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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 Promotion by Gwenyth Gail Andestad B.A., The University of British Columbia A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  (PLANNING)  in THE FACULTY OF GRADUATE STUDIES School of Community and Regional Planning  We accept this thesis as conforming e required stan  THE U1”JIVERSIT’/JF BRITJS COLUMBIA September, 1994 © Gwenyth Gail Andestad,  1994  In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for fmancial gain shall not be allowed without my written permission.  School of Community and Regional Planning The University of British Columbia Vancouver, Canada  Date: September 1994  U  Abstract  Health benefits associated with vacation activities are increasingly important factors in the North American leisure market.  Health promotion is often a goal of holiday  activity 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 meeting peopl&s desires for health promoting or health restoring vacations. Industry analysts have recently noted the emergence of a growing and revitalized health resort industry that is accommodating a new consumer demand for multidimensional approaches to weliness. Expanded and enhanced development of the health resort business in Canada has the potential to provide social as well as economic benefit to Canadians from domestic and international markets.  At this time a number of demographic, environmental, and  cultural factors are supportive of a renewed health resort industry. This paper analyzes the health resort industry in Canada from a planning perspective and is structured in three parts: a review of the history and modern trends in the health resort industry, a survey of  twenty key informants to document opportunities and constraints in the development of health resorts today, and an analysis of government policy and industry actions relevant to the growth of a network of health resorts in British Columbia.  UI  Table of Contents  Abstract Table of Contents List of Figures Acknowledgment  v vi  1.0 Chapter 1 Introduction 1.1 Background 1.2 Study Objectives 1.3 Organization of Report 2.0 Chapter 2 Characterization of the Health Resort Industry 2.1 Leisure, Health and Health Resorts 2.2 Definitions and Concepts 2.2.1 Leisure 2.2.2 Health Spa 2.2.3 Health Resort 2.2.4 Health and Wellness 2.2.5 Health Promotion 2.2.6 Health Tourism 2.3 History and Cultural Geography of Health Resorts in the Western World 2.3.1 European Traditions and Perspectives Traveling to the Source of Health The Shadow of Elitism Government Policy 2.3.2 The British and North American Experience The Role of the Work Ethic The Role of the Medical Profession Healing versus Social Dimension in Spa Activity The Role of Expanding Transportation Networks Patterns in Urban Development Early Examples of Health Resorts in Canada 2.3.3 Climate as a Factor in Health Resort Development 2.4 Modem Trends 2.4.1 The Revitalized Health Resort Phenomenon 2.4.2 Forces Influencing the Health Resort Industry in North America Cultural and Economic Forces Social Forces Demographic Factors The Forces of Demand and Supply 2.5 Summary 3.0 Chapter 3 Research Purpose and Plan 3.1 Rationale 3.2 Technique and Approach to Analysis  1 1 3 3 5 5 5 5 7 8 8 10 10 11 11 12 13 14 15 15 16 17 18 19 19 20 22 22 23 23 25 26 26 27 29 29 29  .  jj  3.3 Strengths and Weaknesses 4.0 Chapter 4 Report of Research Findings 4.1 The Health-Leisure Connection 4.1.1 Cause and Effect or Interconnection 9 4.1.2 Empirical Evidence 4.1.3 Opposing Forces 4.2 Health Resorts as a Resource for Employers 4.2.1 Background 4.2.2 Health Resorts as an Incentive Tool 4.2.3 Health Resorts and Corporate Health Goals 4.2.4 Importance of Pleasure 4.2.5 Health Resorts as a Venue for Employee Education 4.3 Cost Considerations 4.3.1 Cost to the User 4.3.2 Cost to the Provider 4.4 Terminology 4.5 Natural Resources 4.6 Human Resources 5.0 Chapter 5 Recommendations for Government and Industry 5.1 Preamble 5.2 Summary Recommendations 5.3 Policy Objectives 5.4 Specific Recommendations 5.4.1 Government 5.4.2 Recommendations for the Health Resort Industry 6.0 Chapter 6 Conclusions and Areas for Further Research 6.1 Conclusions 6.2 Recommendations for Further Research  .31 32 32 32 33 33 34 34 34 35 36 36 36 36 37 38 39 40 41 41 42 43 44 45 46 48 48 48  Reference List Personal Communication Bibliography  50 50 52  V  List of Figures  Figure 1. A Framework For Health Promotion  43  vi  Acknowledgment  I feel privileged to have spent the last two years in the School of Community and Regional Planning at the University of British Columbia where I have benefited from the ideas of students and teachers in areas of interest both similar to and quite different from my own.  I have appreciated the flexibility of this graduate programme which has  allowed me to pursue my interests in community planning and tourism issues. Professor Michael Seelig’s practical instruction in physical design and planning practice provided a welcome balance to theoretical material. Courses in tourism policy and planning taught by 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 Columbia School of Community and Regional Planning, and Professor Peter Williams of Simon Fraser University School of Resource and Environmental Management. I am also indebted to the health, leisure, business and tourism professionals who, as key informants, contributed to this research project.  1.0 Chapter 1 Introduction  1.1 Background Since the early 1 970s there has been a tremendous increase in leisure products that provide or purport to provide health benefits to users in North America (Reed 1981). There are more fitness centers offering activities such as weight-training, aerobic exercises and yoga classes giving participants the opportunity to improve their health and weilness through increased physical fitness (Tuck 1976). Capitalizing on this trend, most large 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 hotels may appear to be a new phenomenon, there is actually a long history of health promotion associated with the travel and hospitality industry (Hall 1992). For over a hundred years in North America specialized resorts have provided people with places where they may take part in a variety of leisure and therapeutic activities towards the overall objective of promoting, maintaining, or restoring health. Recently tourism industry analysts have noted a surge in the number of health resorts in operation over the last decade, and they predict that this segment of the leisure industry will continue to grow (Stein, Dcv and Tabacchi 1990, ISTC-Tourism Canada 1991). The actual efficacy of health resort visitation as a factor in the health of resort clientele is difficult to determine. Although these resorts do have a high rate of repeat visitors, which suggests visitors may have incorporated health promoting activities more fi.illy in their lifestyle than non-health resort visitors, it is unknown whether the health status of resort guests is better than that of the general public. No large-scale study of regular health resort users in North America and the outcome of their health promotion habits has been done. However, a positive relationship has been found to exist between  2  perceived weilness and leisure enjoyment (Ragheb 1993). In addition, the health benefits of regular physical activity and pleasing visual landscapes, which are components of most modem health resorts, has been well documented (Paffenbarger, Hyde and Dow 1991, Ulrich, Dimberg and Driver 1991). In spite of there being little systematic study of the behavior, it is clear that an increasing number of people are going to places and participating in activities that they believe will be beneficial to their health. Health resort users, either of their own volition or with the assistance of resort personnel and culture, appear to be proactive and participatory in the promotion and maintenance of their own health. A review of the history of health resorts in Europe and North America shows that these facilities originally grew in response to people’s quest for better health at a time when few other alternatives were available, and these resorts declined as modern scientific medicine developed (Kamenetz 1963, Patmore 1968). The health benefits that have been realized from modem medicine have been dramatic and numerous. But, it now appears that the health of our population as a whole is not improving relative to the increasing amount of resources that are being spent on scientific medicine. It has been recognized that the greatest gains in health status are now to be found through people making healthy life-style choices (Epp 1986). North American society is experiencing both a pull and a push with respect to health care options. Most people are naturally attracted to the idea of good health whether or not they are actually acting in support of their own health. Now the apparent limits of technology and the cost of health care are pushing society to seek health improvement in other ways than through traditional medicine. It can be argued that the creation of an ethic of health promotion, maintenance or restoration as a priority in society will result in substantial economic and social benefits, and this ethic ought to permeate all aspects of daily life including leisure time. The revitalization of health resorts as a leisure product has the potential to further embed health promoting ideas and behaviors in our culture.  3  1.2 Study Objectives This research is directed at understanding the opportunities and constraints regarding the development of health resorts.  This paper will examine health resorts from a  planning perspective with the objectives of characterizing the industry, reporting the perceptions and opinions on health resort development of key informants acquainted with health and leisure issues, and recommending how public and private bodies can best respond to growth in the health resort industry.  1.3 Organization of Report The analysis of health resorts begins in chapter two with a literature review of these resorts as a health promoting leisure product. Historical influences, cultural geography, and modern trends have created a wide array of activities that are often associated with health resorts. The literature review will show that there is a dichotomy in our society with respect to the support of leisure-based health promotion behavior. In the twentieth century, the large organizing systems of medicine, academia and government have been slow 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 this apparent 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 of key informant interviews in the field research portion of this paper.  This will be  followed 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 the nascent health resort industry can best respond to the growth of this activity in British Columbia. The final chapter will discuss the implications of this research with respect to  4  planning for leisure-based health promotion. It will also identify areas of further research in this expanding field of investigation.  5  2.0 Chapter 2 Characterization of the Health Resort Industry  2.1 Leisure, Health and Health Resorts While 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 the health resort industry (Hall 1992). Understanding the connection between health and leisure as it is manifested in health resorts is important in planning for this leisure product. These connections can be seen in the definitions of key terms which are covered at the beginning of this chapter.  The lengthy association of health with leisure is  illustrated in the following history and cultural geography of health resorts.  The  variations in this type of leisure activity over time and geographic space have contributed to the wide variety of health resorts that currently exist. Developers of future health resorts need to be aware of the historical and cultural influences that have shaped the industry through the years. Finally, modem trends in the health resort industry in North America today show that leisure-based health promoting activity has endured in the shadow of scientific medicine and is now emerging as a vehicle for new thinking about health.  2.2 Definitions and Concepts 2.2.1 Leisure McMillen has defined leisure as “an institution that guides human behavior according to a loosely codified but widely recognized set of rules, roles, and norms” (McMillen 1990). It is these rules, roles and norms that allow us to discriminate between a health resort and a hospital. Both can provide a place for people to rest and recuperate, but the resort would be considered a leisure product while the hospital would clearly not be classified that way. As well, the social organization of leisure requires people, activities,  6  and places (McMillen 1990). As a leisure product, a health resort is a place where people engage in activities intended to improve or maintain their health. In an attempt to further understand leisure, its benefits have been categorized as physiological, psychological, social, environmental, and economic. Benefits are defined as the positive consequences of leisure involvement for the individual.  The most  extensive research has been done on the physiological benefits of leisure, particularly those due to physical exercise.  According to a comprehensive review “[research]  examining the impact of nonexercise forms of leisure on physiological outcomes associated with stress, illness and so-called lifestyle diseases is clearly lacking” (Mannell and Stynes 1991). Health resort operators want to provide pleasurable experiences that will result in improved health status for guests during their leisure time, however, the outcome of these intentions has been poorly documented. Popular perspectives concerning leisure appear to be ambiguous. Modem people congratulate themselves for creating an economy that has freed the masses from the drudgery of endless hours of work, and many are proud of the varied choices that leisure time has brought. Yet others lament that increased free time has undermined a commitment to competitive work and 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, the utilitarian, Puritan cultural legacy in North America is seen by some to cause leisure to be trivialized as foolish, superfluous activity (Martin 1967, Ryan 1991). Research on leisure 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 European counterparts (Hall 1992).  7  2.2.2 Health Spa In the English language, the term health spa is frequently used to describe a place where people go in their leisure time in order to restore or maintain their health. The word 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 the story of a Belgian man who, in 1326, drank the iron-containing waters of a fountain in the woods near his home. Finding that the waters cured him, he established a health resort at the site of the spring water which eventually became known as the town of Spa in Belgium (Licht 1963). Since its early use in English, spa has been primarily associated with water in some form or another (Simpson and Weiner 1989). During the early modem period when people 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 promote individual spa properties (Hamlin 1990).  Today, in European health resorts, water  treatments are frequently administered usually under the supervision of a specifically trained 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 play an important part in the treatment programme. In the nineteenth century health resorts in North America were often developed along the lines of famous European spas where people came to “take the waters,” but that resort culture has not endured here. Instead, the emphasis has been placed on diet and fitness rather than on medical treatment (ISTC-Tourism Canada 1991).  In recent years the  programmes at many North American health resorts have expanded to encompass emotional and spiritual as well as physical restoration. The term health spa is also widely used to refer to urban fitness centers or figure salons 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 prevalent  8  in most large hotels (Crossley 1986, Bonn 1986, Masterson 1986). Within the hospitality industry, Monteson and Singer define a spa resort or spa destination as a place where the health reinforcing experience is paramount to everything done at the resort. In contrast, a resort 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 of spa by calling a spa resort an exclusive domain or dedicated spa (Colbert 1988). 2.2.3 Health Resort The terms health spa and health resort are often used interchangeably, and it is largely a matter of personal preference when referring to places in a leisure setting that people visit 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. Health resorts do not have the same historical association with water treatment or medicinally focused 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 particular entity. 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 the product consists of goods and services aimed at the maintenance or improvement of a guest’s physical or mental health. 2.2.4 Health and Weliness The changing nature of health resorts has occurred amid changing notions of health and wellness in western society. The view of health as merely an absence of disease was challenged as early as 1947 by the World Health Organization (WHO). It defined health as “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” (World Health Organization 1947).  This positive and all  encompassing definition of health was expanded upon in the early 1 960s by academics who saw the individual’s health as something linked to the health of the family,  9  community, society and the environment (Dunn 1961). This larger, holistic vision of health gave root to the wellness movement of the early 1 970s in which individuals acquired 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, was widely hailed as a landmark document reflecting this new thinking about health (Minider 1989). The Lalonde Report redefined the health field as something that includes human biology, the condition of the environment, and the lifestyle of the individual as well as the traditional health organization of physicians, hospitals and medical support services (Lalonde 1974).  This report, influenced by Thomas McKeown complemented the  growing self-help behavior towards health.  McKeown expressed the growing public  sentiment that: Modem medicine is not nearly as effective as most people believe. Physicians, biochemists, and the general public assume that the body is a machine that can be protected from disease primarily by physical and chemical intervention. This approach, rooted in 17th century science, has led to widespread indifference to the influence of the primary determinants of human health—environment and personal behavior—and emphasizes the role of medical treatment, which is actually less important than either of the others. It has also resulted in the neglect of sick people whose ailments are not within the scope of the sort of therapy that interests the medical professions. (McKeown 1990). This changed perception of health and how we might attain it led to a widespread belief that the greatest overall improvement in the health of people would not come from more expensive medicine but from health promoting changes in lifestyle and the environment (Lalonde 1974, Province of Ontario 1987, Woodward and Stoddart 1989, Province of Alberta 1989, Province of Nova Scotia 1989, Province of British Columbia 1991a).  10  2.2.5 Health Promotion After the Lalonde Report, in Canada health education expanded with the creation of departments of health promotion. As the new discipline evolved, the WHO defined health promotion as “the process of enabling people to increase control over, and improve their own health” (WHO 1984). This definition highlights the trend in evidence today of government trying to enable people to have good health rather than only being seen as providers of such services. This shift in thinking about health recognizes that people must participate in the provision 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 encouraged to participate in their health. These interconnections have influenced the recent rapid growth of health resorts and can be expected to continue to fuel the development of health resorts in North America. 2.2.6 Health Tourism In the 1980s a new term emerged in the tourism field which dealt with the behavior of tourists seeking health benefits. The evolution of the concept has been traced from medical tourism to health care tourism to health tourism. Health tourism is defined as the deliberate attempt to attract tourists by promoting health-care services and facilities in addition to regular tourist amenities. These services may include medical examinations by qualified doctors and nurses at the resort or hotel, special diets, acupuncture, transvital injections, vitamin-complex intakes, arthritis treatment and herbal remedies (Goodrich 1993).  11  2.3 History and Cultural Geography of Health Resorts in the Western World  In linking the modern day North American health resort in all its many variations with the theme of health through leisure it is helpful to look at related antecedents in Europe and North America.  2.3.1 European Traditions and Perspectives Historically, water has played a central role in the development of health resorts. William Thomson claims that there is an ancient tradition, stemming from man observing animals, that waters heal, and the power of water to cure was ritualized by the creation of religious 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 the balance of bodily humors to restore health (Jackson 1990). In the Roman world it was common to find public baths, built either by wealthy individuals or by town councils for the benefit of the whole community.  The baths  provided a place where one might wash, exercise, socialize, have a massage, be groomed or obtain medical advice from athletics trainers (Jackson 1990). In addition to the civic baths, certain natural sources of water, usually located outside of urban areas, drew primarily rich people to partake of the water’s healing properties. During the first century BC, Baiae, site of an ancient hot spring on the north side of the Bay of Naples, became the most fashionable Roman spa resort.  Throughout the Roman Empire baths, or  thermae, were often built to serve both the recuperative needs of sick, wounded, or tired soldiers stationed in the provinces and to provide a leisure facility for the military detachments during peacetime. Archeological evidence in the Roman provinces shows that Gallic and Germanic deities associated with the healing powers of natural springs were supplanted by Roman gods of healing (Jackson 1990).  12  Today, the holistic notion of health teaches the importance of integrating the needs of the mind, body, and spirit in people’s lives (Edlin and Golanty 1985). Interestingly, the structure and function of Roman baths shows that this framework is not new in human history.  The structure of the baths gave people an opportunity to come together to  socialize with others. Once together people could benefit from intellectual exchange or the emotional satisfaction of being with others in a relaxing place. In this setting the body was cared for through cleansing, exercise and massage. The presence of deities at the baths indicates an acknowledgment of the spiritual aspect of health and leisure. In modem times we have re-invented a concept of health that existed long before we became so discouraged with scientific medicine. This begs the question of whether we will also resurrect old structures of health by having centers of health and leisure once again as an integral part of our communities. Traveling to the Source of Health After ancient times, the use of water as a medicinal agent continued. In 1326, the iron-containing waters at Spa, Belgium were discovered to be therapeutic by Collin le Loup (Licht 1963). Le Loup subsequently promoted the location as a resort for the healing properties of its water. As the fame of this resort spread, other sources of water across the continent and in Britain were developed along similar lines. Those who could afford to travel were drawn to seek healing at the places where special waters were located. In early times, the impetus for travel among health seekers was to access special waters in particular locations.  The water was often not considered portable so the  consumer had to travel to the water. Very quickly these health spas became popular as much for their social environment as for their curative waters. Today, people are still traveling to special places in search of health but the attraction is not always tied to a source of water or any other physical resource. In history and in modem times we see the  13  phenomenon of people going to some place other than that where they usually live in order to become healthier. The effect of being in a new environment on health and the process of changing one’s behavior deserves further research. The Shadow of Elitism Although therapeutic bathing never actually disappeared from popular culture in Italy, with the Renaissance came a renewed interest by physicians in mineral water bathing as a health treatment.  In spite of their wish to manage spa treatment, the  physicians were consulted less frequently than guidebooks by people visiting Italian spas. People were inclined to make their own diagnosis and determine their own treatment presumably because self-help was often at least as effective as professional help (Palmer 1990). In addition to bathing, the essential environment for a cure, according to Andrea Bacci, included, “...a quiet orderly life in pleasant surroundings, good food and wine, and a maximum of comfort” which sound much like the object of the environment in a modern 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 occupation of the leisured class.  Since most Italian baths during the Renaissance were run by  entrepreneurs, the benefits of the bath were open only to those who could pay. Because a cure by water treatment might take some time, it was mostly the wealthy who patronized these baths (Palmer 1990). History shows that early health resorts in Europe and North America were once mainly the domain of the wealthy elite in society. Today, luxury health resorts costing several 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 resorts which 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. This  14  misconception of the range of health resort products can be damaging particularly when support and encouragement for the industry is needed from government sources. Government Policy Today, in Canada and the United States health resorts receive no special consideration as national health resources. This is in contrast to the European countries of Austria, France, Germany, Hungary, Israel, Italy, Switzerland, Spain, Poland, the former Czechoslovakia, and the former Soviet Union where governments have taken an active role in regulating the function of and influencing the access to health resorts as a health resource (Licht 1963, Thomson 1978, Bywater 1990, Straburzynski 1990, Hall 1992, Mezga 1993). The history of government involvement in French health resorts provides an interesting case study. In France, as in Britain, the aristocracy had a key role in popularizing spas as a source of health benefit. For most of the sixteenth century France lagged behind Italy in the development of health spas. This was partly because the French court ascribed to the thinking 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, to the 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 spas were flourishing.  Physicians were enthusiastic and eager to maximize earnings by  drawing patients from near and far. Treatment at a French spa was a sober affair in the seventeenth century with purging and bleeding commonly done before people took the waters. The resulting serious atmosphere of French spas was unlike the lively social life that was found at Spa and Bath in the eighteenth century (Brockliss 1990). The extensive involvement of government in French health spas today with respect to certification, regulation, and treatment managed and partly financed by the state has an historical precedent in the early administration of spa waters. During the late sixteenth  15  century spas were under state supervision from a medically qualified attendant who was appointed by the King’s physician. Health resorts have been taken seriously in France ever since. Clearly, governments can and do have the ability to influence the way that health resorts develop. The extent of government involvement in French health resorts today is a reflection of how French people think about their health and the value they place on their country’s extensive infrastructure of health resorts. Canada and France share the perception that health is a resource to which all citizens are entitled. Whether the public sector in Canada will recognize health resorts as legitimate suppliers of a health rather than a strictly leisure benefit remains to be seen.  2.3.2 The British and North American Experience The history of health resorts in Britain is particularly relevant to an understanding of the health resort industry in North America because of the long-standing cultural connections between these regions. The Role of the Work Ethic In the sixteenth century, with renewed interest by physicians and a growing leisured class emerging from the prosperity of late Tudor times, mineral water springs became centers of health and leisure in Britain (Patmore 1968). It has been suggested that health spas thrived in this period because they provided a legitimate form of leisure in a time when 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 are evident in the social history of this period. Before the Civil War, under the Puritan regime the spas had greater emphasis on health than on pleasure, and development around spas proceeded slowly. With the Restoration period, change in leisure activities  16  occurred rapidly and hedonistic pleasure eventually over-shadowed treatment benefits at British spas (Patmore 1968). In North America during the seventeenth century poor travel infrastructure and a strong Protestant work ethic contributed to the absence of leisure facilities such as health resorts (Epperson 1986).  However, in the eighteenth century hot springs and warm  springs 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 resort suffered a more dramatic decline than in the English-speaking world (Bywater 1990, Porter 1990).  Some authors have attributed this phenomenon to the work ethic that  pervades English-speaking cultures (Lawrence 1983, Epperson 1986). The acceptance of leisure as a necessary component of life is integral to the health resort product. The extent to which North Americans are incorporating the historical work-ethic in their lives today will have a bearing on the growth of the health resort industry. The Role of the Medical Profession Perhaps more important to the fate of health resorts than the Puritan work ethic was the influence of modern medicine in people’s quest for health. The relationship of the medical profession to health spas in Britain has evolved over time. During the rapid expansion of spas in the seventeenth and early eighteenth centuries many doctors were involved in the promotion of one property over another. Their evidence of the health promotion properties of certain waters was largely empirical, unscientific, and sometimes clearly self-serving.  By the middle of the seventeenth century a more critical and  analytical approach in medicine led to the development of water therapies very similar to those still practiced today. Reflecting the more humanitarian values of the eighteenth century, charity hospitals were often established near health spas.  While a medical  17  rationale for spa therapy was part of spa culture, in eighteenth century Britain, the social component was dominant (Patmore 1968). During the nineteenth century science and technology afforded chemists greater ability to analyze the constituents in mineral water.  The later decline in health spa  popularity cannot be attributed to the opinions of these chemists for they were somewhat more inclined than physicians to believe that mineral water had some medicinal benefit (Hamlin 1990). Even today a medical rationale for the recuperative powers of certain health spa therapies exists (Grassi, Messina, Fraioli 1982). However, the limited scope and time consuming nature of spa treatments has not allowed them to compete in a society that values the diverse and relatively rapid effects of pharmaceutical treatment. Over the years the medical profession has been able to distance itself from the quackery once associated with many spa treatments. The rise of specialized medicine and the creation of the National Health Service in the 1 940s in Britain preserved what seemed to be the most rational aspect of the declining spa industry in the form of specialist rheumatology hospitals. A number of spa physicians trained in hydrotherapy techniques 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 the medical community were either incorporated into hospital physiotherapy departments or they were dismissed (Licht 1963, Thomson 1978). Healing versus Social Dimension in Spa Activity The first recreation facilities at British spas were oriented around exercise as a component of spa treatment.  Amenities such as bowling greens, tennis courts, and  walking galleries could be found at the early resorts. Later, recreation was centered around 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 rules and customs of fashionable people (Searle 1977). In Britain, unlike France, city fathers  18  and estate developers were quick to take advantage of the lucrative opportunities to develop spa locations (Porter 1990). The decline of medicinal water-based health spa activity in the twentieth century throughout the English-speaking world appears to have been due to social forces as much as it was to scientific medicine.  No matter what therapeutic value mineral water  treatment has, the strength of the therapy was not enough to ensure the loyalty of the upper classes. When cheap rail transport brought the working and middle classes to inland health spas in the early nineteenth century, the British aristocracy moved on to sea-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 class  structure after World War I, the “socially significant” aspects of a health spa cure were out of step with public thinking and modem medicine (Patmore 1968). The Role of Expanding Transportation Networks The influence of transportation networks on leisure travel is seen in the history of the British and North American pattems of resort development. When economical travel to resorts by train became possible in the 1 830s in Britain visits to spa towns increased by the middle class, and the arrival of railroads brought further resort development in North America (Epperson 1986). During the nineteenth century railroads opened the warm climate of California and the hot springs of the Rocky Mountains to health-seeking travelers in the American west (Pomeroy 1957). The physical accessibility of leisure properties to centers of population remains a factor in development success. This has particular relevance to the growth of tourism in British Columbia where mountain topography offers both scenic opportunity and a transportation constraint.  19 Patterns in Urban Development The inland resorts and spas of Britain contributed a pleasant alternative to other urban forms developed for industry, trade or commerce (Alderson 1973). The weakness of these leisure-oriented settlements, however, was their dependence on a single economic activity supported by health habits and social conventions. changed rather abruptly the local economies suffered greatly.  When these activities Currently, in British  Columbia, tourism development is frequently proposed as an alternative for single industry towns suffering from economic restructuring in the resource sector.  The  development of health-oriented tourist activity, like other forms of tourism, is not a panacea for local economic development. It can, however, contribute to economic stability through the diversification of economic activity. Early Examples of Health Resorts in Canada In 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 popular health resort (Wall 1983). The location of Cathartick near Ottawa was developed as a resort in the 1 870s. It was later renamed Carlsbad Springs, presumably in reference to the famous European health resort of the same name (Wall 1982).  In 1885 the hot  springs located at Banff, Alberta were the catalyst for the development of the resort town of Banff (Scace 1968). The original Banff Springs Hotel was marketed on the basis of the curative powers of the hot springs found at that location (Robinson 1973). It has been noted that Banffs hot spring resort which was developed in the late nineteenth century has a greater tradition of health benefit than either Radium or Miette hot springs which were developed in the twentieth century (Wightman and Wall 1985). The influence of European health resort traditions can be seen in an advertisement dated 1899 which proclaimed Magi Caledonia Springs in Ontario to be “The peer of the most celebrated European spas” (Magi 1899).  20  This history of Canadian health resorts shows that early development of these facilities was centered around water as a curative resource.  A critical factor in the  survival of many of these early attractions into present day has been the existence thermal water rather than just mineral water resources. In this century the possible health benefits of these hot spring resorts has been overshadowed by the marketing of recreational opportunities. However, recent development proposals are once again considering the health properties of privately and publicly operated hot spring resources (DPA Consortium 1980, Vernon Engineering 1981, conversation with Jim Mitchell 1994, conversation with Michel Audy 1994).  2.3.3 Climate as a Factor in Health Resort Development While most of the travel to health resorts during this historical period was for the purposes of taking the waters, the case of the development of Nice as a destination for British aristocrats during the eighteenth century reveals that climate could be an attractive commodity to people willing to travel for the sake of their health (Nash 1979). During the late nineteenth century, the favorable climate of the west coast of North America and the 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 a resource 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 “its wonderful climate” (Coronado Beach 1896). Colorado Springs promoted its high altitude location for invalids by promising health and pleasure (Colorado Springs 1903). Similarly, Kamloops, British Columbia embarked on a campaign to promote that city as an ideal location for a health resort due to its favorable, dry climate (General Statistics 1895).  21  It has long been recognized that climate can influence health.  Generally, when  unwell, people gravitate towards warmer climates. This trend must be considered in any health resort development in Canada where most regions are subject to harsh weather for several months out of the year.  22  2.4 Modern Trends  2.4.1 The Revitalized Health Resort Phenomenon Growing participation in health oriented vacations has emerged since the early I 980s in North America (ISTC-Tourism Canada 1991a). While reports vary from 1.2 million to over 5 million people taking a health spa vacation in 1987, this specialized market has attained a significant size in the tourism industry. Industry analysts predict health spa visits will reach 30 million per year by the end of the current decade (Stein, Dev and Tabacchi 1990, ISTC-Tourism Canada 1991a). Not only has the market for health resort vacations grown but the characteristics of the market have also changed (Sarnoff 1989, Stein, Dev and Tabacchi 1990).  Once  health spas were the exclusive domain of the well-to-do. Today, as with many other forms 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 sometimes  perceived 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 outnumber men by a ratio of almost three to one, health spas are attracting greater numbers of professional and retired men (Wickens  1988,  ISTC-Tourism Canada  1991a).  Increasingly, corporations are using health resort destinations as meeting locations and as travel incentives (ISTC-Tourism Canada 1991 a). The clientele of health resorts has changed as the product has changed. First in North America, and now in Western Europe, health resorts are concerned with the promotion of well-being rather than the curing of disease or illness (World Tourism Organization 1991). Where once the term, health spa, was associated with regimented treatments and rigid social rules, it has “in recent years come to mean a cheerful relaxed place devoted to health” (Licht 1963). Thomson noted the change, particularly in North America, from a  23  dependence on natural mineral water resources to the use of mud, lake or sea water, man made hot tubs, or climate as the principle treatment in a resort where the primary interest is health (Thomson 1978). Colbert defined a health spa as a facility with “one or more specific functions relating to mind, body, and spirit such as fitness, weight loss, behavior modification, beauty, pampering, or holistic approaches to health” (Colbert 1988). Harding describes a health spa today as a “comfortable environment in which to learn how to use the tools of life enhancement and to get motivated to go back into the real world and practice what has been learned” (Harding 1989).  2.4.2 Forces Influencing the Health Resort Industry in North America Cultural and Economic Forces Individually and collectively, North Americans place a high value on health. That health is valuable to the individual is reflected in a popular adage that says, “Good health is everyone’s major source of wealth. Without it, happiness is almost impossible”. The notion that health is valuable to the whole community is incorporated in the Lalonde report which says “Good health is the bedrock on which social progress is built” (Lalonde 1974). This idea was eloquently stated by a pioneer in modern health education who said: [Health is] the condition of the individual that makes possible the highest enjoyment of life, the greatest constructive work, and that shows itself in the best service to the world... .Health as freedom from disease is a standard of mediocrity; health as a quality of life is a standard of inspiration and increasing achievements. (Williams 1934). In the western world, the value placed on health has been matched with considerable financial resources. The boom in fitness centers across North America (which is driven by people’s desires for health and beauty) has seen individuals pay several hundred dollars per year in membership fees (Tuck 1976, Wartenberg and Allon 1978). People have financed the growth of an extensive medical system designed to treat disease.  24  According 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 finding has been devoted to health promotion. The cost of this activity has been estimated to be a $10 billion industry (Levin 1987). Not only have North Americans been willing to pay for traditional sources of health benefits, but they have also supported the growth of a large alternative or complementary medicine sector much of which advocates a larger role 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 medical specialization has resulted in increasing percentages of government budgets going to health care.  At the same time it has become apparent that the population is not  proportionally more healthy for the amount of money that is increasingly spent on scientific medicine (Brady 1983). Today in North America the greatest health problems that society faces are diseases that are largely determined by lifestyle (Belloc 1973, Wiley and Carnacho 1980, Canton and Lasater 1989, Scrimshaw 1990). The spiraling cost of health care and recognition that the principal gains in health status of the population will come from lifestyle changes and have led provincial governments across Canada to search for new approaches to achieving health.  Presently, there is no  government recognition of the specific contribution to health that health resort activity may have. However, recently the British Columbia Ministry of Health has expanded its vision of how we may ensure health. It includes the role of recreation and leisure activity as components of health promotion (Province of British Columbia 1993). People’s desire for health is a powerful force.  Increasingly the health promotion  activities of popular culture are being acknowledged by government and academia because of the severe financial burden of providing scientific medicine in our society.  25 Social Forces One of the most pervasive influences on modern life is excessive stress. Stress is often the result of pressure in the workplace (Craig, Beaulieu and Cameron 1993, Health and Welfare Canada 1993). Hans Selye, the physician who discovered the biophysical effects of stress in the human body said, “[Once] we get good and tired or exhausted from our work [we need to] take a few weeks restful holidays” (Selye 1974). Yet, for many people 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 duration of American vacations (Waters 1992). Recent research suggests this decline in leisure time for a significant portion of the work force is responsible for a dramatic increase in stress related illnesses (Schor 1991). The stressful conditions that shape consumer choices of how to spend leisure time are revealed in surveys of consumer preference.  In 1980 a survey of 10,000 Americans  revealed that two thirds of the respondents want to rest and relax on vacation (Rubenstein 1990). A 1983 study of Canadians vacationing in Hawaii said the major purpose for their trip was for rest and relaxation (Woodside and Jacobs 1986). Market research for the state of South Carolina revealed that 56% of respondents said their top priority on vacation 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 than ever (Kooyman 1990). Given the prevalence of stress in many people’s lives, the health risks associated with stress, and people’s perception that a vacation will give them some relief from stress, it is not surprising that health resorts have become such popular vacation choices.  26 Demographic Factors Demographic statistics show that, over the next three decades, the number of people aged 50 and over will increase at a much higher rate that those under 50 years of age in Canada and the United States (Statistics Canada 1993, Pederson 1992).  In absolute  terms, it is anticipated that by the year 2000 there will be one hundred million Europeans and 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 the lives of this large segment of the population. Because this cohort has generally been very active in early life, it is anticipated that the popularity of leisure-based health facilities will continue as this group ages (Lago and Poffley 1993). The leading edge of this demographic phenomenon has driven and will continue to influence the health resort market as larger numbers of older people appear in the population. The Forces of Demand and Supply Market research has shown that consumers buy products for the benefits that they receive from using the products (Woodside and Jacobs 1985). Value theory suggests that when a product benefit is consistent with consumer values, customers will chose that product from among other alternatives (Pitts and Woodside 1986). Incorporating health attribute benefits associated with the concepts of wellness and quality of life is regarded as an important ingredient in future tourism product development (Alleyne 1993). This position complements the growing value that North American travelers are placing on health related pursuits. This interest has in part fueled the current expansion of the health resort industry on this continent. The marketplace has responded to the value placed on health with a wide array of health-oriented leisure products. The American Hotel and Motel Association estimated that 40% of American hotels had health clubs on their premises in 1991 (The Vancouver aim,  5 October 1991). No longer are health spas confined to land; numerous cruise ships  27  now offer spa programmes as an amenity (Colbert 1988). More medically oriented than many cruise ship spas, a new health spa on the Queen Elizabeth II, will take advantage of sea water to offer thalassotherapy and an inhalation room for people with respiratory disorders (The Vancouver Sun, 13 March 1993).  In the past, destinations like the  Caribbean would have been an unlikely place to find a health resort because the popularity 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 have incorporated health spa facilities too (Gold 1994). Recently, traditional European health spa treatments such as balneotherapy and lymph drainage have been offered in some urban health spas. This leisure product combines the treatments usually found in the rural 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 under construction in eastern Canada (Wickens 1988). Activity in the health and leisure market demonstrates the interest that people have in combining these two concepts. The dedicated health resort is a growing segment of this market which can provide a refreshing approach to the field of health promotion.  2.5 Summary In this century, people in the English speaking world, with powerful pharmaceutical agents in their armory against disease, rapidly abandoned taking the waters as a route to health (Bywater 1990). Yet, even though the form has changed, the institution of health resorts has survived to present day.  Porter offers an explanation for the survival of  vestiges of the traditional spa in Europe and Britain in contemporary culture “because they [satisfr] a deep desire that the healing enterprise should proceed within frameworks essentially sociable in their nature, and suffused with symbolic cultural meanings” (Porter 1990).  Nowadays, it may be that people perceive that reductionist scientific  28  medicine has reached a plateau in its ability to significantly advance their health and thus they are willing to reinvent an old healing institution to serve their needs. This increased interest in health oriented vacation activity holds potential benefits for various sectors of society and for individuals. In as much as a visit to a health resort can be associated with a vacation, this activity contributes to the creation of a specialized niche in the tourism industry. Entire resorts may be dedicated to the provision of health benefits to their guests. A multi-purpose resort may provide health resort amenities, and with good management health spas can be profit centers for the hotel (Monteson and Singer 1992). Repeat visitation is remarkably high in this segment of the travel industry (ISTC-Tourism Canada l991a).  Although health resorts are primarily a domestic  tourism product, research shows that several travel groups in the western United States are a potential international market for Canadian health resorts.  (ISTC 1991b).  In  addition, the setting of health resorts, usually in a scenic, rural area, could create opportunities for regional economic development (Popma and Pollock 1987). Health resorts promote activity which appears to provide individual physical and psychological benefits. If a leisure activity such as visiting a health resort is an effective vehicle for further disseminating an ethic of healthy living in our culture, our economy and our straining medical care system may benefit from a healthier population.  29  3.0 Chapter 3 Research Purpose and Plan  3.1 Rationale A continued expansion of the health resorts in North America is anticipated. While the health resort industry in Canada is small, it is conceivable that these facilities could play 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 them adopt or maintain healthy behaviors.  Because, at a minimum, the growth of health  resorts represents an economic opportunity and possibly significant health benefits, it is worth exploring what attributes health resorts in British Columbia ought to possess and what an appropriate policy response from government might be with respect to this resort industry.  3.2 Technique and Approach to Analysis Seminal issues in the history of health resort development are explored through a review of the relevant literature. As an extension to this review, twenty key informants were interviewed for their perceptions of the opportunities and constraints confronting the health resort industry in the areas of marketing, financing, natural resources, human resources and product development. Criteria for a key informant included expertise in the health resort, tourism, health or health promotion fields. Focused telephone or face to-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 efficiency and relevance to the research objectives. The use of interviews as opposed to mail-back surveys ensured a high response rate among the key informants, and it allowed quicker access to other respondents and unpublished sources of data. Given that health resort operations in British Columbia are relatively few in number and that part of the inquiry  30  required the respondents to extrapolate from present conditions to possible future scenarios, people with relevant expertise were selected for this research. Individuals who supply or use leisure-based health-promoting facilities were contacted along with people who serve as intermediaries in the leisure-health market. It was assumed, because of their expertise, that this select sample of informants would be better able to envision and advise upon the nature of future health resort development than a random sampling of the adult population. The specific leisure product of a dedicated health resort was defined as: A resort where visitors stay overnight and take part in leisure activities intended to improve or maintain their health. The provision of a health supporting experience in a pleasant environment is the main objective of the resort. Informants were engaged in a dialogue focused around an open ended question asking about 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 review forms the basis of the policy recommendations. The approach to policy development taken here follows generally identified policy frameworks of problem definition, determination of criteria for choice among alternatives, generation of a range of alternative actions, choosing actions that can be implemented and determining indicators of policy effectiveness. Public policy should serve the interests of the public while still allowing the private sector to function. Socioeconomic and environmental goals should guide policy development (Patton and Sawicki 1993). In addition to government policy analysis, recommendations were made regarding appropriate actions for the tourism industry in the development of a network of health resorts in British Columbia.  31  3.3 Strengths and Weaknesses Because of the diverse nature of health resorts or health spas and the lack of information in the literature on planning these facilities, data collection on this topic was communicated in a verbal format.  This allowed the researcher to probe any  inconsistencies in the reported data which may have arisen from varying perceptions of the topics explored. The scarcity of local examples of health resorts also contributed to the necessity of a hypothetical discussion about this leisure product as it might exist here in 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, any particular perspective is subject to the biases of the respondent or author. An attempt to ameliorate this was done by accessing a broad opinion base and by interviewing more than one person with similar expertise whenever possible.  32  4.0 Chapter 4 Report of Research Findings  This chapter reports the information obtained from interviews with twenty key informants acquainted with various aspects of the health resort industry (Reference List page 50).  4.1 The Health-Leisure Connection The respondents to this inquiry repeatedly pointed to the way society collectively thinks about health and leisure in North American culture as a potential constraint in the growth of health resorts. As a society, North Americans are seen to discount the value of leisure in health promotion. This view prevailed in spite of the fact the respondents personally 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 good health.  And, it is equally reasonable that people become displeased when they  experience a deterioration in their health. Pleasure or displeasure, then, can be derived from good health or bad health respectively. From this perspective there appears to be a straightforward relationship of cause and effect between health and pleasure. Actions designed to promote health, according to this view, would not be based on pleasure since it 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 mind can have a profound effect on one’s physical health (Biondi and Kotzalidis 1990, Birney 1991). 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 be a cause of good health. And, it follows from this view that we should employ pleasure either to contribute directly to health or to put people in a frame of mind that makes them more receptive to adopting health promoting habits in their lives.  33  4.1.2 Empirical Evidence Whether there is a reciprocal relationship between health and pleasure may be debatable.  However, the increasing numbers of people who spend leisure time in  activities with health benefits demonstrates that health and pleasure currently have a strong association in our society.  Opinion leaders in this survey expect that this  phenomenon will continue to contribute to the growth of the health resort industry. 4.1.3 Opposing Forces Several respondents said that some social structures as they are presently organized are not supportive of a growing health resort industry. Because it bridges the fields of health and leisure, this industry needs concerted recognition from different government and academic departments of tourism and health. The Ministry of Tourism is the lead government agency in contact with health resort operations in British Columbia. As the health resort product exists now in this province, support or acknowledgment from the Ministry of Health was seen to be unlikely. However, if a facility such as Valley Spa in California, which specializes in physical rehabilitation, or Wildwood Lifestyle Center and Hospital in Georgia, which is medically-oriented, were to be created here, it is conceivable that the Ministry of Health might become involved. In addition to government structures, there are professional structures that may not support health resort endeavors.  Public funds designated for health care and health  promotion are generally channeled through British Columbia’s mainstream medical system of highly specialized health practitioners and health promotion academics. The respondents in this survey see the traditional medical system as a valuable resource but one that is geared towards curing disease rather than preventing illness. The traditional medical sector was sometimes seen to be in competition with the providers of alternative approaches to health care. The health promotion field, which is dedicated to the creation of broad public policy, was seen by some respondents to need better mechanisms of delivering health promotion information to the public.  34  Although no respondent advocated abandoning publicly funded health care in British Columbia, several made the point that there is no incentive in current practice for people to be proactive in maintaining their own health. Comparisons were drawn to the United States where some respondents felt the expense of health insurance creates a greater pressure for disease prevention among certain groups in society. 4.2 Health Resorts as a Resource for Employers 4.2.1 Background It is not unusual for employers to be involved in the provision of some health services to employees. Particularly in larger organizations, employers often pay for or share in the cost of health insurance premiums. Depending on the size of the work-force and the types of activities performed, an employer may provide an occupational health nurse or physician, a first aid team, psychological counseling services, or a safety educator. In recent years, the workplace has been recognized as an important means of accessing a large percentage of the population with health promoting information and programs.  Company sponsored fitness classes are an example of work-site health  promotion. Corporations often subsidize the cost of these activities and access is usually universal to all employees. In addition to physical fitness, companies ascribing to a holistic model of health promote a wide spectrum of resources to their employees in support of wellness. In Europe some employers in conjunction with government programmes support health resort use. Employers interviewed in this survey were asked to consider what role health resorts could play in their plans to encourage healthy life-styles among employees.  4.2.2 Health Resorts as an Incentive Tool Employers did not see health resort visitation as something they could provide to all employees because the cost of such a benefit would be too great. However, health resort vacations were seen as attractive incentives in motivating employees to reach their goals.  35  For companies that have a commitment to health promotion, being able to offer a prize that is both appealing and potentially good for the health and weilness of the employee is an attractive option. The use of a health resort visit as an incentive was also seen to be appropriate for employees participating in workplace health promotion activities.  Jennifer Leslie  reported that a week-end stay at a local resort was a valued prize in the Vancouver Hospital employee weilness programme (personal communication). 4.2.3 Health Resorts and Corporate Health Goals Another way that health resorts can serve the business community is to understand the needs of executives in business organizations. Informants noted that work induced stress 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 the well-being of the company leaders. Because these individuals often control large budget projects, companies have a vested interest in the health of their managers. Although intellectually they are probably well aware of the health risks in their lives, many individuals who are high achievers in corporate systems were said to be resistant to suggestions or pressures for them to change their negative health habits. Getting corporate executives to pay attention to their own health to the extent that they change their behavior is a delicate process. A health resort was seen as a place where senior personnel could be attracted to the recreational amenities that the resort offered. Once there, the company could use the health promoting culture of the resort to set the scene for some health education programmes specifically targeted to the needs of that group. Holding a corporate planning retreat or team-building meeting at a health resort was also seen as an opportunity for a synergistic blending of personal and corporate objectives. Some companies recognize that senior staff act as role models for the whole organization. Lauren St. John of Vancouver City Savings Credit Union said that having  36  the cooperation of senior management in their “Living Well” programme was crucial to its success (personal communication). When the leaders demonstrate health promoting behavior, it is easier to get line workers adopt these behaviors too. 4.2.4 Importance of Pleasure Regardless of the reason a health resort visit might be offered as an incentive or bonus, the respondents were clear that the experience had to be pleasurable.  The  activities and environment at the resort may be good for one’s health, but the reward of pleasure was seen to be more important in motivating people. 4.2.5 Health Resorts as a Venue for Employee Education The use of a health resort as an incentive may provide considerable promotional exposure to a population of employees, but relatively few employees actually experience the health resort through this incentive. However, many companies will contribute to employee health education. Respondents reported that conceivably, corporate education budgets could be used to cover the cost of a seminar or lifestyle education programme at a health resort.  4.3 Cost Considerations The cost of a health resort vacation was one of the most frequently cited constraints on the growth of a health resort industry from both a demand and supply perspective. 4.3.1 Cost to the User In 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 to those who can pay for them.  However, given the need for governments to control  spending there was little support for the idea of public funds being provided to underwrite 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 resort activity and the lack of systematic evidence showing the effectiveness of health resort  37  treatments in bettering the health of users in North America. This is not to say that the evidence does not exist, but rather the study of the contribution of a health resort experience to the health of the population is lacking.  There was general acceptance  among the respondents that public spending on health services needs to be focused on things 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 become too expensive. Two people anticipate that eventually some of these services will no longer be provided free to the public. Therefore, the likelihood of health resort visitation being paid for by public funds was seen to be dependent upon proof of effectiveness of treatment and cost efficiency. 4.3.2 Cost to the Provider Cost considerations from the perspective of the resort developer were consistent with good business sense.  As with most property development, there is a large capital  expenditure in the beginning of the project which can take several years to recapture. A reality of the resort business in Canada is the existence of a short season. This negatively affects corporate cash flows and negatively influences the perception of risk by lending agencies (Pollock 1985). Given current provincial government policy, there is no financial assistance for development of resort infrastructure. Peter Maundrell of the British Columbia Ministry of Small Business, Tourism and Culture said that the tendency now is for the government to assist with planning, technical support and advertising as opposed to capital projects (personal communication). If public funds were to be granted for capital projects in resort development, Bennet Brown recommended spending money to improve the quality of existing resort infrastructure as a preliminary step in the creation of a network of health resorts in British Columbia (personal communication). Most informants believed that the development of health resorts should proceed incrementally as the Canadian market becomes more aware of the benefits obtainable  38  from a domestic health vacation and as the industry becomes more experienced in providing healthy vacation retreats. Lori Lawrie, recalling her experience with a resort development in Kelowna, said the capital costs of building a new resort today are often prohibitive such that redeveloping an existing resort into a health resort is often more feasible (personal communication). The unfortunate demise of the former King Ranch Health Spa and Fitness Resort near Toronto was mentioned in this light. A combination of factors were named for the collapse of this ambitious development. Among these were 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 in warmer climates, Canadian health vacationers are being drawn out of this country. Canada’s currently devalued dollar provides a temporary incentive and opportunity for many Canadians to travel domestically and experience the health resort product.  It  affords a “window of opportunity” for the health and leisure resort concept to become more strongly embedded in the culture of Canadians. Jennifer Leslie identified health resort use as being associated with annual times of renewal: January, September and the spring months of March, April and May (personal communication). Conceivably, a health resort could have a competitive edge over other types of resorts in retaining year-round business in the Canadian climate.  During  summer season, particularly with an exchange-rate advantage, Canadian health resorts should be able to draw foreign travelers. During winter months health resorts need an operational strategy that will ensure business continues in spite of colder weather.  4.4 Terminology The diversity of the health resort product and the different meanings associated with the terminology was discussed in the beginning of this paper. Some informants who have had experience in marketing health resort vacations believed that operators must be  39  careful 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 the general public, spa has connotations of unobtainable expense and luxury, and to men, the word spa is often associated with a women’s activity (personal communication). There is also the danger that the dedicated health resort product image will be tarnished by lesser products marketed as spas (Gruler 1994).  4.5 Natural Resources Like many other tourism experiences, health resorts usually incorporate pleasant scenery, an agreeable climate and access to water for recreation. The availability of these features in British Columbia make this province the location of choice for an expanded health resort industry in Canada according to the people surveyed. Although the architecture and landscaping are important, a beautiful natural setting is considered to be a fundamental component of a health resort. Because winter weather is less severe in southern and coastal British Columbia than elsewhere in Canada, this province 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 the country. 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 health status and local economies by treating hot springs as just recreational resources. Interestingly, recent changes in Canadian National Park policies have been instituted to take better advantage of hot spring resources for recreation and health (personal communication). Plans are underway to revive health-related activities such as massage services and steam baths that were once a seminal part of several National Park attractions.  40  4.6 Human Resources The health resort industry shares some of the same human resource development needs as the hospitality industry in general for food and beverage and accommodation workers (Mitchell 1992). In addition, specially trained personnel are required for the health, fitness, paramedical, and beauty services that health resorts provide. Obtaining suitable staff was cited by Patrick Corbett as being among the most challenging aspects of running a health resort (personal communication).  41  5.0 Chapter 5 Recommendations for Government and Industry  5.1 Preamble The information uncovered in this research describes health resort activity as a diverse and durable cultural phenomenon in Western societies. It is apparent that the current revival of health resort use is not just an old tradition brought to life again but an activity that recalls some ancient wisdom and blends it with new knowledge. The goal of understanding ways that government and industry can foster the growth of health resorts in British Columbia is based on the premise that health resorts are capable of providing a leisure-based health promoting activity in our culture. It is further assumed that health benefits and environmentally sustainable economic activity are valuable to our society. Addressing the issue of social equity in health promotion efforts, Levin sees the middle class with the financial resources and discretionary time as the people in our society 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 class that 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 better education in general, not just on health matters, and creating more economic opportunities 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 of health resorts in British Columbia does not deny the need to simultaneously address the particular health needs of less advantaged people in our society.  But, the health  promotion opportunities that can be accessed by socioeconomic groups who can afford to pay more to enhance their health should be encouraged. The goal of economic development is another, and perhaps more visible, outcome of an initiative to promote the existence of health resorts in British Columbia. Because this  42  leisure product is usually located in pleasing natural surroundings where scenic views and a tranquil environment are obtainable, many rural and semi-rural areas of the province could be the site of this specialized tourist development. In addition to serving the domestic population, a network of health oriented resorts might attract more foreign guests to the less visited regions of the province. The development of a network of hot spring resorts in Hungary during the 1970s provides a case study for this type of regional economic diversification strategy (Grove 1977, Czegledi and Fluck 1989). Hungary recognized that two-thirds of their foreign travelers only visited two major cities. A strategy was implemented for the purpose of attracting more foreign visitors and altering the pattern of tourism. It is unknown how successful 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 international visitors from seventeen to nineteen million foreign visitors per year. The development of the thermal springs was seen as a contributor, both quantitatively to the increase in foreign tourists, and qualitatively in attracting tourists who spend more per day on their holidays (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 visitors to 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 that health resorts can be useful venues for promoting and reinforcing an ethic of health and weilness in our culture. In response to an anticipated increasing demand for health and leisure facilities and because of the natural resources available for health resort development, it is recommended that the provincial government encourage the  43  development of a network of health resorts in British Columbia. This province’s hot springs are recognized as the most strategic resources to employ in fostering a health resort industry. The support, however, should by no means be restricted to hot springs development. While some regions may ultimately attract more health resort development than others the government initiative should target resort development in each of the nine recognized tourism regions of the province.  5.3 Policy Objectives New policies to promote health resort growth should be developed to coordinate with current broad government objectives of individual and societal health.  The existing  policies relevant to this investigation are under the jurisdiction of the Ministry of Health  Fig. 1. A Framework for Health Promotion (Jake Epp. Achieving Health for All 1986, 8).  Aim  Achieving Health for All  Health  Reducing  Increasing  Enhancing  Challenges  inequities  Prevention  Coping  Health  Self-Care  Mutual Aid  Healthy  Promotion  Environments  Mechanism Implementation Strategies  Fostering  Strengthening  Coordinating  Public  Community  Healthy  Participation  Health Services  Public Policy  44  and Ministry Responsible for Seniors and the Ministry of Small Business, Tourism, and Culture. The field of health promotion gained a higher profile in the Ministry of Health in the 1 970s. The 1986 federal framework for achieving health for all consists of three challenges, three mechanisms and three implementation strategies (see Fig 1). Health resorts as venues for health promotion can be classified according to this framework as meeting the challenges of increasing prevention and enhancing coping through 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 seen in light of the reality that “cultural diversity causes multiple patterns of health beliefs and uneven progress towards behavior change” (Levin 1987). The acknowledgment of the leisure sector as a contributor to health promotion has only surfaced very recently in government policy documents. Now that the awareness of this linkage has begun it should be encouraged to continue. Although the aggregate size of the tourism industry is large, coordination of the departments of small business with tourism in one ministry recognizes the smaller nature of most individual tourism operations.  Existing policy in this ministry encourages  economic development in a decentralized way across the province. The coordinating efforts of regional economic development officers should be enhanced with specialists in health-tourism development.  5.4 Specific Recommendations This research has uncovered a number of actions that need to be taken by both government and the health resort industry in concert with one another.  45  5.4.1 Government Government is capable of helping to shape the emerging health resort industry by virtue of its power to create policies and provide financial and organizational support. The government, primarily at the provincial level, should address the following needs:  •  Standards: Help to clarify terminology and adopt a consistent use of terms in government documentation. Set standards for identification and accreditation of health resorts. Establish an evaluation mechanism which will contribute to credibility in the industry.  •  Recognition: Leisure pursuits need to be recognized as legitimate and valuable methods of health promotion. Including leisure, recreation, and tourism as resources for healthy living 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 relationship of health to pleasure activities, the efficacy of leisure-based health promotion, and the understanding of other cultures’ approaches to health through leisure.  Sponsor  workshops on health resort issues to serve the information needs of this market niche from both supply and demand perspectives.  •  Advisory and technical support: Financial resources should be available to assist the private sector with feasibility studies. A data base of consultants experienced in health resort development should be available covering aspects of physical and programme planning relevant to health resort activity. Plans for accredited facilities should strive for a holistic health resort product that complements the indigenous landscape, borrowing  46  the most useful and meaningful forms from the past history of health resort activity and incorporating 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 health resort industry.  •  Financial incentive: Provide a tax incentive to encourage the development of accredited health resort facilities.  •  Partnerships: Because health resorts bridge the disciplines of leisure and health the industry requires the provincial government ministries responsible for tourism and health to cooperate in support of health resort ventures. Government should consider limited capital investment in plans for accredited health-promoting facilities to encourage health resort development.  •  Public relations: As the product becomes more established, promote British Columbia’s network of health resorts as venues where good health can be reinforced.  Create a  directory and include the health resort product in advertising strategies.  5.4.2 Recommendations for the Health Resort Industry The primary responsibility for the creation of a network of dedicated health resorts in the province of British Columbia will rest with the private sector.  The industry should  address the following needs:  •  Partnerships: The industry can benefit through establishing business and information partnerships with government and academia in order to gain credibility.  47  •  Research: Industry should contribute not only to tourism market research, but also to theoretical research on the health benefits of leisure pursuits in order to address the current lack of information.  •  Standards: By addressing the need for industry standards, particularly in the area of terminology, the image of the health resort product will become better established in the minds of the North American public and international visitors.  •  Education: Develop strategies to make health promoting leisure a cultural habit by forming liaisons with educators, the medical profession, business and ethnic groups.  •  Recognition: Demonstrate the efficacy and cost effectiveness of health resort stays so that accredited facilities can seek access to public or private health insurance funds for treatment remuneration.  48  6.0 Chapter 6 Conclusions and Areas for Further Research 6.1 Conclusions This research into the nature of health resorts as locations where health and pleasure can be attained results in a call for leadership by government. Rather than asking for the health-leisure resource to be state sponsored like our traditional medical system, this report asks for the government to enhance the opportunity that citizens of and visitor to this province have to support their own pursuit of health. Leadership embodied in these policy recommendations will guide the stake-holders in this emerging industry to produce a health resort product that sets a new international standard for the blending of health and pleasure.  6.2 Recommendations for Further Research The opportunity for both economic development and health benefits as a result of health resort development in British Columbia deserves serious consideration. Enough information 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 and development will be required. Based on this study’s initiatives, several important areas for 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 vís the process of behavior change.  •  Document the change in health resorts in North America from a social history perspective.  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 and state-funded support for health resorts.  •  Study the approaches to health and leisure in Scandinavian countries where climate constraints 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 these international markets.  •  Look at ways to democratize the health through pleasure experience using the facilities and programmes of community centers. These potential areas for further research will lead to a greater understanding of the role of health resorts in our society and in the tourism industry.  50  Reference List  Personal Communication Michel Audy. Acting Superintendent, Jasper National Park. Jasper, AB. Telephone conversation August 11, 1994. Bennett Brown. Bennett Brown Associates. Vancouver, BC. Personal conversation August 22, 1994. Patrick Corbett and Juanita Corbett. The Hills Health and Guest Ranch. 108 Mile Ranch, BC. Telephone conversation July 18, 1994. Barbara Crompton. Executive Director and President of The Fitness Group. Vancouver, BC. July 15, 1994. Alison Dennis. Programme Director, YMCA of Greater Vancouver. Vancouver, BC. Telephone conversation August 3, 1994. Dr. W.G. Hartzell. Occupational Physician, Healthserv. Vancouver, BC. Personal conversation April 26, 1994. Sue Hills. Wellness Consultant and Spokesperson for the BC Alliance for Health and Fitness, West Vancouver, BC. Telephone conversation July 20, 1994. Dr. Karen Kruse. Director of Health Services, BC Telephone Company. Vancouver, BC. Personal conversation July 18, 1994. Lori Lawrie. Owner of Okanagan Reservations, Inc. and Marlin Travel Agency, Penticton, BC. (Former shareholder in Quail Ridge Resort development, Kelowna, BC) Telephone conversation August 19, 1994. Jennifer Leslie. Employee’s Centre Supervisor, Vancouver Hospital. Vancouver, BC. Personal conversation July 27, 1994. Michael Loseth. Regional Economic Development Officer, Kamloops-Clearwater, Ministry of Small Business Tourism and Culture. Kamloops, BC. Telephone conversation August 11, 1994. Peter Maundrell. Senior Manager of Industry Development, Ministry of Small Business, Tourism and Culture. Victoria, BC. Telephone conversation July 22, 1994. Jim Mitchell. Director of Sales and Marketing, Harrison Hot Springs Hotel. Harrison Hot Springs, BC. Personal conversation March 21, 1994. Greg Osoba. Public Relations Coordinator, Hollyhock. Cortes Island, BC. Telephone conversation August 10, 1994. Danielle Pratt. Partner, Workplace Health Promotion. Coquitlam, BC. Telephone conversation  51  August 3, 1994. Frank van Putten. President, Spa Finders Travel Agency. New York, NY. Telephone conversation July 25, 1994. Lauren St. John. Employee Relations Coordinator, Vancouver City Savings Credit Union. Vancouver, BC. Telephone conversation July 18, 1994. Collin Stewart. Senior Scientific Technical Officer, BC Ministry of Environment, Lands and Parks, Water Management Branch. Surrey, BC. Telephone conversation August 11, 1994. Mary Tabacchi. Professor, Cornell University. Ithaca, NY. Telephone conversation August 5, 1994. Gordon Tareta. Spa Director, Banff Springs Hotel. Banff, AB. Telephone conversation July 21, 1994.  52  Bibliography Alderson, F. 1973. The Inland Resorts and Spas of Britain David & Charles: Newton Abbot. 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