Health and wellness tourism research

Existing research on health and wellness tourism on the Web of Science and CNKI databases is largely foreign and focuses on medical health and wellness tourism, hot spring health and wellness tourism, and rural health and wellness tourism. However, Chinese research focuses more on forest health tourism, the health and wellness industry, rural health and wellness tourism, and the construction of health and wellness tourism destinations. As an example of the latter, in the 19th century, forest bathing tours started to emerge in Germany. By the 20th century, the forest bathing base in Bad Wörishofen in Germany was regarded to be the earliest forest health and wellness tourism destination. As a natural oxygen bar, the forest is a tourism resource integrating rest, exercise, and wellness. It provides hiking, sunbathing, aerobic walking, and other special tourism projects [13]. Scholars have explored the spatial distribution of forest health and wellness tourism resources by means of geographic analysis methods such as nearest neighbor analysis and geographical concentration degree [14], thus laying the research foundation for forest health and wellness tourism development as well as the construction of tourism destinations.

From the perspective of demand and supply, Kaung Hwa proposed eight customer service elements of health and wellness tourism, including personnel service, environment, healthy diet, leisure, rehabilitation, unique travel experience, social activities, and physical and mental cultivation, and analyzed the health and wellness tourism preferences of elderly tourists [15]. Nikipelova et al. evaluated health and wellness tourism resources in Morsin and ranked it as a national resort. Health and wellness tourism has also become an emerging tourism industry in Pakistan [16]. Ullah et al. argued that the development of a new form of health and wellness tourism depends on the demand and supply of the tourist market and related industries, infrastructure, and external environments [17]. Taking Russia as an example, Dunets et al. concluded that social history, natural resources, economy, infrastructure, ethnic groups, tourism conditions, policies, and the Internet are components of the sustainable development of rural health and wellness tourism [18]. In rural health and wellness tourism activities, familiarization with traditional rural and farming cultures and experiencing the natural environment can meet the tourists’ different emotional needs and benefit physical and mental health.

The industrial revolution has promoted the rapid development of the healthcare industry, and modern medical technology has made the globalization of medical care possible. The problems of ethics and service quality supervision in the medical care system have hindered the rapid development of medical health and wellness tourism, which has thus attracted scholars’ attention and discussion. Karadayi-Usta and Serdar Asan propose a medical tourism service supply chain (MTSSC) model, which supplements the theoretical basis of medical health and wellness tourism service management [19]. The COVID-19 pandemic has brought numerous adverse negative impacts on the global tourism industry, and tourists are more likely to travel to countries or regions with better health care systems. Kaewkitipong et al. suggest that countries with abundant vaccines could develop medical health and wellness tourism to attract tourists from countries with a vaccine shortage to come for sightseeing and get vaccinated [20]. Rogerson and Rogerson found that South Africa is suitable for the development of health and wellness tourism as a climate resort that can treat diseases such as tuberculosis [21]. Ander Village in South Korea has utilized local herbal resources to develop health and wellness tourism and to realize economic recovery and growth [22]. Similarly, it is worth considering that traditional Chinese medicine is a precious resource with functions of medical care and health preservation that can serve the wellness tourism industry. Traditional Chinese Medicine (TCM) treatment has gradually highlighted its unique advantages in the practice of COVID-19 prevention and treatment. TCM tourism is a type of health and wellness tourism with Chinese characteristics. Wang believed that forest farms rich in TCM resources should deeply explore TCM cultural tourism resources on the basis of primary functions [23]. Guo analyzed the development status and problems of TCM tourism in Kaili City and put forward development suggestions from the perspective of consumers [24]. Ethnic medicine health care and longevity health tourism are ways to break through the development bottleneck of the pharmaceutical industry and realize the innovation and transformation of the tourism industry.

The relationship between supply and demand of health and wellness tourism, especially the demand side of tourists, such as psychological needs, physical needs, and the relationship between their motivations and behaviors, needs to be further discussed [25]. For example, in recent studies, Jiang et al. analyzed the diversified demands of health and wellness tourism from the perspective of intra-industry trade [9], and Liu et al. studied tourists’ motivation, inspiration and goal consistency [26]. Health and wellness tourism is highly service-oriented and subsequent research should be tourist-oriented and should focus on the construction of service functions of health and wellness tourism destinations.

Tourism resource value evaluation research

The value evaluation research of tourism resources began in the middle of the 20th century, and the evaluation method was mainly qualitative. China’s tourism resource value evaluation started relatively late as compared to foreign research whereby tourism resource value evaluation research started in the 1970s. At the end of the 20th century, with the development of qualitative and quantitative evaluation methods, more subdivided research on the value evaluation of tourism resources appeared, and value evaluation of tourism resources showed a trend of refinement and diversification. Earlier qualitative evaluation can be traced back to the end of the 20th century, when Huang Minsheng assessed tourism resources in terms of resource value, development conditions, and benefits [27]. Most scholars used a three-level index system to construct the value evaluation system of tourism resources, such as resource value, abundance, tourism conditions, environment, and social economy, and then conducted empirical analysis with specific cases. Cases that have been studied include Shihezi in Xinjiang, Pianguan County, Lanzhou City, and Chongqing City. However, Wu (2008), and Chen and Wan (2021) constructed the evaluation index system from the aspects of brand value and environmental protection coefficients, practicality, hedonism, and symbolism of customer value experience [28, 29].

Based on tourism planning and the tourism value theory, Murtini et al. evaluated the tourism value of Ria Kenjeran beach from four aspects: attraction, infrastructure, suitability, and development strategy [30]. Velasco et al. evaluated the tourism value, socio-economic value, and market value of marine resources [31]. Belmonte Serrato et al. analyzed the scientific and educational value, accessibility, and tourism value of wasteland resources in Murcia [32]. Brzovska et al. used an experience economy model to evaluate the experience value of wine tourism [33], and Pantoja et al. evaluated suitability factors and resource advantages of beekeeping tourism in Chile [34]. However, Chekalina and Ryglová et al. established a multidimensional model for the strategic evaluation of tourism resources [35, 36], Hou and Li et al. innovatively introduced sensor technology and artificial intelligence neural network model to build tourism resource recommendation and evaluation model [37, 38]. Therefore, value evaluation of tourism resources has experienced a range of qualitative to quantitative evaluation methods, and from single to diversified evaluation contents. At present, different types of scientific evaluation systems have been formed in the academic community, which occupy an important position in tourism research. These value evaluation theories and methods of tourism resources have been studied in many fields, but research in the field of health and wellness tourism remains limited. Very few scholars have constructed the evaluation index system of forest health and wellness tourism and hot spring tourism from different perspectives, and there are few studies on the overall value evaluation index system of health and wellness tourism.

Research methods

Fishbein-Rosenberg evaluation model.

Rosenberg and Fishbein put forward the model of behavior and attitude measurement and evaluation in the same basic form [43]. This evaluation model is most often used when analyzing consumer decisions and in the comprehensive evaluation of tourist destinations. In the field of tourism resource evaluation, the Fishbein-Rosenberg evaluation model has a high application value and is a classic evaluation method. The calculation formula of the model is as follows.

Where E is the comprehensive evaluation value, n is the total number of factors, Q_i is the weight of the i^th factor, and P_i is the evaluation score of the i^th factor. This study tries to improve the evaluation model by introducing the evaluation opinions of experts, administrators, and tourists, and assigning different weights to make it more suitable for the value evaluation of health and wellness tourism resources.

Primary selection of indicators

The traditional three-level system is adopted to construct the evaluation index system of health and wellness tourism resources. The selection of the first-level index is mainly based on the first-level categories in Classification, Investigation and Evaluation of Tourism Resources (GB/T 18972–2017), that is, resource elements’ value, environmental value, and development and construction value are selected as the three first-level indicators. When selecting the second-level index, on the basis of China’s relevant evaluation criteria and domestic and foreign studies, the index is modified and added according to the characteristics of health and wellness tourism resources. Nine second-level indexes are selected, including tourism health value, cultural value, resource dependency, resource added value, environment quality, diversity, stability, location characteristics, and construction conditions. In the selection of the three-level index, starting from the three main characteristics of health, regimen, and elderly care, and referring to the index system constructed by domestic and foreign scholars, a total of 36 indicators are determined.

Data type, source, and method of data collection

Adhering to the principle of objectivity and comprehensive evaluation, the information of experts studying health and wellness tourism was randomly searched on the literature platform. Scholars were invited to participate in the expert consultation by e-mail and telephone, and 35 interviewed experts who voluntarily participated in the whole consultation were identified. The interviewed expert group was composed of experts in tourism geography, ecology, Chinese Traditional Medicine and other research fields, among which 28 were engaged in tourism research, accounting for 80%. This study was approved by the Biomedical Research Ethics Committee. Participant experts provided consent via email and telephone communication, thus the experts involved throughout the consultation process voluntarily agreed to participate in the study.

The expert consultation questionnaire included three parts: the judgment of the importance of primary indexes, rationality of index system, and suggestions of index correction. Based on the increasing order of importance of indexes, they were divided into five dimensions, and assigned as 1, 3, 5, 7 and 9 points in turn. The first round of expert consultation was conducted from August 17, 2021, to August 29, 2021. A total of 35 expert consultation forms were sent out by email and all of them were collected. After analyzing the first round of expert consultation, the index system was modified, and a second round of questionnaires was formed. The second round of expert consultation took place from December 1, 2021, to December 8, 2021, with no change in the list of experts. A total of 35 expert consultation forms were distributed and all of them were collected. All the consultation questionnaires were completed and valid, and the effective recovery rates of the first and second rounds were 100%.

The final index system was determined through the first two rounds of expert consultation, and the pairwise importance comparison matrix of three levels was constructed respectively to form the relative importance assignment matrix table. The relative importance of the pairwise index was compared by using the 1−9 fractional scale method, and the third round of expert consultation was continued. Experts participating in the first two rounds were invited to fill in the relative importance assignment matrix table between January 5, 2022, and January 12, 2022. A total of 35 consultation questionnaires were sent out and all of them were collected. All the consultation questionnaires were completed and valid. The effective recovery rate of the third round of expert consultation questionnaires was 100%.

Degree of concentration, dispersion, and coordination

Concentration degree (M) can reflect the importance of indicators. The larger the concentration degree, the more important the indicators that need to be retained. Usually, if M is between 7 and 9, the corresponding indicators can be retained. If M is between 5 and 7, the two indexes of dispersion and coordination should be combined, or the choice should be made according to experts’ opinions and characteristics of health and wellness tourism resources. If M is less than 5, it is recommended to delete the indicator directly. Dispersion degree (S) is used to describe the dispersion of the evaluation of various indicators by experts. Generally, the second round of expert consultation can only be entered when S is higher than 0.63. Coordination degree (V) is used to measure the coordination of experts’ opinions. When V is between 0 and 0.33, the coordination degree is high, and the opinions among experts are more unified, so relevant indicators can be retained. The calculation formulas of the concentration, dispersion, and coordination degrees are as follows.

Where n is the total number of experts interviewed, k is the expert serial number, and Q_k is the value of the kth expert on the indicator.

Modified evaluation index system

First round of expert consultation.

In the results of the first round of expert consultation, the mean concentration degree of evaluation indicators was 6.82, the maximum was 8.26, and the minimum was 5.23. The mean dispersion degree was 1.57, the maximum was 2.08, and the minimum was 0.99. The mean coordination degree was 0.24, the maximum was 0.35, and the minimum was 0.12 (Table 1). In the first level of resource elements’ value, coordination degrees of cultural value of filial piety, resource integrity, and resource awareness were greater than or equal to 0.33, indicating that the importance and coordination of these three indicators are weak. Therefore, the filial piety cultural value, resource integrity, and resource awareness were deleted. Accordingly, based on the revised suggestions put forward by experts, the two second-level indexes of resource dependency and resource added value were merged into resource dependency and added value, and diversity and stability were merged into one index of diversity and stability. In the second level, diversity of species and stability of ecological environment were sufficient to support diversity and stability, so the two indexes were deleted. On the layer of development and construction value, experts suggested that tourism facilities and infrastructure should be merged. Social and economic conditions can better express the level of economic development, and land use conditions and environment capacity have been reflected in other indicators. Therefore, the three indicators of land use conditions, tourism facilities, and environment capacity were deleted, and the expression of economic development level was replaced with socio-economic conditions. In addition, based on the current situation of public health emergencies, two indicators of medical and health services and public health incident plan were added.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Results of the first round of expert consultation.

https://doi.org/10.1371/journal.pone.0288749.t001

Second round of expert consultation.

In the results of second round of expert consultation (Table 2), the mean concentration degree of evaluation indicators was 7.15, the maximum was 8.49, and the minimum was 5.74. The mean dispersion degree was 1.59, the maximum was 2.24, and the minimum was 0.89. The mean coordination degree was 0.23, the maximum was 0.38, and the minimum was 0.10.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Results of the second round of expert consultation.

https://doi.org/10.1371/journal.pone.0288749.t002

Coordination degrees of ‘combination degree of resources’ and ‘distance from main source of visitors’ were greater than 0.33, and the importance and coordination of these two indicators were lacking, therefore these were deleted. The data analysis results of the other indicators were good and retained. After the second round of expert consultation, a revised and confirmed value evaluation system of health and wellness tourism resources was constructed (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Final evaluation index system of health and wellness tourism resources.

https://doi.org/10.1371/journal.pone.0288749.t003

Evaluation model

After a consistency test, the consistency ratio (CR) of levels 1−3 was less than 0.1, therefore the model passed the consistency test. Then, index weights of each level were calculated (Table 4). In the first level, the weight difference of resource elements’ value, environmental value, and development and construction value were small, and the importance of resource elements’ value was slightly higher than that of environmental value and development and construction value. In the second level, construction conditions, environment quality, and tourism health value were the three most important dimensions. Resource dependency and added value, and cultural value occupied a lower proportion and were in a secondary position. The overall index system weights were established and can be applied to the empirical analysis of specific cases.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 4. Weights of the value evaluation index of health and wellness tourism resources.

https://doi.org/10.1371/journal.pone.0288749.t004

Because health and wellness tourism activities involved related research experts, administrators, and tourists, it is segmentary to evaluate a place’s health and wellness tourism resources only from one perspective. Based on the above reasons, the Fishbein-Rosenberg evaluation model is innovatively improved when the evaluation opinions of experts, administrators, and tourists are given different weights. Thus, the value evaluation model of health and wellness tourism resources is established. The improved model is as follows.

Where E is the total evaluation score; P_i is the evaluation score of respondents; Q_i is the weight value of evaluation factors; and m, n, and s represent the total number of surveyed experts, administrators, and tourists respectively.

In tourism activities, administrators represent the supply side and tourists represent the demand side. Both supply and demand are equal, so administrators and tourists are given the same weight. However, experts who study health and wellness tourism are often able to evaluate from a more scientific and comprehensive perspective, so the evaluation weight of experts is slightly higher than that of administrators and tourists in this model. Finally, the weights of this model are determined: the weights of experts, administrators, and tourists are 40%, 30%, and 30%, respectively.

Grade of evaluation

In China’s official tourism resource evaluation criteria, the scoring and classification of individual tourism resource evaluation is explained in detail [6], but there is a contradiction of overlapping classes within the classification. Therefore, according to the clear hierarchy definition in China’s official tourism resource evaluation criteria, the health and wellness tourism resources are divided into five categories, and the expression discourse of the five types is improved. The value evaluation level of health and wellness tourism resources is divided into the following five categories.

1. The value score of health and wellness tourism resources is greater than or equal to 90 points, rated as fifth grade, and classified as super level.
2. The value score of health and wellness tourism resources is between 75 to 89 points, rated as fourth grade, and classified as excellent level.
3. The value score of health and wellness tourism resources is between 60 to 74 points, rated as third grade, and classified as good level.
4. The value score of health and wellness tourism resources is between 45 to 59 points, rated as second grade, and classified as ordinary level.
5. The value score of health and wellness tourism resources is between 30 to 44 points, rated as first grade, and classified as poor level.

Reflections on China’s official tourism resource evaluation criteria

Between 1997 and 2017, China continuously explored and improved the evaluation standards of tourism resources, forming the latest official criteria of Classification, Survey and Evaluation of Tourism Resources (2017). Although some problems that appeared in previous tourism evaluation have been amended, China’s official tourism resource evaluation criteria is still characterized by the traditional understanding of tourism resources. First, the value evaluation index system is rough and blunt, which is not conducive to the in-depth value exploration of tourism resources. Second, in the evaluation of tourism resources, China’s official criteria adopts the direct scoring method of survey team to calculate evaluation level, which appears to be subjective and fails to take into account different opinions of stakeholders. Third, there is redundancy in its classification. For example, fifth-grade tourism resources are classified as special grade and excellent grade together with fourth grade and third grade ones.

Therefore, on the basis of critical reflection on China’s official tourism resource evaluation criteria, a value evaluation model of health and wellness tourism resources that is different from the official criteria is constructed, which is specifically reflected in the following three aspects. First, the characteristic elements of health and wellness tourism resources and public health incident plan are added in the evaluation system. Second, the opinions’ weight of administrators and tourists is included in score calculation. Third, the grade description discourse is improved.

In the evaluation process of health and wellness tourism resources, objective and subjective indicators should not be confused. The evaluation of objective indicators should be based on the real and objective analysis of ecological and environmental data and socio-economic data. As for the evaluation of subjective indicators, this study advocates for the design of a special questionnaire or interview outline to comprehensively consider the real experience of experts, administrators, and tourists for investigation, so that evaluation can be more objective.

Reflections on the value evaluation of health and wellness tourism resources

Health and wellness tourism has been in dynamic development. With the evolution and upgrading of tourism and major public events, the value evaluation index will also change. Differing from existing studies, the index system constructed in this study adds the elements of health, wellness, and public health incident plan. The value evaluation research of health and wellness tourism resources should focus on long-term and dynamic analysis and make timely adjustments to the selection and modification of evaluation indicators based on national, social, and people’s conditions, so as to improve the scientific accuracy of the value evaluation on health and wellness tourism resources. In follow-up research, several different types of health and wellness tourism destinations can be selected for empirical and comparative study. It can also subdivide the types of tourists, further adjust the evaluation model through in-depth research, and enhance the universality and applicability of the evaluation system.