The tourism health interface in New Zealand : can the health promotion model be applied as a strategy? : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in the College of Business, Massey University
Tourism health issues in New Zealand affect many stakeholders including inbound tourists, outbound tourists, travel agents, doctors (GPs) and the Accident Compensation and Insurance Rehabilitation Corporation (ACC). In attempting to deal with the complex issues that arise at the tourism health interface, Stears (1996) has suggested that the health promotion model developed by Tannahill (1985) can be applied to tourism health issues. The health promotion model is based on the assumption that the behavioural and environmental causes of ill-health should be addressed concurrently and consists of three core activities of education, prevention and protection. The behavioural causes of tourism health problems are addressed by education activities while environmental causes are addressed by protection and prevention activities. Prevention is primarily the responsibility of doctors, while protection is the responsibility of the government of destinations. This thesis examines whether the health promotion model can be used as a strategy to reduce the incidence of international tourism health problems. Case study methodology has been used because it provides a methodology for examining tourism health problems from the perspectives of different stakeholders. It also provides a means of increasing the validity of the research. Accordingly, in this research the case study is 'tourism health problems in New Zealand' and this subject has been examined from the perspectives of travel agents, GPs, inbound tourists and outbound tourists. Five separate surveys have been undertaken in which the application and effectiveness of the health promotion model activities of education, prevention and protection are examined from the perspective of the stakeholder being surveyed. Travel agents are regarded by many as the most appropriate stakeholder to undertake travel health education activities. However, this thesis shows that their role in the tourism distribution channel and their attitude towards tourism health issues means that they are ineffective as a source of health advice and few New Zealand outbound tourists receive accurate advice from them. GPs are another source of health advice and in a twelve-month period, approximately 12% of outbound New Zealand tourists visited their doctor for education and preventive services. As expected, the advice given by GPs is on the whole, accurate and appropriate. Both GPs and travel agents consider that tourism health problems are the responsibility of the public health sector. This thesis has sought to identify the extent of tourism health problems in New Zealand and how different stakeholders are affected. It is estimated that approximately 150,000 New Zealand outbound tourists travel to medium- or high-risk destinations each year without receiving accurate information or preventive services. It is estimated that during a twelve-month period, GPs treated approximately 13,000 New Zealand residents for health problems sustained while travelling overseas, including 300 cases of malaria and 100 cases of dengue fever. Approximately 73,000 overseas tourists visited a GP while in New Zealand, primarily for minor illnesses and injuries. During a twelve-month period in 1997/1998, approximately 3,000 Accident Compensation and Insurance Rehabilitation Corporation (ACC) claims were made by GPs for New Zealanders injured while travelling overseas and 17,000 claims are made for overseas tourists injured in New Zealand, altogether costing $5,500,000. The health promotion model has been developed as a strategy for reducing the incidence of health problems and assumes that many health problems occur because individuals are unaware of the risks associated with their behaviour. Stears (1996) argues that this assumption can also be applied to many tourism health problems and tourists are educated about the risks they face, they will modify their behaviour accordingly. While this research has indeed shown that many tourists are unaware of the risks they face, it has also shown that increased knowledge of health risks does not appear to affect the incidence of health problems experienced. Although travel health promotion activities have been widely undertaken in the United Kingdom (UK) in the past ten years, the incidence of health problems experienced by tourists from the UK is no different from those experienced by tourists from other countries. These results suggest that travel health promotion activities have been relatively ineffective in reducing the incidence of tourist health problems. Both socio-demographic and psychographic factors affect the tourism health experience but this research shows that socio-demographic factors have a far greater influence than psychographic factors on the advice received by tourists. This thesis argues that the most important factor affecting tourism health problems is destination, rather than behaviour yet the health promotion model has no appropriate strategy for dealing with this factor. This thesis argues that the health promotion model has a number of weaknesses when applied as a strategy to tourism health problems. These include the difficulties that arise in applying it in an international environment; the existing strategies cannot be applied in the post-travel phase; the fact that treatment is not a strategy, yet this activity results in improved tourist health; and that no strategy exists for identifying high- and medium-risk destinations. Two new models have been developed in the course of this research. The first of these was developed to explain how health and safety factors influence the overall tourism experience and many stakeholders in the tourism process. This is the Tourism-Health Interface Model and shows the context within which this research takes place. The second model, the Tourism Health Management Model has been developed to address some of the weaknesses of the travel health promotion model and includes the strategies of risk-assessment and treatment. Risk assessment is a strategy which addresses the importance of destination as a factor affecting tourist health experiences while treatment provides a strategy for dealing with tourism health problems at all three stages of the tourism process. The Tourism Health Management Model acknowledges the different phases of tourism and the range of tourist health problems that occur. Overall therefore this thesis examines the effectiveness of the health promotion model as a strategy for reducing the incidence of tourism health problems by examining the effectiveness of the three core activities of education, protection and prevention. This thesis argues that prevention is the most effective of the three health promotion activities while education appears to be relatively ineffective and protection is difficult to apply in an international environment. The tourism health management model has been developed to address these issues.