Within the economy, human capital has always been one of the most important drivers for success and quality [1]; this is also true for the tourism industry. Yet, it has been proven that the human factor only adds to success if individuals have the right qualifications. Over the last several decades, a discussion in the literature emerged, focusing on the various kinds of education in the field of tourism, especially on the necessity of obtaining academic degrees within this field [2-6]. There was a time when the only document required to find a job in travel was a stamped passport [2]. Twenty years ago, travel was not even seen as a profession; however, the trend toward higher education has filtered down through all levels of the travel industry. According to John Jenkins, the head of tourism and hospitality management at the Southern Cross University in Lismore, undergraduate degrees are now expected in the industry [2]. Especially in health tourism, qualifications of human resources must be interdisciplinary [7]. Health tourism, which has emerged as a special sector within the broad field of tourism, has become economically valuable and is seen as one of the growing markets of the future. Reasons behind such growth are numerous, ranging from demographic changes in the population to changes in personal values and increased health awareness of tourists [8,9]. A crucial prerequisite for positioning within this market lies in the quality of both products offered and of the professionals delivering these products, such that the human factor verifiably contributes to the success of tourism product offerings [10]. Particularly in the field of health tourism, attention should not only be placed on qualitatively high-educated therapists and physicians, who come into direct contact with tourists, but also those not in direct contact with the end-consumer, such as executives and managers of health tourism-oriented facilities (hotels, destinations, etc.) [11]. To ensure evidence-based health tourism offerings of high quality, professionals within this area must have a certain level of academic training. Especially within the Germanspeaking Alpine area, the Austrian Moderate Altitude Studies (AMAS) showed medical evidence that individually adapted and coached health vacations at moderate altitudes (1500–2500 m) have multiple health benefits; these studies also outlined the need for qualified personnel to deliver these offerings [12,13]. However, in this relatively new field of tourism, sound academic education is lacking [14]. Despite the topic of higher education in tourism being discussed in the scientific literature, health tourism has not received much attention with respect to the need for academic education at present. The current research aims to evaluate the demand for academically qualified staff in the field of health tourism and the willingness of health tourism providers to take part in such education programs. For this first evaluation, the Germanspeaking area was chosen due to its importance in Alpine tourism in general and its high density of destinations and hotels that focus on spas and health. This area will also be analyzed for the offerings of such training opportunities.

State of research

Health tourism in the German-speaking Alpine area: Of sampled Germans, 68% see health as one of their biggest concerns by the year 2020, making health second only to unemployment [15]. When considering activities that promote greater personal health, people are generally convinced that all kinds of absences from work, whether leisure time at home or on vacation, is recuperative and healthy [16]. Based on these findings, tourism has grown and new tourists are both, more demanding and flexible [17]. The awareness of one’s own health is growing. More and more people see vacation as a chance to improve their personal health, to relieve daily stress, to recover, and to regain power for daily business. The aim of health tourism, as part of overall tourism offerings, lies in maintaining and stabilizing health by encouraging travel to a place outside one’s usual environment. There are divisions of health tourism, dealing with restoring someone’s health, for example traveling to another country to undergo surgery (due to quality and/or cost reasons).This field, namely medical tourism is still lacking scientific evidence with respect to the question if medical services should be a component of local tourism or not [18] but is beyond the scope of the present work. These services relate to different psychological and physiological interventions (physical activities, nutrition, medical and therapeutic services) [14]. Based on the opinions of many researchers, health tourism will be one of the major economic drivers of the tourism industry [19]. The increasing demand for health-tourism offerings in the German-speaking Alpine region faces an almost unmanageable health tourism market. Searching for “health tourism” using Google retrieves approximately 450,000 results, and adding the term “products” increases the results to 1 million. These examples illustrate that it is practically impossible for an individual to gain an overview of these offerings. Hence, this is not only a problem for a health-oriented tourist but also for all service providers trying to position themselves within this immensely increasing market.

Quality management of health tourism

A 1979 study of Porter found that one possibility for saturated markets lay in the quality of services offered [20]. Due to the abovementioned offerings, different providers attempted to differentiate themselves by building brands based on quality standards. In Austria, for example, eight wellness cooperation brands exist [21]. A recent study by Bertsch et al. discussed the importance of wellness quality criteria and the positioning of wellness cooperation brands [21]. Results outline that the brand awareness of tourists is quite low, and 65.3% of all respondents deny that they pay attention to the brand when choosing a hotel. Additionally, expected quality influences brand awareness, but experienced quality does not. These expectations are linked to the products the provider offers. Currently, there appears to be a mismatch between offerings and evidence-based medical research regarding these products. The knowledge about the effects of health-related tourism products is not only crucial for the responsible treatment of tourists but should also be considered a quality criterion for the provider. Hotels promise a lot, but which of those promises are supported by scientific evidence? In addition to medical aspects, critically challenging these health tourism offerings and evaluating them regarding their scientific justification should be required [22]. Currently, there is little research on the products offered or their quality. Based on the service gap model, consumers are only satisfied and perceive products as qualitatively high if both expectations and the actual delivery of the service and/or product match. AMAS proved that an active sojourn (combination of hiking and active/passive regeneration) at moderate altitudes (1,500–2,500 m), which is individually designed and accompanied by professional coaches, has positive effects on the health of patients with metabolic syndrome as well as patients suffering from stress [12,13]. The latter example shows how it is possible to enhance the quality of the product. However, these effects are only seen if personnel who are qualified to provide scientifically tested products are employed. Again, quality can be seen in both the products themselves and the personnel delivering the products. Qualified personnel are the key to success [23]. In the same way that health tourism has many facets, professions within this area are diverse [14]. The question that persists in the literature for quite a while aims at what is meant by “qualified personnel”. Does this really mean personnel with an academic education, or is vocational training sufficient when it comes to the tourism and health tourism industries?

The need for academic degrees within the tourism industry

Recently, an increase of higher education courses and programs in travel and tourism, one of the largest global employers worldwide, has been observed [5]. Since the UK and Australia were the first to introduce higher education in tourism, most previous studies were performed in these countries. According to Major and Evans [5], there is a current shortage of research assessing the view of the travel industry regarding the recruitment of graduates. A study in the UK outlined that only 12% of university graduates go on to a job in the tourism industry [24], which has the reputation for recruiting staff with comparatively low-level skills. The discussion is primarily based on the gap between what is taught at universities and what is needed by the industry [2-4,6,25]. Stuart-Hoyle did a study in 2003, outlining that most educational institutions drift away from the aim of preparing graduates for a career within the industry [26]. Obviously, there are different expectations. Employers emphasize practical skills, whereas educators develop more conceptual skills [5,27]. Results of the study by Major and Evans [5] showed that roughly 30% of employers hired employees with an undergraduate degree but only 7.7% of these had a travel or tourism-related degree. Statistical cross-references showed that employers with an academic degree were more likely to hire employees with an undergraduate degree [5]. There are researchers who support academic education in tourism more than others. Ring et al. [25] highlight that tourism education, which initially focused on the specific training for employees, developed into vocational schools and finally into undergraduate and graduate programs, caused by the continuous growth of tourism worldwide [25]. These authors claim that graduates need to be prepared for the changing environment they will face within this industry and therefore need education to think critically and analytically and be able to use creative new ideas. The limitation of sole vocational training is that it treats the existing tourism world as given and focuses on working in this environment without questioning its existence. Tourism is one of the fastest changing industries worldwide, and employees must have the skills to adapt quickly [25]. Employers are looking for a more flexible workforce to help their companies become more flexible [27]. Although no consensus has been reached yet, one fact resulting from the latter studies is that including the industry within the planning of academic study curricula is inevitable, as is offering job placement where vocational training occurs. In Austria and Germany, this finding was also reflected through the introduction of Universities of Applied Sciences, a system that closely connects with the industry [27]. Health tourism, as a subcategory of tourism, demands even more specified qualifications than general tourism. Especially in health tourism, providers need to deal with the topic of qualitative education since this market is steadily growing and will continue to grow [9]. Therefore, players within this market need to think about strategies to position themselves within the market and to contribute to the professionalization of the health tourism sector. Qualified human resources will play a significant role in such positioning strategies [10]. It is known that consumers of health tourism presume high-quality hardware (wellness and spa facilities), which are the main aims for certifications in health tourism [11]. Yet, also the role of the physician will change in the future, as people expect much more than just filling prescriptions [11]. However, high-quality staff is not only crucial in situations where the client or guest is in direct contact with medical staff, but is also important for hotel owners, managing directors, and destination managers. These individuals are important because they have the potential to guide the guest through the decision-making process for one or another destination, for one or another hotel. It is hard for clients to maintain an overview of the various offerings. For health tourism, qualified employees are a component for successful quality management [27] , which is one the other hand crucial part of the selling proposition and perceived first by the “clients”. Especially in health tourism, researchers agree that there is a lack of substantial education in this field [11,14,23]. In the field of health tourism, discussions about an academic degree go a step further. Employees in this field not only need generic skills but also knowledge about the health system of the country in which they are working, basic knowledge about health-supporting and -restraining factors, and interpersonal skills to communicate these factors. Higher education in health tourism should result in the provision of higher-quality services and improve the positioning of various destinations, regions, and hotels. The health tourism education landscape is very heterogeneous and different countries tried to address the issue. German, for example introduced an education to become a consultant in health tourism, but up to today, a homogenous educational approach in health tourism is internationally missing [28]. The need for such an education though is broadly discussed, yet no general agreement has been reached so far.

The literature on this issue, especially for the German-speaking Alpine area, with respect to health tourism is rare; a hands-on search by the authors found that the offerings of higher education in health tourism is not very extensive, as shown in Table 1, which only includes education programs that focus on health tourism. Additional providers integrate health within the general tourism curricula, but mostly as optional subjects or at a very basic level. As stated by the literature above, there is no general agreement whether it needs higher education within the field of health tourism. Thus, this research is mostly grounded in the English-speaking countries and no research is available yet with respect to the German-speaking Alpine area. Qualified employees are inevitable in most economic sectors and as outlined there are a lot of supporter for higher education in health tourism as well.

Table 1: Provider of Higher Education in Health Tourism.

The main aim of this current research is to evaluate the importance of higher education programs in the health tourism field as well as the willingness of these key players to attend such educational programs, if they have not already done so. Furthermore, this study aims to assess the knowledge of key players in the health tourism industry about the offerings of health tourism-related education.

To do so the following hypotheses shall be tested:

(1) Key players in the health tourism industry show a lack in health-tourism specific knowledge

(2) Key players in the health tourism industry acknowledge the importance of higher education in the field of health tourism and

(3) Are willing to attend the respecting educational programs. Results shall evaluate the need of higher education in the field of health tourism in the German-speaking Alpine area and to determine what is regarded as important by the industry for the development of integrated curricula. Overall, this study aims to amend on the overall quality within the academically young field of health tourism.

To deal with the hypotheses and to receive a first impression on what key players think, this cross-sectional research used a quantitative approach by distributing a questionnaire to key performers of tourism destinations that focused on health tourism. This research project was done in cooperation with the Management Center Innsbruck (MCI), which performed a study with respect to the importance of wellness quality criteria and positioning strategies of wellness cooperation brands. The MCI study consisted of three phases. The first two phases consisting of expert interviews and a Delphi method were used to generate information on items important to build the right framework for successful operations within health tourism, whereas the last phase was meant to verify the generated information. To do so, destination managers and Chief Executive Officers from tourism destinations in Tyrol, South Tyrol, Bavaria and Grisons, including 64 relevant Alpine tourism destinations, were handed out an online questionnaire. This sampling method provides a representative cross-section of the German-speaking Alpine area. Thanks to the cooperation and the fact, that higher education in health tourism migh add to the quality management strategy, the authors of this study were allowed to use the exact same sample for this research. Prior to sending out the questionnaire, the respondents were informed by the author of the MCI study, that they will additionally receive a questionnaire with respect to education in health tourism. With this measure, we expect to increase the response rate. The questionnaire was constructed online and accessible between June 12 and July 3, 2012. A reminder e-mail was sent to increase the response rate. The link to the questionnaire was sent to 58 key players and included an informal consent to be signed before participation. Data protection regulations were followed, and the responses were transmitted anonymously and transformed into an SPSS file. The questionnaire was approved by the research committee for scientific and ethical questions of the Private University for Health Sciences, Medical Informatics and Technology and contained 27 questions in total, almost all close-ended. The research instrument was developed by consulting existent literature on the discussion of higher education needs in health tourism and included items supposed to address the research questions outlined in the aims and objectives of this research. A pretest was done with 10 tests-persons. Descriptive statistics were used to present the data; Fishers Exact test was used to evaluate potential differences in the answers regarding knowledge, willingness, and importance with respect to gender. The significance level was set at p<0.05. In cases displaying the mean, the corresponding standard deviation was displayed as well.

Twenty respondents returned the questionnaire; only 17 were included in the analysis due to incomplete responses from the remaining three respondents, leading to a response rate of 29.3%. Responses from all of the four questioned countries were retrieved (64.7% (n=11) Austria, 17.6% (n=3) Germany, 11.8% (n=2) Italy, and 5.9% (n=1) Switzerland), and the majority of respondents were between 31 and 50 years (82.4%, n=14). Gender of the sample was distributed almost evenly with 10 male and 7 female. Of all respondents, 13 already had an academic degree, but 16 did not have a special education in health tourism. All of the respondents were employed in tourism associations/ destinations, and 16 hold a leading position.

Importance of higher education in health tourism

When asked about the importance of higher education in health tourism, 13 of the respondents assessed higher education as important to very important. When the key players were asked how important they believe higher education is from a guest’s point of view, 10 (58.8%) believed specified education in health tourism is important. The authors were also interested in the actual knowledge of the respondent group when it came to the terms and content of health tourism. Results are displayed in Table 2.

Table 2: Knowledge about definition and content of health tourism.

With regard to the need for employees who acquired higher education in health tourism, the sample was divided into 47.1% (n=8), who saw little need, 29.4% (n=5) who saw a moderate need, and 17.6% (n=3) who saw a high need. Only 11.8% (n=2) key players employed staff with an academic degree in health tourism. These individuals had a higher educational degree themselves, but not in health tourism. 7 respondents believed a substantial education in the field of health tourism (academically or non-academically) of the respective employees plays a role in the decision-making process of guests for or against a destination or hotel, and 4 answered this question as hard to assess. No significant differences between the individual countries and/or socio-demographic attributes were found with respect to the subjective feeling related to the importance of higher education. When asked to compare the competencies of employees with a university degree in health tourism and those who had no academic degree at all, 9 answered it was hard to assess, whereas 6 assessed the competencies of those with a university degree in health tourism better than those who had no university degree. When asked to further compare employees with a university degree in tourism with those with degrees in other specialties, 11 indicated it was hard to assess, 4 thought both types of employees had the same competencies, and 1believed the health tourism specialists had higher competencies. The two respondents who employed staff with university degrees in health tourism assessed the competencies of staff with health tourism degrees as 100% better than the competencies of their employees without any university degree and 50% better than those with a degree in a different specialty.

Interest in higher education in health tourism and willingness to use these offerings

Almost one-half (n=8) of the respondents showed an interest in university degrees in health tourism, but only while continuing working full-time. Motives for and against using such offerings are outlined in Tables 3 and 4. Of the respondents who said they would generally make use of offerings of higher education in health tourism (n=8) 6 would invest money for this purpose. Of the 8, who showed interest in higher education, 4 would invest between 500 and 999 €, and 1 would invest between 1.000 and 1.499 €. The rest (n=3) did not provide an answer to this question. Of the 8 respondents who would take part in higher education, 6 would spend 1–9 days per year for the education and 2 would invest 10 days or more. None would spend Sundays for education. Regarding the distance between place of study and home, 8 respondents would tolerate a distance up to 100 km, and 1 respondent would tolerate a greater distance but not more than 500 km. As with the other fields of interest, no significant differences of willingness/interest and socio-demographic attributes were identified.

Table 3: Reasons for taking part in higher education programs in health tourism.

Table 4: Reasons against taking part in higher education programs in health tourism.

Awareness of provided education in the field of health tourism

The mean with respect to the evaluation about the offerings of academic education in the field of health tourism (0=insufficient, 4=very good) was 1.8 (standard deviation ± 1.08) with only 3 respondents judging it as very good to good. 2 respondents did not want to answer this question. 13 did not know an educational provider for the subject of “health tourism”, 1 did not indicate an answer, and the remaining 3 referred to the Donau University Krems (Austria) as offering higher education in health tourism and a specialization in general sport sciences. No significant differences were found between different countries, the state of education that the individual key players themselves possessed, and the awareness of what is provided in the educational field of health tourism.

The health tourism market is facing challenges and key players are questioning how to find attractive, innovative product offerings to position themselves within this highly demanding and competitive market. As mentioned above, qualified human resources have always been a key to success in any economy, including tourism [1,7], but educational offerings to build these resources in health tourism are lacking, as shown in the literature [11] and the results of this study. Considering the necessity of higher education in tourism, one major question to answer is the need for higher education in health tourism from the perspectives of key industry providers. This study outlines that the knowledge about health-tourism oriented education, as well as the perceived need and the willingness to take part in the latter is still very heterogeneous. Results mirror discussions about the need for higher education in tourism in general displayed in the current literature [2-5] and are supported by the very low percentage of respondents who actually employ staff with degrees in health tourism (n=2). These two providers, who both have higher education degrees (although not in the field of health tourism), are in accordance with the same findings of Major and Evans [5]. Although only 2 respondents employed staff with a degree in health tourism, respondents assessed the competencies of those with degrees in health tourism to be better than those without an academic degree (n=6) or those with an academic degree but not in health tourism (n=1) Concentrating on the knowledge about the content behind the term “health tourism,” the respondents showed uncertainty with respect to key definitions and basic offerings of health tourism. Only 5 of the respondents saw a clear definition of health tourism, consistent with the literature, which offers several interpretations and definitions of health tourism and outlines a need for further education. An agreedupon definition for health tourism appears to be lacking [14]. This dissonance was also shown by answers to the question about whether wellness and medical wellness can be clearly differentiated, thought to be “no” by 11 of the respondents. This lack of clear definitions and generally agreed on terms, was also criticized several times by in the literature [11].

Another aspect needs further attention in future studies is the need for higher education with respect to evidence-based health tourism products. Currently, there are only a few products for which providers can claim proven health benefits, which is needed for medical quality assurance [22]. Finally, 7 respondents believed that having a substantial education in the field of health tourism could influence the decisionmaking processes of guests, which would be of great benefit for positioning in a competitive market. If the employees had a grounded academic education in the field, they would most likely appear much more authentic, when selling their products to potential customers. Additionally, as mentioned earlier, employees that question given facts and think critically are most wanted within an industry, which is exposed to continuous change [25].

Based on the discussions above and the findings of this current study, there is a need for substantial education for many reasons, but there also seem to be a number of restraints to achieving such an education. The authors of the study tried to trigger some answers by looking at how important higher education is within the minds of the key players. Within this area, results showed that 13 respondents saw higher education in health tourism as essential and important, and 8 of the key players were themselves interested in higher education in health tourism, indicating that this might not be the reason either. Additionally, the respondents assessed the offer of such education as sufficient. Based on discussions within the literature on education in tourism in general, the authors directly questioned the limitations in the use of higher education offerings to determine whether there were similarities to reasons provided in the literature. The biggest constraint is a lack of time, combined with the fact that it takes too long, followed by not knowing an institution offering such an education. Only 1 respondent indicated that such an education is not useful in practice, which is one of the main constraints discussed in the tourism literature [2-5]. These results imply a discrepancy between the subjectively assessed need of academic education in health tourism and the personal interest to take part in the latter, which were shown by the respondents showed and their actual education in health tourism. Additionally, respondents outlined a sufficient offer of academic education within the field of health tourism although, objectively the educational landscape is rare and the not even within the minds of the respondents. As previously mentioned, 13 respondents did not know of any institution that offers health tourism education. Referring to the hands-on search, there is a tiny market, and very few providers appear to reach out to this specific target group. It seems to be a basic problem that currently, almost all education providers are privately based and the education is quite expensive. The results of the current study show that respondents are not willing to pay more than 1.499 €/semester for a health tourism education but real costs are currently much higher.

Even though clearly structured, the study does have some limitations. First, the sample size is small, as the health tourism industry is very young and there are a limited number of key players at present. This small sample size has an effect on the generalizability of the study results. Yet, the aim of the study was to receive a first overall impression of the situation. The results were not meant to be generalized but more to be taken as impression where potential problems arise and how to possibly deal with these problems. Additionally, the target population itself is only one part of an entire industry (destinations); therefore, it could be of benefit to question other key players, for example, hotels in the studied sector. The fact that the target population consisted primarily of managers, most with a university degree and working in high positions, the willingness to take part in further education might be limited. Questioning young professionals, not as advanced in their careers, might result in different findings. Future studies in this field are needed and should include a larger sample size from different field out of the overall health tourism industry.

Presently, most studies relating to education in tourism have been conducted in the UK and Australia; to the best of our knowledge, no study has evaluated higher education in the field of health tourism. The current research, although limited by sample size, is the first attempt to obtain an overview on the health tourism education environment in the Alpine areas of Germany, Switzerland, Italy, and Austria. Secondly, the chosen target group was asked for its first impressions on the importance of such education for the industry. Some points discussed in the overall tourism literature also apply to health tourism, such as the need for higher education in health tourism in general. However, the limiting factors outlined in the field of health tourism differ from tourism in general. There is no gap between what the industry wants and what universities offer. It does seem that providers of health tourism studies do not reach out to potential consumers, and offerings are too time-consuming and costly, keeping in mind that such an education is secondary. One the one hand there is a potential customer that communicates his/her interest in academic education in the field of health tourism and knows about its importance within a framework of quality management and on the other hand there are institutions that offer this product, which obviously do not reach these customers and to not take into account potential cost- and time constraints. This study implies that academic education in health tourism is important based on many reasons. It further implies a gap in research assessing the need taking into account arguments from discussions previously held with respect to education in the entire field of tourism. Due to the small sample size, this study only shows a tendency and opinions of those experts who took the time to respond to the questionnaire. Further research, with a larger sample size and experts from additional fields related to health tourism such as hotels, spas and others could provide valuable information to get a more general insight into the topic. The fact that health tourism is an emerging market with high potential and qualified personnel in short supply should motivate the industry and educational providers to work together and develop an educational system that fits both parties to ensure a successful health tourism environment based on quality, not quantity. After all, this part of the tourism industry deals with one of the most important “products” of human beings: their own health.

The study at hand was funded by the Tyrolean Science Fund and performed in cooperation with the Management Center Innsbruck.

There is no conflict of interest.