health, wellness and medical tourism

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Sheila Flanagan, Dublín Institute of Technology, Ireland. Tania Gorcheva, Tsenov ... University, Taiwán. Pauline Sheldon, University of Hawaii, United States.
Editorial Team Editor in Chief

España Pablo A. Muñoz-Gallego, University of Salamanca, España Francisco Riquel-Ligero, University of Huelva, España Josep Francesc Valls-Giménez, ESADE, España

Alfonso Vargas-Sánchez, University of Huelva, Spain Associate Editor T.C. Huan, National Chiayi University, Taiwan Books Review Editor Steve Watson, York St. John University, United Kingdom Secretariat Cinta Borrero-Domínguez, University of Huelva, Spain Mirko Perano, University of Salerno, Italy Style reviewer and text editor Beatriz Rodríguez-Arrizabalaga, University of Huelva, Spain

Editorial Board José Manuel Alcaraz, Barna Business School, República Dominicana Mario Castellanos-Verdugo, University of Seville, España José Antonio Fraiz-Brea, University of Vigo, España José Manuel Hernández-Mogollón, University of Extremadura, España Shaul Krakover, Ben Gurion University, Israel Jean Pierre Levy-Mangin, University of Quebec, Canadá Tomás López-Guzmán, University of Córdoba, España Alfonso Morvillo, National Research Council (CNR), Italia Yasuo Ohe, Chiba University, Japón María de los Ángeles Plaza-Mejía, University of Huelva, España Nuria Porras-Bueno, University of Huelva, España João Albino Silva, Algarve University, Portugal

Advisory Board (Spanish Members) César Camisón-Zornoza, Jaume I University, Spain Enrique Claver-Cortés, University of Alicante, Spain María Teresa Fernández-Alles, University of Cádiz, Spain José Luis Galán-González, University of Seville, Spain Félix Grande-Torraleja, University of Jaén, España Inmaculada Martín-Rojo, University of Málaga, Spain Antonio Manuel Martínez-López, University of Huelva, España Francisco José Martínez-López, University of Huelva, Rector, España María Jesús Moreno-Domínguez, University of Huelva,

Advisory Board (Other European Members) Paulo Aguas, Algarve University, Portugal Gustavo Barresi, University of Messina, Italy Carlos Costa, Aveiro University, Portugal Salvatore Esposito de Falco, University of Rome “La Sapienza", Italy Sheila Flanagan, Dublín Institute of Technology, Ireland Tania Gorcheva, Tsenov Academy of Economics, Bulgaria Tadeja Jere-Lazanski, University of Primorska, Slovenia Metin Kozak, Mugla University, Turkey Álvaro Matias, Lusiada University, Portugal Claudio Nigro, University of Foggia, Italy Angelo Presenza, University "G. D'Annunzio" of ChietiPescara, Italy Renee Reid, Glasgow Caledonian University, United Kingdom

Advisory Board (Members from the rest of the world) John Allee, American University of Sharjah, United Arab Emirates Nestor Pedro Braidot, National University of La Plata, Argentina Roberto Elias Canese, Columbia University, Rector, Paraguay Luca Casali, Queensland University of Technology, Australia Nimit Chowdhary, Indian Institute of Tourism and Travel Management, India Steven Chung-chi Wu, National Pingtung University of Science and Technology, Taiwán Dianne Dredge, Southern Cross University, Australia Daniel Fesenmaier, Temple University, United States Babu George, University of Southern Mississippi, United States Dogan Gursoy, Washington State University, United States Kanes Rajah, Tshwane University of Technology, South Africa Albert Yeh Shangpao, I-SHOU University, Taiwán Pauline Sheldon, University of Hawaii, United States Germán A. Sierra-Anaya, University of Cartagena de Indias, Rector, Colombia Xiaohua Yang, University of San Francisco, United States

J.A. Quintela; C. Costa; A. Correia

HEALTH, WELLNESS AND MEDICAL TOURISM – A CONCEPTUAL APPROACH Joana A. Quintela GOVCOPP – Research Unit in Governance, Competitiveness and Public Policies DEGEIT – Department of Economics, Management, Industrial Engineering and Tourism University of Aveiro (Portugal) [email protected]

Carlos Costa GOVCOPP – Research Unit in Governance, Competitiveness and Public Policies DEGEIT – Department of Economics, Management, Industrial Engineering and Tourism University of Aveiro (Portugal) [email protected]

Anabela Correia Business School | Polytechnic Institute of Setúbal (Portugal) GOVCOPP – Research Unit in Governance, Competitiveness and Public Policies DEGEIT – Department of Economics, Management, Industrial Engineering and Tourism University of Aveiro (Portugal) [email protected] ABSTRACT Nowadays, health, wellness and medical tourism are recognized as one of the most developed and growing sector of today’s thriving tourism industry that has increased its activity worldwide, due to a lot of social and economic circumstancies that leads people to achieve and pursue a better quality of life. However, these kind of tourism face a multitude of challenges and one of that challenges is the discrepance on its different conceptual approaches and definitions. A literature review on this topic with a descriptive, comparative and exploratory nature was conducted, building a theoretical framework on this field of study. Units of meaning for the definition of the concept categories were elected, which allowed to reflect and sintetize the different approaches to the topic. This analysis brought other perspectives of identification and description of distinct themes, including a few issues about health, wellness, medical tourism, wellbeing and quality of life. Therefore, the main goal of this paper is to summarize and clarify this complex and sweeping concept that assumes in a prominent role in the global context of tourism and results in a concise overview of the literature produced on the subject towards a small contribution to a better understanding of the concept. 1 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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KEYWORDS Health and Wellness; Tourism; Literature Review; Conceptual Definition.

ECONLIT KEYS Z31; Z32; Z39.

1. INTRODUCTION

Health, wellness and medical tourism are recognized as one of the most developed and growing sector of today’s thriving tourism industry and it has increased its activity worldwide (Costa, Quintela and Mendes, 2015:23). It is a multifacetaded industry that add other segments such as spa tourism, holistic and spiritual tourism (Smith and Puzckó, 2015). Academically, health, wellness and medical tourism have emerged since the 80’s (Álvarez García et al., 2014) as one of the fastest growing areas of academic research interest in both tourism and health studies because of its’ rapid development in the last decades. The main reasons of this fast growth and development are related with multiple demographic, social and economic factors that have been affecting and influencing the worldwide population. Demographically, there has been a clear increase of the elderly population, mostly in European countries, that is translated in a major concern in that developed societies about their elder people, starting taking serious the 1970’s World Health Organization (WHO) definition of health “as a state of complete physical, mental, and social wellbeing, not merely the absence of disease of infirmity”. This holistic perspective induces the consumers looking for wellness products that “offers enough services to enhance their wellbeing in its different dimensions (physically, psychologically, and/or spiritually)” (Chen and Prebensen, 2009:231), providing and assuring their quality of life, regarding an increase in life expectancy. In this sequence, another factor that represents an opportunity for health tourism is the decrease of the consumption of medicines (Peiró and Moure, 2015:133), promoting the use of wellness services and products not only in a curative perspective, but in a preventive one. Socially and economically a lot of changes in lifestyles has been intensified. In the last few decades, “the post-war baby-boom generation is approaching the age of 2 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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highest disposable income and highest propensity to travel” (García-Altés, 2005). Besides that and because of the economic world crisis that since the years of “2007/2008 has put an extra pressure on people’s psycho-physical state of health” (Konkul, 2012:585) that moves people towards the necessity of looking for new ways of relaxation and evasion of the high stress-levels of the daily working life and “the resultant desire to slow down, to simplify, and to find meaning in life” (Voigt et al., 2011). In this context, a perspective of growth is certain and wellness industry is expected to develop further and further as these influences show no sign of decrease. However, this kind of tourism faces a multitud of challenges and constraints which one is the discrepance on its different conceptual approaches and definitions. The next part of this paper undertakes a conceptual approach to those concepts, where a literature review with a descriptive, comparative and exploratory nature was conducted, building a theoretical framework, clarifying and designing its expansion across the last decades, making also a brief analysis of its historical evolution since its origines, enlightening the motives that allowed and promote its development until present. For all the above, there are many reasons for conducting this approach, the main goal of this paper is to summarize and clarify this complex and concepts that assume a prominent role in the global context of tourism. Thus, the objective of this research is to provide a comprehensive review of the literature about health and wellness conceptualization nowadays. A reflective perspective is also one propose present in this research, with an emphasis its different interconnections.

2. CONCEPTUAL APPROACH

Health and wellness tourism is one of the most ancient forms of tourism. Its’ roots can be find around 5000 BC with the Indian Ayurvedic practices or some beauty and cosmetic rituals that women used around 3000 BC used in the Ancient Egypt Civilization and also with the chinese medical practices around 1000 BC. The Ancient Greece and Rome have left a legacy of baths to the Europeans (Konkul, 2012) where we can find the birth of thermalism and when the earliest reference to healing waters of SPAs [from the latin expression sanus per aqua] 3 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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appears around the year of 1700 BC. So, travelling for other regions searching for the cure of some diseases is an ancestral ritual that defines the basis and origins of thermalism that has registered a lot of different phases of contraction during the Middle Ages and expasion along the XIX and XX centuries. With such a long history, health, wellness and medical tourism are a complex area of study (Hall, 2011:13), which research focuses on a significant number of themes, in the disciplinary and cultural context within which the research has taken place. Many terms are used to describe the relationship between health and tourism in the framework of special tourism products such as health tourism, medical tourism, hospital and clinical tourism, wellness tourism, and sometimes medical travel, “often conceptually completely inconsistently” (Kušen, 2011:95). In this context, the aim of this paper is to precisely define these types of tourism and clarify it position in its complex conceptual and theoretical framework. The next points of this paper provide an overview of the academic health, wellness and medical and health tourism literature, identifying simultaneously some key themes and issues such as wellbeing, healthcare and quality of life that are also analysed and clarified.

2.1

THE UMBRELLA OF ‘HEALTH’

As we notice in the small introduction above, travel for health reasons is nothing new and has long been recorded as a driver of visitors to thermal springs and coastal locations (Hall, 2011). We can say, in a relatively glentle form, that health tourism has a long and unbroken history (Connel, 2010:12) but, besides that, there is no single definition for today’s health tourism and what exactly consists health tourism varies, as we can confirm with the multiple definition of health tourism we can find in literature. Although a lot of the difficulties in defining health tourism (Hall, 2011), the term has come to be more widely used internationally along with the notion of medical tourism and with the fact that health nowadays focuses simoultaneously on wellness and prevention as well as curing illness. World Tourism Organization (UNWTO) defined Health Tourism by the kind of tourism that aims to achieve “a state of complete physical, mental and social 4 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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wellbeing and not merely the absence of illness or disease” (Álvarez García et al, 2015:101) or, in a more concise manner, Health tourism is based on travelling outside home to care one’s health (García-Altés, 2005:262). Tabacchi, reinforces this idea defining health tourism as "any kind of travel to make yourself or a member of your family healthier.” (de la Barre et al, 2005:25). On the ohter hand, the International Union of Tourist Organizations (IUTO), defines it as ‘‘the provision of health facilities utilizing the natural resources of the country, in particular mineral water and climate’’ (IUTO, 1973:7). Therefore, in seeking to provide a definition, consistent with official definitions of tourism, Hall (2003:274) suggested that health tourism be defined as: “a commercial phenomenon of industrial society which involves a person travelling overnight away from the normal home environment for the express benefit of maintaining or improving health, and the supply and promotion of facilities and destinations which seek to provide such benefits.”

Goodrich and Goodrich (1987:217) defined health tourism in terms of the narrower concept of health-care tourism as: “the 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.”

In the same line of thought, some experts (de la Barre et al., 2005:26) define health tourism as: “the sum of all the relationships and phenomena resulting from a change in location and residence by people in order to promote, stabilize and, as appropriate, restore physical, mental and social wellbeing using traditional public or private health services.”

Kaspar (1996, cit. by Lam et al., 2011), however, noted health tourism as an overarching concept encompassing all forms of health-related tourism activities: “the sum of all the relationships and phenomena resulting from a change of location and residence by people in order to promote, stabilize and, as appropriate, restore physical, mental and social wellbeing.”

Such as Goeldner (1989:7) that classified health tourism in three different categories as: ‘‘1. staying away from home; 2. health as the most important motive; 3. done in a leisure setting’’ and recognized five components of health-related tourism market segments attached to it, such as: 1. leisure tourism; 2. outdoor recreation, adventure tourism, sports tourism and wellness tourism; 3. health tourism and wellness tourism; 4. Spa tourism and wellness tourism; 5. Medical and dental 5 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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tourism (Hall, 2011:5). This approach proposes a framework of relationships between the various subcategories of health tourism. In this sense and getting a synthesis of this concept, two main sides or points of view can be observed in health tourism: 1. the therapeutic point of view – associated with medical tourism, that inludes surgery and/or therapeutic treatment for cure and/or for preventing diseases; 2. The recreational point of view – which makes up what is known as wellness or wellbeing tourism, focusing on relaxation, leisure and escape from the routine (Jallad, 2000). The concept can even be seen from another double perspective: 1. the consumer perspective – health tourism can be defined as traveling for the maintenance, enhancement or restoration of wellbeing in mind and body (Carrera and Bridges, 2006); 2. the supplier perspective – health tourism can be defined as traveling to destinations which provide facilities and healthcare services explicitly and in addition to their regular tourist amenities (Goodrich and Goodrich, 1987). Aside from having no universally definition about health tourism, it is still not sufficiently elaborated from both professional and legal standpoints. In everyday use and in practice, health tourism is located in the very broad context ranging from wellness tourism to hospital-clinical tourism and from specialized hospitality enterprises to health providers. As referred in the introduction of point 2 (Conceptual Approach), other concepts such as medical tourism, wellness tourism, and medical travel that also share conceptual similarity with health tourism so that they are agreed by some as interchangeable concepts (Smith, 2008). On this basis, spa tourism can be considered a component of health tourism that relates to the provision of specific health facilities and destinations which traditionally include the provision of mineral and thermal waters but which may also be used to refer to tourist resorts which integrate health facilities with accommodation (Leandro et al., 2015). Besides that a Spa is a place where people “can become aware of their physical and mental potential and steer it towards creative health.” (Peiró and Moure, 2015:134) and they figure as “entities devoted to enhancing overall wellbeing through a variety of professional services that encourage the renewal of mind, body and spirit.” (ISPA, 2011). According to ISPA – International Spa Association, there are 6 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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seven different types of spas: club spa; cruise ship spa; destination spa; medical spa; mineral spring spa and resort/hotel spa. Concluding, wellness and medical tourism could be considered prominent subcategories of health tourism and the designation of ‘health tourism’ can be used “as a comprehensive umbrella term that subsumes wellness and medical tourism” (Voigt et al., 2011:16). 2.2 THE ‘WELLNESS’ CONCEPT

Following Voigt’s lign of thought, there’s no consistency in the literature regarding the concept of wellness tourism (2011:16). Steiner and Resinger (2006:6) note that “wellness tourism remains insufficiently conceptualized” and Smith and Puczkó (2009:83) remember there are multiple reasons for that fact when they conclude that the term ‘wellness’ was “used quite uniformly as a label for all forms of healthorientated services”, but as the demand for a diversity of services is growing faster and faster and the customers are becoming more stringent, that perception is no longer sufficient. A ‘wellness revolution’ has started – arised many decades ago (Conrad, 1994; Kirsten et al., 2009) – and consists in the intention of individuals attempt to “redesign their life, sometimes in superficial and sometimes in profound ways, to achieve higher levels of physical, emotional, mental, and spiritual wellness” (Bushel and Sheldon, 2009). The main cause of this ‘revolution’ maybe found among the complexity and speed of modern life that urgently requires counterbalancing experiences for human beings to feel well and wellness tourism does fulfils that need, because a part of it is based on: “getting in touch with what is (inside or outside us) without reasoning it through or even having the words to express what is going on. We have lost our natural way and seek it in wellness tourism” (Steiner and Reisinger, 2006:9).

In this context, one distinguishing characteristic of wellness tourism is that it is ‘‘pursued solely by ‘‘healthy’’ people, their prime aim being prevention’’ (Mueller and Kaufmann, 2001:7) that has in common a lot of aspects such as the importance they give of lifestyle in a lifelong approach, the notion they have of self-responsibility in a more holistic approach to health taking responsibility for one’s own actions, and the exploitation of a person’s potential for a better quality of life. Although, quality of life is 7 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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a complex, multidimensional, and subjective concept and it means different things to different people, the search for quality of life is an ambiguous human drive that motivates much tourism activity, particularly the one associated with outdoor leisure, rejuvenation, relaxation and inspiration and also with and in this way, preventing health problems to stay well in balance both physically and mentally. To underline the specification of wellness we can also “compare” it with medical tourists primarily travel to cure or treat a certain illness or medical condition Voigt et al. (2011) in contrast with the one’s go on vacation to maintain or improve their health and wellbeing (Muller and Kaufmann, 2001). This distinction between ‘‘illness’’ and ‘‘wellness’’ is consistent with recent wellness tourism definitions and typologies (Muller and Kaufmann, 2001; Smith and Puczkó, 2009; Voigt et al., 2011). Even though wellness tourists can be differentiated from medical tourists based on different underlying needs, the term ‘‘wellness tourism’’ is commonly used by writers to describe a very broad range of tourism activities and contexts, and the sub-sector of spa tourism has tended to dominate the concept of wellness tourism. Although its particularities, ‘wellness tourism’ stills sometimes regarded as a sub-category of health tourism and there is a lot of overlap between health and wellness tourism, as referred in the point above. It is often difficult to separate the two types of products and services being offered to visitors in the contemporary health and wellness tourism industry. This is quite different than the same experts’ definition of “wellness tourism” which is proposed to: “be 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 in whole or in part, is to maintain or promote their health and wellbeing, 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 wellbeing.”(de la Barre et. al. 2011:27)

In that sense, there’s some definitions in literature that has been adopted. To Chen and Prebensen (2009:231) it is: “a phenomenon to enhance personal wellbeing for those traveling to destinations which deliver services and experiences to rejuvenate the body, mind and spirit of the participant”.

Although that constraint, the literature has developed a theoretical perspective about wellness that: 8 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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“can be defined as the balanced state of body, spirit and mind, including such holistic aspects as self-responsibility, physical fitness/beauty care, healthy nutrition, relaxation, mental activity and environmental sensitivity as fundamental elements.” (Messerli and Oyama, 2004:9)

Wellness in this instance, can be described also as: “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 wellbeing.” (de la Barre et. al, 2005:5)

And it can also 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.” (de la Barre et. al, 2005:7)

Even within some of the diverse typologies of wellness tourism, there are many subsectors (e.g. within spa tourism), the best is to make a distinction between products and motivations of tourists (Smith and Puckzó, 2010). Wellness tourism products and services are also connected to luxury products and five-star hotels. In other words, wellbeing tourism can contain products and services form a wider scale; it can include pampering, different activities, and experiences of luxury but it is not necessarily connected to or “realizing” in high-class hotels. Smith and Puckzó (2009:42) argue that there is a strong link between people’s lifestyles and their inclination to wellbeing and wellness tourism. However, in a holistic perspective, other activities have also been classified as, or related to, wellness tourism, such as new age tourism, volunteer tourism, outdoor, sport and adventure activities such as hiking, yoga tourism, as well as spiritual and religious tourism (Smith and Kelly, 2006), as Figure 1 illustrates.

9 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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New Age Tourism

Volunteer Tourism

WELLNESS TOURISM

Spiritual & Religious Tourism

Yoga Tourism

Outdoor, Sports and Adventure

Figure 1. Holistic representation of wellness tourism Source: Author’s

One common argument in these writings is that these tourism activities lead to an increased level of wellness, health, or quality of life, and can therefore be defined as wellness tourism. However, as most tourism activities promote health and wellbeing in some way, a pure demand-based definition of wellness tourism seems to be of little practical value. Hedonism is not the only motivator, as an increasing number of tourists seem to be looking for meaning through their vacation and leisure time. Aligned with societal and consumer demands for greater social and environmental responsibility from the tourism industry, is the expectation that “wellness tourism” should be seriously engaged with the delivery of health and wellbeing benefits associated with different styles and types of experiences (de la Barre et al., 2005:4). The wide variety of health and wellness definitions being used in the spa, health and wellness tourism industry can be illustrated with a review of current spa categories as defined by the industry. Academically, wellness tourism has reached sufficient critical mass to become a significant field of study and to warrant the attention of academics and tourism has to 10 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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prove itself in the academic arena as a serious field of study, it is even more so with this subsector. Although, to build a universal definition of wellness tourism it is necessary to be attentive to the contribution of medicine, public health, psychology, sociology, business, management and marketing, among others (Bushell and Sheldon, 2009:4).

2.2.1) The sub-concepts of wellbeing and healthcare

The concepts of wellbeing and wellness are sometimes used as synonyms (Konu et al., 2010:41) for many reasons, inclusively by the fact of the translation of the terms, that has been challenging in many countries (Smith and Puczkó, 2009), even though there are significant differences between them. For instance, the purpose of the trip can be healing illness or preventing it, and promoting wellbeing. Under this perspective, wellbeing and healthcare tourism are seen as sub-concepts of health tourism. Wellbeing tourism differs from healthcare tourism in terms of travelling motives. In healthcare tourism the main travelling motive is to treat illness, when in wellbeing tourism it is to prevent illness or maintain one’s health wellbeing. In addition of preventing illness and maintaining wellbeing, the goal of wellbeing tourism to experience pleasure and luxury (Muller and Kaufmann, 2001). Finish Tourist Board (2005) has defined the different concepts of health and wellbeing tourism for their purposes. In their definition health tourism is seen as mains concept which divides into two parts: to healthcare/medical tourism and to wellbeing tourism. Healthcare/medical tourism contains treatments, operations and service packages connected to treating illness. Wellness tourism is seen as an entity which includes diverse products and services which aim to promote and maintain holistic wellbeing. Here holistic wellbeing means wellbeing of body, mind and soul. Wellness product is seen as a part of wellbeing tourism and it can hold all or just one wellbeing services. Along this pursuit of health – as synonymous of wellbeing, happiness and longlife without ailments or similar problems (Leandro et al., 2015) – in this context of inflation has also been taking new impact the “health tourism” that includes not only medical tourism, medical tourism but still assumes special significance where the welfare and happiness of tourists. In a context where there is a growing awareness 11 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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about the body and mind and abound-called “diseases of civilization”, many people live in search of evidence capable of (re)enchant, forget the hardships of day-to-day, make new discoveries, dreaming, living new emotions and rebuild its interior and physiological space. Globally, tourism health and holistic wellbeing are composite and complex, because of its scope and by-products, while privileging the paradigm of health and wellbeing recommended by the WHO (World Health Organization), invests in tourism and increasingly sought happiness business. This are some of the challenges and opportunities ahead, as health tourism finds its prominence in the practical and conceptual domains of tourism (García-Altés, 2005:262).

2.3

THE ‘MEDICAL’ DIMENSION

Medical tourism has had a long gestation period, and as we referred on the introduction of the second point of this paper, as one of the very earliest forms of tourism, that were directly aimed at increased health and wellbeing. Similarly as health and wellness, ‘medical tourism’ is a contested term. The term “medical tourism” refers to the movement of persons across international borders with the intention to access medical care, paid for out of pocket and without any formal referral from their home healthcare system (Johnston et al., 2012), travelling overseas for operations and various invasive therapies, especially for cosmetic surgery. This kind of tourism has grown rapidly since the late 1990’s due to the civilized world conjucture that appeals for that for many reasons, including the privatization of healtcare in post-industrial economies, the economic and time cost dimension – high costs and long waiting lists at home; the regulatory structures that restrict availability of a medical service in the generating country do not exist in the destination country. Regulation that makes some services completely unavailable even though the medical technology exists, for example, the case of stem-cell medicine and some fertility and reproductive procedures and cross-border represents cheaper medical services than those available in the medical tourism generating country and the reduced transport costs, the Internet marketing have played a role as medical services can be consumed in a relatively exotic location in conjunction with a holiday, the accelerated globalization of healthcare and tourism, the growing dependence on technology, including the remarkable focus, even obsession, with 12 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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bodily appearance, where health and its visible signs have become more and more important (Connel, 2010). The main sources of such tourists are developed countries and the main destinations are located in Asia. According with Hall (2011), citing ESCAP (2009:1), ‘medical travel’ is: “the international phenomenon of individuals travelling, often great distances, to access healthcare services that are otherwise not available due to high costs, long waiting lists or limited healthcare capacity in the country of origin, and medical tourism referring: [. . .] specifically to the increasing tendency among people from developed countries to undertake medical travel in combination with visiting tourist attractions.”

In this perspective, medical tourism is often seen as adding medical services to common tourism. Or in contrast, medical tourism can be also understood as a more generic term that refers to ‘‘foreign travel for the purpose of seeking medical treatment’’ (Balaban and Marano, 2010:135) and according to Connell (2006), this travel motivation may include or not a holiday or the consumption of tourism services. This fact has permitted conventional tourism to receive a considerable set of benefits through medical tourism (that includes: transportation, food and beverage services and hospitality services and cultural and leisure services). Following this line of though, it is clearly that the different dimensions of medical tourism are not mutually exclusive. The development and growth of this torism sector – increasingly promoted by national governments as an economic development strategy – emphasizes a large number of contemporary themes as a rapidly growing industry that is primarily developed for its economic potential. In medical tourism context there are a lot of key issues that intrinsically differs from the other tourism activities and that constitute critical aspects simultaneously for medical tourists and for medical tourism academic researchers. One of them is the different design and provision of healthcare among different countries (Hall, 2011:7). Researchers are increasingly exploring this phenomenon, with a particular emphasis on the potential impacts this growing industry may have upon various stakeholders, including the patients traveling abroad as well as home and the population of medical tourism destinations (Hall, 2011). This issue assumes a main importance, because medical tourism’s impacts may be very positive and profitable for some of these 13 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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stakeholder groups, and the regulation for patients across borders is urgently needed also to protect them of the particularly influences of stakeholders (Johnston et al., 2010) that have a great interest in their investment. In this sense, the inherent risks in medical tourism raise new ethical issues for health professionals which, as referred before, have been receiving considerable attention from researchers. Another one is the potential biosecurity risks with respect to humans acting as vectors for disease. For that reason, medical tourists should be aware of the potential risk that occur when they deliberately travel to be exposed to a medical environment and the only way to control this risks – over public and individual health – is to create and apply an adequate regulation of health that include and supervise all the dimensions of international mobility (Hall, 2011) to help defining the concept and, mainly, to assure the good future and desirable development of this particular sector of tourism.

3. CONCLUSIONS

The most relevant conclusions reached as a result of the research that has been carried out. The literature review exposed along the body of the paper evidences and justifies the growing importance of the development of health, wellness and medical studies. Analyzing each one of the three concepts, become clear that wellness and medical tourism, are integrated within the overall context of health tourism and are presented in a permanent relation of wellness to illness, and of health to preventive and curative health approaches. Due to these facts, a great percentage of the referred and analyzed authors agrees with the urgent need of a conceptual standardization definition of health and wellness tourism and its variants in order to give a solid theoretical framework to this subject for the future studies and contributing simultaneously for a growing scientific status of Tourism as a specific field of research. Considering tourism as a science is necessary to conceive the tourist phenomenon in its whole history and its own specifications properly and well defined in the context of social sciences with its own limits more defined and established in the academic context. 14 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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Acknowledgements

The authors would like to acknowledge the financial support of the Portuguese funding institution FCT – Fundação para a Ciência e a Tecnologia, through the Ph.D. scholarship research project [SFRH/BD/102413/2014].

References

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Smith, M.; Puczkó, L. Health and Wellness Tourism. Oxford: Butterworth-Heinemann – Elsevier, 2009, ISBN 978-0-7506-8343-2 Smith, M.; Puckzó, L. Taking your Life into your own Hands? New Trends in European Health Tourism. Tourism Recreation Research, Vol. 35 (2), 2010, pp. 161172. Smith, M., Puczkó, L. More than a special interest: defining and determining the demand for health tourism. Tourism Recreation Research, Vol. 40 (2), 2015, pp. 205219. Steiner, Carol J.; Reisinger, Yvette. Ringing the fourfold: A philosophical framework for thinking about wellness tourism. Tourism Recreation Research, 2006, Vol. 31(1), pp. 5-14. Voigt, C.; Brown, G.; Howat, G. (2011). Wellness tourists: in search of transformation. Tourism Review, Vol. 66 (1/2), 2011, pp. 16-30, ISSN 1660-5373.

18 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 1-18 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

ANALYSIS OF SPA TOURIST MOTIVATIONS: A SEGMENTATION APPROACH BASED ON DISCRIMINANT ANALYSIS Marcelino Sánchez-Rivero University of Extremadura (Spain) [email protected] Cristina Rodríguez-Rangel University of Extremadura (Spain) [email protected] Lidia Andrades-Caldito University of Extremadura (Spain) [email protected] ABSTRACT Changes in lifestyle and a growing awareness of the importance of health and quality of life are leading to a growing interest in health tourism in general and spa tourism in particular. For this reason, spa tourist motivations are changing and expanding, going from uni-motivational behaviours (cure an ailment or disease) to other that are clearly multimotivational (rest, relaxation, visit to cultural and natural destinations, enjoyment of food, etc.). The aim of this paper is to confirm the existence of a multi-motivational behaviour pattern in spa tourism as well as to quantify the percentage of the current demand showing this pattern. To do this, with the help of a discriminant analysis used to quantify the probability of the existence of several specific reasons for the practice of thermalism (search for rewarding emotions and feelings; improvement of health; relax; and improvement of physical condition), a segmentation of the demand of spa services in Extremadura (Spain) has been carried out. The results allow researchers to define three groups of tourists: the unmotivated, the multimotivated and the half-motivated. Multi-motivated tourists represent less than 14% of the total number of tourists, and show a high motivation to improve their physical condition and their health, as well as to simply relax in a spa resort. Consequently, although they still represent a small percentage of the market, multi-motivational behaviour in spa tourism is regarded as an emerging segment that will change both the future of spa resorts offer and the way in which customer demands are managed. KEYWORDS Spa tourism; motivation, Extremadura; discriminant analysis; segmentation; multi-motivated clients. 19 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

ECONLIT KEYS C38; C10; C80; D12.

1. INTRODUCTION Nowadays, health and wellness is growing rapidly and its activity is increasing worldwide (Costa, Quintela & Mendes, 2015). Spa tourism falls within the realm of wellness tourism, which, in turn, is part of health tourism. However, there is some confusion regarding these terms, mainly because of two reasons. On the one hand, there is the considerable weight of spa tourism in health tourism. Regarding this, Bonfada, Bonfada, Gándara & Fraiz Brea. (2008) affirm that thermalism is, in many countries, including Spain, the main form of health tourism. On the other hand, there is the extension of the term health, which allows it to be understood as something that is beyond a concept opposed to disease, and makes it possible that destinations offering this type of tourism can provide services aimed at meeting the needs of both categories (Ranćić, Pavić & Mijatov, 2014). In any case, this sector is booming, which is favoured, among other things, by changes in lifestyle as well as by a greater awareness of the importance of health and quality of life (Larrubia & Luque, 2009). This, in turn, has led to changes in the motivations of spa tourists, who now seek not only to be cured of an ailment or disease, but also to break with routine, get in touch with nature, live a different experience, etc. Therefore, it can be assumed that a visit to a spa may be due to various motivations, and in this sense, the study of these motivations becomes of particular relevance. Ranćić et. al.(2014) argue that different people have different motivations to visit a spa. Therefore, the different motivations for visiting a spa should be related to specific socio-demographic variables that enable the segmentation of the demand according to their motivations. In this context, regarding the study of motivations, age has been traditionally considered as a discriminating factor, associating the visit of younger people to a spa to the enjoyment of a relaxed environment that allows them to escape the stress of 20 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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daily routine, while considering that elderly people seek to improve their health (Boekstein, 2014; Larrubia & Luque, 2002, and Peris-Ortiz, Del Rio, Alvarez, 2015). This research paper aims to confirm whether this assumption is valid in the case of the tourism market of Extremadura, as well as to broaden the criteria for market segmentation to a set of variables in the case of spa tourism in this region. For this purpose, this paper has been divided into the following sections: following this introduction, section 2 focuses on the issue under consideration presenting an analysis of the existing literature on the study of spa tourist motivations. In section 3, the spa tourism market of Extremadura is contextualised, which serves as a basis for the analysis. Then, the methodology used is detailed in section 4. Section 5 shows the main results obtained from the analysis and, finally, the most relevant conclusions are summarised.

2. SPA TOURIST MOTIVATIONS Travelling for the purpose of health improvement is one of the oldest motivations in tourism (Swarbrooke & Horner, 1999). Therefore, health tourism stands out as one of the longest established types of tourism. Indeed, the origin of the use of thermal waters for healing purposes dates back to the earliest civilisations (Erfurt-Cooper, 2009). In any case, thermalism has experienced periods of greater and lesser growth throughout history. Thus, we find that it enjoyed its golden years in Roman times, when there was a strong thermal tradition, later continued in Spain by the Arabs (Larrubia & Luque, 2002). Nevertheless, at other times, this activity decreased, as in the Middle Ages, when it was prohibited as a result of the spread of epidemic diseases and the lack of religious rigour that was attributed to such habits (Costa et. al, 2015). And so it was until the 80s, when the interest in thermalism was renewed (Larrubia & Luque, 2002) and, although it can be considered a clearly defined niche of the tourism market, the truth is that it has a great growth potential compared to traditional tourism, which gives it an important strategic value (Álvarez, Del Río, GonzálezVázquez & Merigó, 2015)

21 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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The high rate of growth demonstrated by this tourism sector is favoured both by the changing factors in the demand, and by the importance attached to it by the Government, as it is a strategic sector due to the benefits that is generates for destinations from different perspectives. With regard to its relevance as a strategic sector for destinations, there are different specific features of this sector that justify this assumption. To begin with, spas are usually located in inland destinations, so they become dynamising elements of the local economy (Alén, Fraiz & Mazaira, 2001). Moreover, Antunes (2012) states that spa resorts are seen as real drivers of development at local and regional level, generating indirect effects on the economic and social fabric, and also contributing to the improvement of the quality of life of the local population and the reduction of regional asymmetries. Furthermore, this is a tourism segment that helps increase the average length of stay of tourists, due to the long stays required by treatments, as well as it helps reduce the inherent seasonality of tourism, as most of these stays are usually registered in the low season. In Spain, the Social Thermalism programme of the IMSERSO contributes to this. It is a programme funded by the Ministry of Health, Social Services and Equality of the Government of Spain, which offers retired people the chance to enjoy a stay of between 10 and 12 days in spas, getting medically prescribed treatments, and to enjoy a few days of leisure at low cost. Finally, its relevance as a strategic sector resides in the fact that it integrates the three essential dimensions needed to be considered as a form of sustainable tourism, given that it is supposed to promote social and cultural sustainability, respect for natural resources and the environment, and that it is an economically viable activity, due to its ability to generate financial resources and employment (Martínez Moure, 2008). For all these reasons, it is not surprising that it is considered a strategic sector for Spanish tourism, as evidenced by its inclusion as a priority sector in the National and Integral Tourism Plan (2012-2015). In addition, from the demand perspective, significant economic changes are taking place, as well as demographic, social and cultural changes which point to a great future growth potential of this kind of tourism.

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From a demographic perspective, the aging of the population implies that any tourism activity that is likely to be targeted at this segment of the population is especially attractive, given both for the current size of the potential market and its prospects for future growth. Thus, Smith & Puzckò (2009) indicate that the main factor influencing the development of wellness tourism is the aging of the population, coupled with the desire to live longer and better. In this sense, the quest for quality of life becomes a major concern for the population as a result of the emergence of certain diseases associated with changes in lifestyle, such as stress. The concept of health now comprises not only physical but also mental health, and in a world with increasing work stress, health tourism is expected to continue to grow in the future (Boekstein, 2014). This extension of the term health, which begins to be understood not only as opposed to disease, has helped hydrotherapy and balneotherapy regain their position as therapeutic remedies, especially in developed countries, where there is a growing concern among the population about the search for quality of life (Melgosa Arcos, 2000). In this new context, in order to improve the competitiveness of the thermal sector, spas need a new direction that allows them to overcome the perception as health centres to which they are traditionally associated and extend their services to new market segments (Larrubia & Luque, 2002). This new strategy is not without risk. Some authors indicate that spas are in danger of losing its identity as health centres, focusing more on recreational purposes aimed at a young audience at a time when the population is aging, which is dangerous given that this market positioning depends on fashion and social habits (Peris-Ortiz, et. al., 2015). Gilbert and Van der Weert (1991), meanwhile, suggest that part of the success of European spas has been due to their market repositioning strategy, which focuses on health improvement based on the treatment of illnesses but in a leisure context. In any case, it is clear that spas have opted for a change in its traditional business model that, in turn, has led to increase in tourists’ motivations to visit them. In this regard, the analysis of the motivations of spa tourists has become an interesting field of study that has fostered the emergence of numerous research works (Larrubia & 23 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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Luque, 2002; Ranćić, et. al., 2014; Mak & Wong, 2007; Bonfada et. al., 2008; Boekstein, 2014). In these research studies, age has been traditionally used as the main segmentation criterion for spa visitors, in association with one or another motivation. This study aims to analyse and segment spa tourists in Extremadura considering this variable, while incorporating, at the same time, new variables that facilitate a more accurate segmentation of the market. The following section will analyse the main features of the spa sector in Extremadura in order to provide thorough contextualisation of the results.

3. SPA TOURISM IN EXTREMADURA. Extremadura is located in the southwest of the Iberian Peninsula and is regarded as an inland tourism destination. In this regard, as previously noted, spa tourism stands out as a key sector due its capacity to generate wealth and employment for the local population in the destinations where spa resorts are located. Based on the definition of spa provided by the ANET, which describes it as a place with minero-medicinal waters declared of public utility, medical service and adequate facilities to deliver prescribed treatments, Extremadura has a total of seven spas distributed between two provinces, which makes it the autonomous region with the seventh largest number of spas in Spain (National Observatory of Thermalism, 2015). Regarding their potential to generate tourism activity, it is worth noting that six of them have a hotel, offering a total of 763 beds distributed in 379 rooms. Besides, this number increases as a result of the existence of other hotels located nearby whose clients are predominantly tourists attracted by the possibility of having a spa in the area. This additional accommodation supply provides a total of 901 extra beds distributed in 412 rooms. The spas of Extremadura are an attractive tourism resource, due to both the tourism services that they offer and the uniqueness of the facilities themselves. In this sense, the Spa of Alange, built on the foundations of a Roman spa dating from

24 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

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the second century AD and designated as World Heritage by UNESCO in 1993 due to the state of conservation of its thermal baths, stands out. With respect to the characterisation of the sector, it should be noted that it generated a total of 215,302 overnight stays by 45,984 travellers in 2014, as reported by the Tourism Observatory of Extremadura (OTEX), which implies an average length of stay of 5.6 days that is well above the average stay of generic tourists in Extremadura. Moreover, the importance of this segment in the tourism sector of this region is demonstrated by the relative weight of overnight stays, which account for almost 7% of total overnight stays of tourists in Extremadura. Regarding the analysis of the characteristics of the demand, some data can be outlined in view of the results of the study performed by the OTEX on which this work is built. From the analysis of the origin of spa tourists in Extremadura, it can be deduced that they are an eminently domestic tourists, which is a distinctive feature of this sector. Moreover, the main market is Extremadura itself, followed by Andalusia and Madrid. Regarding age, people over 65 are the largest group of spa tourists in the region, representing two-thirds of total spa customers in Extremadura. Most of these customers have only primary education and usually travel with their partner. Besides, in most cases, their level of household income is below 1,500 euros per month. Once the main features of this sector have been summarised in order to help the reader gain a better understanding of the results presented in the sections below, the analysis methodology used in this study will be detailed.

4. METHODOLOGY In order to obtain the results presented and discussed in the next section, two statistical tools have been used: discriminant analysis and segmentation techniques, whose essential features will be described in this section. Discriminant analysis is a technique used to determine whether significant differences exist between the mean values of a set of (discriminating) variables regarding two or more groups defined a priori. This technique is also used to predict

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the group to which an individual should belong on the basis of the values taken by the discriminant variables in his or her case. In the case of having only two groups, this technique defines a discriminant function as a linear combination of the discriminating variables. This discriminant function should be the one that best discriminates between the two groups defined a priori, that is to say, the one that maximises inter-group variability. Thus, assuming a multivariate normal distribution in the two groups being analysed, N1; and N 2 ;  , Fisher`s discriminant function is given by the following expression: x b 

x  1  1   2  12      1     2 1 2   1 

(1)

being b  k  1  1   2  and where k is any constant. Likewise, the average values of the discriminant function in the two groups are given by the following expression: 1 b 

1  1  1   2  12      1     2 1 2   1 

2 b 

2  1  1   2  12      1     2 1 2   1 

(2)

(3)

Provided that p1 and p2 are the probabilities of belonging to the two groups under consideration, being f1 x  and f2 x  the multivariate normal density functions of the two groups, Bayes' theorem can be used as a criterion for the classification of the individuals analysed by calculating the a posteriori probabilities of belonging to the two groups. These a posteriori probabilities are calculated as follows: Pgrupo 1 x  

p1 f1 x  p1 f1 x   p2 f 2 x 

(4)

Pgrupo 2 x  

p 2 f 2 x  p1 f1 x   p2 f 2 x 

(5)

Thus, the observation x will be assigned to the group obtaining the largest a posteriori probability. 26 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

Segmentation techniques are essentially aimed at identifying a certain number of groups (or clusters), based on the information provided by a sample and analysing the greater or lesser degree of similarity between the individuals analysed. The groups identified should have the lowest possible degree of intra-group variation and, at the same time, the highest possible inter-group variation. Although there are many segmentation techniques, the scientific literature usually distinguishes between hierarchical and non-hierarchical methods. Although Aldenderfer and Blashfield (1984) indicate that the choice of a technique to be used for segmentation will depend on the objectives of the classification, the type of measure used to quantify the

similarity

or dissimilarity

between

individuals,

the

variables

used

for

segmentation, etc., the fact is that a determining factor when choosing between a hierarchical and a non-hierarchical method is sample size, that is, the number of individuals to be classified. According to Hair, Anderson, Tatham & Black (1998), the use of hierarchical methods is recommended when the number of individuals to be classified is small (under 200 individuals) as the results obtained from large samples are unsatisfactory and unreliable. By contrast, non-hierarchical methods, among which k-means algorithm is the most widely used, are particularly appropriate when the number of individuals to be classified is very high. Furthermore, Hair et al. (1998) also point out that these non-hierarchical methods are much less sensitive to the presence of atypical cases (individuals) or irrelevant classification variables. For these reasons, and considering the size of the sample used in this study (466 individuals), it was opted to segment the population of spa tourists in Extremadura using the k-means algorithm. This method involves making a first initial grouping into k groups, where k value is previously determined by the researcher. Once an initial classification of the individuals into the groups has been made, the centroid (vector of mean values of the classification variables) of each group is calculated and the Euclidean distance existing between each individual and the centroid of each group is measured. Then, those individuals showing a Euclidean distance to the centroid of their group that is greater than the Euclidean distance to the centroid of another group are relocated and included in the group that yields the shortest Euclidean distance. Due to the fact 27 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

that this relocation of the individuals to k groups involves a change in the centroids of the groups, the Euclidean distances between the individuals and new centroids of the groups must be calculated again. Subsequently, individuals will be relocated into groups, and so the process will continue until all individuals are located into the group whose centroid is closer.

5. ANALYSIS OF RESULTS The data used in this research paper come from a survey completed by a total of 514 spa users conducted by the Tourism Observatory of Extremadura between June and October 2014. In one of the questions of the survey respondents, spa tourists were asked to indicate their main motivations for visiting a spa and practicing thermalism in this region. Out of a list of twelve motivationsi, the four most common motivations noted by respondents have been chosen for this paper. These four motivations are: 

Search for rewarding emotions and feelings (EMOTIONS) (80.5% of total).



Improvement of health (HEALTH) (75.9%).



Relax (RELAX) (57.2%).



Improvement of physical condition (PHYSIQUE) (46.5%).

Therefore, the affirmative or negative answer to these four motivations to practice thermal tourism was used to define a priori groups, so that for each of these motivations, two groups were defined: the group of those who noted that motivation as one that determined their presence in the spa (affirmative answer) and the group of those who did not choose that motivation (negative answer). Once the groups which served as the basis for the discriminant functions were defined, the next step was to consider the discriminating variables, that is, those variables that could best discriminate tourists with a specific motivation for the practice of spa tourism from those who lacked such motivation. Thus, considering the information provided by the questionnaire, the following six discriminating variables were taken into account: 

Age



Educational level 28

Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito



Household income



Type of accommodation



Travel group size



First visit to a spa

Due to the impossibility of obtaining the value of the discriminant function in those cases in which there was no answer in any of the above discriminating variables, the analysis forced the exclusion of 48 cases. Therefore, the total number of cases analysed amounted to 466 and for each of these cases it has been possible to obtain the value of the discriminant function for each of the four motivations considered. After that, a discriminant function for each one of the four motivations was built based on the six discriminating variables available. The main objective of this task is to determine the discriminating power of the discriminating variables, together and separately. In order to perform this joint analysis, Table 1 presents the Wilks’ Lambda statistic used to test the discriminating capacity of the function created. As it can be observed in that table, the discriminating variables failed to clearly differentiate between the two defined groups regarding two of the four motivations studied: improvement of health (HEALTH) and search for rewarding emotions and feelings (EMOTIONS). That is to say, regarding the two most common motivations for spa tourism, the discriminating variables considered did not seem to be significant enough to condition them, to a greater or lesser extent. However, the other two motivations considered, relax (RELAX) and improvement of physical condition (PHYSIQUE), show different values in their centroids in relation to the discriminating variables. This means, therefore, that the degree of willingness to consider relax and improvement of physical condition as determining motivations for spa tourism varies depending on tourists’ features such as age, educational level, income level, etc. Motivation EMOTIONS HEALTH RELAX PHYSIQUE

Wilks’ Lambda 0.997 0.988 0.950 0.961

Chi-square 1.183 5.493 23.781 18.461

d.f. 6 6 6 6

Signif. 0.978 0.482 0.001 0.005

Table 1. Comparison of the discriminant functions associated with the motivations for spa tourism Source: authors’ own elaboration based on calculations performed using SPSS 19.0. 29 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

Additionally, and in order to determine the individual discriminating power of the discriminating variables chosen regarding the motivations for spa tourism, Table 2 shows the combined intra-group correlations between those discriminating variables and the standardised canonical discriminant function created for each motivation. With the additional data contained in Table 3, which shows the value of the discriminant functions in the centroids of the two groups considered (motivated: positive answer to a motivation; unmotivated: negative answer to that same motivation), it is possible to establish the following relations between the discriminating variables and each one of the motivations studied: - Search for rewarding emotions and feelings: the discriminating variables are virtually uncorrelated with the discriminant function, with the only exception of the first visit to the spa. Actually, this variable shows a high positive correlation with the discriminant function, which means that those tourists visiting a spa for the first time are more likely to search rewarding emotions and feelings there than those other tourists who have already visited a spa before. -

Improvement of health: the two discriminating variables most closely

related to the discriminant function are travel group size and educational level. The negative correlation between group size and the discriminant function should be interpreted as meaning that the improvement of health as a motivation for spa tourism is more common among tourists who travel in large groups than among those who travel in small groups. Moreover, the positive correlation between educational level and the discriminant function implies that the higher the level of education of spa tourists, the weaker their motivation to improve their health during their stay at a spa resort. -

Relax: Age is the discriminant variable that shows the highest

correlation with the discriminant function set for this motivation. This means that younger individuals are more motivated by relaxation in the spas of the region that those of advanced age. Likewise, it is also noted that those tourists staying in high-class hotels (4 or 5-star) are more likely to seek relaxation during their stay at a spa than those staying in lower class hotels or in non-hotel establishments. A greater tendency to relax as the main motivation for spa 30 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

tourism is also observed among those who have previously visited a particular spa resort than those who visit it for the first time. Finally, the negative correlation between educational level and the discriminant function means that relax is a more frequent motivation among tourists with a higher level education. Improvement of physical condition: the discriminant function taken into

-

consideration in order to differentiate between those tourists who state this motivation versus those who do not shows a high positive correlation with both type of accommodations and age, and a somewhat weaker negative correlation with group size. This circumstance results in the fact that tourists staying in high-class hotels and younger tourists exhibit a higher motivation to improve their physical condition. In contrast, tourists who travel in large groups are those less inclined to visit spas to improve their physical condition. EMOTIONS

HEALTH

RELAX

PHYSIQUE

-0.068 0.157 -0.123 -0.005 0.186 0.873

0.338 0.481 0.254 0.241 -0.579 0.010

0.780 -0.396 -0.256 0.657 -0.160 0.442

0.585 -0.025 0.190 0.666 -0.320 0.148

Age Educational level Household income Type of accommodation Group size First visit

Table 2. Combined intra-group correlations between the discriminating variables and canonical discriminant function Source: authors’ own elaboration based on calculations performed using SPSS 19.0.

In the second part of the empirical analysis, the discriminant functions set have been used to calculate the a posteriori probability of belonging to the group of motivated visitors in each of the four causes of motivation being considered, by applying Bayes' theorem. Then, according to the characteristics of each tourist (age, educational level, income level, etc.), the probability of having answered affirmatively to all four motivations studied has been calculated, which results in a total of four probabilities per tourist surveyed.

Motivated Unmotivated

EMOTIONS

HEALTH

RELAX

PHYSIQUE

-0.025 0.104

-0.060 0.198

-0.200 0.264

-0.213 0.191

Table 3. Discriminant functions evaluated in the centroids of the groups of motivated and unmotivated tourists Source: authors’ own elaboration based on calculations performed using SPSS 19.0. 31 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

Based on these four probabilities and using the k-means algorithm, a segmentation of the sample in a total of 3 groups has been carried out. In order to determine the optimal number of segments to be considered, we have used the methodology proposed by Aguiló and Rosselló (2005), given that any a priori decision had been taken regarding the number of segments. Following this methodology, several non-hierarchical cluster solutions have been obtained in which the number of potential segments varies. The results are shown in Table 4. As can be seen, from 4 segments on minor groups (with a value for the overall population of 10% or less) appear whose specific behaviour is not interesting due to their marginal relevance to the overall market of spa tourism. For this reason, it has been opted for 3 segments as a solution.

Group A B C D E F G H

2 65% 35% -

3 53% 14% 33% -

Number of groups 4 5 6 23% 45% 15% 33% 10% 39% 34% 19% 9% 10% 12% 20% 14% 4% 14% -

7 20% 25% 12% 6% 9% 24% 4% -

8 7% 33% 11% 6% 13% 4% 11% 16%

Table 4. Percentage of the sample in each segment (range of solutions from 2 to 8 segments) Source: authors’ own elaboration (adapted from Aguiló and Rosselló, 2005) based on calculations performed using SPSS 19.0.

In addition, also following Aguiló and Rossello (2005), the inter-group variability in this solution of 3 segments has been determined by calculating the absolute Euclidean distance between the end centroids of these groups. Since the variables used for segmentation have been the probabilities of providing a positive answer to each one of the analysed motivations, this variability refers, in fact, to the differences in the probability of motivation among the identified groups, which is presented in the table 5. As it can be readily appreciated, segment B presents more differentiated levels of motivation for spa tourism than the other two segments, because of its variability with respect to segments A and C is significant. However, the variability 32 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

between segments A and C is significantly lower, which highlights a more similar behaviour as far as motivations are concerned. Group B C

A 0.6258 0.2870

B 0.3468

Table 5. Inter-group variability (3 segments) Source: authors’ own elaboration (adapted from Aguiló and Rosselló, 2005).

Thus, once the segmentation has been performed, the values corresponding to the average probability of each group for the motivations considered, which can be used to describe such groups according to their motivational attitude, are shown in Table 6. Based on that, the population of spa tourists can be divided into the following three groups: Unmotivated (group A) (53.2% of total tourists): these tourists show an average probability of giving an affirmative answer that is never higher than 50% regarding the four motivations studied. They are, therefore, less motivated than other segments identified, showing especially weak motivation for the improvement of their health and their physical condition. Multi-motivated (group B) (13.7% of total tourists): This is the most motivated group, since the average probability of positive answer is in all cases over 50%, with its high motivation for both improving their physical condition as their health especially noteworthy. Although to a lesser extent than the previous two motivations, these tourists seem to be the most highly motivated by mere relax in spa resorts. Half-motivated (group C) (33.0% of total tourists): this third group also shows a probability of providing an affirmative answer to the motivations considered higher than 50%, but it differs from the multi-motivated segment regarding the fact that the average probability this time is lower, ranging between 50% and 54% in all cases.

EMOTIONS HEALTH RELAX PHYSIQUE

Group 1 Unmotivated 50.0% 42.7% 47.5% 42.2%

Group 2 Multi-motivated 50.0% 67.0% 57.6% 70.8%

Group 3 Half-motivated 50.4% 54.2% 52.2% 54.5%

Table 6. Segmentation of spa tourist population according to motivation (average probability of affirmative answer to motivations) 33 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

Source: authors’ own elaboration based on calculations performed using SPSS 19.0.

This segmentation of the spa tourism demand in Extremadura based on the probability associated with different motivations must go hand in hand with the analysis of other behavioural variables related to each one of the segments, providing a much clearer characterisation. Accordingly, the last part of this empirical analysis has involved the performance of this characterisation on the basis of the results shown in the Appendix to this paper. Unmotivated tourists: These are elderly tourists (more than 90% of them are 65 years of age) who usually travel in very small groups (1 or 2 persons in most cases). Moreover, their educational level is the lowest of the three segments identified, since almost 70% of them have no education or only primary education. Their level of income is low considering that two-thirds of them perceive a monthly income below 1,500 euros. Another clearly defined feature of these tourists is the long average length of their stay in the spa resorts they visit (95% of them stay in the region more than 5 nights) and their strong preference for middle-class hotels to stay overnight (almost 90% of tourists belonging to this segment stay in 1 to 3-star hotels). Besides, these tourists show the lowest average expenditure in both accommodation and meals, but, curiously, they are those who spend more on leisure and shopping. In addition, health is a major motivation in this segment given that 8 out of 10 of them have come to the spa to seek treatment for a health problem. "Word of mouth" is the most effective marketing tool among these tourists since more than half of them knew about the existence of the spa where they stayed through the recommendation of friends or relatives. These tourists are clearly related to the social thermalism programme of the IMSERSO, considering that 7 out of 10 of them booked their stay at the spa through this agency of the Ministry of Health, Social Services and Equality. Finally, they are those who have the strongest intention to return to the spa where they have been and to recommend it to their relatives or friends. Their spa experience is extensive, in view of the fact that 93% of them have already visited a spa before, even when the frequency of their use of the spa services is low (86% of 34 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

them travel to a spa once a year or less). Moreover, the level of loyalty that they show to a spa in particular is far higher than in other segments as 7 out of every 10 of these tourists affirm that they almost always travel to the same spa. Multi-motivated tourists: This is the youngest segment of tourists, taken into account that more than 60% of them are aged between 30 and 50 years, while those over 65 years old are a minority. They are also those who most commonly travel with their family and in large groups (more than a quarter of them travel in groups consisting of 4 or more people). Besides, these tourists show the highest educational level (two-thirds of them have completed intermediate or university education) and income level (1 of every 3 tourists has a monthly income of, at least, 2,000 euros). However, their average length of stay in spas is the shortest of the three segments, since more than half of them only stay one or two nights. Their preference for high-class hotels is more than evident, given that 94% of them stay in 4 or 5-star hotels. Their high average level of expenditure on accommodation and meals is also significant, which is clearly the highest of the three segments identified. However, their average expenditure on leisure and shopping is the lowest of all segments. Moreover, it is the only segment in which the motivation purely related to holidays is far stronger than the motivation related to health. These are the tourists who most often known and get informed about the spa resorts they visit through the Internet, and they are also the ones who most frequently use this tool for booking their stay, as well as they also outperform all other segments in terms of percentage of direct reservations. Finally, although more than 90% of these tourists express their interest in returning to the spa resort where they have stayed, the fact is that they are those who most usually express a desire not to return to it and not to recommend it to relatives or friends (slightly less than 5% of them in both cases). Besides, this is the segment of tourists with less spa experience, as more than a third of them had not visited any other spa before. However, they are those who use the services offered by the spas most frequently (30% of them visit spas twice or more times a year) and those who

35 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

are less likely to repeat their visit to the same spa (two thirds of them prefer to visit different spas and not to repeat the visit to the same one). Half-motivated tourists: This third group of tourists occupies an intermediate position with respect to many aspects characterising the previous two segments, showing, therefore, less polarisation than the observed in both unmotivated and multi-motivated tourists. Thus, while this segment accounts for the highest percentage of people aged between 51 and 65 years (more than a third of total tourists), these tourists share with unmotivated tourists the preference for being in the company of their family and partner; and with multi-motivated tourists, the high average size of group they travel with. In addition, these tourists show the highest percentage of people with no education, although this is not the segment with the lowest educational level, as they show a higher percentage of tourists having completed secondary or university education. They also share with unmotivated tourists a low monthly household income and a long average stay in the spa resort, though the latter is lower in the case half-motivated tourists (stays for longer than 5 nights are less frequent while 1-5 night stays are more common). Moreover, the polarisation observed in the previous two segments in relation to the type of accommodation used does not appear in this third segment, since there is a certain balance between tourists of this group staying in 4-5 star hotels and those staying in 1-3 star hotels. This third segment has the lowest tourism expenditure per day, which leaves it far behind multi-motivated tourists in terms of expenditure on accommodation and meals, and also behind unmotivated tourists regarding expenditure on leisure and shopping. Furthermore, like in the case of unmotivated tourists, the motivation for health is stronger than for holidaying, although much less pronounced. This segment of tourists makes less use of the internet to find and obtain information about a particular spa than multi-motivated tourists, although slightly more than unmotivated tourists. Despite this, the percentage of tourists that find out about a spa through the IMSERSO or through the recommendation of friends is very similar between the first and third segment identified. The Social Thermalism programme of the IMSERSO also plays a key role in this third segment, since most tourists booked their stay at 36 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

the spa through this agency, although this percentage does not approach that of the group of unmotivated tourists. In order to complete the characterisation of this third segment, it should be noted that its members lag behind multi-motivated tourists in their interest to return to the same spa and to recommend it to their relatives or friends; but forge ahead in terms of spa experience, although it does not reach the level observed among unmotivated tourists. The frequency of use of the services offered by spas among tourists of this third segment is lower than among multi-motivated tourists and very similar to that reported by unmotivated tourists. Finally, it is observed that there is a strong balance in this segment between those visiting almost always the same spa and those who, on the contrary, choose to vary and not repeat their visit to the same spa.

6. CONCLUSIONS Health tourism, which includes spa tourism, is presented as an interesting tourism segment due to its current high growth rate as well as the growth potential attributed to it. Spa tourism, in addition, is shown as a strategic sector given the elevated number of stays that it generates, its contribution to the reduction of the seasonality associated with the tourism activity, its nature as a kind of sustainable tourism and the opportunities provided for inland destinations to help create wealth and local employment. The high growth rate shown by this sector is explained by demographic, cultural, social and economic changes. It is worth noting the increase in the possible uses of spas that has allowed for diversification of the profile of clients attending these facilities, which begin to have different kinds of customers who go to spas driven by different motivations. In this sense, the study of motivations becomes an attractive field given the need to generate knowledge that enables spas to segment their market and better meet the needs of the different profiles of the target market they intend to address. By using demographic variables such as age, educational level, household income, type of accommodation used, travel group size and first visit to the spa, 37 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

three segments of spa tourists in Extremadura have been obtained according to the different motivations that make go to a spa. To do this, a total of four motivations have been considered: care for health, improvement of physical condition, relax and search for rewarding emotions and feelings. Thus, a multi-motivated segment of tourists was obtained whose profile corresponds to the youngest customers, with the highest educational level and level of income; they usually travel with their family and stay in high-class hotels for short periods of time, having a high expenditure on accommodation, food and drinks. On the opposite side, the segment of unmotivated tourists corresponds to older tourists, with a lower level of education and income, who have longer average stays and opt for lower class establishments, with leisure and shopping for souvenirs or gifts being the main components of their tourism expenditure. The segment of half-motivated tourists is in an intermediate position between the two previously stated. The results obtained in this paper reflect the need for spa resorts to orient their offer to an audience characterised by increasingly varied motivations and shorter stays. The idea of a spa as a simple centre offering treatments for ailments or diseases is, therefore, becoming obsolete; while its consideration as a multipleactivity centre, which is creating new niche markets as a result of the changes in the current society, responds more faithfully to what spa resorts will be (or should be) in the future.

*Funding This research work was supported by the Junta of Extremadura and co-financed with ERDF funds (GR15072).

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39 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

Hair, J.; Anderson, R.; Tatham, R.; Black, W. Multivariate Data Analysis.6 th edition. Upper Saddle River: Prentice Hall, 1998. ISBN: 01303229290. Jobson, J.D. Applied Multivariate Data Analysis: Volume II. Categorical and multivariate methods. New York: Springer-Verlag, 1992. ISBN: 978-1-4612-6947-2. Larrubia, R.; Luque, A.M. Las estaciones termales en Andalucía: de la explotación tradicional a la configuración de un nuevo producto turístico integral. Cuadernos de Turismo, volume 10, 2002, pp. 101-122. Mak, A.H.N.; Wong, K.K.F. Motivation of Hong Kong residents seeking spa experiences when travelling away from Hong Kong Proceedings of 5th Asia-Pacific CHRIE and 13 th Asia-Pacific Tourism Association Joint Conference. 2007. Martínez Moure, O. Talasoterapia y turismo: los recursos terapéuticos del agua del mar como mecanismo sostenible de promoción turística para los municipios costeros: el caso de la provincia de Pontevedra (Galicia) Medicina Naturista, voume 2, issue 2, 2008, pp. 136-142. Melgosa Arcos, F.J. Turismo de Salud: termalismo y balneario. En: Blanquer Criado, D. (Dir) III Congreso de turismo, universidad y empresa, 2000, pp. 259-386. Tirant lo Blanch. Observatorio

de

Turismo

de

Extremadura

(OTEX):

http://turismoextremadura.com/viajar/turismo/es/pie/observatorio-2015.html (accessed January 2016) Observatorio Nacional del Termalismo: http://www.observatoriotermalismo.org/ (accessed January 2016). Peris-Ortiz, M.; Del Río, M.C.; Álvarez, J. Barriers to Implementing Quality Management in Spanish Thalassotherapy Centers. In: Peris-Ortiz, M. & Álvarez, J. (Eds.), Health and Wellness Tourism, Switzerland. Springer International Publishing, 2015. ISBN: 798-3-319-11489-7. Ranćić, M.; Pavić, L.; Mijatov, M. Wellness center in Slovenia: tourists´profiles and motivational factors, Turizam, volume 18, issue 2, 2014, pp. 72-83. 40 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

Smith, M.; Puczkó, L. Health and Wellness Tourism. Oxford: Elseiver. ISBN: 978-07506-8343-2. Swarbrooke, J.; Horner, S. Consumer Behaviour in Tourism. Butterworth, Oxford, 1999. ISBN-13: 978-0-7506-6735-7.

41 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

APPENDIX PROFILE CHARACTERISTICS OF THE TOURIST SEGMENTS IDENTIFIED Age: Under 30 years old Between 30 and 50 years old Between 51 and 65 years old More than 65 years old Who do you travel with? : My partner My family Friends Colleagues I travel alone Travel group size: 1 person 2 persons 3 persons 4 persons 5 persons More than 5 persons Educational level: Uneducated Primary Secondary Higher Monthly household income: Less than 1,000 euros Between 1,001 and 1,500 euros Between 1,501 and 2,000 euros Between 2,001 and 2,500 euros More than 2,500 euros How many nights are you staying in this region on this trip? : 1 night 2 nights 3 nights 4 nights 5 nights More than 5 nights N/A Type of accommodation: 4 or 5-star hotel 1, 2 or 3-star hotel Non-hotel accommodation Daily tourist expenditure per person: Accommodation Meals, coffee, soft drinks, ... Leisure Shopping (gifts, souvenirs, ...) Main travel motivation: Holidays Health Another reason

Unmotivated

Multi-motivated

Half-motivated

0 .0% 0 .8% 8 .1% 91.1%

9.4% 60.9% 20.3% 9.4%

0.6% 5.8% 34.4% 59.1%

54.4% 12.5% 19.8% 0.0% 13.3%

59.4% 21.9% 17.2% 0.0% 1.6%

54.5% 18.8% 16.9% 0.6% 9.1%

13.3% 71.0% 10.5% 2.8% 0.4% 2.0%

1.6% 59.4% 10.9% 10.9% 1.6% 15.6%

8.4% 56.5% 8.4% 14.9% 4.5% 7.1%

21.4% 47.2% 14.9% 16.5%

9.4% 21.9% 34.4% 34.4%

22.1% 34.4% 26.0% 17.5%

44.8% 22.6% 9.7% 14.1% 8.9%

26.6% 28.1% 12.5% 12.5% 20.3%

45.5% 24.0% 13.6% 7.1% 9.7%

0.4% 0.8% 0.0% 0.0% 2.0% 95.2% 1.6%

17.2% 37.5% 12.5% 3.1% 4.7% 25.0% 0.0%

1.3% 3.9% 5.2% 3.2% 5.8% 79.2% 1.3%

4.8% 88.7% 6.5%

93.8% 4.7% 1.6%

54.5% 43.5% 1.9%

29.20 euros 21.99 euros 20.76 euros 45.09 euros

53.45 euros 33.03 euros 15.00 euros 28.65 euros

37.24 euros 24.53 euros 17.98 euros 38.93 euros

16.9% 65.6% 79.4% 31.3% 3.6% 3.1% Source: Authors’ own elaboration.

30.5% 62.3% 7.1%

42 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

M. Sánchez-Rivero; C. Rodríguez-Rangel; L. Andrades-Caldito

PROFILE CHARACTERISTICS OF THE TOURIST SEGMENTS IDENTIFIED (Continuation) How did you know about this spa?: IMSERSO Friends’ recommendation Brochures and guidebooks Internet Advertising in the press, radio, TV... Travel agency recommendation Other N/A How did you book this trip?: Through IMSERSO Through the Internet Through a travel agency Directly (personally) Through other means N/A Would you like to return to this spa?: Yes No N/A Would you recommend this spa?: Yes No N/A Is this your first visit to a spa?: Yes No How regularly do you make use spas services?: Once a year or less A couple of times a year Several times a year Almost every month N/A Do you usually visit the same spa?: Almost always I prefer to change/I do not like to repeat N/A

Unmotivated

Multi-motivated

Half-motivated

24.2% 56.0% 2.0% 8.1% 0.4% 0.0% 9.3% 0.0%

7.8% 34.4% 1.6% 43.8% 1.6% 0.0% 9.4% 1.6%

22.7% 52.6% 0.6% 18.2% 1.9% 0.6% 3.2% 0.0%

68.1% 3.6% 0.4% 25.8% 2.0% 0.0%

15.6% 32.8% 6.3% 28.1% 14.1% 3.1%

54.5% 9.7% 3.9% 26.6% 5.2% 0.0%

98.0% 0.4% 1.6%

92.2% 4.7% 3.1%

91.6% 3.9% 4.5%

99.2% 0.8% 0.0%

92.2% 4.7% 3.1%

94.2% 3.2% 2.6%

6.9% 93.1%

35.9% 64.1%

21.4% 78.3%

86.1% 9.1% 1.3% 0.9% 2.6%

70.7% 12.2% 17.1% 0.0% 0.0%

78.5% 15.7% 0.8% 0.8% 4.1%

70.6% 29.0% 0.4%

34.9% 65.1% 0.0%

48.0% 52.0% 0.0%

Source: Authors’ own elaboration.

i

 The motivations presented in the survey question were not mutually exclusive, so that each tourist could choose as many motivations as he or she considered appropriate. 

43 Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 19-43 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.).

D. Bozok; Ö. Açıksözlü; E. Güleç

FACTORS AFFECTING THE PERCEPTION OF HYGIENE AIMED AT TURKISH HAMAMS AS CULTURAL HERITAGE: ANTALYA Düriye Bozok Balıkesir University (Turkey) [email protected] Övgü Açıksözlü Balıkesir University (Turkey) [email protected] Emin Güleç Balıkesir University (Turkey) [email protected] ABSTRACT This study has been carried out in order to identify the factors affecting the perception of hygiene aimed at Turkish Hamams as cultural heritage. With respect to this goal, a survey has been performed by means of a sample method for local and foreign tourists who have used the hamams in the central district of Antalya. In total, 210 people have been reached. The value for Cronbach’s alpha in the survey has been measured as 0.797. In the analysis of research data regarding the statistical method, factor analysis, regression and correlation have been used as analysis methods. As a result of the research done on factors affecting the perception of hygiene aimed at Turkish hamams, the elements such as the sensitivity of hamam personnel on hygiene, the fulfilment in general principles of hamam, and the physical competence of hamam have been identified as the three significant factors by the tourists involved in the survey. KEYWORDS: Turkish Hamams; Hygiene; Sanitation; Antalya. ECONLİT: Z390; I190; M390; Z100.

44  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

1. INTRODUCTION Water has been one of the primary sources for life since the ages of adoption of natural existences as god.

In ancient times, people made use of water for the

purification of body and soul and used it for the arrangement of places that acted as the temple of body with the shape of open and close rooms intended for preservation of health. Afterwards, these places have formed the hamam structures which act as the source for today’s bath culture. According to Kilito (1992), individuals experience the important instants of human existence in the bathroom. In other words, they do not only perform religious duties in religious places but they also purify themselves as a precept of their religion with water, thereby living and experiencing a feeling of crossing over to the other side in baths. The Turkish Hamam interrelates the hygiene of soul and body. Hamams are also an indicatior of the respect for the TurkishIslamic tradition in that they provide the needs for washing, ritual cleaning and purification of soul (Tsikaloudaki et al., 2013). In Arabic, the word hamam is derived from the stem of “hamm” - ‘to heat, to be hot’- and it means “the place that is heated” (Sarmento and Kazemi, 2014) and heat treatment (Hoheb, 2010). The word ‘hamam’ is used as a general term for the structures in providing the needs of people for washing and cleaning (Aktaş, 2011, 63; Apaydın, 2009; Savaş, 2007; Bozok, 2006). Bath houses and public bath structures which have existed since the Hellenistic period, developed in the Roman and Byzantian periods (Sibley, 2006), and later were begun to be used in the Ottomon period. Being a religious requirement and having developed as a bath complex next to other religious structures, Turkish hamams have had an impact on the emergence and development of a powerful bath tradition (Smolijaninovaitė, 2007). Having nourished on the architectural and bathing culture brought by the Seljuks to Anatolia in the 11th century, the Turkish hamam became the most significant element of daily life and civil architecture in the Ottoman period. In the Ottoman society, Turkish hamams were sort of spaces for socialization and acted as entertainment areas for match-making, activities such as ‘bath for bride and groom’, besides being used by people for bathing, cleaning, and cures (Apaydın, 2009). 45  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

Playing an important cultural role today, hamams are notably a colorful part of the national culture of Turkey. According to Smolijaninovaitė (2007), Turkish Hamams can be defined as locations where exotic and erotic cultures are blended, moreover they provide more specific traces belonging to Turks mostly by the effect of Islam. However, Turkish Hamams are used as issues for idioms, literature, movies, and they carry the Eastern mystical aura to the West. Today the Turkish Hamam has placed itself as hot spring units being in the structure of accommodation enterprises in the tourism industry and particularly thermal resorts. In addition to that, they reside as health centers called SPA centers (Salus Per Aquas = Health by or through water) which apply various treatment styles as a part of technological developments. In pursuit of living different experiences, people also visit Turkish hamams on their trips to those centers.

Presenting a

possibility for experiencing the distinctive traditional Turkish culture to tourists, Turkish hamams are visited for various purposes such as interest, curiosity, search of alternative, advice from friend, bathing, and getting rubbed with a kese. On the other hand, the maintenance of hygene in baths is one of the most essential topics regarding tourist health. Water is a very considerable matter for hygiene and sanitation considering the protection against contagious diseases (Katherine et al., 2014).

Hygiene is the

complex of science which applies the information about health as a synthesis in order to protect and promote human health for the individual and society, and make them lead a healthy life for a long period of time (Yumuturuğ, 1980). Sanitation is derived from Latin; the word “sanitas”. It means health and cleanness (Aktaş and Özdemir, 2012, 243). In general, the meanings of hygiene and sanitation are mistaken for each other.

Hygiene refers to health rules whereas sanitation refers to the

precautions taken for promotion of hygiene, health condition, and its continuity, in other words, it refers to the entire operations of required sterilization done for the creation of health conditions and their continuity (Merdol et al., 2000; Çiçek, 2008). Bacterial reproduction is prevented by the implementation of sanitation programs (Öztaş, 2002). Hamams are areas where people go for personal cleaning and get cleaned to be healthy, therefore these areas are very important for human health. Hamams should 46  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

have dust, water, and microbe repellant surfaces that are easy to clean. While cleaning hamams we should not only consider visible contamination but also invisible threats. The applications of hygiene include both the necessary precaution for those invisible threats and the effort in establishing their control and elimination. The achievement of secure applications of hygiene and formation of health services in hamams have a vital importance in effacing the risk of transmission of diseases and infections, and their control (Kratzke et al., 2014). In hamams, it deems necessary to drift away the microorganisms which threaten human health from the environment they are in, hence it is primarily necessary to pay attention to the quantity of water and conservation of possibly proper level of water heat (Boge et al., 2013; Açıksözlü, 2015). On the other hand, people carry the pathogenic microorganism in their body without being infected and can transmit them to everywhere when in contact. Apart from its transmission by means of direct contact, the transmission of diseases and infections can be possible by touching the contaminated surfaces and objects in hamams and spreading them by nose, eye, and mouth to the other people (Kratzke et al., 2014). In spite of the fact that the main goal of the hamam enterprises or hamam units in the body of hotels is to make an economic profit; the fulfillment of customers’ requests and needs, the need in providing the hygienic environment within the context of their level of contentment, and the reflection of a reliable impression of an enterprise are to be considered as crucial matters. In real terms, it requires to be professional to ensure hygiene in hamams because tourist health is affected by several factors including the quality of water, the chemicals used for cleaning and hygiene, and the cleanness of ventilation installation in hamams. This study has been carried out on account of benefiting from the experiences of professional hygiene suppliers and their cleaning sysyems, the training of working personnel on hygiene, and the demand for frequent inspection of hamams. As a matter of fact, it has been concluded that the topics such as hygiene and sanitation are not sufficiently taken into consideration. In addition, when the field of literature relating to research was examined, no studies were encountered considering the perception of hygiene on Turkish hamams. In the light of this study, it has been intended to determine the factors affecting the perception of hygiene of local and foreign tourists aimed at Turkish Hamams as a 47  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

cultural heritage, herewith the degree of importance of aforementioned factors. This study intends to contribute to the literature relating to its field.

2. METHOD

The Model and Hypotheses of Research Being a part of social life, the environment in Turkish hamams will precipitate various contagious diseases to occur unless hygiene and sanitation are applied. In contrast with hamams’ goal to clean and restore health, their risk of spreading contagious diseases will cause a negative impact on customer impression. The variables used in the research are as follows; 1. The Water Quality and Sanitation 2. The General Cleanness of Hamam 3. The Sufficiency of Equipment in Hamam 4. The Disinfection of Hamam Before Use 5. The Hygienic Sufficiency of Hamam and Hamam Personnel 6. The Inspection and Maintenance of Hamam 7. The General Perception of Hygiene on Hamam As a result the hypotheses of research follow the pattern below; H1: The water quality and sanitation have a notable effect on the general perception of hygiene of hamam. H2: The general cleanness of hamam has a notable effect on the general perception of hygiene aimed at hamam. H3: The sufficiency of equipment has a notable effect on the general perception of hygiene aimed at hamam. H4: The disinfection of hamam before using has a notable effect on the general perception of hygiene aimed at hamam. H5: The hygienic sufficiency of hamam and hamam personnel have a notable effect on the general perception of hygiene aimed at hamam. H6: The inspection and maintenance of hamam have a notable effect on the general perception of hygiene aimed at hamam.

48  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

Figure 1: The Model of Research

3.THE EMPIRICAL RESEARCH In this study, the nature of research is based on the local and foreign tourists using hamam enterprises located in the city, Antalya. The data collection method used in the research is the survey study based on convenience sampling. In this context, a survey has been applied on 210 tourists using the hamams in Antalya. 8 questions from the survey which have been used as a data collection method in the research, were taken from Aydın, Tütüncü, and Aydın (2013), and 18 questions were taken from the study done by Açıksözlü (2015). This survey consists of two parts. In the first part, there are demographic characteristics based on the participants, and in the second part there are 29 statements measuring the tourists’ level of perception of hygiene aimed at hamams. During the analyses, 3 statements have been excluded from the scale and in total 26 statements have been proceeded to be used in the analysis. Depending on the aforementioned variables, a 5 point Likert scale has been used.

49  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

The Aim and Importance of Research As a feature, Turkish Hamams are a cultural heritage for Turkey. Having a significant place in the social life of local people, Turkish hamams widely kindle tourists’ interest. Tourists visit hamams because of their intriguing historical and socio-cultural structure, and with the intention of restoring health. However, health problems might be in question in case hygiene and sanitation are ignored concerning efficient health conditions. The aim of this research is to determine the factors affecting the general perception of hygiene aimed at Turkish Hamams in Antalya. The Analysis and Reliability of Data This scale has been formed to measure the general perception of hygiene in hamams and its relability has been tested by Cronbach’s alpha as a technique. The results depending on the reliability analysis are shown in Table 1. Value for Cronbach’s Alpha

Statement Number in Scale

0,797

26 Table 1: Results of Scale on Reliability Analysis

According to the result of analysis, Cronbach’s alpha has been found as 0, 797. This value is sufficient enough to signify the validity of scale as a whole (Altunışık et al., 2007).

Table 2. Findings Based on Demographic Variables

12,9 % of the participants in the survey hold a Bachelor’s Degree, 23,3 % of the participants hold an Associate’s Degree, and 30,5 % of the participants hold a High 50  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

School Degree. 6,6 % of the participants hold a Primary and High School Degree. In addition to that, when nationalities of the participants are regarded, it has been observed that 32,4 % of the participants are German with the highest rate, and 19,5 % of the participants are Russians with the lowest rate.

Table 3. Arithmetic Means and Standart Deviations Based on Hygiene and Sanitation in Hamams

The Arithmetic Means and Standart Deviations Based on Hygiene and Sanitation in Hamams are given in Table 3. When the data in Table 3 is examined, it can be stated that the weakest extent of the values depending on the hygiene of hamams is the quality of water and sanitation. The allocation of water resource, its quality or an ambiguous periodic cleaning and maintenance of the inventories relating to water can be indicated among the factors causing this condition.

51  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

Findings of Factor Analysis Based on the Study The results of the test carried out to classify the variebles in the study are shown in Table 4.

Table 4. Results of Factor Analysis

The result of KMO test which is beneficial to measure the sampling adequacy, is expected to be above 60,0 % (Nakip, 2006). In other words, when the KMO value is high, any variable in the scale might be meant to be impeccably estimated by the other variables. In fact, in the study, the KMO value has had the expected value which is 0,710. Subsequently, in the study the p value for Bartlett’s Test of Sphericity has been measured as 0,0001 which meets the condition that the p value for

52  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

Bartlett’s test has to be lower than 0,05. It has been concluded that the factor analysis can be proceeded in accordance with the results. Each distribution of the statement to factors has been examined in the scale, the fact notwithstanding that the considered factors which have 1 and higher core value are determined to have 6 as the scale factor number. In order to specify on which factor, statements do have a powerful correlation, rotated component matrix has been formed, besides examining whether the statements fulfill the acceptance level of overlapping and values of factor load. Because of the existence of two statements in two different factors and the difference between two factors having a load value lower than 0,1, the statements have been detected to exhibit an overlap. The result depicts that the statements do not measure a single characteristic in the scale and these statements have to be excluded from the analysis. In another statement, the factor load has been lower than 0,40 and the statement has been removed from the scale. Thus, the statement number has dropped to 26 in the scale. Consequently, the total contribution of these factors to the total variance has been viewed as 56,139 %. The variables according to the magnitude of contribution they have made to the total variance defined are enumerated as follows; WQS forming 19,873 % of total variance, GCH forming 11,521 % of total variance, SEH forming 7,283 % of total variance, DHBU forming 6,865 % of total variance, HSHP forming 5,524 % of total variance, and IMH forming 5,073 % of total variance.

Findings Relating to Correlation Analysis A correlation analysis has been done with an eye to put forth the relationship between the general perceptions of hygiene of tourists and the subaltern dimensions on hygiene and sanitation in hamams. The findings of the analysis are shown in Table 5. With regard to the result of correlation analysis, it has been observed that there is a considerable and positive aspect in the intention of referring to three independent variables in the study. The independent variables concerning the correlation levels on the general perception of hygiene in hamams, which are dependent variables, are put in order according to their intensity as follows; the hygienic sufficiency of hamam 53  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

and hamam personnel (0,512), the sufficiency of equipment in hamam (0,208), and the disinfection of hamam before use (0,194).

**Correlation is meaningful at level 0.01. * Correlation is meaningful at level 0.05. Table 5. Findings Relating to Correlation Coefficients of Inter-Variables

In other words, the personnel’s obedience to the rules of cleaning and hygiene in hamams located in Antalya, the effective operation of lighting and ventilation systems, and the precautions taken before use of those hamams positively enhance tourists’ perception of hygiene on hamams. Findings Relating to Regression Analysis A regression analysis has been done with an eye to put forth the effect of the variables relating to hygiene of hamams on the general perception of hygiene. Durbin-Watson test has been applied for the independence of errors in the analysis. The purpose of the application of test has resulted from a regression model, which has been once predicted, can be benefited as a number to test whether or not the terms are in correlation. Thus, the test value has been found as 1,447. Being in the acceptable limits, the value in question is between 1-3 (Nakip, 2006). On the other hand, VIF and Tolerance values are also examined so as to be convinced whether or not the problem of multiple correlation occurs among the variables. It can be stated that since VIF values are lower than 10 and Tolerance values are not lower than 0,01, the problem of multiple correlation of inter-variables does not exist. The results of the test are shown in Table 6.

54  Enlightening Tourism. A Pathmaking Journal, Vol. 6, No 1 (2016), pp. 44-62 ISSN 2174-548X Special issue on “Thermal Tourism, Thalassotherapy and Spas: the water in the health and wellness tourism” Álvarez-García, J. & Del Río Rama, M.C. (Eds.). 

D. Bozok; Ö. Açıksözlü; E. Güleç

R=0,596

R2=0,356

Adjusted R2=0,336 Durbin-Watson=1,447 F(6,390)= 18,665; p