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Linking pleasure with health: the development of health resorts as venues for health promotion Andestad, Gwenyth Gail 1994

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Linking Pleasure with Health:The Development of Health Resorts as Venues for Health PromotionbyGwenyth Gail AndestadB.A., The University of British ColumbiaA THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTS (PLANNING)inTHE FACULTY OF GRADUATE STUDIESSchool of Community and Regional PlanningWe accept this thesis as conforminge required stanTHE U1”JIVERSIT’/JF BRITJS COLUMBIASeptember, 1994© Gwenyth Gail Andestad, 1994In presenting this thesis in partial fulfillment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make it freelyavailable for reference and study. I further agree that permission for extensive copying of thisthesis for scholarly purposes may be granted by the head of my department or by his or herrepresentatives. It is understood that copying or publication of this thesis for fmancial gainshall not be allowed without my written permission.School of Community and Regional PlanningThe University of British ColumbiaVancouver, CanadaDate: September 1994UAbstractHealth benefits associated with vacation activities are increasingly important factorsin the North American leisure market. Health promotion is often a goal of holidayactivity in general, but some people want specific health benefits from their vacation.The health spa segment of the leisure industry has a long history of directly meetingpeopl&s desires for health promoting or health restoring vacations. Industry analystshave recently noted the emergence of a growing and revitalized health resort industry thatis accommodating a new consumer demand for multidimensional approaches to weliness.Expanded and enhanced development of the health resort business in Canada has thepotential to provide social as well as economic benefit to Canadians from domestic andinternational markets. At this time a number of demographic, environmental, andcultural factors are supportive of a renewed health resort industry. This paper analyzesthe health resort industry in Canada from a planning perspective and is structured in threeparts: a review of the history and modern trends in the health resort industry, a survey oftwenty key informants to document opportunities and constraints in the development ofhealth resorts today, and an analysis of government policy and industry actions relevantto the growth of a network of health resorts in British Columbia.UITable of ContentsAbstract.jjTable of ContentsList of Figures vAcknowledgment vi1.0 Chapter 1 Introduction 11.1 Background 11.2 Study Objectives 31.3 Organization of Report 32.0 Chapter 2 Characterization of the Health Resort Industry 52.1 Leisure, Health and Health Resorts 52.2 Definitions and Concepts 52.2.1 Leisure 52.2.2 Health Spa 72.2.3 Health Resort 82.2.4 Health and Wellness 82.2.5 Health Promotion 102.2.6 Health Tourism 102.3 History and Cultural Geography of Health Resorts in the Western World 112.3.1 European Traditions and Perspectives 112.3.1.1 Traveling to the Source of Health 122.3.1.2 The Shadow of Elitism 132.3.1.3 Government Policy 142.3.2 The British and North American Experience 152.3.2.1 The Role of the Work Ethic 152.3.2.2 The Role of the Medical Profession 162.3.2.3 Healing versus Social Dimension in Spa Activity 172.3.2.4 The Role of Expanding Transportation Networks 182.3.2.5 Patterns in Urban Development 192.3.2.6 Early Examples of Health Resorts in Canada 192.3.3 Climate as a Factor in Health Resort Development 202.4 Modem Trends 222.4.1 The Revitalized Health Resort Phenomenon 222.4.2 Forces Influencing the Health Resort Industry in North America 232.4.2.1 Cultural and Economic Forces 232.4.2.2 Social Forces 252.4.2.3 Demographic Factors 262.4.2.4 The Forces of Demand and Supply 262.5 Summary 273.0 Chapter 3 Research Purpose and Plan 293.1 Rationale 293.2 Technique and Approach to Analysis 293.3 Strengths and Weaknesses.314.0 Chapter 4 Report of Research Findings 324.1 The Health-Leisure Connection 324.1.1 Cause and Effect or Interconnection9 324.1.2 Empirical Evidence 334.1.3 Opposing Forces 334.2 Health Resorts as a Resource for Employers 344.2.1 Background 344.2.2 Health Resorts as an Incentive Tool 344.2.3 Health Resorts and Corporate Health Goals 354.2.4 Importance of Pleasure 364.2.5 Health Resorts as a Venue for Employee Education 364.3 Cost Considerations 364.3.1 Cost to the User 364.3.2 Cost to the Provider 374.4 Terminology 384.5 Natural Resources 394.6 Human Resources 405.0 Chapter 5 Recommendations for Government and Industry 415.1 Preamble 415.2 Summary Recommendations 425.3 Policy Objectives 435.4 Specific Recommendations 445.4.1 Government 455.4.2 Recommendations for the Health Resort Industry 466.0 Chapter 6 Conclusions and Areas for Further Research 486.1 Conclusions 486.2 Recommendations for Further Research 48Reference List 50Personal Communication 50Bibliography 52VList of FiguresFigure 1. A Framework For Health Promotion 43viAcknowledgmentI feel privileged to have spent the last two years in the School of Community andRegional Planning at the University of British Columbia where I have benefited from theideas of students and teachers in areas of interest both similar to and quite different frommy own. I have appreciated the flexibility of this graduate programme which hasallowed me to pursue my interests in community planning and tourism issues. ProfessorMichael Seelig’s practical instruction in physical design and planning practice provided awelcome balance to theoretical material. Courses in tourism policy and planning taughtby Professor Peter Williams at Simon Fraser University were valuable and enjoyable.In addition to many supportive friends and colleagues, I wish to thank my committee,Professors Alan Artibise and Michael Seelig of the University of British ColumbiaSchool of Community and Regional Planning, and Professor Peter Williams of SimonFraser University School of Resource and Environmental Management.I am also indebted to the health, leisure, business and tourism professionals who, askey informants, contributed to this research project.1.0 Chapter 1 Introduction1.1 BackgroundSince the early 1 970s there has been a tremendous increase in leisure products thatprovide or purport to provide health benefits to users in North America (Reed 1981).There are more fitness centers offering activities such as weight-training, aerobicexercises and yoga classes giving participants the opportunity to improve their health andweilness through increased physical fitness (Tuck 1976). Capitalizing on this trend, mostlarge hotels now have fitness centers which they offer as an amenity to their guests(Masterson 1986, Bonn 1986). While the provision of health and fitness centers in hotelsmay appear to be a new phenomenon, there is actually a long history of health promotionassociated with the travel and hospitality industry (Hall 1992). For over a hundred yearsin North America specialized resorts have provided people with places where they maytake part in a variety of leisure and therapeutic activities towards the overall objective ofpromoting, maintaining, or restoring health. Recently tourism industry analysts havenoted a surge in the number of health resorts in operation over the last decade, and theypredict that this segment of the leisure industry will continue to grow (Stein, Dcv andTabacchi 1990, ISTC-Tourism Canada 1991).The actual efficacy of health resort visitation as a factor in the health of resortclientele is difficult to determine. Although these resorts do have a high rate of repeatvisitors, which suggests visitors may have incorporated health promoting activities morefi.illy in their lifestyle than non-health resort visitors, it is unknown whether the healthstatus of resort guests is better than that of the general public. No large-scale study ofregular health resort users in North America and the outcome of their health promotionhabits has been done. However, a positive relationship has been found to exist between2perceived weilness and leisure enjoyment (Ragheb 1993). In addition, the health benefitsof regular physical activity and pleasing visual landscapes, which are components ofmost modem health resorts, has been well documented (Paffenbarger, Hyde and Dow1991, Ulrich, Dimberg and Driver 1991).In spite of there being little systematic study of the behavior, it is clear that anincreasing number of people are going to places and participating in activities that theybelieve will be beneficial to their health. Health resort users, either of their own volitionor with the assistance of resort personnel and culture, appear to be proactive andparticipatory in the promotion and maintenance of their own health.A review of the history of health resorts in Europe and North America shows thatthese facilities originally grew in response to people’s quest for better health at a timewhen few other alternatives were available, and these resorts declined as modernscientific medicine developed (Kamenetz 1963, Patmore 1968). The health benefits thathave been realized from modem medicine have been dramatic and numerous. But, itnow appears that the health of our population as a whole is not improving relative to theincreasing amount of resources that are being spent on scientific medicine. It has beenrecognized that the greatest gains in health status are now to be found through peoplemaking healthy life-style choices (Epp 1986).North American society is experiencing both a pull and a push with respect to healthcare options. Most people are naturally attracted to the idea of good health whether ornot they are actually acting in support of their own health. Now the apparent limits oftechnology and the cost of health care are pushing society to seek health improvement inother ways than through traditional medicine. It can be argued that the creation of anethic of health promotion, maintenance or restoration as a priority in society will result insubstantial economic and social benefits, and this ethic ought to permeate all aspects ofdaily life including leisure time. The revitalization of health resorts as a leisure producthas the potential to further embed health promoting ideas and behaviors in our culture.31.2 Study ObjectivesThis research is directed at understanding the opportunities and constraints regardingthe development of health resorts. This paper will examine health resorts from aplanning perspective with the objectives of characterizing the industry, reporting theperceptions and opinions on health resort development of key informants acquainted withhealth and leisure issues, and recommending how public and private bodies can bestrespond to growth in the health resort industry.1.3 Organization of ReportThe analysis of health resorts begins in chapter two with a literature review of theseresorts as a health promoting leisure product. Historical influences, cultural geography,and modern trends have created a wide array of activities that are often associated withhealth resorts. The literature review will show that there is a dichotomy in our societywith respect to the support of leisure-based health promotion behavior. In the twentiethcentury, the large organizing systems of medicine, academia and government have beenslow to embrace leisure activity as a tool for behavior modification or lifestyle support.Yet individuals in our society continue to seek health through leisure. Insight into thisapparent ambivalence is needed in order to appropriately plan for health resort activity.Towards that end, chapter three will explain the rationale and method for the use ofkey informant interviews in the field research portion of this paper. This will befollowed by the findings of the field research in chapter four.The fifth chapter will discuss policies of the relevant branches of government.Recommendations will be made regarding ways that the government in concert with thenascent health resort industry can best respond to the growth of this activity in BritishColumbia. The final chapter will discuss the implications of this research with respect to4planning for leisure-based health promotion. It will also identify areas of further researchin this expanding field of investigation.52.0 Chapter 2 Characterization of the Health Resort Industry2.1 Leisure, Health and Health ResortsWhile the benefits of leisure are often taken for granted or undervalued in our society(Schreyer and Driver 1989), the linkage between leisure and health is well known in thehealth resort industry (Hall 1992). Understanding the connection between health andleisure as it is manifested in health resorts is important in planning for this leisureproduct. These connections can be seen in the definitions of key terms which are coveredat the beginning of this chapter. The lengthy association of health with leisure isillustrated in the following history and cultural geography of health resorts. Thevariations in this type of leisure activity over time and geographic space have contributedto the wide variety of health resorts that currently exist. Developers of future healthresorts need to be aware of the historical and cultural influences that have shaped theindustry through the years. Finally, modem trends in the health resort industry in NorthAmerica today show that leisure-based health promoting activity has endured in theshadow of scientific medicine and is now emerging as a vehicle for new thinking abouthealth.2.2 Definitions and Concepts2.2.1 LeisureMcMillen has defined leisure as “an institution that guides human behavior accordingto a loosely codified but widely recognized set of rules, roles, and norms” (McMillen1990). It is these rules, roles and norms that allow us to discriminate between a healthresort and a hospital. Both can provide a place for people to rest and recuperate, but theresort would be considered a leisure product while the hospital would clearly not beclassified that way. As well, the social organization of leisure requires people, activities,6and places (McMillen 1990). As a leisure product, a health resort is a place where peopleengage in activities intended to improve or maintain their health.In an attempt to further understand leisure, its benefits have been categorized asphysiological, psychological, social, environmental, and economic. Benefits are definedas the positive consequences of leisure involvement for the individual. The mostextensive research has been done on the physiological benefits of leisure, particularlythose due to physical exercise. According to a comprehensive review “[research]examining the impact of nonexercise forms of leisure on physiological outcomesassociated with stress, illness and so-called lifestyle diseases is clearly lacking” (Mannelland Stynes 1991). Health resort operators want to provide pleasurable experiences thatwill result in improved health status for guests during their leisure time, however, theoutcome of these intentions has been poorly documented.Popular perspectives concerning leisure appear to be ambiguous.Modem people congratulate themselves for creating an economy that hasfreed the masses from the drudgery of endless hours of work, and many areproud of the varied choices that leisure time has brought. Yet others lamentthat increased free time has undermined a commitment to competitive workand led to an untrained, even unrestrained, pursuit of pleasure (Cross 1990).While many segments of the population have more leisure time now than ever before, theutilitarian, Puritan cultural legacy in North America is seen by some to cause leisure tobe trivialized as foolish, superfluous activity (Martin 1967, Ryan 1991). Research onleisure with respect to health has been focused on physical rather than mental benefits.This is consistent with the observation that, in the first half of the twentieth century,North American health resorts have evolved more as fitness facilities than their Europeancounterparts (Hall 1992).72.2.2 Health SpaIn the English language, the term health spa is frequently used to describe a placewhere people go in their leisure time in order to restore or maintain their health. Theword spa is derived from the Walloon word, espa, which means fountain (Licht 1963).The linking of espa and its English version, spa, to health restoration has its roots in thestory of a Belgian man who, in 1326, drank the iron-containing waters of a fountain inthe woods near his home. Finding that the waters cured him, he established a healthresort at the site of the spring water which eventually became known as the town of Spain Belgium (Licht 1963).Since its early use in English, spa has been primarily associated with water in someform or another (Simpson and Weiner 1989). During the early modem period whenpeople ingested and bathed in mineral water at health spas as a therapeutic treatment,claims on the water’s curative powers rose to ludicrous proportions in efforts to promoteindividual spa properties (Hamlin 1990). Today, in European health resorts, watertreatments are frequently administered usually under the supervision of a specificallytrained spa doctor as part of the spa programme. In North America the term, health spa,is commonly used to refer to a destination health resort where water may or may not playan important part in the treatment programme.In the nineteenth century health resorts in North America were often developed alongthe lines of famous European spas where people came to “take the waters,” but that resortculture has not endured here. Instead, the emphasis has been placed on diet and fitnessrather than on medical treatment (ISTC-Tourism Canada 1991). In recent years theprogrammes at many North American health resorts have expanded to encompassemotional and spiritual as well as physical restoration.The term health spa is also widely used to refer to urban fitness centers or figuresalons where the principle objective is the provision of exercise programmes for patrons.These exercise facilities, marketed as health spas or health clubs, are now very prevalent8in most large hotels (Crossley 1986, Bonn 1986, Masterson 1986). Within the hospitalityindustry, Monteson and Singer define a spa resort or spa destination as a place where thehealth reinforcing experience is paramount to everything done at the resort. In contrast, aresort spa or amenity spa is a facility that has been added to a full service resort(Monteson and Singer 1992). Colbert makes the distinction between these two types ofspa by calling a spa resort an exclusive domain or dedicated spa (Colbert 1988).2.2.3 Health ResortThe terms health spa and health resort are often used interchangeably, and it is largelya matter of personal preference when referring to places in a leisure setting that peoplevisit in search of health. In this paper preference is given to the term health resort,particularly when discussing this leisure product as it exists in North America. Healthresorts do not have the same historical association with water treatment or medicinallyfocused European-style of leisure activity that health spas do.Because of the diversity of health resorts with respect to their facilities, philosophy,setting and programme activities, health resorts are more of a concept than a particularentity. The concept of a health resort, as it is used here, describes a place and a product;it is a place that provides rest and recreation facilities for overnight guests where theproduct consists of goods and services aimed at the maintenance or improvement of aguest’s physical or mental health.2.2.4 Health and WelinessThe changing nature of health resorts has occurred amid changing notions of healthand wellness in western society. The view of health as merely an absence of disease waschallenged as early as 1947 by the World Health Organization (WHO). It defined healthas “a state of complete physical, mental and social well-being, not merely the absence ofdisease or infirmity” (World Health Organization 1947). This positive and allencompassing definition of health was expanded upon in the early 1 960s by academicswho saw the individual’s health as something linked to the health of the family,9community, society and the environment (Dunn 1961). This larger, holistic vision ofhealth gave root to the wellness movement of the early 1 970s in which individualsacquired a more participatory role in their health care (Ellis and Richardson 1991).In 1974 the Lalonde Report, A New Perspective on the Health of Canadians, waswidely hailed as a landmark document reflecting this new thinking about health (Minider1989). The Lalonde Report redefined the health field as something that includes humanbiology, the condition of the environment, and the lifestyle of the individual as well asthe traditional health organization of physicians, hospitals and medical support services(Lalonde 1974). This report, influenced by Thomas McKeown complemented thegrowing self-help behavior towards health. McKeown expressed the growing publicsentiment that:Modem medicine is not nearly as effective as most people believe.Physicians, biochemists, and the general public assume that the body is amachine that can be protected from disease primarily by physical andchemical intervention. This approach, rooted in 17th century science, has ledto widespread indifference to the influence of the primary determinants ofhuman health—environment and personal behavior—and emphasizes the roleof medical treatment, which is actually less important than either of theothers. It has also resulted in the neglect of sick people whose ailments arenot within the scope of the sort of therapy that interests the medicalprofessions. (McKeown 1990).This changed perception of health and how we might attain it led to a widespread beliefthat the greatest overall improvement in the health of people would not come from moreexpensive medicine but from health promoting changes in lifestyle and the environment(Lalonde 1974, Province of Ontario 1987, Woodward and Stoddart 1989, Province ofAlberta 1989, Province of Nova Scotia 1989, Province of British Columbia 1991a).102.2.5 Health PromotionAfter the Lalonde Report, in Canada health education expanded with the creation ofdepartments of health promotion. As the new discipline evolved, the WHO definedhealth promotion as “the process of enabling people to increase control over, andimprove their own health” (WHO 1984). This definition highlights the trend in evidencetoday of government trying to enable people to have good health rather than only beingseen as providers of such services.This shift in thinking about health recognizes that people must participate in theprovision of their own health, and people need health support from all areas of society.Clearly, health resorts are a part of our society, and in these places people are encouragedto participate in their health. These interconnections have influenced the recent rapidgrowth of health resorts and can be expected to continue to fuel the development ofhealth resorts in North America.2.2.6 Health TourismIn the 1980s a new term emerged in the tourism field which dealt with the behaviorof tourists seeking health benefits. The evolution of the concept has been traced frommedical tourism to health care tourism to health tourism. Health tourism is defined as thedeliberate attempt to attract tourists by promoting health-care services and facilities inaddition to regular tourist amenities. These services may include medical examinationsby qualified doctors and nurses at the resort or hotel, special diets, acupuncture, transvitalinjections, vitamin-complex intakes, arthritis treatment and herbal remedies (Goodrich1993).112.3 History and Cultural Geography of Health Resorts in the Western WorldIn linking the modern day North American health resort in all its many variationswith the theme of health through leisure it is helpful to look at related antecedents inEurope and North America.2.3.1 European Traditions and PerspectivesHistorically, water has played a central role in the development of health resorts.William Thomson claims that there is an ancient tradition, stemming from man observinganimals, that waters heal, and the power of water to cure was ritualized by the creation ofreligious wells in Pagan times (Thomson 1978). As early as the time of Hippocrates,Greek bathing was thought to be not just hygienic, but also a means of adjusting thebalance of bodily humors to restore health (Jackson 1990).In the Roman world it was common to find public baths, built either by wealthyindividuals or by town councils for the benefit of the whole community. The bathsprovided a place where one might wash, exercise, socialize, have a massage, be groomedor obtain medical advice from athletics trainers (Jackson 1990). In addition to the civicbaths, certain natural sources of water, usually located outside of urban areas, drewprimarily rich people to partake of the water’s healing properties. During the first centuryBC, Baiae, site of an ancient hot spring on the north side of the Bay of Naples, becamethe most fashionable Roman spa resort. Throughout the Roman Empire baths, orthermae, were often built to serve both the recuperative needs of sick, wounded, or tiredsoldiers stationed in the provinces and to provide a leisure facility for the militarydetachments during peacetime. Archeological evidence in the Roman provinces showsthat Gallic and Germanic deities associated with the healing powers of natural springswere supplanted by Roman gods of healing (Jackson 1990).12Today, the holistic notion of health teaches the importance of integrating the needs ofthe mind, body, and spirit in people’s lives (Edlin and Golanty 1985). Interestingly, thestructure and function of Roman baths shows that this framework is not new in humanhistory. The structure of the baths gave people an opportunity to come together tosocialize with others. Once together people could benefit from intellectual exchange orthe emotional satisfaction of being with others in a relaxing place. In this setting thebody was cared for through cleansing, exercise and massage. The presence of deities atthe baths indicates an acknowledgment of the spiritual aspect of health and leisure. Inmodem times we have re-invented a concept of health that existed long before webecame so discouraged with scientific medicine. This begs the question of whether wewill also resurrect old structures of health by having centers of health and leisure onceagain as an integral part of our communities.2.3.1.1 Traveling to the Source of HealthAfter ancient times, the use of water as a medicinal agent continued. In 1326, theiron-containing waters at Spa, Belgium were discovered to be therapeutic by Collin leLoup (Licht 1963). Le Loup subsequently promoted the location as a resort for thehealing properties of its water. As the fame of this resort spread, other sources of wateracross the continent and in Britain were developed along similar lines. Those who couldafford to travel were drawn to seek healing at the places where special waters werelocated.In early times, the impetus for travel among health seekers was to access specialwaters in particular locations. The water was often not considered portable so theconsumer had to travel to the water. Very quickly these health spas became popular asmuch for their social environment as for their curative waters. Today, people are stilltraveling to special places in search of health but the attraction is not always tied to asource of water or any other physical resource. In history and in modem times we see the13phenomenon of people going to some place other than that where they usually live inorder to become healthier. The effect of being in a new environment on health and theprocess of changing one’s behavior deserves further research.2.3.1.2 The Shadow of ElitismAlthough therapeutic bathing never actually disappeared from popular culture inItaly, with the Renaissance came a renewed interest by physicians in mineral waterbathing as a health treatment. In spite of their wish to manage spa treatment, thephysicians were consulted less frequently than guidebooks by people visiting Italian spas.People were inclined to make their own diagnosis and determine their own treatmentpresumably because self-help was often at least as effective as professional help (Palmer1990). In addition to bathing, the essential environment for a cure, according to AndreaBacci, included, “...a quiet orderly life in pleasant surroundings, good food and wine, anda maximum of comfort” which sound much like the object of the environment in amodern luxury health resort today (Palmer 1990 citing Andreas Bacci, De Thermis,Venice 1571).Historically in Italy, as everywhere else in Europe, travel was usually the occupationof the leisured class. Since most Italian baths during the Renaissance were run byentrepreneurs, the benefits of the bath were open only to those who could pay. Because acure by water treatment might take some time, it was mostly the wealthy who patronizedthese baths (Palmer 1990).History shows that early health resorts in Europe and North America were oncemainly the domain of the wealthy elite in society. Today, luxury health resorts costingseveral thousand dollars per week are still accessible only to the wealthy. Unfortunately,the fame of these resorts often overshadows the fact that there are many health resortswhich cost no more for a health-restoring vacation than other types of resort holiday.Thus, the elitism of some health resorts has become a stigma for all health resorts. This14misconception of the range of health resort products can be damaging particularly whensupport and encouragement for the industry is needed from government sources.2.3.1.3 Government PolicyToday, in Canada and the United States health resorts receive no specialconsideration as national health resources. This is in contrast to the European countriesof Austria, France, Germany, Hungary, Israel, Italy, Switzerland, Spain, Poland, theformer Czechoslovakia, and the former Soviet Union where governments have taken anactive role in regulating the function of and influencing the access to health resorts as ahealth resource (Licht 1963, Thomson 1978, Bywater 1990, Straburzynski 1990, Hall1992, Mezga 1993). The history of government involvement in French health resortsprovides an interesting case study.In France, as in Britain, the aristocracy had a key role in popularizing spas as a sourceof health benefit. For most of the sixteenth century France lagged behind Italy in thedevelopment of health spas. This was partly because the French court ascribed to thethinking of the physician, Galen, who did not believe in the therapeutic effects of water.And, it was partly because the French system of land rights giving control, ultimately, tothe nobility inhibited rampant commercial development (Brockliss 1990, Porter 1990).By the latter part of the sixteenth century with a shift in the thinking at court, French spaswere flourishing. Physicians were enthusiastic and eager to maximize earnings bydrawing patients from near and far. Treatment at a French spa was a sober affair in theseventeenth century with purging and bleeding commonly done before people took thewaters. The resulting serious atmosphere of French spas was unlike the lively social lifethat was found at Spa and Bath in the eighteenth century (Brockliss 1990).The extensive involvement of government in French health spas today with respect tocertification, regulation, and treatment managed and partly financed by the state has anhistorical precedent in the early administration of spa waters. During the late sixteenth15century spas were under state supervision from a medically qualified attendant who wasappointed by the King’s physician. Health resorts have been taken seriously in Franceever since.Clearly, governments can and do have the ability to influence the way that healthresorts develop. The extent of government involvement in French health resorts today isa reflection of how French people think about their health and the value they place ontheir country’s extensive infrastructure of health resorts. Canada and France share theperception that health is a resource to which all citizens are entitled. Whether the publicsector in Canada will recognize health resorts as legitimate suppliers of a health ratherthan a strictly leisure benefit remains to be seen.2.3.2 The British and North American ExperienceThe history of health resorts in Britain is particularly relevant to an understanding ofthe health resort industry in North America because of the long-standing culturalconnections between these regions.2.3.2.1 The Role of the Work EthicIn the sixteenth century, with renewed interest by physicians and a growing leisuredclass emerging from the prosperity of late Tudor times, mineral water springs becamecenters of health and leisure in Britain (Patmore 1968). It has been suggested that healthspas thrived in this period because they provided a legitimate form of leisure in a timewhen recreation was only justified as something that enabled one to do more work(Epperson 1986). This view is supported by the changes in moral philosophy which areevident in the social history of this period. Before the Civil War, under the Puritanregime the spas had greater emphasis on health than on pleasure, and developmentaround spas proceeded slowly. With the Restoration period, change in leisure activities16occurred rapidly and hedonistic pleasure eventually over-shadowed treatment benefits atBritish spas (Patmore 1968).In North America during the seventeenth century poor travel infrastructure and astrong Protestant work ethic contributed to the absence of leisure facilities such as healthresorts (Epperson 1986). However, in the eighteenth century hot springs and warmsprings were in use as health resorts in the United States (Kamenetz 1963). As in Britain,the American mineral springs eventually became more centers of social life than healing(Lawrence 1983).It has been noted that no where has the traditional institution of the health resortsuffered a more dramatic decline than in the English-speaking world (Bywater 1990,Porter 1990). Some authors have attributed this phenomenon to the work ethic thatpervades English-speaking cultures (Lawrence 1983, Epperson 1986). The acceptance ofleisure as a necessary component of life is integral to the health resort product. Theextent to which North Americans are incorporating the historical work-ethic in their livestoday will have a bearing on the growth of the health resort industry.2.3.2.2 The Role of the Medical ProfessionPerhaps more important to the fate of health resorts than the Puritan work ethic wasthe influence of modern medicine in people’s quest for health. The relationship of themedical profession to health spas in Britain has evolved over time. During the rapidexpansion of spas in the seventeenth and early eighteenth centuries many doctors wereinvolved in the promotion of one property over another. Their evidence of the healthpromotion properties of certain waters was largely empirical, unscientific, and sometimesclearly self-serving. By the middle of the seventeenth century a more critical andanalytical approach in medicine led to the development of water therapies very similar tothose still practiced today. Reflecting the more humanitarian values of the eighteenthcentury, charity hospitals were often established near health spas. While a medical17rationale for spa therapy was part of spa culture, in eighteenth century Britain, the socialcomponent was dominant (Patmore 1968).During the nineteenth century science and technology afforded chemists greaterability to analyze the constituents in mineral water. The later decline in health spapopularity cannot be attributed to the opinions of these chemists for they were somewhatmore inclined than physicians to believe that mineral water had some medicinal benefit(Hamlin 1990). Even today a medical rationale for the recuperative powers of certainhealth spa therapies exists (Grassi, Messina, Fraioli 1982). However, the limited scopeand time consuming nature of spa treatments has not allowed them to compete in asociety that values the diverse and relatively rapid effects of pharmaceutical treatment.Over the years the medical profession has been able to distance itself from thequackery once associated with many spa treatments. The rise of specialized medicineand the creation of the National Health Service in the 1 940s in Britain preserved whatseemed to be the most rational aspect of the declining spa industry in the form ofspecialist rheumatology hospitals. A number of spa physicians trained in hydrotherapytechniques made a transition to rheumatology specialization at this time (Cantor 1990).In North America by the middle of the twentieth century therapeutic uses of water by themedical community were either incorporated into hospital physiotherapy departments orthey were dismissed (Licht 1963, Thomson 1978).2.3.2.3 Healing versus Social Dimension in Spa ActivityThe first recreation facilities at British spas were oriented around exercise as acomponent of spa treatment. Amenities such as bowling greens, tennis courts, andwalking galleries could be found at the early resorts. Later, recreation was centeredaround the social component of a stay at the spa and became dependent upon theatres,casinos and parties at private homes. The social activity was surrounded by rigid rulesand customs of fashionable people (Searle 1977). In Britain, unlike France, city fathers18and estate developers were quick to take advantage of the lucrative opportunities todevelop spa locations (Porter 1990).The decline of medicinal water-based health spa activity in the twentieth centurythroughout the English-speaking world appears to have been due to social forces as muchas it was to scientific medicine. No matter what therapeutic value mineral watertreatment has, the strength of the therapy was not enough to ensure the loyalty of theupper classes. When cheap rail transport brought the working and middle classes toinland health spas in the early nineteenth century, the British aristocracy moved on tosea-side locations and resorts in Europe in search of socially agreeable rest and relaxation(Cosgrove and Jackson 1972, Searle 1977). With the leveling of the British classstructure after World War I, the “socially significant” aspects of a health spa cure wereout of step with public thinking and modem medicine (Patmore 1968).2.3.2.4 The Role of Expanding Transportation NetworksThe influence of transportation networks on leisure travel is seen in the history of theBritish and North American pattems of resort development. When economical travel toresorts by train became possible in the 1 830s in Britain visits to spa towns increased bythe middle class, and the arrival of railroads brought further resort development in NorthAmerica (Epperson 1986). During the nineteenth century railroads opened the warmclimate of California and the hot springs of the Rocky Mountains to health-seekingtravelers in the American west (Pomeroy 1957). The physical accessibility of leisureproperties to centers of population remains a factor in development success. This hasparticular relevance to the growth of tourism in British Columbia where mountaintopography offers both scenic opportunity and a transportation constraint.192.3.2.5 Patterns in Urban DevelopmentThe inland resorts and spas of Britain contributed a pleasant alternative to other urbanforms developed for industry, trade or commerce (Alderson 1973). The weakness ofthese leisure-oriented settlements, however, was their dependence on a single economicactivity supported by health habits and social conventions. When these activitieschanged rather abruptly the local economies suffered greatly. Currently, in BritishColumbia, tourism development is frequently proposed as an alternative for singleindustry towns suffering from economic restructuring in the resource sector. Thedevelopment of health-oriented tourist activity, like other forms of tourism, is not apanacea for local economic development. It can, however, contribute to economicstability through the diversification of economic activity.2.3.2.6 Early Examples of Health Resorts in CanadaIn Canada early health resorts developed along European spa traditions. In the 1 840s,a mineral water spring was discovered at Preston, Ontario. This was made into a popularhealth resort (Wall 1983). The location of Cathartick near Ottawa was developed as aresort in the 1 870s. It was later renamed Carlsbad Springs, presumably in reference tothe famous European health resort of the same name (Wall 1982). In 1885 the hotsprings located at Banff, Alberta were the catalyst for the development of the resort townof Banff (Scace 1968). The original Banff Springs Hotel was marketed on the basis ofthe curative powers of the hot springs found at that location (Robinson 1973). It has beennoted that Banffs hot spring resort which was developed in the late nineteenth centuryhas a greater tradition of health benefit than either Radium or Miette hot springs whichwere developed in the twentieth century (Wightman and Wall 1985). The influence ofEuropean health resort traditions can be seen in an advertisement dated 1899 whichproclaimed Magi Caledonia Springs in Ontario to be “The peer of the most celebratedEuropean spas” (Magi 1899).20This history of Canadian health resorts shows that early development of thesefacilities was centered around water as a curative resource. A critical factor in thesurvival of many of these early attractions into present day has been the existence thermalwater rather than just mineral water resources. In this century the possible health benefitsof these hot spring resorts has been overshadowed by the marketing of recreationalopportunities. However, recent development proposals are once again considering thehealth properties of privately and publicly operated hot spring resources (DPAConsortium 1980, Vernon Engineering et.al 1981, conversation with Jim Mitchell 1994,conversation with Michel Audy 1994).2.3.3 Climate as a Factor in Health Resort DevelopmentWhile most of the travel to health resorts during this historical period was for thepurposes of taking the waters, the case of the development of Nice as a destination forBritish aristocrats during the eighteenth century reveals that climate could be an attractivecommodity to people willing to travel for the sake of their health (Nash 1979). Duringthe late nineteenth century, the favorable climate of the west coast of North America andthe high altitude of the Sierra Mountains attracted health seeking travelers from the east(Pomeroy 1957). Titles in historical guidebooks reflect the importance of climate as aresource for health: “Arizona as a Health Resort,” and “California as a Health Resort”(Anderson 1890, Sanders 1916). In Southern California the hotel at Coronado Beach,San Diego advertised “its attractions as a health and pleasure resort” on the basis of “itswonderful climate” (Coronado Beach 1896). Colorado Springs promoted its high altitudelocation for invalids by promising health and pleasure (Colorado Springs 1903).Similarly, Kamloops, British Columbia embarked on a campaign to promote that city asan ideal location for a health resort due to its favorable, dry climate (General Statistics1895).21It has long been recognized that climate can influence health. Generally, whenunwell, people gravitate towards warmer climates. This trend must be considered in anyhealth resort development in Canada where most regions are subject to harsh weather forseveral months out of the year.222.4 Modern Trends2.4.1 The Revitalized Health Resort PhenomenonGrowing participation in health oriented vacations has emerged since the early I 980sin North America (ISTC-Tourism Canada 1991a). While reports vary from 1.2 million toover 5 million people taking a health spa vacation in 1987, this specialized market hasattained a significant size in the tourism industry. Industry analysts predict health spavisits will reach 30 million per year by the end of the current decade (Stein, Dev andTabacchi 1990, ISTC-Tourism Canada 1991a).Not only has the market for health resort vacations grown but the characteristics ofthe market have also changed (Sarnoff 1989, Stein, Dev and Tabacchi 1990). Oncehealth spas were the exclusive domain of the well-to-do. Today, as with many otherforms of leisure, visits to health spas are no longer just the privilege of an elite group.The activity has been democratized and is now accessible to the vacationing masses(Wartenburng and Allon 1978). As a leisure product, health spas are sometimesperceived as “fat farms” frequented by idle women in search of beauty more than health(Colbert 1988). While women visitors in the age range of 35 to 40 years do outnumbermen by a ratio of almost three to one, health spas are attracting greater numbers ofprofessional and retired men (Wickens 1988, ISTC-Tourism Canada 1991a).Increasingly, corporations are using health resort destinations as meeting locations and astravel incentives (ISTC-Tourism Canada 1991 a).The clientele of health resorts has changed as the product has changed. First in NorthAmerica, and now in Western Europe, health resorts are concerned with the promotion ofwell-being rather than the curing of disease or illness (World Tourism Organization1991). Where once the term, health spa, was associated with regimented treatments andrigid social rules, it has “in recent years come to mean a cheerful relaxed place devoted tohealth” (Licht 1963). Thomson noted the change, particularly in North America, from a23dependence on natural mineral water resources to the use of mud, lake or sea water, manmade hot tubs, or climate as the principle treatment in a resort where the primary interestis health (Thomson 1978). Colbert defined a health spa as a facility with “one or morespecific functions relating to mind, body, and spirit such as fitness, weight loss, behaviormodification, beauty, pampering, or holistic approaches to health” (Colbert 1988).Harding describes a health spa today as a “comfortable environment in which to learnhow to use the tools of life enhancement and to get motivated to go back into the realworld and practice what has been learned” (Harding 1989).2.4.2 Forces Influencing the Health Resort Industry in North America2.4.2.1 Cultural and Economic ForcesIndividually and collectively, North Americans place a high value on health. Thathealth is valuable to the individual is reflected in a popular adage that says, “Good healthis everyone’s major source of wealth. Without it, happiness is almost impossible”. Thenotion that health is valuable to the whole community is incorporated in the Lalondereport which says “Good health is the bedrock on which social progress is built” (Lalonde1974). This idea was eloquently stated by a pioneer in modern health education whosaid:[Health is] the condition of the individual that makes possible the highestenjoyment of life, the greatest constructive work, and that shows itself in thebest service to the world... .Health as freedom from disease is a standard ofmediocrity; health as a quality of life is a standard of inspiration andincreasing achievements. (Williams 1934).In the western world, the value placed on health has been matched with considerablefinancial resources. The boom in fitness centers across North America (which is drivenby people’s desires for health and beauty) has seen individuals pay several hundreddollars per year in membership fees (Tuck 1976, Wartenberg and Allon 1978). Peoplehave financed the growth of an extensive medical system designed to treat disease.24According to the 1991 report of the royal commission, British Columbians spend$850,000 per hour on health care (Province of BC 1991a). In recent years more findinghas been devoted to health promotion. The cost of this activity has been estimated to bea $10 billion industry (Levin 1987). Not only have North Americans been willing to payfor traditional sources of health benefits, but they have also supported the growth of alarge alternative or complementary medicine sector much of which advocates a largerrole for individuals in achieving their own state of well being (Wigod 1993).The desire for optimal health in an era of highly technical and expensive medicalspecialization has resulted in increasing percentages of government budgets going tohealth care. At the same time it has become apparent that the population is notproportionally more healthy for the amount of money that is increasingly spent onscientific medicine (Brady 1983). Today in North America the greatest health problemsthat society faces are diseases that are largely determined by lifestyle (Belloc 1973,Wiley and Carnacho 1980, Canton and Lasater 1989, Scrimshaw 1990). The spiralingcost of health care and recognition that the principal gains in health status of thepopulation will come from lifestyle changes and have led provincial governments acrossCanada to search for new approaches to achieving health. Presently, there is nogovernment recognition of the specific contribution to health that health resort activitymay have. However, recently the British Columbia Ministry of Health has expanded itsvision of how we may ensure health. It includes the role of recreation and leisure activityas components of health promotion (Province of British Columbia 1993).People’s desire for health is a powerful force. Increasingly the health promotionactivities of popular culture are being acknowledged by government and academiabecause of the severe financial burden of providing scientific medicine in our society.252.4.2.2 Social ForcesOne of the most pervasive influences on modern life is excessive stress. Stress isoften the result of pressure in the workplace (Craig, Beaulieu and Cameron 1993, Healthand Welfare Canada 1993). Hans Selye, the physician who discovered the biophysicaleffects of stress in the human body said, “[Once] we get good and tired or exhausted fromour work [we need to] take a few weeks restful holidays” (Selye 1974). Yet, for manypeople the demands of their job cause them to limit and fragment their vacation time.Tourism analysts have noted a decrease in both the round-trip distance and the durationof American vacations (Waters 1992). Recent research suggests this decline in leisuretime for a significant portion of the work force is responsible for a dramatic increase instress related illnesses (Schor 1991).The stressful conditions that shape consumer choices of how to spend leisure time arerevealed in surveys of consumer preference. In 1980 a survey of 10,000 Americansrevealed that two thirds of the respondents want to rest and relax on vacation (Rubenstein1990). A 1983 study of Canadians vacationing in Hawaii said the major purpose for theirtrip was for rest and relaxation (Woodside and Jacobs 1986). Market research for thestate of South Carolina revealed that 56% of respondents said their top priority onvacation was to relax and unwind, 95% agreed or strongly agreed that vacations today are“vital to health and well-being,” and 75% said they need vacation breaks now more thanever (Kooyman 1990).Given the prevalence of stress in many people’s lives, the health risks associated withstress, and people’s perception that a vacation will give them some relief from stress, it isnot surprising that health resorts have become such popular vacation choices.262.4.2.3 Demographic FactorsDemographic statistics show that, over the next three decades, the number of peopleaged 50 and over will increase at a much higher rate that those under 50 years of age inCanada and the United States (Statistics Canada 1993, Pederson 1992). In absoluteterms, it is anticipated that by the year 2000 there will be one hundred million Europeansand thirty-five million Americans over the age of sixty-five (C.A.B. International 1991).It can be expected that the chronic diseases of old age will increasingly be a factor in thelives of this large segment of the population. Because this cohort has generally been veryactive in early life, it is anticipated that the popularity of leisure-based health facilitieswill continue as this group ages (Lago and Poffley 1993). The leading edge of thisdemographic phenomenon has driven and will continue to influence the health resortmarket as larger numbers of older people appear in the population.2.4.2.4 The Forces of Demand and SupplyMarket research has shown that consumers buy products for the benefits that theyreceive from using the products (Woodside and Jacobs 1985). Value theory suggests thatwhen a product benefit is consistent with consumer values, customers will chose thatproduct from among other alternatives (Pitts and Woodside 1986). Incorporating healthattribute benefits associated with the concepts of wellness and quality of life is regardedas an important ingredient in future tourism product development (Alleyne 1993). Thisposition complements the growing value that North American travelers are placing onhealth related pursuits. This interest has in part fueled the current expansion of the healthresort industry on this continent.The marketplace has responded to the value placed on health with a wide array ofhealth-oriented leisure products. The American Hotel and Motel Association estimatedthat 40% of American hotels had health clubs on their premises in 1991 (The Vancouveraim, 5 October 1991). No longer are health spas confined to land; numerous cruise ships27now offer spa programmes as an amenity (Colbert 1988). More medically oriented thanmany cruise ship spas, a new health spa on the Queen Elizabeth II, will take advantage ofsea water to offer thalassotherapy and an inhalation room for people with respiratorydisorders (The Vancouver Sun, 13 March 1993). In the past, destinations like theCaribbean would have been an unlikely place to find a health resort because thepopularity of sun, sand and water sports satisfied the Caribbean tourist market. Now,with so much market pressure on health and fitness, Caribbean resorts and hotels haveincorporated health spa facilities too (Gold 1994). Recently, traditional European healthspa treatments such as balneotherapy and lymph drainage have been offered in someurban health spas. This leisure product combines the treatments usually found in therural setting of a health resort with the convenience of an urban location (Reichi 1993).By the late 1 980s three new health resorts were in the planning stages or underconstruction in eastern Canada (Wickens 1988).Activity in the health and leisure market demonstrates the interest that people have incombining these two concepts. The dedicated health resort is a growing segment of thismarket which can provide a refreshing approach to the field of health promotion.2.5 SummaryIn this century, people in the English speaking world, with powerful pharmaceuticalagents in their armory against disease, rapidly abandoned taking the waters as a route tohealth (Bywater 1990). Yet, even though the form has changed, the institution of healthresorts has survived to present day. Porter offers an explanation for the survival ofvestiges of the traditional spa in Europe and Britain in contemporary culture “becausethey [satisfr] a deep desire that the healing enterprise should proceed within frameworksessentially sociable in their nature, and suffused with symbolic cultural meanings”(Porter 1990). Nowadays, it may be that people perceive that reductionist scientific28medicine has reached a plateau in its ability to significantly advance their health and thusthey are willing to reinvent an old healing institution to serve their needs.This increased interest in health oriented vacation activity holds potential benefits forvarious sectors of society and for individuals. In as much as a visit to a health resort canbe associated with a vacation, this activity contributes to the creation of a specializedniche in the tourism industry. Entire resorts may be dedicated to the provision of healthbenefits to their guests. A multi-purpose resort may provide health resort amenities, andwith good management health spas can be profit centers for the hotel (Monteson andSinger 1992). Repeat visitation is remarkably high in this segment of the travel industry(ISTC-Tourism Canada l991a). Although health resorts are primarily a domestictourism product, research shows that several travel groups in the western United Statesare a potential international market for Canadian health resorts. (ISTC 1991b). Inaddition, the setting of health resorts, usually in a scenic, rural area, could createopportunities for regional economic development (Popma and Pollock 1987).Health resorts promote activity which appears to provide individual physical andpsychological benefits. If a leisure activity such as visiting a health resort is an effectivevehicle for further disseminating an ethic of healthy living in our culture, our economyand our straining medical care system may benefit from a healthier population.293.0 Chapter 3 Research Purpose and Plan3.1 RationaleA continued expansion of the health resorts in North America is anticipated. Whilethe health resort industry in Canada is small, it is conceivable that these facilities couldplay a larger role in the health promotion movement here as well as the tourism industry.Without sacrificing, and perhaps enhanced by, the pleasurable aspects of a vacation,health resorts might become a well-accepted resource people can employ to help themadopt or maintain healthy behaviors. Because, at a minimum, the growth of healthresorts represents an economic opportunity and possibly significant health benefits, it isworth exploring what attributes health resorts in British Columbia ought to possess andwhat an appropriate policy response from government might be with respect to this resortindustry.3.2 Technique and Approach to AnalysisSeminal issues in the history of health resort development are explored through areview of the relevant literature. As an extension to this review, twenty key informantswere interviewed for their perceptions of the opportunities and constraints confrontingthe health resort industry in the areas of marketing, financing, natural resources, humanresources and product development. Criteria for a key informant included expertise inthe health resort, tourism, health or health promotion fields. Focused telephone or faceto-face interviews with informants were conducted using a semi-standardized format.This method of data collection was justified on the basis of time and cost efficiencyand relevance to the research objectives. The use of interviews as opposed to mail-backsurveys ensured a high response rate among the key informants, and it allowed quickeraccess to other respondents and unpublished sources of data. Given that health resortoperations in British Columbia are relatively few in number and that part of the inquiry30required the respondents to extrapolate from present conditions to possible futurescenarios, people with relevant expertise were selected for this research. Individuals whosupply or use leisure-based health-promoting facilities were contacted along with peoplewho serve as intermediaries in the leisure-health market. It was assumed, because oftheir expertise, that this select sample of informants would be better able to envision andadvise upon the nature of future health resort development than a random sampling of theadult population.The specific leisure product of a dedicated health resort was defined as:A resort where visitors stay overnight and take part in leisure activitiesintended to improve or maintain their health. The provision of a healthsupporting experience in a pleasant environment is the main objective of theresort.Informants were engaged in a dialogue focused around an open ended question askingabout the opportunities and constraints regarding health resort development.A qualitative examination of information gathered from key informants is presented.This broad spectrum of opinion combined with information from the literature reviewforms the basis of the policy recommendations.The approach to policy development taken here follows generally identified policyframeworks of problem definition, determination of criteria for choice amongalternatives, generation of a range of alternative actions, choosing actions that can beimplemented and determining indicators of policy effectiveness. Public policy shouldserve the interests of the public while still allowing the private sector to function.Socioeconomic and environmental goals should guide policy development (Patton andSawicki 1993).In addition to government policy analysis, recommendations were made regardingappropriate actions for the tourism industry in the development of a network of healthresorts in British Columbia.313.3 Strengths and WeaknessesBecause of the diverse nature of health resorts or health spas and the lack ofinformation in the literature on planning these facilities, data collection on this topic wascommunicated in a verbal format. This allowed the researcher to probe anyinconsistencies in the reported data which may have arisen from varying perceptions ofthe topics explored. The scarcity of local examples of health resorts also contributed tothe necessity of a hypothetical discussion about this leisure product as it might exist herein British Columbia or other parts of Canada.While an attempt is made to provide a balanced range of perspectives on this issue,the opinions may not represent all facets of health resort development. As well, anyparticular perspective is subject to the biases of the respondent or author. An attempt toameliorate this was done by accessing a broad opinion base and by interviewing morethan one person with similar expertise whenever possible.324.0 Chapter 4 Report of Research FindingsThis chapter reports the information obtained from interviews with twenty keyinformants acquainted with various aspects of the health resort industry (Reference Listpage 50).4.1 The Health-Leisure ConnectionThe respondents to this inquiry repeatedly pointed to the way society collectivelythinks about health and leisure in North American culture as a potential constraint in thegrowth of health resorts. As a society, North Americans are seen to discount the value ofleisure in health promotion. This view prevailed in spite of the fact the respondentspersonally think that leisure activities are a useful means of health promotion.4.1.1 Cause and Effect or Interconnection?It is reasonable to assume that most, if not all, people are pleased to have goodhealth. And, it is equally reasonable that people become displeased when theyexperience a deterioration in their health. Pleasure or displeasure, then, can be derivedfrom good health or bad health respectively. From this perspective there appears to be astraightforward relationship of cause and effect between health and pleasure. Actionsdesigned to promote health, according to this view, would not be based on pleasure sinceit is a result of health rather than a determinant of it.In recent years there has been a growing body of evidence that the state of on&s mindcan have a profound effect on one’s physical health (Biondi and Kotzalidis 1990, Birney1991). This thinking suggests that a decrease in mental stress will result in better health.If the experience of pleasure contributes to stress management, then pleasure ought to bea cause of good health. And, it follows from this view that we should employ pleasureeither to contribute directly to health or to put people in a frame of mind that makes themmore receptive to adopting health promoting habits in their lives.334.1.2 Empirical EvidenceWhether there is a reciprocal relationship between health and pleasure may bedebatable. However, the increasing numbers of people who spend leisure time inactivities with health benefits demonstrates that health and pleasure currently have astrong association in our society. Opinion leaders in this survey expect that thisphenomenon will continue to contribute to the growth of the health resort industry.4.1.3 Opposing ForcesSeveral respondents said that some social structures as they are presently organizedare not supportive of a growing health resort industry. Because it bridges the fields ofhealth and leisure, this industry needs concerted recognition from different governmentand academic departments of tourism and health. The Ministry of Tourism is the leadgovernment agency in contact with health resort operations in British Columbia. As thehealth resort product exists now in this province, support or acknowledgment from theMinistry of Health was seen to be unlikely. However, if a facility such as Valley Spa inCalifornia, which specializes in physical rehabilitation, or Wildwood Lifestyle Centerand Hospital in Georgia, which is medically-oriented, were to be created here, it isconceivable that the Ministry of Health might become involved.In addition to government structures, there are professional structures that may notsupport health resort endeavors. Public funds designated for health care and healthpromotion are generally channeled through British Columbia’s mainstream medicalsystem of highly specialized health practitioners and health promotion academics. Therespondents in this survey see the traditional medical system as a valuable resource butone that is geared towards curing disease rather than preventing illness. The traditionalmedical sector was sometimes seen to be in competition with the providers of alternativeapproaches to health care. The health promotion field, which is dedicated to the creationof broad public policy, was seen by some respondents to need better mechanisms ofdelivering health promotion information to the public.34Although no respondent advocated abandoning publicly funded health care in BritishColumbia, several made the point that there is no incentive in current practice for peopleto be proactive in maintaining their own health. Comparisons were drawn to the UnitedStates where some respondents felt the expense of health insurance creates a greaterpressure for disease prevention among certain groups in society.4.2 Health Resorts as a Resource for Employers4.2.1 BackgroundIt is not unusual for employers to be involved in the provision of some health servicesto employees. Particularly in larger organizations, employers often pay for or share inthe cost of health insurance premiums. Depending on the size of the work-force and thetypes of activities performed, an employer may provide an occupational health nurse orphysician, a first aid team, psychological counseling services, or a safety educator.In recent years, the workplace has been recognized as an important means ofaccessing a large percentage of the population with health promoting information andprograms. Company sponsored fitness classes are an example of work-site healthpromotion. Corporations often subsidize the cost of these activities and access is usuallyuniversal to all employees. In addition to physical fitness, companies ascribing to aholistic model of health promote a wide spectrum of resources to their employees insupport of wellness.In Europe some employers in conjunction with government programmes supporthealth resort use. Employers interviewed in this survey were asked to consider what rolehealth resorts could play in their plans to encourage healthy life-styles among employees.4.2.2 Health Resorts as an Incentive ToolEmployers did not see health resort visitation as something they could provide to allemployees because the cost of such a benefit would be too great. However, health resortvacations were seen as attractive incentives in motivating employees to reach their goals.35For companies that have a commitment to health promotion, being able to offer a prizethat is both appealing and potentially good for the health and weilness of the employee isan attractive option.The use of a health resort visit as an incentive was also seen to be appropriate foremployees participating in workplace health promotion activities. Jennifer Lesliereported that a week-end stay at a local resort was a valued prize in the VancouverHospital employee weilness programme (personal communication).4.2.3 Health Resorts and Corporate Health GoalsAnother way that health resorts can serve the business community is to understandthe needs of executives in business organizations. Informants noted that work inducedstress is often coincident with poor health behaviors of senior managers of corporations.There is acceptance of the idea that the health of the company can be influenced by thewell-being of the company leaders. Because these individuals often control large budgetprojects, companies have a vested interest in the health of their managers. Althoughintellectually they are probably well aware of the health risks in their lives, manyindividuals who are high achievers in corporate systems were said to be resistant tosuggestions or pressures for them to change their negative health habits.Getting corporate executives to pay attention to their own health to the extent thatthey change their behavior is a delicate process. A health resort was seen as a placewhere senior personnel could be attracted to the recreational amenities that the resortoffered. Once there, the company could use the health promoting culture of the resort toset the scene for some health education programmes specifically targeted to the needs ofthat group. Holding a corporate planning retreat or team-building meeting at a healthresort was also seen as an opportunity for a synergistic blending of personal andcorporate objectives.Some companies recognize that senior staff act as role models for the wholeorganization. Lauren St. John of Vancouver City Savings Credit Union said that having36the cooperation of senior management in their “Living Well” programme was crucial toits success (personal communication). When the leaders demonstrate health promotingbehavior, it is easier to get line workers adopt these behaviors too.4.2.4 Importance of PleasureRegardless of the reason a health resort visit might be offered as an incentive orbonus, the respondents were clear that the experience had to be pleasurable. Theactivities and environment at the resort may be good for one’s health, but the reward ofpleasure was seen to be more important in motivating people.4.2.5 Health Resorts as a Venue for Employee EducationThe use of a health resort as an incentive may provide considerable promotionalexposure to a population of employees, but relatively few employees actually experiencethe health resort through this incentive. However, many companies will contribute toemployee health education. Respondents reported that conceivably, corporate educationbudgets could be used to cover the cost of a seminar or lifestyle education programme ata health resort.4.3 Cost ConsiderationsThe cost of a health resort vacation was one of the most frequently cited constraintson the growth of a health resort industry from both a demand and supply perspective.4.3.1 Cost to the UserIn Canada, where traditional health care resources are currently provided to everyone,there is an understandable resistance to the idea of certain health benefits going only tothose who can pay for them. However, given the need for governments to controlspending there was little support for the idea of public funds being provided tounderwrite visits at health resorts in the same way that other health services are covered.The strongest reasons informants gave included the non-essential nature of health resortactivity and the lack of systematic evidence showing the effectiveness of health resort37treatments in bettering the health of users in North America. This is not to say that theevidence does not exist, but rather the study of the contribution of a health resortexperience to the health of the population is lacking. There was general acceptanceamong the respondents that public spending on health services needs to be focused onthings that provide the greatest and most essential health benefits to the population.There was also a belief among some respondents that traditional health care has becometoo expensive. Two people anticipate that eventually some of these services will nolonger be provided free to the public. Therefore, the likelihood of health resort visitationbeing paid for by public funds was seen to be dependent upon proof of effectiveness oftreatment and cost efficiency.4.3.2 Cost to the ProviderCost considerations from the perspective of the resort developer were consistent withgood business sense. As with most property development, there is a large capitalexpenditure in the beginning of the project which can take several years to recapture. Areality of the resort business in Canada is the existence of a short season. This negativelyaffects corporate cash flows and negatively influences the perception of risk by lendingagencies (Pollock 1985).Given current provincial government policy, there is no financial assistance fordevelopment of resort infrastructure. Peter Maundrell of the British Columbia Ministryof Small Business, Tourism and Culture said that the tendency now is for the governmentto assist with planning, technical support and advertising as opposed to capital projects(personal communication). If public funds were to be granted for capital projects inresort development, Bennet Brown recommended spending money to improve the qualityof existing resort infrastructure as a preliminary step in the creation of a network ofhealth resorts in British Columbia (personal communication).Most informants believed that the development of health resorts should proceedincrementally as the Canadian market becomes more aware of the benefits obtainable38from a domestic health vacation and as the industry becomes more experienced inproviding healthy vacation retreats. Lori Lawrie, recalling her experience with a resortdevelopment in Kelowna, said the capital costs of building a new resort today are oftenprohibitive such that redeveloping an existing resort into a health resort is often morefeasible (personal communication). The unfortunate demise of the former King RanchHealth Spa and Fitness Resort near Toronto was mentioned in this light. A combinationof factors were named for the collapse of this ambitious development. Among thesewere the creation of a new facility that was much bigger than its initial market.With so few health resorts operating in Canada and the competition from facilities inwarmer climates, Canadian health vacationers are being drawn out of this country.Canada’s currently devalued dollar provides a temporary incentive and opportunity formany Canadians to travel domestically and experience the health resort product. Itaffords a “window of opportunity” for the health and leisure resort concept to becomemore strongly embedded in the culture of Canadians.Jennifer Leslie identified health resort use as being associated with annual times ofrenewal: January, September and the spring months of March, April and May (personalcommunication). Conceivably, a health resort could have a competitive edge over othertypes of resorts in retaining year-round business in the Canadian climate. Duringsummer season, particularly with an exchange-rate advantage, Canadian health resortsshould be able to draw foreign travelers. During winter months health resorts need anoperational strategy that will ensure business continues in spite of colder weather.4.4 TerminologyThe diversity of the health resort product and the different meanings associated withthe terminology was discussed in the beginning of this paper. Some informants whohave had experience in marketing health resort vacations believed that operators must be39careful with the language they use if they wish to attract new markets to health resorts.In particular, the word spa was judged to be a problem. Jennifer Leslie said that to thegeneral public, spa has connotations of unobtainable expense and luxury, and to men, theword spa is often associated with a women’s activity (personal communication). There isalso the danger that the dedicated health resort product image will be tarnished by lesserproducts marketed as spas (Gruler 1994).4.5 Natural ResourcesLike many other tourism experiences, health resorts usually incorporate pleasantscenery, an agreeable climate and access to water for recreation. The availability of thesefeatures in British Columbia make this province the location of choice for an expandedhealth resort industry in Canada according to the people surveyed.Although the architecture and landscaping are important, a beautiful natural setting isconsidered to be a fundamental component of a health resort. Because winter weather isless severe in southern and coastal British Columbia than elsewhere in Canada, thisprovince was seen to be a more likely location for a successful year-round health resort.This region also happens to possess the greatest number of hot spring resources in thecountry. The therapeutic use of thermal mineral water here has been strictly informal.Some people believed we are missing an opportunity to enhance both people’s healthstatus and local economies by treating hot springs as just recreational resources.Interestingly, recent changes in Canadian National Park policies have been institutedto take better advantage of hot spring resources for recreation and health (personalcommunication). Plans are underway to revive health-related activities such as massageservices and steam baths that were once a seminal part of several National Parkattractions.404.6 Human ResourcesThe health resort industry shares some of the same human resource developmentneeds as the hospitality industry in general for food and beverage and accommodationworkers (Mitchell 1992). In addition, specially trained personnel are required for thehealth, fitness, paramedical, and beauty services that health resorts provide. Obtainingsuitable staff was cited by Patrick Corbett as being among the most challenging aspectsof running a health resort (personal communication).415.0 Chapter 5 Recommendations for Government and Industry5.1 PreambleThe information uncovered in this research describes health resort activity as adiverse and durable cultural phenomenon in Western societies. It is apparent that thecurrent revival of health resort use is not just an old tradition brought to life again but anactivity that recalls some ancient wisdom and blends it with new knowledge.The goal of understanding ways that government and industry can foster the growthof health resorts in British Columbia is based on the premise that health resorts arecapable of providing a leisure-based health promoting activity in our culture. It is furtherassumed that health benefits and environmentally sustainable economic activity arevaluable to our society.Addressing the issue of social equity in health promotion efforts, Levin sees themiddle class with the financial resources and discretionary time as the people in oursociety who are best able to act in support of their own health. “It is [the middle class]that can afford a healthy diet of fresh fish, fruits and vegetables. It is the middle classthat can compensate for sedentary work by workouts at the health spas” (Levin 1987, 58).For the poor in our society, addressing structural barriers to health by providing bettereducation in general, not just on health matters, and creating more economicopportunities will have a greater bearing on health status than any other intervention.The development of leisure-based health promotion in the form of a network ofhealth resorts in British Columbia does not deny the need to simultaneously address theparticular health needs of less advantaged people in our society. But, the healthpromotion opportunities that can be accessed by socioeconomic groups who can afford topay more to enhance their health should be encouraged.The goal of economic development is another, and perhaps more visible, outcome ofan initiative to promote the existence of health resorts in British Columbia. Because this42leisure product is usually located in pleasing natural surroundings where scenic viewsand a tranquil environment are obtainable, many rural and semi-rural areas of theprovince could be the site of this specialized tourist development. In addition to servingthe domestic population, a network of health oriented resorts might attract more foreignguests to the less visited regions of the province.The development of a network of hot spring resorts in Hungary during the 1970sprovides a case study for this type of regional economic diversification strategy (Grove1977, Czegledi and Fluck 1989). Hungary recognized that two-thirds of their foreigntravelers only visited two major cities. A strategy was implemented for the purpose ofattracting more foreign visitors and altering the pattern of tourism. It is unknown howsuccessful this plan was in redistributing foreign visitors to less-visited parts of Hungary.However, between 1978 and 1987 Hungary reported an 11.7 % increase in internationalvisitors from seventeen to nineteen million foreign visitors per year. The development ofthe thermal springs was seen as a contributor, both quantitatively to the increase inforeign tourists, and qualitatively in attracting tourists who spend more per day on theirholidays (Czegledi and Fluck 1989).A similar situation to this exists in the tourism industry in British Columbia.Research suggests that there are untapped international markets for health resort visitorsto British Columbia (Province of B.C. 1991b, Andestad 1994).5.2 Summary Recommendations:This investigation into the nature of health resort activity in western society fmds thathealth resorts can be useful venues for promoting and reinforcing an ethic of health andweilness in our culture. In response to an anticipated increasing demand for health andleisure facilities and because of the natural resources available for health resortdevelopment, it is recommended that the provincial government encourage the43development of a network of health resorts in British Columbia. This province’s hotsprings are recognized as the most strategic resources to employ in fostering a healthresort industry. The support, however, should by no means be restricted to hot springsdevelopment. While some regions may ultimately attract more health resort developmentthan others the government initiative should target resort development in each of the ninerecognized tourism regions of the province.5.3 Policy ObjectivesNew policies to promote health resort growth should be developed to coordinate withcurrent broad government objectives of individual and societal health. The existingpolicies relevant to this investigation are under the jurisdiction of the Ministry of HealthFig. 1. A Framework for Health Promotion (Jake Epp. Achieving Health for All 1986, 8).Aim AchievingHealth for AllHealth Reducing Increasing EnhancingChallenges inequities Prevention CopingHealth Self-Care Mutual Aid HealthyPromotion EnvironmentsMechanismImplemen- Fostering Strengthening Coordinatingtation Public Community HealthyStrategies Participa- Health Public Policytion Services44and Ministry Responsible for Seniors and the Ministry of Small Business, Tourism, andCulture. The field of health promotion gained a higher profile in the Ministry of Healthin the 1 970s. The 1986 federal framework for achieving health for all consists of threechallenges, three mechanisms and three implementation strategies (see Fig 1).Health resorts as venues for health promotion can be classified according to thisframework as meeting the challenges of increasing prevention and enhancing copingthrough a mechanism of self-care taught through greater public participation (Epp 1986).The perception of this activity as legitimate health promoting behavior needs to be seenin light of the reality that “cultural diversity causes multiple patterns of health beliefs anduneven progress towards behavior change” (Levin 1987). The acknowledgment of theleisure sector as a contributor to health promotion has only surfaced very recently ingovernment policy documents. Now that the awareness of this linkage has begun itshould be encouraged to continue.Although the aggregate size of the tourism industry is large, coordination of thedepartments of small business with tourism in one ministry recognizes the smaller natureof most individual tourism operations. Existing policy in this ministry encourageseconomic development in a decentralized way across the province. The coordinatingefforts of regional economic development officers should be enhanced with specialists inhealth-tourism development.5.4 Specific RecommendationsThis research has uncovered a number of actions that need to be taken by bothgovernment and the health resort industry in concert with one another.455.4.1 GovernmentGovernment is capable of helping to shape the emerging health resort industry by virtueof its power to create policies and provide financial and organizational support. Thegovernment, primarily at the provincial level, should address the following needs:• Standards: Help to clarify terminology and adopt a consistent use of terms ingovernment documentation. Set standards for identification and accreditation of healthresorts. Establish an evaluation mechanism which will contribute to credibility in theindustry.• Recognition: Leisure pursuits need to be recognized as legitimate and valuable methodsof health promotion. Including leisure, recreation, and tourism as resources for healthyliving by all levels of government authorities and academics will build awareness,credibility, and action among the population in support of this sector.• Research: Make funding available to conduct longitudinal research on the relationshipof health to pleasure activities, the efficacy of leisure-based health promotion, and theunderstanding of other cultures’ approaches to health through leisure. Sponsorworkshops on health resort issues to serve the information needs of this market nichefrom both supply and demand perspectives.• Advisory and technical support: Financial resources should be available to assist theprivate sector with feasibility studies. A data base of consultants experienced in healthresort development should be available covering aspects of physical and programmeplanning relevant to health resort activity. Plans for accredited facilities should strive fora holistic health resort product that complements the indigenous landscape, borrowing46the most useful and meaningful forms from the past history of health resort activity andincorporating features that reflect current trends in health maintenance and restoration.• Specially trained work force: Ensure that programmes of study exist for training chefs,paramedical-recreational specialists, and estheticians to meet the needs of the healthresort industry.• Financial incentive: Provide a tax incentive to encourage the development of accreditedhealth resort facilities.• Partnerships: Because health resorts bridge the disciplines of leisure and health theindustry requires the provincial government ministries responsible for tourism and healthto cooperate in support of health resort ventures. Government should consider limitedcapital investment in plans for accredited health-promoting facilities to encourage healthresort development.• Public relations: As the product becomes more established, promote British Columbia’snetwork of health resorts as venues where good health can be reinforced. Create adirectory and include the health resort product in advertising strategies.5.4.2 Recommendations for the Health Resort IndustryThe primary responsibility for the creation of a network of dedicated health resorts in theprovince of British Columbia will rest with the private sector. The industry shouldaddress the following needs:• Partnerships: The industry can benefit through establishing business and informationpartnerships with government and academia in order to gain credibility.47• Research: Industry should contribute not only to tourism market research, but also totheoretical research on the health benefits of leisure pursuits in order to address thecurrent lack of information.• Standards: By addressing the need for industry standards, particularly in the area ofterminology, the image of the health resort product will become better established in theminds of the North American public and international visitors.• Education: Develop strategies to make health promoting leisure a cultural habit byforming liaisons with educators, the medical profession, business and ethnic groups.• Recognition: Demonstrate the efficacy and cost effectiveness of health resort stays sothat accredited facilities can seek access to public or private health insurance funds fortreatment remuneration.486.0 Chapter 6 Conclusions and Areas for Further Research6.1 ConclusionsThis research into the nature of health resorts as locations where health and pleasurecan be attained results in a call for leadership by government. Rather than asking for thehealth-leisure resource to be state sponsored like our traditional medical system, thisreport asks for the government to enhance the opportunity that citizens of and visitor tothis province have to support their own pursuit of health. Leadership embodied in thesepolicy recommendations will guide the stake-holders in this emerging industry toproduce a health resort product that sets a new international standard for the blending ofhealth and pleasure.6.2 Recommendations for Further ResearchThe opportunity for both economic development and health benefits as a result ofhealth resort development in British Columbia deserves serious consideration. Enoughinformation exists to support the promotion of this nascent industry in this province.However, if a high quality product is to be created, continuous committed research anddevelopment will be required. Based on this study’s initiatives, several important areasfor further investigation emerge:• Exploration of the issue of cost of health resort activity relative to other resort vacations.• Exploration of the importance of individuals being in a non-routine environment vís a vísthe process of behavior change.• Document the change in health resorts in North America from a social historyperspective.49• Examine the approaches to health and leisure through health resorts in Germany, France,Hungary, and Israel where there are well developed, progressive medical systems andstate-funded support for health resorts.• Study the approaches to health and leisure in Scandinavian countries where climateconstraints are similar to those of Canada.• Understand more fully the nature of health resort use in countries such as France,Germany, Italy, and Japan with a view to providing a satisfring product to theseinternational markets.• Look at ways to democratize the health through pleasure experience using the facilitiesand programmes of community centers.These potential areas for further research will lead to a greater understanding of the roleof health resorts in our society and in the tourism industry.50Reference ListPersonal CommunicationMichel Audy. 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