International Journal of Environmental Research and Public Health Article Challenges of Spa Tourism in Andalusia: Experts’ Proposed Solutions Rosa Anaya-Aguilar , German Gemar * and Carmen Anaya-Aguilar Department of Economics and Business Administration, University of Malaga, Campus El Ejido, s/n, 29071 Malaga, Spain; [email protected] (R.A.-A.); [email protected] (C.A.-A.) * Correspondence: [email protected] Abstract: Water is the common thread and attraction factor of the tourism facilities called “spas”, which are part of health and beauty services. Spa use is currently experiencing a boom that reflects changes in populations, such as an increase in economic wellbeing and a desire to reunite with nature. This research’s objectives were to understand spa tourism’s structural and operational dimensions and to assess this sector’s current situation by using the Delphi method with a panel of 22 experts. The results show that these experts believe that, in Andalusia, spas energize the area as a tourism destination through their natural resources and conservation of key elements. However, spa development policies are scarce, including a lack of autonomous community laws regarding these facilities. Keywords: spa; Delphi; tourism; health; Andalusia Citation: Anaya-Aguilar, R.; Gemar, G.; Anaya-Aguilar, C. Challenges of 1. Introduction Spa Tourism in Andalusia: Experts’ The term “health tourism” is a generalized concept that still needs to be defined in Int. J. Environ. Proposed Solutions. greater detail as it encompasses broad concepts such as spa tourism, wellness, and medical Res. Public Health 2021, 18, 1829. tourism [1]. From health tourism’s demand side, a distinction can be made between https://doi.org/10.3390/ijerph18041829 wellbeing and healthcare. Wellbeing is pursued only by “healthy” people, with prevention being the main objective. These consumers may seek services similar to those used by Academic Editors: Sunghyup Sean Hyun and clients of normal “cures”, but they participate in this kind of tourism to preserve their María-del-Mar Alonso-Almeida health [2]. The experiential value of healthy water-based activities confirms its positive impact Received: 6 January 2021 on the quality of life, satisfaction and loyalty of people both towards the experience and Accepted: 10 February 2021 towards the destination [3]. Published: 13 February 2021 Spas offer complete destination health resort experiences that promote an improved state of body and mind and high-quality healthy food. Medical spas specifically offer cos- Publisher’s Note: MDPI stays neutral metic surgery procedures and other related services. These places should not be confused with regard to jurisdictional claims in with traditional spas that offer preventive medical treatments, such as hydrotherapy [4]. published maps and institutional affil- Since ancient times, people have sought hot springs with the idea of improving their iations. health and spas have been born around these springs [5]. Thermal water spas, by definition, are springs of water that flows from the ground naturally, with a high amount of minerals and at a temperature higher than that of the surface by 4 degrees Celsius [6]. These spas have been used since ancient times because these conditions of mineral content and Copyright: © 2021 by the authors. temperature give them therapeutic properties. Although its activity dates back to past Licensee MDPI, Basel, Switzerland. centuries [5] and is normally associated with recreation, health and well-being, today, these This article is an open access article facilities are also associated with concern for water management [7,8]. distributed under the terms and The use of spas and their mineral waters has a long tradition over time; however, at conditions of the Creative Commons present, the Public Health regulations could represent a threat to this practice, since the Attribution (CC BY) license (https:// disinfection processes used in the waters could alter their healing properties [9]. creativecommons.org/licenses/by/ 4.0/). Int. J. Environ. Res. Public Health 2021, 18, 1829. https://doi.org/10.3390/ijerph18041829 https://www.mdpi.com/journal/ijerph Int.Int. J. J. Environ. Environ. Res. Res. Public Public Health Health2021 2021,,18 18,, 1829 x FOR PEER REVIEW 22 of of 17 17 InIn thethe 21st21st century,century, spas spas are are being being reinvented reinvented as as part part of of health health tourism, tourism, based based on on newnew conceptsconcepts andand servicesservices mainlymainly dominateddominated byby people’speople’s desiredesire forfor wellbeing,wellbeing, especiallyespecially asas expressedexpressed byby thethe idealsideals linkedlinked with with spas spas [ 10[10,11,11].]. SpaSpa usersusers thusthus cancan havehave medicalmedical andand wellnesswellness goals.goals. TheseThese twotwo groupsgroups havehave differentdifferent motivationsmotivations asas membersmembers of of thethe formerformer needneed treatmenttreatment for for medical medical conditions, conditions, but but those those in in thethe latterlatter group group are are motivated motivated to to take take care care of of their their existing existing health health [ 12[12]].. In In response response to to these these demands,demands, thethe spaspa sectorsector hashas growngrown exponentiallyexponentially inin recentrecent decades. decades. SpaSpa facilitiesfacilities havehave becomebecome importantimportant sourcessources ofof incomeincome forfor hotelshotels andand resorts,resorts, althoughalthough spaspa clientsclients preferprefer good-qualitygood-quality therapiestherapies atat reasonablereasonable prices prices and and with with a a high high level level of of privacy privacy [ 13[13].]. Andalusia,Andalusia, as as ofof 2019,2019, hadhad 1313 spasspas withwith similarsimilar characteristicscharacteristics (see(see FigureFigure1 )1) including including beingbeing places places with with special special water, water, attractions, attractions, legal legal issues, issues, and and adaptations adaptations to new to new trends trends [14]. This[14]. topicThis topic has aroused has aroused the interest the interest of the of authorsthe authors to better to bet understandter understand the the problems problems of theof the spa spa tourism tourism sector. sector. That That is whyis why the the objective objective of of this this research research was was to to know know the the aspects aspects thatthat favorfavor oror hinderhinder the development of of spa spa tourism tourism in in Andalusia Andalusia from from the the perspective perspective of ofexperts. experts. For For this, this, the the Delphi Delphi method method was was used used to toextract extract the the opinions opinions of ofa panel a panel of of22 22experts. experts. FigureFigure 1.1.Spas Spas inin Andalusia,Andalusia, Spain.Spain. 2.2. LiteratureLiterature ReviewReview AlthoughAlthough healthhealth tourismtourism isis anan ancientancient formform ofof recreation,recreation, thethe rolerole ofof up-to-dateup-to-date healthcarehealthcare methodsmethods inin thisthis formform ofof tourismtourism hashas beenbeen strengthenedstrengthened sincesince 1990,1990, whichwhich hashas sustainedsustained the the popularity popularity of of traditional traditional health health services services in spas. in spas. They They help help satisfy satisfy the demand the de- formand healthy for healthy lifestyles lifestyles in which in which each person each person is held is responsible held responsible for maintaining for maintaining their owntheir health,own health, as well as as well reducing as reducing stress and stress counteracting and counteracting recent developments recent developments in the “evils” in the of contemporary“evils” of contemporary societies [15 societies,16]. [15,16]. AlongAlong withwith thesethese trends,trends, thisthis sectorsector hashas alsoalso experiencedexperienced aa dynamicdynamic increaseincrease inin itsits financialfinancial importance.importance. TheThe globalglobal wellnesswellness industryindustry generatedgenerated 4.54.5 trilliontrillion UnitedUnited StatesStates dollarsdollars ($)($) in 2018, growing growing 6.4% 6.4% annually annually from from 2015 2015 to to2017 2017 (i.e., (i.e., from from $3.7 $3.7 trillion trillion to $4.2 to $4.2trillion), trillion while), while the glob the globalal economy economy grew grew by only by only 3.6% 3.6% annually. annually. The The $4.2 $4.2 trillion trillion spent spent on onwellness wellness expenses expenses account account for formore more than than half half of the of thetotal total spent spent on health on health worldwide worldwide ($7.3 ($7.3trillion), trillion), according according to the to World the World Health Health Organization. Organization. Int. J. Environ. Res. Public Health 2021, 18, 1829 3 of 17 Specifically, the spa sector in 2017 included more than 149,000 facilities, with $93.6 billion in revenue and 2.5 million workers. The spa sector grew 9.9% annually between 2015 and 2017, and the forecast for 2022 is that earnings will reach $128 billion [17,18]. Additionally, international wellness tourists spend an average of $1528 per trip, 53% more than the typical international tourist. Likewise, national wellness tourists spend $609 per trip, 178% more than the average national tourist [19], although the COVID-19 pandemic has paralyzed the planned goals of wellness tourism for 2022, it is no longer in way to meet that forecast. According to the World Tourism Organization (UNWTO) [20], it will take two to three years for tourism to regain pre-pandemic