling proposition is the healing water. Therefore health tourism has
been and can be the product, which makes Hungary a favorite destination for the European
visitors. It is based on several elements, such as the unique thermal bath history in the
country, Budapest is the only spa capital in the World, and the lake of Heviz is the largest
thermal lake in the World. Tourism and bathing organizations are trying to ensure that health
tourism becomes the core product of the country. A combination with dental tourism could
develop Hungary to a medical destination, where tourist come to get healthier, relaxed and
better looking in every sense.
Conclusion
This paper investigates a special type of medical tourism, analyzed from tourism perspectives.
Both the tourism and the medical sector get more involved in the phenomenon, deeper
integration is continuously emerging between them. The case study of Hungary’s dental
tourism has been chosen due to its high specialization and success in this market. The
country’s competitiveness based on its low prices, high quality, modern technology, central
location, and being primer starting with dental tourism, brought the idea to discover its
relevance in terms of tourism, not only in the revenues of the dental clinics.
The findings of the research contains 3 organizational models of Hungary’s dental tourism
supply in the framework of the Get there - Stay there - Live there approach. The 3 models
differ with respect to the intermediaries involved, the degree of integration of the product and
the anchor point of the experience.

Dental tourism in Hungary is still in the growth phase of its lifecycle. It has still few years of
significant presence on the market, before the overhead costs will increase, and the price of
the whole trip will be equal with a treatment in the Western countries.
This study claims, that higher cooperation with tourism, and changing target market gives the
possibility to overcome the decline. To consider repositioning into high price-high quality
dental tourism, would imply the dental treatment to become the by-product of visiting
Hungary for those patients, who are also seeking high quality treatment. This new product
will be developed from the old one using its suppliers, such as the clinics and the agencies,
which will have a higher degree of cooperation with other tourism suppliers.
Whether dental tourism in Hungary repositions and stays still successful or completely
vanishes, would be the scope of a new research, when the phenomenon reaches its maturity
phase. Thinking more globally, further studies could investigate how medical tourism will
react to price increases at different destinations. The changes on the World’s medical supply
map in 10-20 years would be an interesting continuation of the research. Not just in the
supply, also in the demand major changes could occur. Government health reforms and
country developments can originate new targets within new source countries. However people
will always seek high quality deals, especially when their health and beauty are on the stake.

Appendix

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