Keywords

1 Introduction

Nature-based health tourism was particularly popular in the nineteenth century and is therefore not a new phenomenon. Yet, the popularity of this type of health tourism had faded over time due to the increasing quality of medical interventions and changes to the structure of the health sector. Despite these changes, some destinations (particularly those with extensive infrastructure) have continued to offer nature-based health tourism products albeit often in combination with other tourism products. Based on recent research on the health benefits provided by nature in general and certain natural resources in specific [1] have led some individual tourism service providers and tourism to develop innovative evidence-based tourism experiences based on the health benefits of nature.

Trend forecasts have long predicted an increasing likelihood of Europeans viewing nature as an idyllic place for relaxation and withdrawal [2]. In particular, nature is valued highly as a source of peace of mind, strength, and integrity [3]. In a study examining the recommendations of Swedish inhabitants in urban areas to a friend who is feeling stressed, the respondents’ first choice was to recommend a walk in the forest [4]. This subjective perception of the beneficial effects of nature is confirmed by empirical research analysing exposure to nature (either walking 15 min in a natural setting or watching videos of a natural setting), which leads to positive emotions and increases human reflection capacities and the ability to complete attentional tasks [5]. While exercising in nature also provides long-term health benefits [6].

With its tools and practices [7], the HEALPS2 project provides an innovative framework for the (further) development of such health-promoting tourism offers. In order to better adapt these offerings to the needs of the market, it makes sense to take a closer look at demand and supply. On the demand side of nature-based health tourism, this includes the perceptions of nature-based health tourism in general, the perceptions of the Alps as a landscape with health benefits, and the types of diseases and health restrictions that respondents can see themselves address via nature-based health tourism. The level of interest, needs, and expectations of tourists regarding the health benefits of environmental resources in the Alpine region provides a basis for assessing the feasibility of nature-based health tourism offers.

On the supply side, a first necessary step is an analysis of the situation regarding nature-based health tourism [8]. In addition to existing natural health resources, representing the core of the tourism experience, services and socio-cultural offers in the destination should also be analyzed for this purpose. A key success factor for the development of nature-based health tourism is the cooperation of the various stakeholders on the supply side (particularly across the tourism and medical sectors) [9]. The potential on the supply-side must be matched with the needs and expectations of the guests, on the one hand, and with the expected market potential, on the other hand. Although there is an increasing demand for nature-based and health-promoting services and the possibility to differentiate the destination portfolio of tourism experiences based on this form of tourism, the market segment is still relatively small. Thus, despite the fundamentally high quality of supply and the achievable prices, this market segment is only suitable in a few cases as a supporting pillar of the tourism economy for entire regions. As a complimentary tourism experience, nature-based health offers should be compatible with the basic strategy and orientation of the tourism services in the destination. For example, the destination image should fit this type of tourism as well as the existing attractions in the destination or the currently strongest target segment. The consideration of the current and future target segments is certainly an essential part of the supply-side analysis.

All in all, the development of nature-based health tourism is a medium- to long-term development perspective that requires an in-depth analysis of both the demand and the supply side to increase the economic potential of the Alpine region.

2 Methods

A representative survey [10] of the demand side covering six countries of the Alpine Space (Austria, France, Germany, Italy, Slovenia, and Switzerland) was completed with a sample size of n = 3,334 individuals. The data are representative of age, gender, and education and were first analyzed for correlated indications using a factor analysis. 18 indications were deleted from further analysis, and seven indications remained: allergies, stress & burnout, back pain, lack of fitness, overweight, and respiratory and cardiovascular conditions. The survey included questions on the perception of the Alps as a healthy destination in general and on the personal assessment of the health effect of natural resources in particular. In addition, questions were asked about personal health, booking behaviour for nature-based health tourism, and the importance of services for such a holiday.

On the supply side, an explorative online survey [10] was conducted in the German Alps, in which a total of 73 stakeholders from the fields of destination management, accommodation, and gastronomy, as well as (health) tourism services, participated. In this context, the expected economic developments in the field of nature-based health tourism as well as the relevance of individual target groups for such types of offers in a time horizon until 2030 were analysed.

In the following, the results and graphics for both described evaluations can be found.

3 Results

3.1 Perceptions of Alpine Natural Resources in the Context of Health

The evidence base for natural health resources is not common knowledge. Therefore, the perceptions of nature-based health tourism in general, natural landscapes, and particular natural resources are key for understanding the potential of nature-based health tourism. This perception is even more important as the perception of natural landscapes, and natural health resources may affect the health benefits derived from a nature-based health tourism holiday [11].

The results of the survey show that 86.7% of the survey respondents perceive natural environments as providing health benefits (see Table 1). The perception that natural environments provide health benefits is a key basis for the development of nature-based health tourism products, yet, in comparison, fewer of the respondents (50.1%) take possible health benefits into account when choosing their holiday destination. This discrepancy could have three reasons: first, that health benefits are not usually the main reason for travelling; second, that respondents do not equate health with relaxation; and third, that they have too little information regarding health benefits to be able to consider these when planning a holiday. Regardless, 61.3% of respondents state that I pay attention to my health when on holiday.

Table 1 Perceptions of nature-based health tourism
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Due to its diversity of natural resources with health benefits, the Alpine region offers a high potential for the development of health tourism products (see Chap. 1). This is mirrored by the perception of 78.5% of respondents that the Alps are a good health tourism destination.

Health treatments based on scientific evidence are vital for ensuring the accreditation of Alpine health tourism products by health insurance companies [12]. However, lay persons are not in a position to know the scientific evidence of health benefits of natural resources. Figure 1 shows, on the one hand, the perception of the respondents of health benefits of a given alpine natural resource in the treatment of back pain and, on the other hand, the level of scientific evidence for each resource on a range from 1 (low evidence) to 10 (high evidence). Not surprisingly, a comparison of the perception with the evidence reveals a certain lack of scientific knowledge of the respondents. The natural resources “Radon treatment” and “health caves”, for instance have a high level of scientific evidence, but their health benefits are not perceived by the respondents as being particularly high. In contrast, the health benefits of “Forests” are perceived as being high but do not have such a high scientific evidence level. The evidence of health benefits achieved via natural resources needs to be at the centre of product development and subsequent marketing for health tourists to be able to distinguish nature-based health tourism from wellness.

Fig. 1
A group bar graph depicts the y-axis with values in percentage versus x axis with resources. Radon treatment has the highest value at 50 percent. A fluctuating line depicts the evidence level.

Assessment of health benefits of natural resources from the perspective of guests with back pain and current level of evidence for these resources

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Another important factor important for marketing nature-based health tourism are the different diseases or potential health restrictions that potential guests are interested in treating or in taking preventative measures during a nature-based health holiday (see Fig. 2). With 64% back pain is the main disease/restriction that respondents of the survey are interested in addressing, followed by diseases/restrictions that consist of a combination of physical and mental factors. Of particular interest are the perceptions of the target group of possible treatment/prevention measures. Figure 3 shows these perceptions for the target group “back pain” in combination with the evidence level of the particular treatment/prevention measure. Similar to the perceptions of and evidence for natural resources (see Fig. 1), the results demonstrate a certain discrepancy between the perception of the impact of treatment/prevention and its evidence level for some treatments/types of prevention, with some being underestimated (e.g., yoga and climbing), while the effectiveness of other treatments/types of prevention is overestimated (e.g., nutritional advice and cosmetics/beauty offer).

Fig. 2
A horizontal bar graph has a y-axis with 25 types of health conditions indicated, and an x-axis with values in percentage. The highest value in terms of interest in treatment is back pain at 64 percent.

Interest in treatment and correlation of health conditions from the guests’ perspective

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Fig. 3
A bar graph depicts the y-axis with values in percentage versus treatment or prevention measures for back pain. The highest value is massage at 85 percent, and the lowest is mountain hiking and walking at 30 percent.

Importance of booking factors for a nature-based health holiday from the perspective of guests with back pain and current level of evidence for these factors

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3.2 Supply-Side Strategies for and Perspectives on Nature-Based Health Tourism

On the supply side, there are an increasing number of examples of the implementation of nature-based health tourism products [13]. Due to the necessary expertise in the fields of tourism and medicine, there is nevertheless still a great need for knowledge transfer into practice. This is especially true for medical knowledge about the cause-and-effect relationships between natural resources and human health.

The results of the survey show that it is also worthwhile to address the issue of nature-based health tourism from a supply-side perspective. The service providers were asked to assess the economic success of existing nature-based health tourism services and to estimate its development up to the year 2030 (see Fig. 4). Today, these offers already contribute above-average to the success of the service providers. Thus, 57.2% of respondents state that these services currently range from “good” to “very good” success.

Fig. 4
A bar graph has a y-axis with values and 6 parameters based on economic success. Success 2030 is at its highest at 52 percent under very good success, and success today is at its highest under good success at 34.

Economic success of offers in nature-based health tourism today and expectations for 2030 from the perspective of the supplier side

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In perspective up to 2030, this value rises to 76.2%. In this respect, this type of tourism not only has great potential from a scientific and thus rather theoretical point of view but also seems to be a worthwhile development path for the practical actors.

If the above-mentioned relationships between natural resources and health effects are well-defined and there is an overview of the own service portfolio as well as the natural features, the focus should be on the selection of suitable target groups. The target groups can be differentiated according to various characteristics. To develop suitable offers, it is particularly important to consider the health-related motivation and the composition of the tourists, e.g., individuals or families. A first analysis of the importance of the target group constellation from the providers’ point of view, it becomes apparent that primarily couples and individuals are of interest for nature-based health tourism offers (see Fig. 5). Accordingly, these two target groups need to be addressed more intensively in the future. More than 65% of respondents want to increase their focus on couples, and almost 40% on individuals. Families (12% increased targeting) or other groups (3.5% increased targeting) play a rather subordinate role from the providers’ point of view.

Fig. 5
A bar graph depicts the y-axis with 4 groups indicated and the x-axis with values. In increased potential, couples have the highest at 63 percent, and groups with the lowest at 2.

Potential target groups for nature-based health tourism in the future from the perspective of tourism service providers

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As demonstrated for the demand side, the various diseases or possible health restrictions that potential guests are interested in treating or preventing during a nature-based health holiday are an important factor for the development of offers. Conversely, the suppliers’ assessment of the current and future importance of the various health-related target groups is also of interest in this context (see Fig. 6). The results of the survey initially show similar values for both maintaining health or building physical resilience and maintaining health or building mental resilience. Around 57% of respondents currently rate both target groups (physical and mental health) as very or absolutely important. In the expectation of future developments, these values rise to more than 70% in the case of physical health and to around 75% in the case of mental health. If this question is examined in more detail, it becomes apparent that, from the providers’ point of view, guests suffering from psychological stress are an important target group for nature-based health tourism. Currently, about 69% of the providers state that these guests are very or absolutely important for their own offer. In the future, the providers also expect a rise in importance here. Thus, approx. 83% of the respondents state that these guests will be very to absolutely important in the future. Guests with physical complaints (e.g., orthopedic conditions such as back pain or cardiovascular conditions) also play an important role, but these target groups play such an important role for fewer providers, both currently and in future expectations. The values for these two target groups are currently 48% (orthopedic conditions very to absolutely important) and 56% (cardiovascular conditions very to absolutely important), respectively, and increase to nearly 72% (orthopedic conditions very to absolutely important) and nearly 69% (cardiovascular conditions very to absolutely important), respectively, in providers’ future expectations. In this respect, the expected increase in the importance of guests with orthopedic conditions is particularly high. Finally, the providers were asked in this context about the importance of guests who have health problems due to urban and fine dust diseases as a motive. Here, the lowest values for the surveyed motives are found, both currently (41% very to absolutely important) and in the future (66% very to absolutely important).

Fig. 6
A bar graph depicts the y-axis with 12 groups indicated and the x-axis with values. Health improvement of mental stress 2030 at 53 percent has the highest importance.

Importance of health-related target groups for today and future supply in 2030

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4 Discussion

Each destination will possess a different set of natural health resources suitable for various health conditions with diverse levels of evidence. At the same time, most regions considering developing nature-based health tourism will already have some tourism development. Therefore, the strategic development of nature-based health tourism requires the consideration of both supply and demand in a strategic process adapted to the specific situation in the destination to ensure that the nature-based health tourism offers are in alignment with destination strategy and pre-existing offers.

Destinations that feature locally specific natural health resources with proven evidence can develop offers for a specific condition and are thus able to target a very specific group. While this locally specific nature-based health tourism will only cater to a niche market, it can provide a unique selling proposition that cannot be copied by other destinations and can serve to diversify the tourism product, e.g., by extending the season or offering a product in the low season. In addition, these nature-based health tourism services may increase the added value in the region, as several service providers collaborate across sectors (most prominently tourism and the medical sector). However, as the marketing of this type of locally specific natural resource is entirely focused on the health benefits of the natural resource, it is particularly important that there is a high level of evidence for these health benefits. Local clinical studies may be undertaken to underline the health benefits of these resources and should feature prominently in the marketing.

While destinations with non-locally specific alpine natural health resources can develop broad tourism experiences for health conditions that occur across society. In this case, the health tourism aspect of the experience does not need to be at the core of marketing activities but should be incorporated within the experience and the marketing as an additional advantage of a “regular” holiday. On the one hand, such a marketing strategy caters to those tourism service providers who see illness as a stigma and do not want to associate their services with such a stigma. In addition, as demonstrated by the results of the survey of the alpine population, the general perception of the health benefits of some natural resources (e.g., alpine air and forests) are not supported by scientific evidence. Despite this lack of scientific evidence, these natural resources should feature in the general marketing materials (of course, without a direct attribution to potential health benefits).

5 Conclusions

This chapter highlights that there is a demand for nature-based health tourism. Tourism service providers (at least in the case study analysed) see the potential of this type of tourism development. Yet the potential of nature-based health tourism can be further extended by including prevention as an important factor in ensuring and increasing public health. However, the public health care system is currently dominated by a paradigm focused on medical intervention. A shift in public health policy and related funding structures (e.g., health insurance) towards nature-based prevention and treatment will only occur if the health benefits of natural health resources can be monetized as ecosystem services [14] and compared with the costs of classical medicine. Academic research measuring the financial contributions of natural health resources and the savings accrued by public health institutions is necessary to determine the overall potential of nature-based health tourism in the future.