Tourism and Health: Understanding the Relationship
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Maeve Marmion University of Chester
9 PUBLICATIONS 18 CITATIONS
Ann Hindley University of Chester
14 PUBLICATIONS 180 CITATIONS
Tourism and Health: Understanding the Relationship
Maeve Marmion and Ann Hindley Faculty of Business and Management, Department of Marketing, Tourism, & Events Management, University of Chester, Chester, UK
Health Tourism; Medical Tourism; Quality of life; Social Tourism; Subjective well-being
There is a well-established interrelationship between travel, tourism, and health. Indeed, the motivations to participate in early forms of tourism related closely to ideas of well-being, wellness and health, and places or destinations that focus on offering perceived health benefits have long been recognized. Contemporary tourism continues to contribute to perceived health and well-being, and this entry discusses the personal and social rationale for tourism in this context. For some, there are quite specific and predetermined health reasons for travel, whereas for others it’s a more implicit sense of escape and relaxation that leads to a greater sense of well-being. If tourism experiences can potentially improve certain health indicators, then the role tourism can play in fostering health and well-being should be recognized in order to advance the good health and wellbeing agenda.
© Springer Nature Switzerland AG 2019
W.Leal Filho et al. (eds.), Good Health and Well-Being,
https://doi.org/10.1007/978-3-319-69627-0_16-1
An Introduction to Tourism and Health
It is widely supported that having healthy individuals and societies is important from both economic and social perspectives. Healthy populations lessen the strain on health services and resources and can be more productive and less fragmented from political perspectives.
The United Nations World Tourism Organization (2015) recognizes that tourism can contribute to health and well-being in a variety of indirect ways including via the strategic reinvestment of tourism generated income into health-related services. This entry focuses on the direct benefits that tourism experiences can have upon tourists’ health and well-being and discusses the different ways in which health relates to tourism and society in this light.
The entry takes a broad understanding of health in line with the World Health Organization’s 1948 Constitution which defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organisation 2014, p. 1). Meaning the concept of health and the extent to which a person might be “healthy” include their general well-being, quality of life (QoL),
happiness, social well-being, life satisfaction, etc. Moreover, this entry takes a broad understanding of tourism to encompass a whole host of different tourism experiences that involve the movement of people from their ordinary place of residence on a temporary basis (United Nations Department for Economic and Social Information and Policy Analysis Statistical Division and the World Tourism Organisation 1994) for a whole host of reasons. The interrelationships between health, tourism, and society will be explored, firstly from the perspective of the supposed health benefits of being able to access and experience tourism and secondly from the health-related motivations underlying the decisions to travel. Together, these perspectives illustrate the role tourism can play in fostering health and wellbeing for society.
Despite technological and digital advances achieving a hyper connected modern society, research suggests that problems associated with social exclusion and mental health, in particular anxiety and depression, are greater than ever (World Health Organization 2017). Tourism experiences offer the chance to escape from everyday pressures and can be seen to boost interpersonal connectedness for friends, families, and couples (Krippendorf 1986). Mental health is increasingly seen as relevant to tourism research and practice, with tourism enhancing connectedness, fighting against depression or mental fatigue, and boosting happiness.
Moreover, tourism has been conceptualized as a “social force” which when harnessed can have the power to transform societies and global communities well beyond its traditional framing as a “market ideology” or “industry” (Higgins- Desbiolles 2006, p. 1193). Whether or not tourism is recognized as an official “human right,” it is certainly the case that it facilitates the international free movement of people and interlinks with a person’s right to travel, right to rest, and right to have time away from work (ibid). Tourists themselves appear to share this view, in that the perceived necessity of being able to take at least one annual holiday is prioritized above many other household expenditures even at economically difficult times (Bronner and de Hoog 2016). In light of this, social tourism supports the view that tourism should be seen as a need rather than a luxury, and the social inclusion agenda explores the need to break down other barriers and provide “accessible tourism” experiences for all.
Social tourism supports the view that tourism, and specifically the ability to have a holiday, should be seen as a need rather than a luxury in terms of contemporary society. One early definition of social tourism focuses on “the relationships and phenomena in the field of tourism resulting from participation in travel by economically weak or otherwise disadvantaged elements in society” (Hunziker 1951, cited in Minnaert et al. 2009, p. 316). This shapes the perspective that “everybody, regardless of economic or social situation, should have the opportunity to go on vacation” (Haukeland 1990, p. 178) and hence any sociopolitical barriers to this should be supported by the welfare or social systems available. In particular, having access to tourism can be important in order to combat social exclusion (Hazel 2005), and as such, social tourism takes into consideration socioeconomic, health, and political barriers to participation in tourism. Broadly speaking, the various definitions of social tourism encourage “those who can benefit from tourism to do so” (Minnaert et al. 2006, p. 9) and likewise suggest that those who cannot access tourism should be supported in doing so.
Various public sector and third sector bodies from different economies promote and in some cases facilitate access to tourism and leisure through social tourism initiatives (Haulot 1981; Hazel 2005; Minnaert et al. 2006; McCabe 2009). Fostering the benefits of tourism for the disadvantaged in society can have “wide-ranging and policy-relevant” benefits and can help create much needed connectedness between social and mental health policy (McCabe 2009, p. 683). The benefits of holiday-taking can, when viewed holistically, be seen to contribute to public agenda including those in the UK centered on ideas of social inclusion, community and family cohesiveness, child growth and development, mental health, and work-related policy (ibid).
While further research is needed, the rationale for charitable organizations such as the UK’s Family Holiday Association (FHA) funding a holiday opportunity for low-income families is built on the understanding that such experiences enhance participants’ quality of life and subjective well-being (McCabe et al. 2010). The FHA aims to support disadvantaged groups and individuals and include them in the opportunity to have a tourism experience (Minnaert et al. 2006). Indeed the FHA uses the motto “because a little sunshine goes a long way” and reports to help circa 4000 struggling families have a holiday, short break, or day trip each year (www.familyholidayassociation.org.uk). While there are other forms of social tourism, namely, those focused on promoting types of tourism destination, experience, or interaction that has a social aim at its center, it is generally the case that “social tourism see holidays not simply as a product, but as an expression of a certain moral belief” about the value of tourism (Minnaert et al. 2006, p. 9) which resonates clearly with the positioning of tourism as a right or need for individuals in society.
In addition to economic barriers to accessing tourism, the social inclusion agenda also explores the need to break down other barriers including those related to mental and physical disability by providing “accessible tourism” experiences (Kastenholz et al. 2015). Darcy and Buhalis (2011 pp. 10-11) define accessible tourism as tourism that “enables people with access requirements, including mobility, vision, hearing and cognitive dimensions of access, to function independently and with equity and dignity through the delivery of universally designed tourism products, services and environments.” Accessible tourism, in this form, takes a “whole of life approach” which allows for temporary, permanent, and life stage-related access requirements (Darcy and Dickson 2009; Darcy and Buhalis 2011), and when viewed in this light, at any given time, this could include up to 30% of the population (Darcy and Dickson 2009). Furthermore, in light of the earlier discussion on human rights, it stands to reason that individuals with disabilities should be able to access tourism just as they should be able to access all other aspects of society and that barriers to this are of the industry’s making and/or limitations rather than created by the disability or additional need in itself (Michopoulou et al. 2015). If this is accepted, then it is also important to account for the diversity of needs and requirements of tourists requiring accessible forms of tourism (ibid), and while these needs are largely similar to those of nondisabled tourists, it has been suggested that the social and personal benefits for disabled tourists may well be even more important than those felt by the broader population (Kastenholz et al. 2015).
While social and accessible tourism presents challenges, developing more accessible forms of tourism could be enhanced through the “conscious creation of tourism supply” (Zajadacz 2015, p. 200). This would require holistic approaches to the education and skills oftourism employees and students of tourism, architecture, design, marketing, and so on, so that the whole of the tourism supply chain becomes more sensitive and proactive in its adaptation to “diverse demands” (ibid). Indeed, tourism experiences that are cocreated with tourists with different needs could enhance the embodied experience of tourism in new ways for participants if the design process is appropriately managed (Small 2015).
Health Benefits of Tourism Experiences
Butler and Wall (1985) identified health (both physical and mental) as being an important theme for tourism research. Tourism experiences including holidays, short breaks, traveling, and certain leisure activities are suggested to improve certain health indicators for those with the resources to benefit from them. For instance, there is a general acceptance that tourism can benefit well-being (Gilbert and Abdullah 2004; Chen and Petrick 2016; Uysal et al. 2016a) and most studies reveal a positive relationship between the tourism experience and overall quality of life (QoL). In fact, Uysal et al. (2016a, p. 256) propose that the literature to date indicates . .tourist trips do contribute to the quality of life of tourists.” However, in tourism research the definition of QoL appears to be elusive based on the recognition that over a hundred definitions appear throughout the literature (Andereck and Nyaupane 2011) with key terms including QoL and well-being used interchangeably (Kim et al. 2015; Uysal et al. 2016a). Kim et al. (2015, p. 468) suggest that a multidimensional perspective is useful to allow consideration of both satisfaction within an individual’s life domains (such as leisure, work, health, social, family, and finances) and overall quality of life. However they recognize that there is little agreement on the most suitable or important domains for overall QoL (ibid).
Uysal et al. (2016a) identify that while the literature on tourism experiences and quality of life has been fragmented, it is gaining momentum, and further research is warranted to continue to move beyond economic measurements of societal development. In reviewing this emerging literature, Uysal et al. (2016a) recognize that QoL and well-being tend to be approached from various perspectives. With some research focusing on objective or quantifiable measures (i.e., income, life expectancy, etc.), others use subjective dimensions of QoL (i.e., happiness, life satisfaction, etc.) as a means of assessment (McCabe and Johnson 2013), which suggests a recent shift away from “objective measures of wealth and material circumstances” toward a multidimensional concept of subjective well-being (ibid, p. 44).
Increasingly, mental health is seen as relevant to tourism research and practice, and some studies uphold the view that tourism experiences can have benefits for both physical and mental health (Hobson and Dietrich 1995; Richards 1999). This area of tourism research is recognized as emergent and one that requires further exploration particularly in understanding the “underlying psychological process” that ultimately leads to such benefits in terms of wellness and life satisfaction (Chen et al. 2016). However, research has recognized tourism’s potential power in boosting happiness and in fighting against depression (Gilbert and Abdullah 2004; Chen and Petrick 2016) and potentially in recovering from mental fatigue (Lehto 2013). This positive psychology perspective supports the idea that engaging in holiday activities can foster positive emotions and boost happiness generally (Filep and Deery 2010).
While tourism experiences have been researched generally in relation to health, one theme that is worth recognizing is the potential health benefits of engaging with nature and the natural environment. It has been suggested that the natural environment may well have restorative qualities that can benefit health and well-being (Wolf and Wohlfart 2014) and that happiness in particular may be boosted for tourists who are concerned with or appreciate nature as part of their tourism experiences (Bimonte and Faralla 2015; Kim et al. 2015). This supports the suggestion that tourism experiences that are more tightly aligned to tourists intrinsic motives, goals, or values are more likely to lead to enhanced life satisfaction and/or well-being (Kim et al. 2015; Kruger et al. 2015).
This parallels the view that subjective wellbeing and happiness can be boosted in tourists that closely identify with and/or personally value their activities such as the case of sport tourists who actively engage with a chosen sport activity (Bosnjak et al. 2016). Similarly, charity challenges that are goal orientated, personally meaningful, and which often include physical activity are likely to lead to enhanced well-being or mental health (Coghlan 2015).
Research also recognizes a variety of more pragmatic factors in exploring the relationship between tourism and health. For instance, the life stage, length, or intensity of the trip/experi- ence may determine the extent to which this positive effect takes places for individuals (Uysal et al. 2016a). Similarly, it may be that short tourism experiences potentially have restorative powers against work-related stress, while more extended experiences may be more beneficial for recovery and overall life satisfaction (Chen et al. 2016). Furthermore, it is suggested that people may choose to travel more frequently due to their perception that experiential, health, and relaxation benefits could be gained as a result (Chen and Petrick 2016). However, the extent to which any positive effects may last more long term has been questioned (Chen and Petrick 2013), and further research could explore the post-trip health indicators. Interestingly, Uysal et al. (2016a) suggest that the benefits may even extend to the preplanning stage of tourism, which again is worthy of further exploration.
Health-Related Motivations to Travel
There is a wide range of health reasons why people may opt to travel. While the above section outlines the health benefits of having tourism experiences more generally, there are also people who travel for more specific, predetermined health reasons or benefits, for example, those who use tourism experiences to enhance their subjective well-being (Uysal et al. 2016b), to relax and escape (Konu and Laukkanen 2009), to recover from illness or surgery (Hunter-Jones 2003), or to have an elective or cosmetic procedure (Holliday and Bell 2015). Indeed the sought benefits of travel relate to the general pleasure of “soaking up the sun” (Uysal et al. 2016b) which in modern terms links well with the generally accepted nickname of vitamin D as a “sunshine vitamin. ”
Early forms of tourism and the motivations underlying people’s decisions to travel closely relate to ideas of well-being, wellness, and health. Travel was seen as a way to escape (Pearce 1982), and notions such as “taking in the air” were popular (Gray 2006, p. 17). Even in Roman times, residents took opportunities to take a break from the pollution and overcrowding of the urban environments (Page and Connell 2006), and similarly, the need to see and engage with natural surroundings rather than urbanized settings was seen as important in boosting psychological well-being (Kim et al. 2015). While tourism, air, and health are related, so too are tourism, water, and health. The Romans were known to use the sea and also spas as a form of pleasure and relaxation (Page and Connell 2006). Moreover, there has been a long-standing interest in visiting natural, thermal, and mineral springs (Dimitrovski and Todorovic 2015) and perceived healing spaces such as
Lourdes in France, the hot springs in South Dakota, USA, Epidaurus in Greece, and Bath in the UK to name a few (Smyth 2005). Eighteenth- century European tourists were drawn to the idea of the “taking of the waters” (Connell 2006) in which places with naturally mineral-rich water were sought out and the water drank for the perceived health and wellness benefits. Furthermore, in the nineteenth century, this perceived health benefit of water and the tourism which it generated “shifted seaward” beyond the elite few who could afford it, to include the working classes (Connell 2006) as more and more people across society gained access to tourism, for example, through the reduction in travel costs and the introduction of worker holidays in the UK.
As a result of the interrelationship between travel, tourism, and health, places or destinations that focus on meeting these sought benefits have long been recognized. From a geographical or supply perspective, Smyth (2005) recognizes three different types of “therapeutic landscapes” such as those places related to or known for healing, those related to health service provision, and those related to networks of support in the provision of care. Indeed there are such a variety of so-called “health tourism” motivations and activities. These can be thought of across a spectrum ranging from general wellness, e.g., holistic-, leisure, and recreation-based tourism, to medical tourism including more specific medical wellness, medical therapies, or surgical motivations (Smith and Puczko 2008).
Wellness tourism tends to be driven by motivations of relaxation, enhanced quality of life, meditation, general health consciousness, mental therapies, etc. (Chen et al. 2008) and may involve spiritual or yoga retreats or general pampering experiences to name a few. Spa tourism has become so popular in modern terms, e.g., those spa facilities, hotels, and destinations specifically offering treatments and experiences, that increasingly spa tourism is seen as an essential component of more mainstream tourism activities (Mak et al. 2009).
At the other end of the health tourism spectrum, researchers in the fields of medicine and health recognize the emergence of medical tourism which involves the movement of patients traveling with the intent of accessing healthcare (Carrera and Bridges 2006; De Arellano 2007). Similarly, tourism research defines medical tourism as international travel for the express “purpose of obtaining health care” (Smith et al. 2011, p. 277). Within this, it is suggested that nonemergency treatments and procedures can lend themselves well to medical tourism (Reddy et al. 2010) such as cosmetic, dental, cardiology, reproductive, bariatric, and orthopedic procedures (Horowitz 2007).
Medical tourism can offer real benefits to patients who may feel constrained or even desperate in their struggle with illness or access to treatment. In such cases, traveling to access medical care may help to “foster hope” at a particularly difficult time in an individual’s life (Hunter-Jones 2003) and also offer choice and greater agency in the medical decisions individuals can make within the context of their home nations healthcare culture (Mainil et al. 2011). Conversely, medical tourism can also present certain challenges for the industry. For instance, medical tourism can mean the importing and exporting of what are effectively medical patients, albeit also tourists, either as part of formal bilateral and multilateral trade relationships (Smith et al. 2011)or informally as patients-as-tourists opting to travel to a particular place to receive a particular treatment. There are also questions around the expected versus received quality of patient care and around equality issues in the health standards available to local versus visiting patients (Smith et al. 2011). Authors have also questioned the costs and impacts that inbound medical tourists can have if using public healthcare systems such as the National Health Service in the UK (Lunt et al. 2014).
A subset of medical tourism is that of cosmetic surgery tourism, whereby would-be patients opt to travel to undertake their elective procedure abroad. The motivations underlying such a decision can include the cost or time involved, i.e., it may be cheaper or faster (Reddy et al. 2010). Indeed, it may be driven by the perceived superior service delivery or the perceived comfort of recovery posttreatment as part of a holiday (ibid). Furthermore, Bell et al. (2011) suggest that such tourism can promise a duel transformative experience, in terms of the benefits of the holiday itself and then also the resulting cosmetic transformation. This form of tourism has led to some stereotypes such as “surgery and safari” or “tummy tuck and the Taj.”
There are also other medical motivations that might lead to the decision to travel, for example, whereby medical procedures may not be accessible to patients in their home domain due to cultural, ethical, or legal reasons. Examples of this may include travel motivated by the decision to end a pregnancy, e.g., the movement of patients between the Republic of Ireland and Northern Ireland and England, travel for female circumcision, and travel motivated by the need/want to access end of life care as in the case of Switzerland. These create challenges for the travel and tourism industry that should not be ignored, and issues around choice can be considered here, if the patient is not in full control of medical decisions being made on their behalf. While some may question the label tourism in such contexts, the fact remains that these patients’ journey are being facilitated by the infrastructure of the tourism industry in that they require transport, movement across borders, accommodation, and other direct and indirect tourism services.
While this is an emerging area of study, de la Hoz-Correa et al. (2018) found a lack of consensus in the keywords and terminology used within medical tourism research and called for greater consistency and further research. Moreover, Adams et al. (2015) call for more focus on the motivations of medical tourists. Despite these gaps, it is clear there is a market demand for medical, health, and wellness tourism, and this creates competition in destinations seeking to attract what are often seen as valuable, highspend consumers.
While the relationship between health and tourism is well documented, there remains scope to further our understanding in certain areas. For instance, the extent to which there is a lasting or long-term effect on health through tourism has been questioned (Chen and Petrick 2013), and research could explore the post-trip benefits and the extent
to which these are retained once tourists return to their day-to-day lives. Furthermore there is a need to understand the nature of the health benefits for different tourists. For example, the current literature is varied in its reference to and analysis of self-reported benefits, subjective well-being, physical or mental health indicators, social connectivity, and so on. Moreover, it has been recognized that the literature on tourism experiences and quality of life is emergent yet fragmented and that further research needs to be more holistic in its understanding of and measurement of health benefits (Uysal et al. 2016a). A conceptual framework mapping the different types of health benefits, for different tourist types and in different contexts, would add value to the literature.
In addition to the post-trip stage, there would also be merit in exploring the potential benefits to health for those anticipating an upcoming or future trip (Uysal et al. 2016a). For instance, the excitement and buildup of a holiday may boost a person’s mood and help present a “light at the end of the tunnel” effect when managing stress at home and/or in their professional lives. As those in school and/or work benefit from and look forward to a weekend as a break from the norm, a holiday may have a similar effect for those lucky enough to have one planned. The duration and intensity of the holiday experience may also be a relevant factor to research as short breaks may offer different and perhaps lesser restorative benefits than more extended experiences (Uysal et al. 2016a; Chen et al. 2016). Furthermore there could be scope for interesting research that explores the needs or benefits of different market segments when understanding the potential pre-trip stage. For instance, different people may experience this quite differently whether they be parents or guardians, young or old, etc. There may also be significant differences for those responsible for the planning and preparation of a holiday as opposed to those passively looking forward to their break.
Given that different stages of a holiday may have different health-related benefits, research could usefully evaluate the benefits of a tourism experience from the initial planning stage through to the holiday itself and then on through to the post-trip stage. Longitudinal studies looking at the benefits of tourism to health and well-being through different life cycle stages would also add value. Life histories, narrative, or ethnographic approaches, for instance, would potentially illustrate the perceived value of holidays and tourism experiences as part of a “whole of life” perspective rather than understanding holidays as a temporary intervention or bounded relief. Holidays have a nostalgic power to connect individuals and families to their own past selves and to each other, and this could add to the idea of holidays boosting social connectedness over time. This type of research may be of particular value in understanding aging and age-related health challenges in that well-being and sense of self can be grounded in more happy terms of past holiday memories and their positive associations. It is suggested that telling stories about past holiday adventures is potentially one way for older people to remember their past and to connect with listeners in their present (Kotai-Ewers 2011). In an aging society, there is call for renewed focus on older people in research generally, and this is no less the case for tourism and health.
Similarly, the benefits of tourism for mental health in its broadest sense could be explored further. This would be relevant from a variety of perspectives including but not limited to young people’s well-being, social exclusion, those with recognized mental health conditions, those with additional learning or access needs, and so on. In this light, the management challenges for the tourism industry also raise many valid research questions around skills, training, resources, and public-private health partnerships. The extent to which the tourism industry does or needs to understand or cater for the diverse needs of tourists with medical conditions would also warrant research. For instance, understanding and embracing inclu- sivity, accessibility, adaptation, and cocreated experiences at destination level creates a plethora of research opportunities.
Another area with scope for further research is that of medical tourism. For instance, the cost and value of the medical tourist niche market could be explored from both individual and social perspectives. In this light Adams et al. (2015) call for more focus on the motivations of medical tourists. Furthermore, there is also scope for research that explores bespoke tourism experiences that target certain health issues such as obesity (e.g., health retreats) and the market potential for these. Food and food-specific health requirements may also warrant research from a tourism perspective, and this includes but is not limited to diabetes, celiac disease, and food allergies and intolerances. Research could also explore the extent to which the quality and timeliness of post-illness or postoperative recovery could be enhanced if spent in a restorative setting or destination abroad.
Building on this, while this entry largely focuses on the health benefits of tourism for those who have the experience themselves, there may be scope to explore the indirect health benefits for some, when others that they care for are away on a trip. For instance, the physical and mental respite a carer may feel as a result of their charges being on holiday would be an interesting addition to this area of study. Moreover, these indirect health benefits may be felt by parents or guardians when their children are away, for example, on a school trip.
From a social tourism perspective, there could be research evaluating the merit, rationale, and/or appetite for more holistic medical treatment or services that take into account the benefits of tourism experiences for those who would have a discernable health benefit as a result. If it is accepted that tourism does indeed boost wellbeing and health and that healthy societies are in everyone’s interest, then there may need for the political will and social and economic resources to drive participation and accessibility of tourism for as many as possible.
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