2014 03-20 secondary-rsch_hnee_final

WelDest project has been funded with support from the European Commission. This report reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein.

Lead by Dipl.-Kfm. Steffen Lange, Ph.D. University for Sustainable Development, Eberswalde, 2014

WelDest

Literature Review

Health and Well-Being in Tourism Destination

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http://weldest.blogspot.com

WelDest Literature Review 2014

Content

LIST OF TABLES ...................................................................................................................................... 4

LIST OF ILLUSTRATIONS ....................................................................................................................... 4

1 INTRODUCTION TO HNEE ........................................................................................................... 6

2 RESEARCH AND DEFINITION ...................................................................................................... 6

2.1 Research objectives and methodology .................................................................................................... 7

2.1.1 Research object I - Current state of existing health andwell-being destinations ................................ 7

2.1.2 Research object II - Current state of literature about health andwell-being destinations .................. 7

2.1.3 Research object III - Possible models to analyze health andwell-being destinations .......................... 8

3 FINDINGS OF SECONDARY RESEARCH...................................................................................... 9

3.1 Current state of existing health and well-being destinations................................................................... 9

3.2 Current state of literature about health and well-being destinations – literature review ...................... 18

3.3 Possible models to analyze health and well-being destinations ............................................................ 19

3.3.1 Tourism models .................................................................................................................................. 19

3.3.1.1 Tourism area model ...................................................................................................................... 20

3.3.1.2 Tourism time model ...................................................................................................................... 22

3.3.1.3 Extended modular model of tourism ............................................................................................ 23

3.3.1.4 Economic tourism model............................................................................................................... 24

3.3.1.5 Framework of touristic mobility .................................................................................................... 27

3.3.1.6 System tourism by Bieger .............................................................................................................. 28

3.3.1.7 Micro-analytical system of tourism ............................................................................................... 30

3.3.1.8 Swiss tourism concept ................................................................................................................... 32


3.3.1.9 Determinants of DMO success ...................................................................................................... 33

3.3.1.10 Destination competitiveness and sustainability Model ................................................................ 35

3.3.1.11 Main elements of destination competitiveness ............................................................................ 35

3.3.1.12 Guide to Tourism Destination Management (UNWTO) ................................................................ 37

3.3.2 Health models .................................................................................................................................... 39

3.3.2.1 Health cluster model ..................................................................................................................... 39

3.3.2.2 Step model to freight division of health economics ...................................................................... 40

3.3.2.3 A concept of “Wellbeing Tourism in Finland” ............................................................................... 41

3.3.3 Wellness models ................................................................................................................................ 43

3.3.3.1 Wellness model by Dunn ............................................................................................................... 43

3.3.3.2 Model for wellness by Ardell ......................................................................................................... 45

3.3.3.3 Model for wellness by Hettler ....................................................................................................... 47

3.3.3.4 Model for wellness by Travis ......................................................................................................... 48

3.3.4 Service qualitymodels ........................................................................................................................ 50

3.3.4.1 Perceived service quality by Parasuraman et al. ........................................................................... 50

3.3.4.2 Donabedian Model ........................................................................................................................ 51

3.3.4.3 Grönroos Model ............................................................................................................................ 53

3.3.4.4 “Moments of Truth” model ........................................................................................................... 54

3.3.4.5 Meyer and Mattmüller model ....................................................................................................... 55

3.3.4.6 Parasuraman, Zeithaml and Berry model ...................................................................................... 56

3.3.4.7 Dynamic process model by Boulding, Staelin, Kalry and Zeithaml ................................................ 59

3.3.4.8 Model of relationship quality by Liljander and Strandvik.............................................................. 60

3.3.5 Models and theory in regional management and destination development .................................... 61

3.3.5.1 Model of action dimensional circles .............................................................................................. 61

3.3.5.2 The export base theory ................................................................................................................. 62

3.3.5.3 Polarisation theories ..................................................................................................................... 63


3.3.5.4 Endogenous development theories /-distinctive regional development ...................................... 65

3.3.5.5 Milieu approach (Innovative and creative environment) .............................................................. 66

3.3.5.6 Cluster approach ........................................................................................................................... 67

3.3.5.7 New Economic Geography ............................................................................................................ 67

3.3.5.8 Learning Regions ........................................................................................................................... 68

3.3.5.9 Transaction cost theory ................................................................................................................. 68

3.3.5.10 Institutional density (New institutions approach) ......................................................................... 69

3.3.5.11 Evolution economics ..................................................................................................................... 70

3.3.5.12 Residential Economics ................................................................................................................... 71

3.3.5.13 Smart specialization ...................................................................................................................... 72

4 CONCLUSION SECONDARY RESEARCH .................................................................................. 73

5 LIST OF REFERENCES ................................................................................................................. 74


List of tables

Table 1: Marketed health and well-being destinations per country. Own illustration. ............ 9

Table 2: Results of research - regional analysis. Own illustration............................................ 17

Table 3: Results of literature review. Own illustration. ........................................................... 19

List of illustrations

Illustration 1: Process of literature review. ................................................................................ 8

Illustration2:Tourism area model. Freyer 2006, p.43. ............................................................. 20

Illustration 3: Tourism time model. Freyer 2006, p. 44. .......................................................... 22

Illustration4:Extended modular model of tourism. Freyer 2006, p. 47. .................................. 23

Illustration5: Factors of economic interest, in accordance with Freyer 2006, p. 48. .............. 24

Illustration6: Economics of tourism, Freyer 2006,p. 51 ........................................................... 25

Illustration 7: Framework of touristic mobility. Grümer 1993, p. 18 ....................................... 27

Illustration8: System of tourism (static). Bieger 2010, p. 84.................................................... 29

Illustration9: Micro-analytical system of tourism, in accordance with Pompl 1994, p. 6 ....... 30

Illustration 10: Swiss tourism concept. Beratende Kommission des Bundesrates 1979, p.84.32

Illustration 11: Comparison of success determinants for an ideal DMO and destination. T.

Bornhorst et al. / Tourism Management 31 (2010) 572–589 .................................................. 34

Illustration 12: Integrated Model of Destination Competitiveness .......................................... 35

Illustration 13: The main elements of destination competitiveness, Dwyer/Kim (2003) ......... 36

Illustration 14: Elements of Destination Management,UNWTO (2007) .................................. 37

Illustration 15: Step model to freight division of health economics. BMBF 2010, p.42 .......... 40

Illustration16:Recommended concepts of health tourism by the Finnish Tourist Board (FTB by

Liisa Renfors 17.9.2010) ........................................................................................................... 42

Illustration 17: Wellness model by Dunn. Image source:

http://classconnection.s3.amazonaws.com/1084/flashcards/622455/jpg/dunn-wellness-

grid2.jpg .................................................................................................................................... 44

Illustration 18: Model for wellness by Ardell. Image source:

http://well.pacificrimwellness.com/1999_fall/articles/teacher_wellness.html ..................... 46


Illustration 19: Six dimensions of wellness. Image source:

http://c.ymcdn.com/sites/www.nationalwellness.org/resource/resmgr/docs/sixdimensionsf

actsheet.pdf, 1976 .................................................................................................................... 47

Illustration 20: Illness-wellness continuum. Image source:

http://www.wellpeople.com/images/Illness_WellnessContinuum.jpg, 1972 ........................ 49

Illustration21: Model of perceived service quality. Gleitsman, Guttzeit, & Roschk 2010, p.9. 50

Illustration 22: Model of Donabedian. Image source:

http://www.studydroid.com/imageCards/04/ek/card-4673550-back.jpg .............................. 52

Illustration 23: Grönroos model. Image source: http://water.prevos.net/category/blog/ ..... 53

Illustration24: Model of servicequality by Meyer and Mattmüller ......................................... 55

Illustration25: Model of service quality by Zeithaml, Parasuraman and Berry. Zeithaml, V.,

Parasuraman, A. & Berry, L. (1992), p. 49. ............................................................................... 57

Illustration26: Dynamic process model according to Boulding, Staelin, Kalry and Zeithaml .. 59

Illustration 27: Model of action dimensional circles ................................................................ 62

Illustration 28: Income cycle of export basis approach, L.Schätzl (1996) ................................ 63

Illustration 29: Regional polarisation (own presentation) ....................................................... 64

Illustration 30Milieu approach, H.-J. Domhardt et al. (2009) .................................................. 66

Illustration 31: New institutions approach (own presentation) ............................................... 70

Illustration 32: Dominant development path of evolution economics (own presentation) ... 71


p. 6 weldest.blogspot.com

1 Introduction to HNEE

With about 1,900 students and 70 academic staff, Eberswalde University of Applied Sciences

(HNEE) is the state of Brandenburg's smallest university of applied sciences. By now, 14

programs have been developed which have shaped the university's profile as a place of

genuine commitment to the concept of sustainable management. It is the only university in

Germany that brings together different disciplines that relate to rural areas, i.e. forestry,

landscape management and nature conservation, organic agriculture, wood science and

technology, regional management and tourism. These attractive, unique programs lure

students from all over Germany and abroad to Eberswalde. HNEE has several subtask leads

in the WelDest project, e.g. they are hosting the international networking and benchmarking

event in Berlin (2014) and leading the secondary research. They are actively participating in

dissemination and exploitation in Germany, and in the creation of educational material.

2 Research and Definition

The aim of the secondary research is to get knowledge from the existing researchabout

health and well-being tourism and competencies needed in theareas of e.g. destination

development, regional planning, possible best practices and development tools.

Simultaneously a list of the existing health and well-being destinations, and their approach

to health (e.g. preventive approach, medical approach) in participating countries has been

compiled.This list consists of destinations which already market themselves as health and

well-being tourism destinations. The results will also be used as input for the stakeholder

research. Secondary research is conducted in all partner countries.



2.1 Research objectives and methodology

At the first WelDest project meeting in Attergau, the project partners developed a definition

of a H&WB destination, which was the basis for the secondary research. The definition: A

health and well-being destination (H&WB-destination) is an area chosen by

customers/guests (with either preventive or curative motives) as a travel destination to

improve their state of health and/or well-being. The destination includes all necessary

infrastructure such as accommodation, restaurants and other facilities, with a systematically

developed offer for health and well-being. The destination is managed and marketed

professionally as a unit.

2.1.1 Research object I - Current state of existing health andwell-being

destinations

The HNEEteamshould identify destinations which market themselves as health and well-

being destinations in the participating countries. According to the project definition,

theHNEEteam derivedcriteria to verify the state of a H&WB-destination. To ensure the

international approach of the review, the criteria were discussed with the other project

teams. After several changes a template was developed to guarantee the same review

processes in all participating countries. The review in each participating country was done by

the project teams involved. The consolidation and examination of collected data was done

by the HNEE team.

2.1.2 Research object II - Current state of literature about health andwell-

being destinations

The HNEE team should identify existing literature about health and well-being destinations

and about related topics. According to the project definition of aH&WB-destination, the

teamderived a list of keywords for further literature review. As a result,some changeswere

made to the keywordlist,and a final template for literature review in all participating

countries was developed. The research in each participating country was done by the

involved project teams. The consolidation and examination of collected data was done by

the HNEE team.



Illustration 1: Process of literature review.

2.1.3 Research object III - Possible models to analyze health andwell-being

destinations

The HNEE team should identify existing models to analyzehealth and well-being destinations.

According to the project definition of a H&WB-destination theHNEE team researched 5

approaches to find suitable models. The approaches were tourism, health promotion,

wellness, service quality and regional/ destination development. Out of the actual literature

the HNEE team identified suitable models from each approach. Furthermore they pointed

out the individual advantages and disadvantages for analyzing a H&WB-destination

usingeach model.

Literature Review

1. Research in library catalogs for

books/articles

2. Research in relevant databases for

articles/projects

3.Research in Internet for projects/associations/webs

ites



3 Findings of secondary research

3.1 Current state of existing health and well-being

destinations

With input from five universities across Europe – Germany, Finland, Austria, the United Kingdom and the Czech Republic – this report examines the current state for health and well-being in these regions. All partners communicated their findings on destinationsaccording to the following criteria:

Marketed itself as H&WB destination

Has natural resources

Has tourism infrastructure

Has a regional management structure

Has medical and wellness facilities Searches were conducted on the database that is attached to this document. Based on the keyword list the project teams identified 131 H&WB-destinations.

Current state of H&WB destinations per country

Country Investigated destinations

Identified H&WB destinations

Austria 10 8

Czech Republic 35 24

Finland 15 11

Germany 60 48

UK 40 40

160 131

Table 1: Marketed health and well-being destinations per country. Own illustration.

To sum up, 160 destinations were researched and 131 destinations could be identified as

H&WB destinations. The most H&WB destinations could be identified in Germany with 48,

followed by the United Kingdom with 40 H&WB destinations.

Results of research - regional analysis

Nr. Country Destination

signed and marked as a healthcare

region

natural resources

tourism infrastructure

regional management

structure

medical and wellness facilities

result of the evaluation

health and wellness

destination

1 Germany Metropolregion Rhein Neckar x x x x x 5 Yes

2 Germany Gesundheitsregion Stuttgart x x x x x 5 Yes

3 Germany Gesundheitsregion Schwaben x x x 0 x 4 Yes

4 Germany Gesundheitsregion Bad Dürrheim x x x x x 5 Yes

5 Germany Gesundheitsregion Bad Mergentheim x x x 0 x 4 Yes

6 Germany Gesundheitsregion Freyung-Grafenau x x x x x 5 Yes

7 Germany Gesundheitsregion Bad Reichenhall - Berchtesgadener Land

x x x x x 5

Yes

8 Germany Gesundheitsregion Passauer Land x x x x x 5 Yes

9 Germany Gesundheitsregion Garmisch-Partenkirchen

x x x x x 5

Yes

10 Germany Gesundheitsregion Bad Bayreuth x x x x x 5 Yes

11 Germany Gesundheitsregion Bad Griesbach 0 x x 0 x 3 No

12 Germany Gesundheitsregion Allgäu x x x x x 5 Yes

13 Germany Gesundheitsregion Berlin Buch x x x x x 5 Yes

14 Germany Gesundheitsregion Berlin Brandenburg

x x x x x 5

Yes

15 Germany Region Templin 0 x x 0 x 3 No

16 Germany Region Eberswalde 0 x x x x 4 Yes

17 Germany Region Wandlitzer Seengebiet 0 x x 0 x 3 No

18 Germany Region Prignitz x x x 0 x 4 Yes

19 Germany Erlebnis- & Gesundheitsregion Spreewald

x x x x x 5

Yes



20 Germany Wellnessregion Niederlausitz 0 x x 0 x 3 No

21 Germany Bad Saarow x x x x x 5 Yes

22 Germany Region Luckenwalde 0 x x 0 x 3 No

23 Germany Schwielosee 0 x 0 0 x 2 No

24 Germany Bremen 0 x x x x 4 Yes

25 Germany Gesundheitsregion Hamburg e.V. x x x x x 5 Yes

26 Germany Gesundheitsregion Nordhessen x x x x x 5 Yes

27 Germany Marburg-Biedenkopf 0 x x x x 4 Yes

28 Germany Rhein-Main x x x x x 5 Yes

29 Germany Gesundheitsregion Mecklenburg-Vorpommern

x x x x x 5

Yes

30 Germany Gesundheitsregion Mecklenburgische Ostseeküste

x x x x x 5

Yes

31 Germany Gesundheitsregion Fischland Darß-Zingst

x x x x x 5

Yes

32 Germany Gesundheitsregion Insel Usedom x x x x x 5 Yes

33 Germany Gesundheitsregion Insel Rügen x x x x x 5 Yes

34 Germany Gesundheitsregion Hannover-Braunschweig

x x x 0 x 4

Yes

35 Germany Gesundheitsnetzwerk Weser-Ems x x x 0 x 4 Yes

36 Germany Gesundheitsregion Osnabrücker Land in Weser-Ems

x x x x x 5

Yes

37 Germany Osnabrück x x x x x 5 Yes

38 Germany Health Region Cologne Bonn x x x x x 5 Yes

39 Germany Gesundheitsregion Göttingen e.V. x x x x x 5 Yes

40 Germany Gesundheitsregion Saar x x x x x 5 Yes

41 Germany Gesundheitsregion Vogtland 0 x x x x 4 Yes

42 Germany Gesundheitsregion Erzgebirge 0 x x x x 4 Yes

43 Germany Gesundheitsregion Sächsisches x x x 0 x 4 Yes



Elbland

44 Germany Gesundheitsregion Carus Consilium Sachsen

x x x x x 5

Yes

45 Germany Gesundheitsregion Oberlausitz x x x x x 5 Yes

46 Germany Harz x x x x x 5 Yes

47 Germany Halle Saalekreis x x 0 0 x 3 No

48 Germany Dübener Heide 0 x x x x 4 Yes

49 Germany Gesundheitsregion Magdeburg 0 x x x x 4 Yes

50 Germany Gesundheitsregion Nord x x x 0 x 4 Yes

51 Germany Gesundheitsregion Kreis Segeberg x x x x x 5 Yes

52 Germany Gesundheitswirtschaft Nord x x x x x 5 Yes

53 Germany MedCom Gesundheit Südholstein x x x x x 5 Yes

54 Germany Gesundheitsregion Thüringer Wald x x x x x 5 Yes

55 Germany Gesundheitsregion Saale-Ilm-Elster 0 x x 0 x 3 No

56 Germany Gesundheitsregion Finsterbergen x x x 0 x 4 Yes

57 Germany Gesundheitsregion Weimar x x x x x 5 Yes

58 Germany Gesundheitsregion Masserberg 0 x x 0 x 3 No

59 Germany Gesundheitsregion Bad Sulza 0 x x 0 x 3 No

60 Germany Gesundheitsregion Bad Mergentheim x x x 0 x 4 Yes

61' Czech Republic

Poděbrady x x x 0 x 4

Yes

62 Czech Republic

Lázně Toušeň x x 0 x 0 3

No

63 Czech Republic

Třeboň x x x x x 5 Yes

64 Czech Republic

Bechyně 0 x x 0 x 3 No

65 Czech Republic

Vráž 0 x x 0 x 3 No



66 Czech Republic

Konstantinovy Lázně x x x x x 5 Yes

67 Czech Republic

Karlovy Vary x x x x x 5 Yes

68 Czech Republic

Mariánské Lázně x x x x x 5 Yes

69 Czech Republic

Františkovy Lázně x x x x x 5 Yes

70 Czech Republic

Jáchymov x x x 0 x 4 Yes

71 Czech Republic

Lázně Kynžvart x x 0 0 x 3 No

72 Czech Republic

Teplice x x 0 x x 4 Yes

73 Czech Republic

Klášterec nad Ohří x x 0 0 0 2 No

74 Czech Republic

Dubí x 0 0 0 x 2 No

75 Czech Republic

Mšené – lázně x x x 0 x 4 Yes

76 Czech Republic

Lázně Libverda x x x x x 5 Yes

77 Czech Republic

Lázně Kundratice x x 0 0 x 3 No

78 Czech Republic

Janské Lázně x x x x x 5 Yes

79 Czech Republic

Lázně Bělohrad x x x x x 5 Yes

80 Czech Republic

Velichovky 0 0 x 0 0 1 No



81 Czech Republic

Lázně Bohdaneč x x x 0 x 4 Yes

82 Czech Republic

Hodonín x x x x x 5 Yes

83 Czech Republic

Lednice x x x x x 5 Yes

84 Czech Republic

Jeseník x x x x x 5 Yes

85 Czech Republic

Lipová - lázně x x x x x 5 Yes

86 Czech Republic

Velké Losiny x x x x x 5 Yes

87 Czech Republic

Teplice nad Bečvou x x x x x 5 Yes

88 Czech Republic

Bludov 0 x 0 x x 3 No

89 Czech Republic

Slatinice 0 0 0 0 0 0 No

90 Czech Republic

Luhačovice x x x x x 5 Yes

91 Czech Republic

Ostrožská Nová Ves x x 0 x x 4 Yes

92 Czech Republic

Kostelec u Zlína 0 x 0 0 x 2 No

93 Czech Republic

Karviná - Darkov x x x x x 5 Yes

94 Czech Republic

Karlova Studánka x x 0 x x 4 Yes

95 Czech Republic

Klimkovice x x x 0 x 4 Yes



96 Finland Rokua x x x x x 5 Yes

97 Finland Savonlinna Region x x x x x 4 Yes

98 Finland Levi x x x x x 2 No

99 Finland Southern Ostrobthnia x x x x x 4 Yes

100 Finland Naantali 0 x x x x 4 Yes

101 Finland Vierumäki x x x 0 x 4 Yes

102 Finland Tahkovuori x x x 0 x 2 No

103 Finland Kainuu (Kuhmo& Sotkamo) 0 x x 0 x 4 Yes

104 Finland Peurunka x x x 0 x 4 Yes

105 Finland Rovaniemi x x x 0 x 3 No

106 Finland Salla x x x 0 x 3 No

107 Finland Lahti x x x 0 x 4 Yes

108 Finland Imatra and Lappeenranta x x x x x 4 Yes

109 Finland Pohjois-Savo x x x x x 4 Yes

110 Finland Ikaalinen x x x x x 5 Yes

111 Austria Gesundheitsregion Pinzgau (Salzburg) 0 x x 0 0 2 No

112 Austria Laufarena Bad Tatzmannsdorf x x x 0 x 4 Yes

113 Austria Vitalwelt Hausruck x x x 0 x 4 Yes

114 Austria Hohe Tauern Health x x x x 0 4 Yes

115 Austria Thermenland Steiermark x x x x x 5 Yes

116 Austria Bad Aussee x x x x x 5 Yes

117 Austria Vulkanland (Steiermark) x x x x 0 4 Yes

118 Austria Naturpark Zirbitzkogel-Grebenzen 0 x x x 0 3 No

119 Austria Joglland (Steiermark) x x x x 0 4 Yes

120 Austria Xundheitswelt x x x x x 5 Yes

121 UK Dartmoor and Exmoor National Parks 0 x x x x 4 Yes

122 UK New Forest and South Downs National Parks

0 x x x x 4 Yes



123 UK The Broads National Park 0 x x x x 4 Yes

124 Uk Peak District National Park 0 x x x x 4 Yes

125 Uk Cairngorms National Park 0 x x x x 4 Yes

126 Uk Northumberland 0 x x x x 4 Yes

127 Uk Lake District 0 x x x x 4 Yes

128 Uk Trossachs National Park 0 x x x x 4 Yes

129 Uk Snowdonia National Park 0 x x x x 4 Yes

130 Uk Brecon Beacons 0 x x x x 4 Yes

131 Uk Pembrokeshire National Park 0 x x x x 4 Yes

132 Uk Cotswolds 0 x x x x 4 Yes

133 UK Powys, Mid Wales 0 x x x x 4 Yes

134 UK Yorkshire 0 x x x x 4 Yes

135 UK Surrey 0 x x x x 4 Yes

136 UK Devon 0 x x x x 4 Yes

137 Uk Cornwall 0 x x x x 4 Yes

138 Uk Poole and Bournemouth 0 x x x x 4 Yes

139 Uk Manchester 0 x x x x 4 Yes

140 Uk Liverpool 0 x x x x 4 Yes

141 Uk Bristol 0 x x x x 4 Yes

142 UK Kent 0 x x x x 4 Yes

143 UK Northern Ireland 0 x x x x 4 Yes

144 Uk Witshire x x x x x 5 Yes

145 Uk Edinburgh 0 x x x x 4 Yes

146 UK Cheshire 0 x x x x 4 Yes

147 UK East Midlands 0 x x x x 4 Yes

148 UK England 0 x x x x 4 Yes

149 UK Bath x x x x x 5 Yes

150 Uk High Peak, including Buxton 0 x x x x 4 Yes



151 UK Scotland 0 x x x x 4 Yes

152 UK Worcestershire, including Malvern and Droitwich

0 x x x x 4 Yes

153 Uk Wales 0 x x x x 4 Yes

154 UK Blackpool 0 x x x x 4 Yes

155 UK Brighton 0 x x x x 4 Yes

156 Uk Warwickshire 0 x x x x 4 Yes

157 UK London 0 x x x x 4 Yes

158 Uk East Anglia 0 x x x x 4 Yes

159 UK Hertfordshire 0 x x x x 4 Yes

160 UK Berkshire, including Windsor 0 x x x x 4 Yes

Table 2: Results of research - regional analysis. Own illustration.

3.2 Current state of literature about health and well-being

destinations – literature review

Many authors have made attempts to define health, wellness and wellbeing. An extensive review of the literature was conducted, involving on-line database keyword searches,additional searches for other studies, screening of abstracts, assessing the relevance to thereview and integrating the findings. Almost two hundred journal articles, books and websites were accessed and examined to give an overview of the existing literature and to findresearch and typical models to support the WelDest Project. The literature search process included the following major steps:

Development of keywordlist (to decide which keywords were suitable for research, HNEE team conducted a brainstorming session as the first step. The other participating countries were involved for the second step, with the project teams approving the list);

Review of the references sections of articles already in the teams’ possession to identify potentiallyuseful studies;

On-line searches of databases for potentially relevant articles;

Review of government departments and NGO websites and related links foradditional studies and/or unpublished documents;

Screening of the abstracts to identify studies for further review; and,

Canvassing of selected academic experts, organizations and governmentdepartments for additional studies and/or unpublished documents.

To decide which keywords were suitable for research objective 2, the HNEE team conducted a brainstorming session as the first step.The second step involved the other participating countries, with the other project teams approving the list. The search terms originally developed were refined during the course of the on-linesearches to reflect the terms and keywords used by various on-line services and authors. Searches were conducted in the database which is attached to this document. Based on the keyword list the project teams identfied 188 references. During the study, there were no deviations from the methodology.

Country References Allocation in %

Germany 79 42%

UK 31 16%

Finland 28 15%

Austria 7 4%

Czech Republic 1 1%

Other 42 22%

188 100%



Table 3: Results of literature review. Own illustration.

3.3 Possible models to analyze health and well-being

destinations

3.3.1 Tourism models

Tourism theory describes the overall system of tourism in different models. They differ in

terms of the notion of an overall social system and the advantages and representation of the

specific system.1 Currently there is no single comprehensive worldwide accepted model for

tourism. Various scientific approaches have only been merged. However distinctions are

made in:2

- Economics (supply and demand)

- Sociology (group activities, social order, social values, etc.)

- Ecology (environmental impact)

- Geography (spatially relevant aspects)

- Psychology (personality traits, needs and motives)

- Political Science (national and international regulations in travel)

Other areas of science transfer their methods to tourism:

- Transport Economics Tourism traffic

- Medical Tourism medicine

- Planning Tourism planning, etc.

As a result of this, isolated observation means splitting the tourism science disciplines. For an

comprehensive perspective a completely uniform analysis of tourism is to be made (all 6

areas)3. The individual patterns of tourism are presented.

1 Vgl. Freyer, W. (2006), p. 36

2 Vgl. Freyer, W. (2006), p. 39

3 Vgl. Freyer, W. (2006), p. 39



3.3.1.1 Tourism area model

The word "tourism" is based on the word "tour", which means round trip or return trip.

Tourist trips are therefore always associated with a return to the starting point. Therefore,

the tourist area model differs in three factors:4

Home area

Transport area

Destination area

Illustration2:Tourism area model. Freyer 2006, p.43.

4Freyer, W.(2006), p. 42f.



Advantages: The model defines the word destination as a place to which a person is going. A

synonym would be the journey’s end. So the H&WB destination can be seen like this. Guests

choose the area while leaving their home for a certain time, which is defined with the word

trip. Whether in the first two figures or in the third one, which describes a roundtrip, each

shows the destination as a unit.

Disadvantages: Although the model describes the destination very clearly, it includes only

facts about the area and nothing about the time. It remains unmentioned how long guests

stay at the destination and what their motivation to come is. Furthermore it is not clear what

the external and internal influences are,or details about the infrastructure. The H&WB

definition takes “necessary infrastructure” as a given, but the model cannot servefully here.

All in all, it is to say that the tourism area model is not enough to explain the whole H&WB

destination. The description of a destination is a good way to start examining the theme.

However it will need further models to represent all requirements.



3.3.1.2 Tourism time model

The tourism time model is also known as a "springboard model of travel." It is different every

day, and during different times. The tourist is often moving around. The tourism time model

is suitable to map the spatial and cultural experience. Three factors have to be considered:5

- Home or everyday time

- Transport time

- Stay or destination time

Illustration 3: Tourism time model. Freyer 2006, p. 44.

Advantages: This model is as intelligible as the tourism area model, because time, just as

area, is subdivided into three fields and they are clearly distinguished from oneanother. If

people are in the transport or destination time, they have chosen the destination as required

in the H&WB definition.

Disadvantages: The model is limited to the factor time.Some more facts need to be

defined,such as the place where the guest is, and how they interact with the destination. It is

not stated whether or not the destination is managed as a unit and which necessary facilities

are situated there.

5 Vgl. Freyer, W. (2006), p. 42f.



The tourism time modelwas developedto define the aspect of time and how long guest stay

in a destination. The tourism time model could also be useful in addition to further models.

According to the project the model is not sufficient enough to explain detailed how a H&WB-

destination works or what it is.

3.3.1.3 Extended modular model of tourism

Theextended modular model of tourism explains mainly economic relations in touristic

areas. The model describes the interaction of different factors e.g.the relation between

visitors and institutions or between politics andecology. The aim of the model is to show

how a destination works withregard to interactions.6

Illustration4:Extended modular model of tourism. Freyer 2006, p. 47.

6Vgl. Freyer, W. (2006), p. 45f.



Advantages:The model shows several internal and external influences on the trip. Moreover

the infrastructure, especially the facilities of a destination, are influenced by political,

economic and other circumstances. People, individuals and natural environment are as

important as the other facts. How a destination is created and which image is established

depends on the influences. A destination which is marketed and managed as a unit may have

in general a relatively high level of consensus and mutual assistance.

Disadvantages: It is remarkable that the model does not include all facts, especially what the

destination which is influenced is. Moreover the guest and their motivation to improve their

health are in no way mentioned, and the factors do not influence each other in the model,

ratherit seems these are closed units.

The extended modular model demonstrates that a destination is influenced by various

factors and that it needs to react tothese. However, the model is not sufficient to illustratea

H&WB definition.

3.3.1.4 Economic tourism model

This model considers all economic activities related to the organization of the whole trip and

the different aspects such as travel preparation (tour operators), travel through (transport,

stay in a foreign country) and return to the origin (post-trip). From the perspective of the

economy the "production" as well as the purchase and sale of various tourism products is

important. The economic aspects are distinguished in economics and business

administration. The following facts are important:7

economic Economically

- Growth and economic - Development of price levels - Employment - Distribution (income and assets) - Competition - Taxes and subsidies

- Profit and Revenue - Pricing - Job quality - Costs and expenses - Sales and Marketing - Procurement and Purchasing - Taxation and Finance

Illustration5: Factors of economic interest, in accordance with Freyer 2006, p. 48.

7 Vgl. Freyer, W. (2006), p. 48



Illustration6: Economics of tourism, Freyer 2006,p. 51

a ) The economic model of tourism

The economics between consumers (buyers) and producers (providers) is distinguished. Here

both economic agents come intothe market with each other. The state itself forms the third

factor. The providers are distinguished in the model again,more closelyin reference to the

tourist industry, as well as witha tourist economy edge. The consumers are divided into

travelers, those not traveling, users of vacation packages and individual travelers. All of these



suppliers and demanders are between different markets, since it itself is no longer "the

tourism market" but rather various tourism sub-markets. These markets include, for

example, a partial market for accommodation, a transport services market (flight market,

railway market), etc.8

b) The economicalmodel of tourism

Tourism businesses focus their marketing activities mainly on the supply situation

(competition) and demand requirements e.g. market research and market strategies.

Accordingly, the sub-elements and operational management functions form a central role. In

addition to the business functions (purchasing, production, marketing),there are other

especially service-oriented functional areas of importance in the tourism industry, such as

potential, process, and outcome function.9

Advantages: The economic model of tourism focuses on economic and economical

perspectives. As described in the model, there is an infrastructure, such as the

transportation available and the facilities (like hotels)atthe destination. The destination is

chosen by the guest,whichis described in the economic model. The buyer comes intothe

tourism market to choose the best offer from a wide range of providers; therefore, the

offers need to meet the consumer’s expectations.

Disadvantages: In the model there is no relation to health, medical facilities or the

motivation of a guest to stay for a certain time to improve their state of health. The

importance of a uniform management in the destination is not mentioned here. It is

mentioned that the destination should be tailored even more closely to customer

requirements.

The economic model of tourism describes, in a very detailed way, which economic factors

influence the destination and the market activities. Otherwise the model gives just small

insight into the influences on a destination. Therefore it is not enough to describe the

H&WB destination.

8 Vgl. Freyer, W. (2006), p. 56

9 Vgl. Freyer, W. (2006), pp. 56



3.3.1.5 Framework of touristic mobility

A combination of factors influencetouristic mobility. Sociopolitical means administration and

legal orders. Socioeconomic are factors such as education and income. Sociocultural are

values and norms. Touristic mobility is influenced by:10

Natural Environment

Economy

Politics

Society

Illustration 7: Framework of touristic mobility. Grümer 1993, p. 18

10Grümer, K-H. (1993), pp. 17



Advantages:All the included factors are parts of the infrastructure ofa destination. Roads,

facilities, political order, natural environment and the society have an impact on the

development of a destination.

Disadvantages: The model shows only the external influences on the development of

touristic mobility. The internal influences and the interdependence of the factors are not

contained in the model. A reference to health, as well as the motivation of visitors, is also

missing here.

Because of thisone-sided view, the model is not sufficient to explain an H&WB destination.

Although it is about mobility, the model does not include the traveler, his motivation and

where he is going (destination). The model is not sufficient to explain H&WB.

3.3.1.6 System tourism by Bieger

The"system tourism" model by Thomas Bieger shows the interactionwith the

environment.The following are seen as environmental aspects:

- Economics

- Technology

- Society

- Ecology,and

- Politics

These facts can be reduced to economy, natureand society.Policyis an expressionofsocial

intention, while technology is aninterface areawithinsociety, economyand nature.11

11 Bieger, T. (2010), pp. 84



Illustration8: System of tourism (static). Bieger 2010, p. 84.

Advantages:Bieger’s model is similar to the model of touristic mobility, but here the

influencing parts are interconnected. Moreover, it shows that all factors have impacts on

tourism as a system. According to the model, system tourism consists of different

subsystems such as destination, transport, travel agents and demand. Thecomplete

combination of all these systems is “tourism.” So the idea of a unique destination is included.

All the factors work together to meet the demand, and so the subsystems and thus also the

facilities could therefore interact as a unit in this area.

Disadvantages:The model looksonly at the provider’s side. The “system tourism” is just the

destination and the factorsthatinfluence it, but the guests of the destination and their

motivation to come tothis area is missing.

Thomas Bieger’s model of “system tourism” is a good way to explain which facts influence,

and which parts are parts of tourism. The combination of travel agents, transport companies

and local companies is similar to the tourism area model and describes the interactions

between these facilities and infrastructures. The model contains important factors to

describe an H&WB destination, but it is not enough to explain it fully.



3.3.1.7 Micro-analytical system of tourism

The micro-analyticalconcept by Pompl(1995) shows a similar form of tourism to Thomas

Bieger’s model. The core of system tourism consists of tour operators, travel agents and

travelers. It is center of the “system tourism.” The following factors create, with their

interaction and interdependence, the tourism system:

- Suppliers

- Service providers

- Institutions

- Attractions12

Illustration9: Micro-analytical system of tourism, in accordance with Pompl 1994, p. 6

Advantages: The core system includes the traveler as a single part of tourism and defines the

person as self-determined. He chooses the destination for a particular purpose. All the

subsystems meet the buyer’s needs and add the requirements while marketing as a unit.

12 Müller, H. (1999), pp. 16



Disadvantages: In the model it is not shown whether the different factors influence each

other or interact. Furthermore the relation to health care is missing, so it is not clear what

the motivation of the guest (the traveler) is.

The micro-analytical tourism system has similar approaches to the previous two models. The

idea of external influences is recognized, so it is clear which factors influence the system.

Alone it is not suitable to explain a H&WB destination, but the idea of “system tourism” can

be adapted.



3.3.1.8 Swiss tourism concept

The Swiss tourism concept consists of three subsystems which are interdependent:

- Society

- Economy

- Environment

According to the figure, the system is controlled by legal and social norms,tourism

investment and consumer spending. Furthermore the direct and indirect tourism policy has

an impact. 13

Illustration 10: Swiss tourism concept. Beratende Kommission des Bundesrates 1979, p.84.

13Müller, H. (2007), pp.18



Advantages: The factors in the model interact, which is very important. The society has a big

influence on what happens, and therefore it is clear that the guests of a destination have it

too. The socioeconomic system meets the expectations, otherwise no visitors would come to

the destination.

Disadvantages: It remains unclear how the destination interacts. This means that thereis

nothing written about the way the destination is managed and marketed. Whether the

destination works as a unit, or whether every facility is doing its own business, is not stated.

But in the H&WB definition it is an important aspect. Also missing is the motivation of the

guest coming to the destination and what the single demands are.

The Swiss tourism concept is a good way to underline the importance of society and policy as

impacts on local tourism. It is important to remember this while searching for the most

effective factors for the best model of an H&WB destination.

3.3.1.9 Determinants of DMO success

The model deals with main impact factors of successful destinations and tourism

management (DMO).

It shows variables and builds a model that supports the existence of a relationship between

the success of tourism destinations and DMOs with respect to community relations,

marketing, and economic indicators. Unique to DMO success were supplier relations,

effective management, strategic planning, organizational focus and drive, proper funding,

and quality personnel and community support.14

14 T. Bornhorst et al. (2010) pp. 572



Illustration 11: Comparison of success determinants for an ideal DMO and destination. T. Bornhorst et al. / Tourism Management 31 (2010) 572–589

Advantages: For the model, many stakeholders were asked about their needs and

expectations in relation to tourism and destination development. The model shows a wide

range of factors that influence tourism. A tourism destination has two primary roles and a

number of important supporting roles. First and foremost, it must seek to enhance the social

and economic well-being of the residents who live within its boundaries. Secondly, to be

classified as a tourism destination, it must provide this enhancement of residents’ well-being

by offering a range of activities and experiences of the kind that we identify as ‘‘tourism’’

experience.



Disadvantages: In the model there is no regard to health or medical facilities. The model

focuses primarily on shareholder, marketing and economic aspects. Therefore it is not

enough to describe a H&WB destination.

3.3.1.10 Destination competitiveness and sustainability Model

The model of destination competitiveness shows the correlations between situational

conditions and destination resources. The aim is to figure out the relative strengths and

weaknesses of different tourism destinations and different influences affecting the

competitiveness. The destination competitiveness and sustainability model can be used to

develop strategies for improving competitiveness of a destination. The model is used by

industry and governments to boost the tourism sector.

Illustration 12: Integrated Model of Destination Competitiveness

Advantages: The model shows the given effects on a destination and includes tourism

demand awareness, perception and preferences. Actors can enhance the appeal of the core

resources and attractors, and strengthen the quality and effectiveness of the supporting

factors and resources.

Disadvantages: The model cannot capture a destination’s hard and soft factors. Even though

the model describes the effects of destination competitiveness in a very detailed way, it is

not sufficient enough to be congruent with the H&WB definition. In addition to this

definition, and given the destination resources, there is no relation to health and wellbeing.

3.3.1.11 Main elements of destination competitiveness

The main elements of destination competitiveness which are mentioned in the model are

the following: the ability of the destination to be better that its competitors in delivering



goods and services which should exceed all the guest’s expectations. Price differentials and

the provided service and its quality in comparison to competitors are further elements. The

implementing institutions can be the government or the industry. Influenced by the

environmental framework and the demand, the ability of being competitive can be defined.

“Resources” contain endowed (natural - mountains, cultural - language), created

(infrastructure, entertainment) and supporting (hospitality, accessibility to destination)

resources.

Illustration 13: The main elements of destination competitiveness, Dwyer/Kim (2003)

Advantages: The resources give a destination their specific orientation and build up

attractiveness to visitors. A destination needs good management to provide such services,

and therefore destination management becomes necessary. Working as a unit here means

to have companies interacting with each other and pursuing the same goals. So it becomes

possible for a destination to be competitive. The model shows the interaction between the

several influencing factors and the importance of each one of them.

Disadvantages: Despite the advantages, the model of destination competitiveness is

insufficient for the definition of an H&WB destination. The health aspect is not mentioned

here, therefore the destination’s focus is not clearly defined. Moreover the guest’s

motivation is unknown. In conjunction with the given H&WB definition, the guest’s purpose

for the stay and the market guidance become negligible.



3.3.1.12 Guide to Tourism Destination Management (UNWTO)

The practical guide to tourism destination management, published by UNWTO, describes

measures, aims and reasons for the necessity of destination management in a region. In this

regard the destination described can be a centre or a town up to a whole country. Things like

organization, responsibilities, objectives, strategies and following up are discussed in detail.

Furthermore the special character of tourism as a part of industry gives an idea for the

equality and differences between tourism and other categories of industry.15

Illustration 14: Elements of Destination Management,UNWTO (2007)

Advantages:

The title gives an idea of the main aspect in this guide: an area which is managed and

organized as a unit; it acts and is marketed like this. The success of such a destination

depends on the state of the infrastructure, the demand of guests and the high quality of the

product. It means the destination which offers the guest a whole package of

15UNWTO (2007), pp. 2



accommodation, service, treatments, etc. could also be marketed with a brand to stay in a

guest’s mind. Determining the USP of the region and the specific target market are essential

for long-lasting success. All in all, the guide focuses on the marketing aspect very strongly

and so it isclear that building up networks and acting in cooperation takes an important role.

Disadvantages:

The guide describes destination management in general. So the reference to health and

wellbeing in a destination is completely missing. Moreover the supplier side is focused on,

which is why the guest’s motivation to come with the intention to improve his state of

healthis not mentioned. The practical guide to tourism destination management is a good

way to get an overview for the influencing factors and their importance in a destination.

Although health is mentioned as one of many types of tourism, for the health aspect (kinds

of accommodation, treatments and service etc.) further sources should be considered.16

16UNWTO (2007), pp. 8



3.3.2 Health models

In this section, individual models ofthe health sector are presented.

3.3.2.1 Health cluster model

Health Cluster in this section corresponds to a possibility for models in the healthcare

industry. Based on this limitation, a small insight into the structures of health models is

given. Below are the different approaches for clusters which can be applied analogously to

the healthcare industry.17

The cluster can be divided into two different types.

Type A is a variant of cluster support, which is seen as a comprehensive regional

development concept. It is an analysis of future developments, and aims to promote and

improve processes to establish the region’s future.18

Type B considers the existing strengths of the region and develops them further, adhering to

the principle of "strengthening the strengths".19

Advantages: The health cluster approaches show that such a model aims for cooperation

among the facilities and organizations of a region. These should encourage support between

the facilities. A cluster meets the requirement of working as a unit, and therefore it is an

important aspect for the H&WB definition, and it gives access to a wide range of skill sets

and capabilities. A cluster is a good way to offer a well-developed infrastructure, especially in

the health care system.

Disadvantages: It remains unclear in the model, why types A and B exist on their own with

no combination or overlap. It seems to imply that just one way is possible, either to analyze

the future development or to strengthen the current strengths. The idea of a mix of both

types with a concept about current measures and future development is not mentioned.

Furthermore, the reference to tourism and guests is not given. So it is not said whether the

region is directly carried by the visitors.

The health cluster model is suitable to show how facilities can work as a unit in the

destination. Although the model does not include a definition of the destination in detail, it

is included in the term of clustering.

17 Vgl. Groh, O.(2006), p. 48.

18 Vgl. Groh, O.(2006), pp. 48

19 Vgl. Groh, O. (2006), p. 49



3.3.2.2 Step model to freight division of health economics

The healthcare industryincludesthe productionand marketing of goodsand servicesfor the

prevention, treatment, rehabilitation and care.According to thestep model, researchand

development are thebasic level.The first threestages:

- Mainhealth-relatedinputs(Level I)

- Core areaof the healthcare industry(stage II)

- Advanced healthcare industry(level III)20

Illustration 15: Step model to freight division of health economics. BMBF 2010, p.42

Advantages: The German health care system is a complex structure and includes a lot of

rules and standards. The destination with its facilities and infrastructure is relative to the

system. It meets the requirements of guests who come with the motivation to improve their

state of health. Whether the visitor wants to have wellness treatments or medical

treatments is not mentioned. The H&WB destination does not need to focus on one aspect.

20BMBF (2010), pp. 41



Disadvantages: The model does not include the uniform management of the destination.

Moreover guests, and most times patients,do not in every case take offers completely

voluntarily. Facts, such as disposable income, assets, accessibility, urgency of interventions

etc., influence the choice of patients and guests. These external influences are not

mentioned.

All in all the model shows very clearly the detailed parts of the health care system, but it is

not suitable for a H&WB definition, because it is not a common system in all member states

of the European Union or the members of the WelDest project.

3.3.2.3 A concept of “Wellbeing Tourism in Finland”

The concept describes Finland as a region which is rich in resources, especially a natural and

peaceful, harmonious environment. Factors like service quality and basic infrastructure are

well-developed in Finland, too. The Nordic countries represent a whole product for natural,

relaxing and also active stays and so, guests recognize it as a “brand.” Finland as a single

country needs to highlightspecific aspects, otherwise it will not stand out.

Three regions in Finland were analyzed as suitable wellbeing regions: Jyväskylä, Kainuu

(biggest tourism resort Vuokatti) and Vaasa. Each region has a special focus, e.g. high quality

of know-how in education and technology (Jyväskylä), wide range of sports and indoor /

outdoor activities (Vuokatti) and a distinct offer of regional food (Vaasa).



Illustration16:Recommended concepts of health tourism by the Finnish Tourist Board (FTB by Liisa

Renfors 17.9.2010)

Advantages: Finnish tourism is characterized by nature and its offers. It has a remarkable

range of physical activities and spa offers such as saunas and sauna baths. The tourist’s

motivation to visit one of these areas is often to maintain his health and to prevent illness.

That means guests come on their own and have a strong will to act.

Disadvantages: In regard to the advantage of many opportunities to do sports, there is a

related disadvantage: The Finnish tourism concept lacks a strict understanding of pampering.

Beauty farms, massages and other treatments where the guest is just passive are not

included. The concept creates an active guest with the ambition to move. Moreover the

aspect of stays with a cure and healing motivation are not mentioned. And as a last point, it

is important to emphasize that networking and acting as a unit is not yet current. The

structure is at the moment missing, but very necessary. The internal (networking between

companies in one region and cooperation between institutions) and external (marketing for

a single brand, as a single unit) communication do not function properly.



3.3.3 Wellness models

Scientists, physicians, educators and organizations have dealt with the development of

various spa models to explain the "idea of wellness" in its whole extent. In the following, the

various spa models are illustrated.21

3.3.3.1 Wellness model by Dunn

Dunn describedwellness asa methodologicalframeworkto maximizeindividualpotential

availableunder the givencircumstances.22 In Dunn’s opinion patients are not dependent on

the doctor’s decision, but also make their own.Dunn called this "High Level Wellness". This

corresponds to an active lifestyle that allows people the greatest possible utilization of its

productive potential.23

Wellness is not the absence of disease, illness, and stress but the presence of:

purpose in life, active involvement in satisfying work and play, joyful relationships, a healthy body and living environment, and presence of happiness

21 Vgl. Berg (2008), p. 12

22Deutscher Wellness Verband (o.A.)

23 Vgl. Berg (2008), p. 13



Illustration 17: Wellness model by Dunn. Image source:

http://classconnection.s3.amazonaws.com/1084/flashcards/622455/jpg/dunn-wellness-grid2.jpg

Advantages: Compared with the predefined explanation of an H&WB destination, Dunn

confers self-management skills on the patient. The patient is responsible for his own health

and chooses wellness as the way to reach a higher level “of functioning” (Dunn, 1961[3]).

There is the patient’s motivation in the focus to improve health.

Disadvantages: The model approachesthe destination from one single perspective - the

consumer’s. As mentioned in the definition, the area of the destination is important.

Moreover, the necessary infrastructure such as accommodation and other facilities are not

considered and so it is not clear, whether the destination is marketed as a “unit”. Dunn

refers only to patients, not even to guests. It can therefore be concluded that people who

come to the destination do so with the intention of improving their health. But according to

the definition it is also possible to improve the state of wellbeing and so he limits it.

Even though Dunn’s model portray’s the patient as a self-determined one, it is not complex

enough to meet all the requirements given by the H&WB definition.



3.3.3.2 Model for wellness by Ardell

Dr. Donald Ardell and Travis extended Dunn’s model by building on prevention and personal

responsibility. Ardell’s model is based on the following elements:24

- Conscious diet

- Stress management

- Environmental awareness

- Physical fitness

- Self-responsibility

12 years after the Dunn model, Ardell has his own model which adapts to changing

environmental conditions and other conditions. The elements of the model are

complementary:25

- Self-responsibility and medical prophylaxis

- Find meaning in life

- Stress Management and boredom

- Nutrition and fitness

- Norms and social rules

24 Vgl. Berg (2008), p. 13

25 Vgl. Berg (2008), p. 13



Illustration 18: Model for wellness by Ardell.

Image source: http://well.pacificrimwellness.com/1999_fall/articles/teacher_wellness.html

Advantages: Guests are self-determined and cometothe destination to improve their state

of health or wellbeing. Another factor which appears similarly ismotivation. Ardell built up a

complex system which mentions physical, social, creative, coping and essential aspects. But

also the infrastructure of an H&WB destination should address the needs of guests to create

a large customer base. To reach them, the Infrastructure should meet guest’s expectations.

Disadvantages: As noted in Dunn’s model, the idea of an area which is marketed as a “unit”,

is not detected. Joint selling of the products and services offered in the destination is not

mentioned. In addition, Ardell refers only to guests. However, people could visit the

destination to improve their health as patients. Under this condition a certain infrastructure

would be necessary.

As mentioned in the last model, the Wellness Model of Ardell is not sufficient enough to

meet all the ideas of the H&WB definition. On the one hand the internal influences are

described in detail such as physical and coping aspects. But on the other hand, external

influences of the destination on the patients and guests are not completely considered.



3.3.3.3 Model for wellness by Hettler

Bill Hettler describes the balance and equilibrium in the forefront of his theories. In this case

all components must have the same meaning to be attached to create a balance. The

selected components are:26

- Physical fitness and nutrition

- Emotional intelligence

- Social relationships and environmental awareness

- Mental fitness

- Spiritual awareness and life philosophy

- The joy of career

Illustration 19: Six dimensions of wellness. Image source:

http://c.ymcdn.com/sites/www.nationalwellness.org/resource/resmgr/docs/sixdimensionsfactsheet.

pdf, 1976

Advantages: In Hettler’s model guests strive to reach balance in life. It might be reasonably

assumed that people are self-determined and come with a specific motivation. If the

26 Vgl. Berg (2008) p 14

http://c.ymcdn.com/sites/www.nationalwellness.org/resource/resmgr/docs/sixdimensionsfactsheet.pdf

http://c.ymcdn.com/sites/www.nationalwellness.org/resource/resmgr/docs/sixdimensionsfactsheet.pdf



destination is chosen, it will have a suitable infrastructure. The area will be focused on

consumer needs.

Disadvantages: What is not mentioned, however, is what the infrastructure should include

in detail. The idea of an area, which is managed by one institution to create a complex

destination of offers and services, may give an inkling. It includes manners and conditions of

the whole life, but it is not mentioned where the balance should be reached. It is not clear if

a stay in an H&WB destination becomes necessary and how a balanced lifestyle can be

created. The destination as an area which bundles together all the terms of infrastructure

and organization is not mentioned.

In conclusion, Hettler’s model is shown from the customer’s point of view in a very detailed

and structured way. The motivation is shown in achieving balance and equilibrium.

3.3.3.4 Model for wellness by Travis

John W. Travis describes the state of health as an ongoing process that is influenced by a

variety of situations (Illness / Wellness Continuum). Thewellnessthat Travis refers to is a

constant health of the harmony of body, mind and soul. At the neutral point of the Illness /

Wellness Continuum, neither health nor disease symptoms are visible. The left side of the

model leads from "malaise" to the "death". This corresponds to the range of the traditional

health care system. The goal is to relieve the symptoms, but without the promise of

complete health. The right side of the model considers the flow from "malaise" to a "better

life". The model is intended to show that wellness can be attached to any point on the

continuum.27

The wellness model by Travis includes the following twelve elements:

- Self-responsibility and love

- Proper breathing

- Sensitivity of the senses

- Healthy eating

- Appropriate exercise

- Allow expressions of feelings and

27 Vgl. Berg (2008) p 14



- Mental activities

- The joy of work and play

- The meaning of one's life

- Spiritual awareness

Illustration 20: Illness-wellness continuum. Image source:

http://www.wellpeople.com/images/Illness_WellnessContinuum.jpg, 1972

Advantages: Guests’ motivation directs them to the H&WB destination, so they choose the

area by themselves. People become aware that they want to improve their state of health

and so the destination should meet that. The infrastructure should be available for different

customer needs, otherwise people look for another destination. The idea of rethinking

illness and wellness, and that it means an ongoing process of health policies, is occupying

ever more space in the minds of the people. That idea is shown in Travis’ model.

Disadvantages: The model’s approaches focus on the idea of the state of health which starts

in people’s minds. It still remains unclear what the destination needs to offer in detail,

which institutions and facilities should be present and who will lead the area. According to

the definition of a H&WB destination, it should be marketed as a “unit”, but that is not

required by Travis’ model.

Even though the model describes the state of health in a very detailed way, it is not

sufficient enough to be congruent with a H&WB definition. In addition to this definition, a

second one would be essential which defines the destination and its function in relation to

health and wellbeing.

http://www.wellpeople.com/images/Illness_WellnessContinuum.jpg



3.3.4 Service qualitymodels

Inservice it is crucial that the quality of the first attempt meets the expectations of

customers, or better still, outperforms them. Since the service is supplied together with the

customer, quality deficiencies are also immediately apparent. Although mistakes can often

be rectified, the customer is usually highly influenced by his first impression.

3.3.4.1 Perceived service quality by Parasuraman et al.

The model is based on the principle of the conformation-disconfirmation paradigm from

customer satisfaction research. The paradigm reognizes perceived service quality as the

difference between expectations and the results of a service.

Due toexperiences, word of mouthand individual needs, the consumer expects several kinds

of service.Thiswill be compared withthe perceivedservice.Thus,the perceivedservicequalityis

created. The perceived service and the expected service are made up of features like

reliability of service and the environment.

- Service : reliable, reactive, secure, empathetic

- External material environment

- Customer : experiences, word of mouth, needs28

Illustration21: Model of perceived service quality. Gleitsman, Guttzeit, & Roschk 2010, p.9.

Advantages: The model describes the service quality and how customers perceive it. From

this, it can be deduced that the destination has to operate as a single unit, because

28 Gleitsman, Guttzeit, & Roschk (2010), pp. 7



customersrecognize the service as a product of all activities and services in the destination.

So it’s necessary for the H&WB destination to build up a unit and operate in this way.

Otherwise the different facilities and their provided services will inhibit each other, because

of unequal demands and standards of service.

Disadvantages : The model describes the service quality and how it is formed, but it makes

no references to health and healthcare. Therefore the model is not complex enough to

define an H&WB destination. People expect several kinds of service, but it is not said what

their motivation to visit the area is.

The model about Perceived service quality by Parasuraman et al. is a good way to explain

why it is so important for a destination to operate as a unit. A single management can create

a uniform market appearance and define the state of service quality. Through measures, e.g.

regular progress controls, consultations and regular training sessions, a destination can

develop as a “unit”.

3.3.4.2 Donabedian Model

Donabedian developed one of the first service-specific quality models, in which the three

components – quality strucure, process and outcome are differentiated. The term

"structure" is understood by Donabedian as the permanent resources of a service provider,

such as employee skills, the technical equipment of the company, etc. The term "process"

denotes all activities that take place during the actual service provision. "Outcome" means

the result of the performance finally started. Based on the three components, the quality of

a performance can be estimated.29

- System factor : structure of health system

- Processes of care : consultancy, examination, treatment

- Health outcomes : state, symptoms, mortality, costs

29 Vgl. Auer,C. (2004) pp. 87



Illustration 22: Model of Donabedian. Image source:

http://www.studydroid.com/imageCards/04/ek/card-4673550-back.jpg

Advantages: The Donabedian model includes, firstly, the aspect of health care. Here is a

clear link to the health care system, the work of medical and wellness facilities and the

health as a product. Components are included in the infrastructure, e.g. hotels. A destination

which offers a number of facilities like thisappears as a unit.

Disadvantages: Otherwise the model just deals with service and service quality, but not with

the description of where the service is provided. In what kind of area the service is going to

be offered and in which dimensions is not stated. In addition to that, a second factor,

motivation, is missing when comparing it with the H&WB definition. It simply represents

people who come to improve their state of health as patients, but whether wellness

activities are motivation too, is not touchedupon.

To sum up theDonabedian model, is to say that this one is a simple but effective way to

show how service quality especially in health care can be described. In the three

components, aspects of the H&WB definition can be recognized. The model characterizes

the kind of care, which interactions are done and how the patient feels after treatment.

Suitable factors of the definition are necessary infrastructure such as hotels, sports and

medical facilities. Doctors and other qualified staff need to be on site for interactions like

consultancy and treatments. The quality of the outcome and the provided service are crucial

to the success of the destination. The Donabedian model is not enough on its own to explain

the H&WB definition, but in addition to a suitable definition of a destination, it may be

satisfactory.

http://www.studydroid.com/imageCards/04/ek/card-4673550-back.jpg



3.3.4.3 Grönroos Model

In his model, Grönroos highlights the mainly subjective perception and evaluation of the

quality produced. This is the result of all of the criteria, which before the demand, during or

after the production process are perceptible.30

A company's imageactsas a filterin the performance of the

customer,betweentheexperiencedservice qualityand the twoquality dimensions. Influenced

by service obtained inthe past, ithas an impact on expectationsin the current time.

- Technical and functional dimension form the basis of comparison (expected and

received service)

- Technical dimension: "what" does the consumer receive

- Functional dimension: "how" does he receive it

Illustration 23: Grönroos model. Image source: http://water.prevos.net/category/blog/

Advantages: In the Grönroos model, the service quality is described on the basis of

experiences, expectations and perceived service. As a consequence, the customerevaluates

the whole area as a unit. If the customer had a bad experience with a provider, or if the

service of an institution was unsatisfactory, it would reflect on the whole destination. To be

marketed as a unit is apredefined aspect of a H&WB destination.

30 Vgl. Zolloondz(2006), pp. 211



Disadvantages: The model has no relation to healthcare. It could be used for any other

definition in the service sector and therefore it is not completely suitable for the H&WB

destination. In addition, the guest’s motivation, and which kind of facilities are in the “single

area” is not mentioned.

The Grönroos model shows the importanceof a destination operating as a unit. But in

comparison to the Parasuraman et al. model, theybear a strong resemblance. The difference

is small and only in the way the image was built. Grönroos sees the image as just the result

of two dimensions, what the customer receives and how he receives it. For Parasuraman

other aspects like reliability count too. In conclusion, the Grönroos model is not enough to

meet the requirements of the H&WB definition.

3.3.4.4 “Moments of Truth” model

The concept of "Moments of Truth" developedby Carlzon,found that particular contact with

customers plays a special role in service companies’ employees. Their daily behavior quite

significantly impacted the impression of the customer regarding quality. He speaks of

opportunities - in the moment they have the chanceto take advantage of an opportunity and

leave a very good impression, or to offer a poor performance.31

Advantages: There is emphasis on the necessity of having a good infrastructure, especially

qualified staff.

Disadvantages: There is nothing about health, and nothing about motivation.

31 Vgl. Gardini, M.(2009),p. 234



3.3.4.5 Meyer and Mattmüller model

Meyer / Mattmüller developed a comprehensive quality model which has adescription of the

development of quality in the course of the whole service process to the target. It integrates

aspects of Donabedian and Grönroos and highlights in particular the effects of quality on the

demander.32

- Based on potential, process and outcome

- Potential quality divided into vendor and buyer

Illustration24: Model of servicequality by Meyer and Mattmüller

Advantages: The focus on service and how it builds is more detailed than in the models

before. Here it is clear that the buyer and vendor develop the kind and quality of service .The

ideathat service is also built up during the process means that an ongoing first class service is

necessary. To develop a destination, it needs to work as a “unit” and provide the same

quality standards in all facilities.This idea is included in the H&WB definition and therefore

seen here as an advantage.

32 Vgl. Preißl, K. (2004), p. 25



Disadvantages: As with the following models, the Meyer and Mattmüller model also does

notinclude which kind of area and destination isasked for. Furthermore, the model does not

mention what the motivation of the guests is. Whether there is an individual feeling to

improve one’s state of health, or the need to doit, is not included.

The Meyer and Mattmüller model is based on the quality model by Grönroos with its two

dimensions, technical and functional. Meyer and Mattmüller have realized that the

customer’s behavior is as important as the vendor’s. The model on its own is not enough,

substantially, to be the same asthe H&WB definition.33

3.3.4.6 Parasuraman, Zeithaml and Berry model

While the above models are theoretical, Parasuraman / Zeithaml / Berry chose an empirical

approach to the study of service quality. The five dimensions of service quality are based on

customer interviews from various industries and extracted by factor analysis. They are:

- "Tangibles" for the convenience of the material environment and material

surrogates. This includes the totality of the physical environment of a service,

including the premises of the institution and the external appearance of personnel;

- "Reliability" as a promise of reliability respectively. Compliance is the ability of

employees to perform the promised services, reliably and accurately

- "Responsiveness" as openness, readiness and willingness to perform.The provider

includes the use of open-mindedness and willingness of their employees to help the

customers solve a problem quickly;

- "Assurance" as a performance expertise extends to the fields of knowledge,

competence, courtesy, kindness, respect, trust and security;

- "Empathy" means the willingness to respond individually to each customer.

33 Vgl. Ates, Z. & Büttgen, M. (2009), pp. 18



Illustration25: Model of service quality by Zeithaml, Parasuraman and Berry. Zeithaml, V.,

Parasuraman, A. & Berry, L. (1992), p. 49.

Advantages: The model defines very clearly, where gaps in the communication process can

be a problem. The relation between customer and provider becomes more transparent.

Knowing these gaps can help avoid a lot of mistakes in communication and offering services.

The destination seems to operate as a unit if service works. The companies and institutions

enrich the infrastructure while providing the expected service.

Disadvantages: It remains unclear, which kind of destination is suitable for the H&WB

definition. Moreover it is not stated which motivation causes the guests to visit the

destination or if they choose the destination voluntarily.



The model is not suitable for destinations. It describes the development of service in each

branch and therefore it is not enough for the H&WB definition. The model of gaps in

communication and service can be very helpful to build up an efficient service quality

system. With good management and regular controls, a high level service quality could build

up a professional image of the destination.



3.3.4.7 Dynamic process model by Boulding, Staelin, Kalry and Zeithaml

Boulding / Staelin / Kalry / Zeithaml demonstrate in their model how expectations and

perceptions change over time and cause different behavior compared to the service

company. According to this model, the perceived quality is affected by three factors:

- the will-expectancy (verisimilitude, what will happen with this provider),

- set expectations (the reasonable, for example in the industry, what should happen)

- performance delivered straight during contact with the company

Illustration26: Dynamic process model according to Boulding, Staelin, Kalry and Zeithaml

Advantages: The decision making process is shown in a detailed way with actions between

the provider and the customer. All institutions and parts of the infrastructure need to work

as a unit. Otherwise mistakes occur and at any time somethingcan go wrong. The model

shows that the expected service will be compared with the perceived service,



leadingtobehavioralintention. That means taking up service is influenced by the current

situation. The permanent risk that a customer cancels a service confirms the necessity of a

high service quality.

Disadvantages: The aspect of health care is not mentioned. It remains unclear whether the

people visit the destination to improve their health. The model explains how service quality

develops, but there is no right way how to interact. Even though the model describes the

idea of provided service, it is already incomplete for using it in a destination.

The model is very comprehensive in relation to service quality. But it is not enough to explain

a H&WB destination with its patients and guests, who come with a particular purpose.

3.3.4.8 Model of relationship quality by Liljander and Strandvik

Liljander / Strandvik assume that positive service quality and customer satisfaction lead to

greater customer loyalty, and thus are an important determinants of the success of

acompany. They look at individual episodes, and their effect on the overall relationship.

Then for each contact there is a comparison of the service provided to a comparison

standard.

- High quality

- Satisfaction

- Loyalty increases

- Comparison and permanent weighing

Advantages: The decision making process takes place throughout the entire trip. The

approach of Liljander / Strandvik is that highly qualified service satisfies the customer. As a

consequence, satisfied customers feel high loyalty and these people have lower price

sensitivity.Keeping old customerstakes priority over exclusively winning new ones. The

model defines the way thatdestinations should work. Focusing on satisfying long lasting

customers, and less on gaining new ones, can bring successful influences in the management

of a destination.

Disadvantages: The model is kept to a minimum. No relation to a health care system or

destination is remarked upon. Offering good service quality is emphasized, but in no way is it

explained how organizations, institutions or even destinations should interact.



Together with the previous models about the service quality,built on the provider’s and the

customer’s behavior, the Liljander / Strandvik model could be a good way to define the

framework for good service quality. Although the service model includes loyalty as the first

aspect, this alone is not enough to explain the concept fully. The H&WB definition needs

more, like facts about infrastructure, and the guest’s motivation.

3.3.5 Models and theory in regional management and destination

development

For regional management there exist few suitable models. The objects and needs of the

regions are highly differentiated. The basis of regional management models are business

models and economic models. (See also economic and tourism models). In the field of

regional management the SWOT analysis toolis suitable.However, it is not a model.

3.3.5.1 Model of action dimensional circles

The model shows the benefits of small-scale models of management and political

assertiveness in the region. Although large-scale approaches to larger subspace, planning

associations or district level institutions usually have a higher penetration power outward to

their regional acceptance, however, it is less pronounced. Transboundary approaches can

obviously combine a relatively high regional acceptance and a high load capacity at best.



Illustration 27: Model of action dimensional circles

Advantages: The model shows the conflict between effectiveness of regional development

concepts and enforceability. The H&WB definitionrequires a uniform development strategy

for the whole region. An increasing geographical expansion reduces the acceptance among

stakeholders.

Disadvantages: The model describes only the territorial aspect of regional management. The

model does not deal with infrastructure, health, medical and tourism aspects.The model of

action dimensional circles shows the conflict between regional acceptance and sustainability

of regional management. With a larger radius and increasing numbers of stakeholders, the

effective implementation and acceptance decreases.

3.3.5.2 The export base theory

As the name of the export base theory suggests, it is based on the central assumption that

the development or economic growth of a region depends on the export sector (and thus,

the extra-regional demand). The export base approaches were developed in the 1950s.

Income cycle of export basis approach



Illustration 28: Income cycle of export basis approach, L.Schätzl (1996)

Regarding the generation of income in a region, there is a distinction between "basic

activities" and "nonbasic activities". The former refers to the export activity and the latter

describes the income from activities within the regional market. The basic sector is the

economic base of a region on which the development of the nonbasic sector depends. For

regional development this means that competitive frameworks for regional exports are

created and promoted. The export base theory considers only the demand side, specifically

case export demand as the only criterion of regional growth. In addition to this disregard of

other factors, the export demand is also considered as exogenous.34

3.3.5.3 Polarisation theories

Joseph A. Schumpeter (1959) has laid the foundations for polarisation theories. Schumpeter

defines in his theory of "creative destruction" innovations as impulses of growth. The

impulse- like character of innovation leads to wavelike growth. Innovations destroy physical

capital and human capital in the short term, but in the long-term leads to higher growth. A

distinction is made between sectoral and regional polarisation. In our case regional

34L. Schätzl (1996)



polarisation is important. With "Regional Polarisation", polarisation theories try to explain

the regionally uneven progressive growth.

Regional polarisation

Illustration 29: Regional polarisation (own presentation)

Regional polarisation: The regional polarisation applies Schumpeter’s theory in a regional

context. It explains how successful economic activity attracts droves of entrepreneurs. The

spatial effects play a major role. This means that depending on the region, different sectors

are variously pronounced with the consequence that the growth is sectorally and regionally

unbalanced. Myrdal differentiates between two possible effects of regional polarisation

between a high-growth region and neighboring regions: backwash effects and spread

effects. The backwash effects describe the effects of withdrawal (withdrawal of labor,

productive capital, resources), while the spread effects (for example,the diffusion of

knowledge) describe the positive effects of the growth region. This means for regional

politics that at a transition to new standards or technologies, specific losses must be

accepted. The focus should always be directed toward long-term goals and growth

opportunities. The spread effects of a high-growth region can be encouraged through the

promotion and strengthening of networks and collaboration.35

35B. Buser(2005)



3.3.5.4 Endogenous development theories /-distinctive regional

development

Theories of endogenous development (1960) see regional economic growth justified by

intra-regional potential. They form the basis for socio-economic development of a region.

Development should be something self-specific. A comprehensive theory of endogenous

regional development does not exist; there are more various partial-sets and guiding

principles that have to be understood. The basic assumption of the endogenous theories is

that regional development is determined by the endogenous (regional) development

potential. The latter is defined as the totality of the development opportunities of a region in

time, and spatially demarcated areas of effect. The intra-regional potentialis activated by

overcoming existing bottlenecks (scarcity of factors of production), use of region-specific

skills and talents, or by the initiation of intra-regional circuits. Endogenous development

theories apply in addition to prevailing theoretical and regional political doctrines.36

36L. Schätzl(1996)



3.3.5.5 Milieu approach (Innovative and creative environment)

The basic assumption of the milieu approach (1980) is that the production and use of

knowledge are the basis for the growth of a region. Knowledge increases the

competitiveness and innovative capacity of a region and the production factor knowledge is

thereby given to half of the general value. There are numerous studies demonstrating

knowledge as a determinant of economic growth. For regional politics, this means that

regional growth depends on knowledge, and thus on human capital. If it is assumed that

knowledge is mobile, a region benefits also from the human capital of the neighboring

regions. For the innovators and creators environment, it is assumed that for a knowledge

network, the spatial proximity and thus the density of knowledge is important. Concrete

regional measures of this are the establishment of universities, strengthening of technology

transfer - networking and the generation of knowledge.37

Milieu approach

Illustration 30Milieu approach, H.-J. Domhardt et al. (2009)

37 H.-J. Domhardt et al. (2009)



3.3.5.6 Cluster approach

The cluster approach (1990-2000) is based on the theory of competition by Michael Porter. A

cluster is formed when multiple actors work together in an economy along a value chain and

thereby located in close proximity to each other. Networking in regions is often present. The

competitive theory of Porter states that the enforcement of production systems (in a specific

industry) is determined in a region by the following four factors: factor conditions

(availability/exchange of labor), demand conditions, industry environment and competitive

behavior of regional actors. In conjunction, these four determinants stimulate growth and

development. For regional development, this means that in principle every region can gain a

competitive advantage with their own industry equipment. Regions could use the cluster

approach without requiring conditions like a low population or poor infrastructure

equipment for competitive advantages in all industries.By specializing in certain clusters,

these regions should try to achieve growth. In promoting the regional economy the cluster

approach implies that it is selected between value-added and low-value-adding industries.38

3.3.5.7 New Economic Geography

The New Economic Geography (1990) explains trade between industries (intra - industry),

the formation of agglomerations and the increase in specialization in production. The main

representative of this theory is Paul Krugman. In the New Economic Geography the

assumption of a perfect market is dropped, and several equilibria are possible. In addition,

spatial components are included in the model. The New Economic Geography distinguishes

between so-called centripetal and centrifugal forces. The former are, for example, mobile

factors of production, which lead to the centralization of production and thus to the

formation of agglomerations. Centrifugalforces for example are immobile factors of

production such as land. These immobile production factors lead to trade and barter and

there is no formation of agglomerations. For the regional economy, this means that the

elimination of trade barriers is not equally beneficial for all regions. It can cause

agglomeration and thereby income differences, which potentially increase over a long

period. In immobile factors of production, the elimination of trade barriers can lead to

welfare gains for the concerned region. Regional politics require an exact study of

thestructure of regional economies.39

38M. Perlik&P. Messerli 39M. Perlik&P. Messerli



3.3.5.8 Learning Regions

The Learning Regions approach (1990) applies the operating scientific model of the learning

organization in the region. The Learning Regions approach refers to the knowledge of a

region developed through constant learning. "Learning regions are considered spatial units

in which knowledge is bound locally and in which continuous learning processes between

regional actors emerge from the spatial knowledge bond that enhances the regional

knowledge base"40. The central point is that a learning region's concept aligns with

networking and processes of strategic market focus. A region is not as well structured and

organized as a company and so it requires strong impulses and intensive management.41

3.3.5.9 Transaction cost theory

The transaction cost theory (main representative: Ronald Coase) states that production

levels can be outsourced at low transaction costs and thus specialization and growth are the

result. Transaction costs are the costs incurred by negotiation (on prices, delivery, etc.) on

outsourced products. The extended transaction cost theory suggests that in addition to the

collectable business relations (negotiations on prices, etc.) although the relationships of

regional actors that are not directly detectable play an important role.For each region, the

majority of these relations are often informally designed, and transaction costs are therefore

not accurately known. In this context, reference is also made to untradable

interdependencies or non-tradable portion action costs;by this, he is referring to so-called

network relationships. This brings benefits to the regional actors. This also means that in

regions the outsourcing of production stages (in the broadest sense) is facilitated through

the promotion of networks.42

40H.-J. Domhard et al. (2009) 41 Hertig, Hans-Ruedi (2002) 42M. Perlik&P. Messerli



3.3.5.10 Institutional density (New institutions approach)

The new institutional approach states that regional growth is also explained by the quality of

their network relationships. The latter depends to a large extent on institutional bodies and

associations (institutional thickness). The improvement of this new approach is the

importance of the non-economic actors (institutions). In regional politics this implies an

increasing attention on the institutions and the promotion of „institutional thickness“.43

New institutions approach

New institutions approach

43M. Perlik&P. Messerli



Illustration 31: New institutions approach (own presentation)

3.3.5.11 Evolution economics

Evolution Economics (2002) explains that in a market the best quality and best priced

products do not automatically prevail. Rather, certain innovations spread quickly and then

manifest as standard. Due to the costs that would arise in the conversion or modification of

such standards (see Schumpeter's theory of creative destruction), for other innovations (or

technology standards) it is more difficult to assert or enforce themselves in the market. The

consequence is that certain products in the market prevail, followed by a certain

development path (from which the development occurs). On the one hand there is a range

of development opportunities, and on the other hand this is limited by the initial conditions.

Applied to regional development, this means that a region will continue to develop even

atproduction is only half successful. An example is specialization in tourism. It is important

that those in "long-established" specialization fields review the regions, and that strategy

changes are central in long-term effects.44

44M. Perlik&P. Messerli



Dominant development path of evolution economics

Illustration 32: Dominant development path of evolution economics (own presentation)

3.3.5.12 Residential Economics

The economist Laurent Davezies (2008)45 shows that in France, the rural areas are becoming

increasingly attractive due to the local income of commuters, pensioners, tourists, second

home owners and newcomers. The residential economy is based on the assumption that the

income of the "inactive (or elsewhere employed), temporary or permanent residents

enriches the local economy in all circumstances, regardless of their actual production

capacity"46. Thus, the residential economy has moved away from the value proposition of

the classical theories of growth. Production locations are not forced locations at which

people spend their income. The awareness and willingness to pay for high standards of living

and quality of lifeas well as so-called proximity services (sports, leisure, housing services)

rises. According to the residential economy, production is not the driving force of the

regional development process. Davezies designated two key aspects to the residential

economy: firstly, the influence on the regional external source income (and its use), and

secondly, the regional supply of goods and services. On one side, the productivitysector

(production of goods and services) is examined. This is the source of the tax revenue of the

state. On the other side, residential sectors (mainly rural areas) want to have the income of

highly mobile economic actors. This includes, for example, pensioners, tourists and

commuters. A portion of the income of these actors is consumed locally. In this case, the

45H. Egli (2009), p. 80

46H. Egli (2009)

dominant development path

(with dominant technology/strategy)



multiplier effect is triggered, which has a positive effect on regional economic development.

The specialisation of a region according to residential economics on living attractiveness as

well as on services and leisure activities can promote regional growth.

3.3.5.13 Smart specialization

Smart specialization is not an economic theory, but rather a new form of research and

innovation politics (or strategy). The goal of smart specialization is targeted establishment of

investment, with lasting effects of the highest added value. A strategy for smart

specialization can be explained as follows: all the strengths and weaknesses for the

determination of a region of the evidence base are considered. So it refers to not only

specific research topics, but also topography, population structure, mineral resources,

culture and other areas. In smart specialization the dynamic process of decision making is

central ("Entrepreneurial Discovery"). This means that different stakeholders from business,

politics and society are involved in the process. In addition, the strategy of intelligent

specialization of different angles is considered, while the global point of view plays a big role.

It is primarily concerned with the notion that investments can be targeted.47

47 Europäische Kommission (2012)



4 Conclusion secondary research

Aspart of the secondary research the project partners reviewed 160 destinations, found 188

references and discussed more than 30scientific models. Focusing on the WelDest project

goals, the mode of operation was to review the given advantages and disadvantages of each

model. Because of the different approaches, and the quality and quantity of the researched

models, a comprehensive picture of the current scientific discussion could be given to the

readers. Furthermore the number of located references relating to the topics of H&WB

destinations gives a good insight into the current theory.

Even though the reviewed models and references deal with some of the main criteria of a

H&WB destination, not one of the modelsis able to analyze and to describe all single criteria,

the interaction and interdependencies of a H&WB destination. Subsequently the main

outcome of secondary research is, despite of all efforts, that currently no models exist which

could be used for a comprehensive review of a H&WB destination.This fact, leads the

WelDest project team to create a new model for analysing H&WB destinations.



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