Keywords

1 Introduction

Tourism has been one of the most important drivers of prosperity and regional development in the Alpine region for decades. After years of growth driving not only income but also, among other things, the cost of living for locals, environmental problems, and cultural alienation, these and other problems and challenges have recently become apparent, not least because of the Covid pandemic [1,2,3,4,5]. During this time, it has also become apparent that the tourism industry is extremely vulnerable to these multiple challenges, which are primarily economic [6], but also environmental and socio-cultural.

Current consequences include increased planning uncertainty for companies, the associated loss of income, and an increasing migration of workers to other sectors [7]—whereby these effects are mutually reinforcing. From an economic point of view, this has a doubly negative impact. On the one hand, the real income in the tourism industry decreases; on the other hand, the tax revenues in the region. This development is intensified by a growing seasonality, which increasingly fluctuates between a failing winter season and a (regional) crowded summer season, recording new lows and highs in arrivals and overnight stays [8]. Overtourism, meanwhile, has shifted from metropolitan areas to natural areas, which also has a double negative impact from an ecological point of view. On the one hand, the problem of individual mobility is shifting to regions that are even less prepared for it; on the other hand, the sensitive natural areas are suffering from the larger number of guests and their partly inappropriate behavior.

Sustainable tourism is one of the central development goals for the Alpine region [9, 10], but currently this goal is far away—even if there are already numerous positive examples, the overall picture is rather unsustainable [11, 12].

A possible approach for more sustainability in the tourism development of the Alps can be seen in the field of health [13]. Today, health is already a global megatrend [14]. And that this trend can also stand for an overarching development perspective is shown by the fact that the current discussion on the topic is increasingly less about the small-scale consideration of an individual and more about a holistic view [15]. Individual symptoms cannot be viewed in isolation from the rest of the body. And the body itself is also integrated into a superordinate system. The frame of reference for individual health is becoming increasingly complex. It is no longer just a matter of individual responsibility, but of a complex interplay of effects that are beyond the individual’s control in many areas. This holistic concept of OneHealth links human health with the health of the environment [16]—right up to the global level.

With the pandemic, the importance of individuals, as well as general health, has become a key resource. This is increasingly reflected in the tourism sector. Travelers are looking for health-promoting forms of vacation, especially in nature, and hosts are experiencing a new counter value to the economy. An example of such forms of offer and, at the same time, one of the most innovative fields of development in tourism is nature-based health tourism based on medical evidence. Here, tourism offers with proven health effects (evidence) are created on the basis of natural, alpine resources [17, 18]. Although this market segment has played only a minor role in tourism to date, at the same time it holds a great potential in terms of a sustainable diversification of Alpine tourism.

2 The KPI-Based Approach

The Key Performance Indicators (KPI) approach presented here is intended to enhance the understanding of the development potential of the Alps in terms of nature-based health tourism with medical evidence and so help regions to valorize this potential. On the one hand, this is done by transferring knowledge from research to practice about the meaning and use of the underlying indicators of the KPI approach. The basic building of awareness of the need for sustainable tourism still represents an essential aspect. On the other hand, the KPI approach can also be used to identify very specific development paths in the form of target group-specific offers for nature-based health tourism with medical evidence, adapted to the respective regional characteristics of the Alpine regions.

To assess this potential, the KPI approach uses current scientific findings on the health effects of natural resources, as well as a number of indicators that are relevant in terms of basic tourism development. The indicators of the KPI approach can be divided into five main categories. The two main categories are “Natural Resources” and “Services” (economic resources). In addition, basic “Tourism Key Figures”, information on “Image & Attractions” as well as on “Cooperation & Networks” of the region are used for the analysis. Medical evidence is integrated into this approach via the assignment to the natural resources as well as the services. How exactly this assignment happens will be explained in more detail later in this chapter.

Overall, this approach can be seen as an element for the development of sustainable tourism in the Alpine region. Although nature-based health tourism with medical is currently a niche market in tourism, it still has high growth potential and equally good growth opportunities [19, 20]. This is not least due to the increasing health awareness among the population, which has been growing for years and has received a further boost as a result of the pandemic [21]. Furthermore, this form of tourism already offers many starting points for addressing specific sustainability goals due to its structure. Existing forms of supply show that many of the challenges described can at least be actively addressed and thus either mitigated or even avoided altogether [12]. Moreover, this form of tourism offers additional opportunities for sustainable development, for example, with regard to occupational health care or socially relevant public health issues. Based on the three dimensions of sustainability—economy, ecology, social—and its derived Sustainable Development Goals (SDGs) [22], the KPI approach can be used to support, among others, the following goals in the context of Alpine tourism development.

  • Goal 3: Ensure healthy lives and promote well-being for all at all ages

    • Creation of new, nature-based health offers that not only serve classic vacation motives such as recreation or adventure, but also provide socially relevant added value in the form of health (prevention, therapy, rehabilitation) that can be used by guests and locals alike.

    • Creation of health-oriented innovations by changing the perspective on the topics of health and vacation. Health moves to the center of attention, and experiencing nature and outdoor activities gain a new, concrete value through measurable health effects.

  • Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all

    • Strengthening of alpine tourism through the creation of innovative forms of offers and the associated increase in quality as well as further differentiation and expansion of offers in the direction of health.

    • Creation of new or protection of existing jobs in the cross-sectional area of tourism and health and, associated with this, an increase in the attractiveness as a place to live and work in Alpine regions, especially for well-educated young people.

    • Expansion of existing or creation of new, regionally anchored value chains in the field of health.

  • Goal 15: Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss

    • Raising awareness of the value of nature by creating new, measurable value for natural resources through the topic of health.

    • Increasing the protection of natural resources or entire ecosystems by attributing value to health on the one hand and the need for healthy nature as the basis for economical use on the other.

    • Creation of control instruments for visitor guidance in the natural area by embedding nature use/activities in fixed value chains.

In this way, the abstract entity of the idea of sustainability results in concrete added values in a regional context. One could also speak of a kind of nature- and community-based health tourism.

However, the KPI approach must be viewed as one part of an overall process that additionally requires both upstream and downstream activities. Tourism product development, and thus in principle destination development, can be divided into four superordinate process steps. At the beginning there is the basic intention of further development (initial phase). This should be done with the broadest possible consensus among all regional stakeholders from politics, administration, business, and society. This primarily strategic step is followed by an analysis phase in which, among other things, the current status, existing challenges, and open potentials are surveyed. Based on this, suitable target groups for further development can be identified in a synthesis phase, under consideration of current trends, for example. With the help of these findings, the fourth step can finally be the concrete product development and market launch (product realization phase). The KPI approach can be located in this context as the link between the analysis and synthesis phases, which defines the framework of the analysis and supports the acting persons in the development. The KPIs are to be understood as a set of indicators that are used as a basis for assessing and analyzing the current situation of a region with regard to its development potential for nature-based health tourism with medical evidence and, finally, for identifying possible development paths for specific target groups based on indications. This supply-side analysis is integrated into a more comprehensive analysis that also considers the demand side, i.e., the perspective of the guests. This is done by a continuous guest survey in the Alpine region on expectations and needs. Also, in preparation for the downstream product development, socio-cultural characteristics of the region, e.g., customs, traditions, or special agricultural products, are considered. Through this extension of the analysis, on the one hand, the market potential for the potential development paths can be better estimated, and, on the other hand, the regional anchoring of the products can be promoted. Figure 1 shows the KPI approach in a schematic overview.

Fig. 1
A schematic diagram illustrates a process with indicators per region, in two phases categorized as general strategy and development paths.

source authors

Schematic overview of the KPI approach

Full size image

The actual analysis of the regional potential for nature-based health tourism with medical evidence is done in several steps. First, health-promoting combinations of indicators are defined for the included indications on the basis of scientific findings. Thus, a data-driven evaluation of the individual indications is conducted. In this context, the indications represent the health-seeking target groups, e.g., guests who suffer from back pain and look for suitable tourism offers. In order to distinguish the appropriate combinations of indicators with respect to the different target groups, each indicator is assigned a value between 1 and 10, and this value may change depending on the importance of the indicator in terms of health impact for a target group. In this way, theoretically optimal combinations of important (health-promoting) and unimportant (health-neutral) indicators are obtained for each target group, so-called optimal conditions. These optimal conditions are taken as fixed for a certain period of time but must be adjusted at regular intervals to reflect new research findings. This applies in particular to the evaluation of natural resources and services. In a next step, the actual conditions, i.e., the individual indicators, are surveyed in the region to be analyzed. A specially developed questionnaire is used for this purpose. Values between 1 and 10 are then assigned to the collected data with the help of defined conversions, depending on the characteristics of the data. This is followed by a comparison of these values of the indicators, which represent the real conditions in the region, with the previously defined optimal conditions (benchmarking). In this way, the existing framework conditions in the respective region are analyzed with regard to the needs of the defined target groups and, finally, the theoretically most suitable target groups for the region are identified on the basis of the surveyed framework conditions. The result of this analysis is made available to the region in the form of texts and graphics. The meaning and the possible use of each indicator for the development of offers for the theoretically most suitable target group will be explained. In addition, the development paths identified in this way are placed in the context of nature-based health tourism and information is provided on the current state of scientific research (evidence) regarding the recommended combination of natural resources and services. In this way, the regions receive a comprehensive overview of their basic development potential as well as the significant indicators (KPI) for nature-based health tourism based with medical evidence.

The KPI approach described here and the associated analysis and synthesis steps form the core of an automated, ontology-based decision support system for alpine health tourism [23, 24], which was developed as a collaborative design approach within the HEALPS2 project.

In the following, the indicators behind the superordinate categories of the KPI approach are presented and, for a selection of the indicators, their relevance for the development of nature-based health offers is explained. First, the focus is on the two main categories of the approach, “Natural Resources” and “Services”. Then, the three remaining categories, “Tourism Key Figures”, “Image & Attractions” and “Cooperations & Networks” are examined in more detail.

2.1 Natural Resources and Services

There are already a large number of studies that confirm or at least suggest numerous health effects of natural resources at different levels of evidence (see also [25]). Starting with training for professional athletes [26], the development of the immune system in early childhood [27, 28], the findings also cover various groups of people specifically relevant to tourism, such as couples or the 65+ generation [29]. There is still a great need for research in this area, but for some indications such as allergies, overweight, lack of fitness, back pain, respiratory diseases, cardiovascular diseases, as well as stress and burnout, there are sufficient good findings to develop high-quality tourism offers. For the KPI approach, the following natural resources are considered by default:

  • Alpine healing waters/thermal water,

  • Alpine water—blue space (e.g., rivers, lakes, glaciers),

  • Kneipp,

  • Waterfalls,

  • Forest,

  • High altitude (>2500 m),

  • Moderate altitude (1000–2500 m),

  • Protected areas,

  • Alpine farming,

  • Radon treatment,

  • Honey,

  • Alpine milk & dairy products,

  • Alpine plants/Phytotherapy,

  • Healing cave/tunnel (Heilstollen),

  • Moor.

Looking at the way in which natural resources develop their health effects, two types can be distinguished in principle. On the one hand, there are resources that can be characterized as having active health effects. On the other hand, there are those whose health effects can be described as passive. This means that active resources have an effect primarily due to their presence, e.g., radon. Passive resources can also have a positive health effect on their own, but they primarily only define a framework that stands for a health potential fundamentally included in it, such as a mountain. This distinction becomes clearer when changing the viewing angle, away from the natural resource to the user. From the user’s point of view, these activity levels are reversed. In order to be able to access the health potential of a passive natural resource, the user must be active himself. For example, when hiking on a mountain. With an active natural resource, on the other hand, it is sufficient for the user to have simple, passive contact with the resource, such as in a radon-filled healing tunnel. However, the boundaries between these two types are fluid, depending on the objective or indication, because in reality, the resources do not always work separately from each other but together. An example of this is alpine air, which has just as much influence on the user in almost every use of another natural resource as the resource actually used. Nevertheless, this distinction helps in the evaluation of the respective natural resources with regard to the development of indication-specific, nature-based, and health-promoting tourism offers (e.g., alternation of exercise and relaxation) and likewise with a suitable target group approach (e.g., active vs. relaxation vacation). Table 1 shows a selection of natural alpine resources and their characterization in terms of their potential health effects. More detailed information on the effects of the individual resources can be found in this book in the article by Pichler et al. [25].

Table 1 Characterization of natural alpine resources as a basis for the development of nature-based health tourism offers (own selection and characterization)
Full size table

Thinking further about the use of natural resources for tourism, there is also a need for a range of services or activities that directly promote the intended health effect (e.g., treatments) or indirectly support it (e.g., advice). Depending on the target group, different combinations of health- and recreation-promoting services and activities can be used. Within the framework of the KPI approach presented here, the following services or activities are considered by default:

  • Health Manager,

  • Health check before & after,

  • Courses in sport and exercise,

  • Gymnastics/Balance training,

  • Courses/services for relaxation,

  • Massages,

  • Physiotherapy,

  • Nutritional advice,

  • Meditation,

  • Yoga,

  • Guided hiking,

  • Hiking,

  • Climbing/Outdoor bouldering,

  • (Nordic)Walking,

  • Winter—snow-based activities,

  • Winter—not snow-based activities,

  • Cosmetics/Beauty offers,

  • Spa treatments,

  • Barrier-free,

  • Car-free destination,

  • Bicycle or E-Bike availability (e.g., rental or charging service).

Overall, offers of nature-based and health-promoting tourism are thus based on scientific knowledge (evidence) about the health effects of certain activities (e.g., hiking) in a natural environment (e.g., forest). And the basis is always a combination of natural resources and specific activities or services. It is advisable to combine several natural resources and activities, which are adapted to the target group to be addressed, not only in terms of the health effect, but also with regard to the attractiveness of the offer. All in all, high-quality but not necessarily high-priced offers can be created in this way, which fulfill the principles of sustainable tourism in many ways. In addition to a strong focus on cross-sectoral regional value chains, a high level of awareness for nature and health among guests and locals can also contribute to this. This can lead to a more sustainable use of resources and thus, for example, to the long-term preservation of nature as the basis for this type of economy.

2.2 Tourism Key Figures

Tourism is linked to numerous other economic sectors through complex interdependencies. This makes it difficult to calculate the generated added value precisely. Nevertheless, the economic significance of tourism in general for a region or an individual destination can be measured and evaluated with the help of tourism indicators [30]. These indicators include, for example, the number of arrivals, the number of overnight stays, and the number and quality of existing accommodation facilities and available beds. These indicators, furthermore, can be used to derive other indicators for evaluating tourism, such as the average duration of stay or tourism intensity. The following indicators from this category are considered as part of the KPI approach:

  • Number of inhabitants,

  • Number of arrivals,

  • Number of overnight stays,

  • Distribution of guests among the 4 seasons,

  • Source markets,

  • Average age of tourists,

  • Share of women among tourists,

  • Duration of stay (DoS = overnight stays/arrivals),

  • Tourism intensity ((TI = (overnight stays/inhabitants) * 1000)).

Tourism intensity is a key indicator for assessing local tourism. Basically, the more, the more important tourism is for the destination. However, this is only an economic indicator that does not allow any conclusions to be drawn about the ecological or socio-cultural carrying capacity of the region. In this respect, also environmental (ecological footprint) and socio-cultural (social carrying capacity) indicators should always be used when assessing tourism intensity. With regard to the development of offers in the segment of nature-based and health-promoting tourism, tourism intensity can also be an indirect indicator of the suitability of the region/destination for a certain target group. This is because tourism intensity can also indicate the social and psychological stress associated with tourism [31].

The average duration of stay indicates how long a guest stays in a region on average. This key figure therefore allows conclusions to be made on, among other things, the type of vacation and the type of guests [32]. In addition, the average duration of stay is also an important indicator from a business point of view, as it allows to calculate the bed occupancy rate in an accommodation company [30]. In the context of nature-based and health-promoting offers, the average duration of stay can also be of great importance since the expected health effect is often directly linked to the length of the stay. In this context, health can be seen as a good way to increase the average duration of stay in a region. On the one hand, this can be done by credibly demonstrating a higher health effect during a longer stay at a stretch. On the other hand, there is also the possibility to generate health improvements for the guests over a longer period in several stages, e.g., over three weekends per year, and thus bind the guests longer to the destination.

Another indicator for assessing tourism in a region can be seen in the origin of guests. Basically, within the tourism industry, one aim is to diversify the source markets with not too high shares in only one or two markets. On the one hand, in order to avoid being too economically dependent on just one or two markets. On the other hand, however, also in order to be able to address a sufficient number of potential guests throughout the entire year and at different seasons [33]. Covid-19 and the Russia-Ukraine conflict have softened this rule somewhat, as it is/was sometimes only possible to address domestic travelers, or entire markets have broken away completely. Nevertheless, a high degree of diversification should be considered in the source market analysis. In the future, one possible focus could be on source markets from which the Alps are also easily accessible by land (car, train).

Seasonality also plays an important role in tourism. In the interests of sustainable development of tourist destinations, the aim is to achieve a balanced distribution of guests throughout the year. Among other things, this provides greater planning security for operators and thus also for employees [34]. Nature-based and health-promoting tourism can in principle be seen as a year-round tourism. However, depending on the target group, seasonal differences in the distribution of these offers are reasonable. This can be related to the conditions of use or the availability of the underlying natural resources on the one hand and to the demand behavior of potential guests on the other hand.

Likewise, socio-demographic characteristics such as age or gender of current and potential guests are important for the design of offers. This applies on the one hand to the exact design of the offers and on the other hand to the marketing. Therefore, information about the possible target groups should already be available in advance because only then a targeted and, at the same time, market-tailored offer development can take place. Examples of the significance of socio-demographic characteristics with regard to different target groups (indications) are the burnout syndrome (related indications: burnout, chronic fatigue, severe stress) and back pain. For example, the following Figs. 2 and 3 show how the level of suffering of those affected changes with age and gender.

Fig. 2
The bar graph depicts the lifetime prevalence of burnout syndrome in Germany for men and women. Women have the highest peak among the 6 age ranges.

Lifetime prevalence of burnout syndrome in Germany 2014 [35]

Full size image
Fig. 3
A bar graph depicts the Proportion of adults with back pain within the last twelve months by gender and age in Germany in 2020. Women have the highest peak among the 6 age ranges.

Proportion of adults with back pain within the last twelve months by gender and age in Germany 2020 [36]

Full size image

2.3 Image and Attractions

The image of a tourist region plays an increasingly important role in the choice of a destination by the guests [37]. Thereby, the image is significantly influenced by the most important unique selling propositions (USP) and attractions. Therefore, when developing and marketing offers in the segment of nature-based and health-promoting tourism, it should also make sure that the core values of the product are also reflected in the region as a whole. A correspondingly suitable image should therefore also be used specifically for the marketing of nature-based and health-promoting products. For target groups seeking health, the image can be an important reason for booking. In addition to the fundamental combinations of natural resources and services, the topics of air, light and noise pollution in particular offer very good approaches for the further development of a healthy image for destinations in the Alpine region. The period of time since a destination has been associated with health can also be used for a product marketing campaign. For example, a long tradition of health can be positioned as a quality attribute for health-promoting tourism. New, health-oriented aspects of the image can also be marketed as an innovative and timely development of the destination’s own strengths. In the case that the unique selling proposition of a destination has a direct connection to nature, this should be used in the overall destination image, but especially in the external presentation of nature-based and health-promoting offers.

Finally, the tourist image is also related to the expectations of the guests. In this context, authenticity is increasingly seen as a quality feature in tourism. However, authenticity has not been defined uniformly in tourism science to date. Rather, there are several levels of authenticity. For example, a distinction is made between objective, constructive and existential authenticity [38]. An in-depth discussion of this challenge for tourism will not be conducted here, but rather some fundamental aspects in this context should be pointed out. Authenticity can be seen, among other things, as the subjective perception of a place, an attraction, or an encounter by the guest, who is increasingly looking for genuine and regionally typical offers and interactions [39]. How exactly an authentic impression is made on the guest depends on his or her individual expectations and ideas [40]. In this respect, the image of the destination and the marketing of individual products play an essential role in the generation of expectations and thus for the authenticity of your offers. Therefore, regardless of one’s own assessment of product authenticity, the guests’ perceptions should be evaluated regularly in order to be able to adjust possible differences between expectations and perceived reality. In principle, staged authenticity is part of tourism. In the sense of genuine and regionally typical experiences, however, it should be ensured that the staging does not have a purely touristic character and that the locals can also identify well with it, independently of an economic interest. This includes, among other things, also the real estate market, which should not focus on chalet investments, but on affordable and good housing for the local population in the future. After all, authenticity can only be created if the locals can both afford to live locally and at the same time really identify with the tourist offers. In this respect, it is important to think about offers that appeal equally to guests and locals and thereby automatically create shared moments between travelers and tourists. The question of authenticity is also a good example of the corrective potential of partnerships and networks. Within the KPI approach, the following indicators are considered from the Image & Attractions category:

  • Unique selling proposition (USP),

  • Attractions,

  • Authenticity,

  • Tourism image,

  • Health tourism image,

  • Tradition in health tourism.

2.4 Cooperation and Networks

Cooperation is important for the successful development of the destination as a whole as well as for the implementation of individual tourism products. Cooperations also play an important role for a successful and lasting establishment on the market [41]. Depending on the development phase as well as on the product orientation, there are variously important cooperation partners. Here it is important to form, maintain and further develop appropriate structures—e.g., through joint products.

Since tourism is to be understood as a cross-sectional industry, cooperations in the most diverse constellations are important. On the one hand, within the tourism sector itself, e.g., between destination management, hotels, and tour guides. On the other hand, however, also beyond the own branch borders, e.g., between hotels, craftsmen, agriculture, and the creative industries. With the focus on health tourism, innovative forms of cooperation between tourism and the health industry are also particularly important. These, but also the other forms of cooperation, represent an essential success factor. In principle, these cooperations can be local, regional, national, or international. In addition to these primarily content-oriented partnerships, good relations with administrative units such as state authorities and politics are also advantageous. For the KPI approach, the following indicators are analyzed from this category:

  • Cooperation between stakeholders in the tourism industry,

  • Cooperation between actors from different sectors (cross-sectoral cooperation),

  • Cooperation with medical service providers,

  • Cooperation with authorities and politics,

  • Network participation (regional, national, international),

  • Experience in projects,

  • Share of regional food.

The cooperation with authorities and politics represents an important framework for the tourism development of a region [42]. In this context, the approach of nature-based and health-promoting tourism should be defined as a common and long-term goal of cooperation in the sense of economically beneficial and at the same time socially fair and ecologically responsible regional development. Best practices show that the establishment of a regional habitat management can be a viable option [43]. Here, ecological, as well as economic and social issues, can be addressed with the involvement of all stakeholders, and suitable solutions for the region can be developed. There are also examples that show how public–private partnerships can contribute to the positive development of nature-based and health-promoting tourism [44]. And finally, innovative approaches that integrate co-financed health prevention into tourism products could be developed in cooperation with politics.

Good cooperation within the tourism industry (e.g., in product development) can also lead, for example, to joint programs for employee retention, e.g., through the joint use of health-promoting offerings. Overall, cooperative behavior among all tourism stakeholders can contribute to both a higher quality of offerings and a better working climate within the industry [41]. This is therefore also important with regard to the attractiveness of employers, e.g., due to seasonal fluctuations, as well as the fundamental challenges of finding good employees.

Cooperation with partners from other industries is important in the context of the development of a nature-based and health-promoting tourism, in order to be able to develop and offer regionally anchored products with differentiated contents. Therefore, targeted partnerships should be sought that complement tourism offering with regionally authentic content, such as regional food, regional crafts, or other regional services. Examples of regionally-based product development in this area include organized tastings of regional products and visits to small-scale productions (e.g., show dairies). And especially the area of health-promoting tourism offers innovative cooperation opportunities, such as the local bakery developing special offers for people with diabetes.

Regional value chains can therefore contribute to success in tourism in many ways. On the one hand, industries within the region that are not directly involved in tourism can also benefit. On the other hand, it can also serve the guests’ wishes for more authenticity and local resonance. This is particularly important against the background of a changing value system in society since, among other things, these values are becoming more and more important and are thus becoming an increasingly important part of the vacation. In this respect, these topics can also be used specifically for marketing purposes. The use of regional foods is a good example of this trend. Further examples, which can be important also for the guests, are among other things the topics of customs and handicrafts. A possible implementation idea is the integration of these aspects into existing services. For example, a breakfast buffet can be used as a “performance show” of regional agriculture/farmers. This could also be combined with a direct linking of the offered products to the producers. Also, the transfer of knowledge about the partnership, local traditions, and production methods can be exciting for the guests.

One possibility to improve the cooperation with different partners and thus also the own level of knowledge, as well as the innovative power, is the active participation in networks. Regional networks are particularly important for successful and sustainable development. Therefore, participation in regional networks should be actively forced. Among other things, ideas for your own product development can be generated, and open questions around the topic of nature-based and health-promoting tourism can be discussed and improved in a regional context. This is because regional networks strengthen small-scale market structures and thus increase the resilience of the region to future challenges such as climate or demographic change. National networks can be important, especially with regard to national strategies, e.g., in the area of funding, as well as current legislation. At the same time, however, individual challenges in product development can also find a place here. International networks can provide new perspectives on one’s own issues. In addition, they provide easy access to current developments at the international level, e.g., with regard to current developments within the EU. A concrete and good possibility to find new partners and networks and, therefore, also new knowledge is the participation in scientific projects on the topic of nature-based and health-promoting tourism. These projects can be anchored regionally, nationally, or internationally.

3 Conclusion

The KPI approach supports regional tourism development that focuses on the use and protection of natural resources and the health of guests. At the same time, however, numerous other aspects of the overall development are also considered, thus promoting a development that is aligned with the principles of sustainability. As with the idea of sustainability, the KPI approach is implemented from a view of the big picture to a detailed consideration of the regional situation, considering supra-regional trends and framework conditions. In this way, different development paths for a very concrete development of offers in the region can be identified and assessed.

However, the actual implementation in a region is also associated with potential obstacles. Thus, the KPI approach is initially embedded in an overall process that additionally requires both upstream and downstream activities. These, in turn, are associated with the use of financial and time resources. Moreover, this form of development is not feasible for most regions on their own, as medical expertise is required in addition to tourism expertise. This becomes particularly clear when the aim is to develop a region’s own evidence, tailored to its natural resources. Possible solutions are to be seen in the cooperations of several partners as well as in a (co-)financing of the project via public funding, e.g., in the form of practice-oriented research projects, as the EU supports them through the Interreg programs.

Within the KPI approach, it must also be considered that the optimal conditions used for the analysis must be regularly reviewed and adjusted, not least in view of the available evidence. This also applies to the consideration of future tourism trends. A transfer of the approach to regions outside the Alps, which is possible in principle, also requires an adjustment of the indicators to the respective (natural) conditions.

Overall, there is still a need for further development. This is not necessarily limited to tourism development but can also be extended to other areas against the background of the described references to sustainability. One example is certainly the use of nature-based offers with medical evidence in the context of prevention, therapy, or rehabilitation measures in the sense of a holistic public health strategy.