The development of a wellness tourism program in Thailand: a community-based participatory action research approach with an empowerment theoretical framework

Introduction : Thailand has not had a comprehensive effort to collaborate on a wellness tourism regional program for foreign travelers. The purpose of the study was exploring the key components necessary for a wellness tourism program in the lower northern region in Thailand. Methods : This is a qualitative, community-based, participatory action research guided by the empowerment theory. A descriptive qualitative approach to data collection and analysis was used to explore stakeholders’ perspectives on the development of a wellness tourism program. A total of 40 key stakeholders from nine provinces in the lower north region of Thailand participated in two phases of the study’s data collection. Individual and focus groups interviews were conducted and analyzed thematically. The purposive sample included semi-structured questionnaires among community leaders, village health volunteers, and workers from various occupations who lived in the communities. Results : Four themes emerged from the qualitative interviews and focus groups: 1) honoring local wisdom as the heart of a regional wellness tourism program; 2) the integration of historical traditions and regional lifestyles into a wellness tourism program; 3) the need for government supportive policies that help to fund community wellness initiatives to boost the local economy and tourism ;and 4) attention needed to improve the quality of life for the local communities while promoting wellness tourism in the region. Conclusion : This community-based participatory action research approach created a synergy among stakeholders from multiple provinces in the lower north region of Thailand. Preliminary steps are underway to continue with the development and implementation of a wellness tourism initiative that can showcase the unique cultural, historical, and environmental attributes related to the health and wellbeing within this region.


Introduction
Wellness tourism is a broader concept than the earlier notion of medical tourism or medical travel, which referred to seeking medical services or procedures that promote physical or mental health while traveling in other countries.While wellness tourism may also include such services, it is now generally conceptualized as travel to other countries to seek opportunities to promote physical and mental health and to enhance overall wellbeing (Kemppainen, et al., 2021;Majeed and Gon Kim, 2023).Wellness tourism focuses on a wide range of opportunities to enhance wellbeing within a given location that go well beyond the typical spa, yoga, alternative therapy, herbal or meditation centers.Unique historical sites, cultural traditions and traditional foods are showcased as well as natural resources such as hot springs, beaches, rivers, mountains, or unusual native animals.Wellness tourism contributes significantly to the economy of Thailand.A recent systematic literature review on the re-emergence of wellness tourism in Thailand revealed seven components that constitute the concept: destination environment; travel and tourism policy; infrastructure; man-made and cultural resources; wellness strategy and structure; innovation potential and collaborative and proactive marketing (Phutong et al., 2021;2022).Covid-19 severely impacted not only the wellness tourism businesses in Thailand and other middle-income countries in Asia but also affected many people's ability to find work to support their families.This also compounded other potential effects of the pandemic related to physical or mental wellbeing such as isolation, depression, anxiety, grieving over the death of loved ones, or physical illness from the virus.A recent study comparing seven middle-income countries in Asia reported that Thailand had the highest scores related to the negative impact of Covid on mental health -as measured by the Impact-Event Scale (IES-R) and had the highest stress, anxiety and depression levels as measured by the DASS-21 (Wang et al., 2021).Informal workers were particularly adversely affected during the pandemic (Li, Wang and Shen, 2022).They generally have less job security and work for marginal wages.Informal workers contribute significantly to the economy of Thailand, and they represent slightly more 50% of the nonagricultural workers in Thailand.The lower northern part is a developing area for prosperity and hub, happiness, creative economy and smart and innovative city termed as MICE: Meeting, Incentive, Convention, and Exhibition.Empowerment is the process of building autonomy, power, confidence, and capacity which enhance the developmental process in this area (Thailand National Statistics Office, 2019).
In order to address the economic, mental and physical effects from the Covid-19 pandemic, the Thai government implemented a new campaign in 2022 entitled "Amazing Thailand New Chapter."This is managed by the Ministry of Tourism and Sports (Sangian and Thadafrom, 2022).While some regions of Thailand have embarked on recent wellness tourism initiatives (Muenchan et al., 2018;Puntien et al., 2022).the lower north region of Thailand has not had a comprehensive effort to collaborate on a wellness tourism regional program for foreign travelers.This could improve not only the local economy and wellbeing of Thai people in this region but also serve to promote health for those who journey to Thailand based on the empowerment theory.

Research design
We conducted a descriptive qualitative study using a community-based participatory action model based on the empowerment theory.We utilized Creswell and Poth's. (2018) steps for the purposive sampling, data collection, study protocols and data analyses using a thematic approach.
Community-based participatory action research (CBPAR) is referred to as a method, a framework and sometimes, an epistemology, that is -a philosophy or knowledge about the way that the research should be conducted.Fine and Torre. (2021) define it as "a framework for engaging research with communities interested un documenting, challenging, and transforming conditions of social injustice."CBPAR is an inclusive process that includes researchers and key informants that seeks to transform an outcome that is based in inequity in the community of concern (Fine and Torre, 2021).
The concept of empowerment is an integral component of CBPAR as it speaks to the transformation of the root causes of social injustice being examined.A critical review of the empowerment theory by Joseph (2021) revealed that there is agreement within the literature on the definition of empowerment.The key characteristics include that it is a transformative process which supports disenfranchised people to take action to mobilize their own strengths in order to change the dynamics of unequal power in which they are situated.Fawcett et al. (1995) proposed a model using empowerment theory decades ago to establish collaborative partnerships targeting community health and development in the US.The three dimensions in their model were integrated in our study: person or group factors, environmental factors and empowerment capacity and outcomes.We sought to include the voices of multiple stakeholders from various levels of Thai society in our deliberations which focused on social, cultural, health promoting and environmental factors that can contribute to wellness tourism.The goal of our program development process is to ultimately impact the outcomes of Thai people's economic status, wellbeing as well as the health and wellbeing of our visitors.See Figure 1 for our Conceptual Model of Empowerment using a CBPAR Approach.
We first engaged the community stakeholders though direct calls and use of our contacts in each province to invite them to participate in this project.We sent summaries of our CBPAR goals and objectives and proposed methods.We sought to empower the people in the lower north of Thailand through interviews with leaders in the communities as well as common laborers.We used individual interviews and focus group interviews to gather data with the aim of identifying the key elements needed in a lower north regional wellness tourism program.All interviews were audio-recorded and later transcribed.Field notes were taken at all interviews which included observations and reflective notes about the process of the study.These notes were taken into consideration during the analysis phase.

Sampling method
The sampling for the interviews and focus groups was a purposive sampling method for the first stage of 90 interviews with a quota sampling strategy to ensure that each group was represented by at least some community leaders, some entrepreneurs/business leaders and some nonmanagerial workers including farmers and from other sectors of the economy.The participants in the subsequent workshop were drawn from the original group of 90 and were invited purposively to again ensure there was representation from various types of stakeholders.

Study protocol
The data were collected between 16 August 2021 to 15 August 2022.This article reflects the first four steps in this process which included: Step 1. Gaining access to the community of interest; Step 2. Interviewing 90 people who were considered key informants within each of the nine provinces.Step 3. Conducting a critical reflection workshop using focus groups with 40 invited participants from the earlier interviews.4. Determining recommendations for a proposed wellness program based on the workshop outcomes.Implementing and evaluating the wellness tourism program will be the two final steps.The implementation phase is underway, and it is anticipated that an evaluation of the outcome of the program will be conducted within two years of its initiation.Ethical approval for the study was obtained from the Naresuan University Institutional Review Board (IRB No. P2-0153/2564, COA No. 368/2021), Naresuan University, Thailand, dated on August 14, 2021, until August 14, 2022.All participants who were interviewed signed an informed consent after the researchers thoroughly explained the purpose of the study, its methods, and protections related to the participants' autonomy and privacy.

Data analysis
We used Creswell and Poth's (2018) steps in data analysis which included: ensuring security of all data files; taking field notes throughout -pre, during and post interviews; continually summarizing field notes; working with words -reading recorded transcripts line by line; identifying codes; reducing codes to themes; relating themes to the literature; creating a point of view; and final report of data.

Standards of validation
Bradbury et al. ( 2019) suggested seven indicators of quality that researchers should address in action research.They include articulation of objectives; partnership and participation; contribution to action research theory and practice; clear methods and process; actionability; reflexivity and significance.A limitation of our paper is that we have not yet reached the stage of actionability as this was the first stage of the process of development of a wellness tourism program in lower north Thailand.However, we articulated our objectives and processes in this paper in order to contribute to the practice and policies of other potential CBPAR collaborations in Thailand and Southeast Asia.We established protocols so that our process was transparent.Reflexivity throughout all phases of this study was emphasized through field notes by researchers and reflective discussions within the key informants in the focus groups during the second stage of data collection.The potential significance of the process has been identified but the outcome of this CBPAR project is still to be determined.

Results
Ninety key stakeholders participated in this study.After access to the community was obtained with the support of the community leaders, the next phase of the study involved recruitment of 90 people which consisted of ten people from nine provinces in the lower north region of Thailand.Each of the nine groups included representatives from community leaders (n=3), business leaders/entrepreneurs (n=3) and workers from various other sectors of the economy as an employee (n=4).The focus of their interviews was on the feasibility of a regional wellness tourism program.
A sub-sample of 40 participants was later selected from the group of 90 participants as a focus group to attend a critical reflection workshop to further an actual program development of a wellness tourism model for the region.This group of forty participants were from the provinces of Sukhothai, Phetchabun, Phitsanulok, and Uttaradit.They lived in both rural and urban areas.The age range was 24 to 65 years old.The average income was 10,000 Bahts per month which is a medium income.The majority were married (60%) and half had attained a college degree.Forty percent were farmers and the remainder held jobs in other industries.Most reported chronic diseases were such as diabetes, high blood pressure (40%) and hyperlipidemia (30%).None reported current smoking; however, many acknowledged they sometimes drink alcohol during festival times or at parties.See Table 1 for a demographic description of both entire sample of 90 study participants and the sub-sample selected for the workshop.

Results from the critical reflection workshop
Four themes emerged from the workshop data.They were descriptive of themes related to key components in the development of a wellness tourism program for this region.They included as follow 1) Honoring local wisdom as the heart of a regional wellness tourism program; 2) The integration of historical traditions and regional lifestyles into a wellness tourism program; 3) The need for government supportive policies that help to fund community wellness initiatives to boost the local economy and tourism; and 4) Attention needed to improve the quality of life for the local communities while promoting wellness tourism in the region.Each theme had supporting quotes including the following examples:

Honoring local wisdom as the heart of the program
The participants in this study realized the importance of local wisdom in the development of wellness tourism.They sought to create a unique program that had a distinctive identity.For example, types of massage and also food preparation and local food choices are considered part of the local wisdom in terms of what types of massage are offered or what foods have been chosen to be farmed or caught in the local waters.Food choices and availability were considered a cornerstone of tourism development in each area -most of which are quite unique.Several commented on the idea of respecting local wisdom.
"Where now there is a boom in health tourism….but if we don't put our local wisdom into it, it's all the same.Visitors can travel anywhere.They don't have to come to our communities or our hotels."(Entrepreneur no 1, 56 years old) "Nowadays, local wisdom is regarded as the key point that makes us stand out from the rest.Otherwise, Thailand, especially most of the northern region, is similar.If we are going to focus on tourism for good health, it must be our local wisdom.Our food, our massage is like no other since the generation of our great-grandparents.We must make it different, so people will come."(Entrepreneur no 1, 64 years old)

Integration of historical traditions and regional lifestyles
The participants shared stories that reflected the long and treasured history of the provinces.In addition the varied customs and ways of life within each community can be integrated into a wellness

Need for government supportive policies
The key stakeholders who participated in this study identified the importance of government policy and support, which is the current key mechanism in driving the economy and upgrading health tourism in the lower northern region to be sustainable and concrete.They acknowledged how the Covid-19 disease outbreak has caused the interruption of Thai tourism.They recognized that to stimulate and conduct wellness tourism, the community requires concrete economic and sustainable policies with government support.Three participants shared their thoughts on this theme:

"The Thai government issue policies to support health tourism. Due to coronavirus disease outbreak, if the government does not help us -what shall we do?
Who will come to visit?Even if our tourism program is excellent and service is good, if no one travels here… so, there is no money, and we cannot operate our tourism.Government must help us."(Employee no 1, 24 years old).
"Policies and support from government and agencies are very important.Anything that can go on must be guided by government.We are trying to help ourselves.But if government supports us, it would be very good.Consequently, we will have people be able to travel, have jobs, have income, and we can operate it by ourselves."(Community leader no.3, 61 years old).
"We can operate the wellness tourism, but it's not as good as government support.Policies must be beneficial in the long run.If only us… we can do the wellness tourism.However, it is not sustainable.Currently, the government must enhance us as well.Government and communities must help each other, so we can survive."(Employee no 2, 32 years old).

Attention needed to improve the quality of life for the local communities while promoting wellness tourism in the region
The participants explained in their interviews about the importance of health and wellness tourism in improving the quality of life.They spoke of quality of life in terms of physical, mental, emotional, social, and spiritual dimensions.The wellness tourism must be consistent with the context, lifestyle, and characteristics of the community in the lower northern region, such as eating local healthy food, and exercise in accordance with the local lifestyle.Three workers shared their thoughts on this theme: "According to reading from the internet, the wellness tourism is good as well.But to improve the quality of life, it must be developed with the way of life of those communities or groups.For example, whoever comes to eat vegetables all the time is not, but we know how to eat things that don't change many lives, such as Khao Pan vegetable which is a heathy food.If we eat good food and exercise, it should be better."(Employee no 3, 35 years old).
"How can we operate the wellness tourism?If we prefer to improve our life quality, the wellness tourism should be adjusted to the life way of communities and tourist groups.The wellness tourism should not enhance the life way of communities in a short way, so the end of project is nothing."(Employee no 3, 49 years old)."I have worked for a long time; however, the wellness tourism must be in the middle way and can be adjusted to everybody.It should not emphasize too much health.If the wellness tourism does like that, we do not have money to afford.In other words, it should be suitable for us as well."(Employee no 4, 42 years old).

Discussions
This study was the first to address the needs of the lower northern section of Thailand which encompasses nine provinces as social needs about the wellness tourism.It was developed by the public health and nursing faculty at a public university in the lower north region of Thailand in alignment with a goal to stimulate innovate programs and entrepreneurship within the region.Using a participatory action approach to the formation of a regional cluster of wellness tourism has been reported in Australia (Bradbury et al., 2019).
In Thailand, Puntien et al. (2022) developed a provincial level of a wellness tourism but did not frame it as a participatory action approach despite following many of its principles.Other reports have identified the role the university as a leader in community participatory action research initiatives as well (Perkins, 2021).Our program development differed from another recent wellness tourism model from Ranong province (Puntien et al., 2022) in that it is based on a cultural attraction with three basic elements, which are tourism attraction potential, supporting tourism and the potential to support tourism management (Puntien et al., 2022).
Component 1: Tourism attractiveness means attracting attention or having artistic and cultural value that can impress and delight tourists.Component 2: The capacity to support tourism refers to the elements that contribute to enhancing the cultural resources to be important and suitable for tourism management.Component 3: Management refers to the ability to control, supervise, operate, and manage tourist attractions.
Health tourism covers travel activities of tourists related to improving one's health.The person who travels for the primary motivation of health seeks to improve his/her physical, mental, and spiritual, health through medical and wellness-based activities.In terms of health tourism of the lower north, t these are a group of provinces that stand out in history and natural culture including Dharma tourism, which is based on the lifestyles, Thai culture, Thai context, religion and spiritual as a Dharma tourist attraction.Also, it is an outstanding historical and cultural attraction as a World Heritage site, with a beautiful natural attraction, local wisdom tourist attraction, and health tourism, beauty, and Thai traditional medicine are located in these areas.As a result, the wellness tourism can be connected to intra-regional tourism and links with the Mekong sub-region which are sister cities and potential cities such as in China, India, Europe, America, and international countries.Particularly, travel grouping, such as Dharma, historical, cultural, natural, ecological tourism, and tourism related to community way of life, elderly people, and healthcare has a special feature as the North-South economic corridors are integrated networks of infrastructure such as highways, rails, roads, and ports within a geographical area designed to stimulate economic development.The East-West Economic Corridor and the other economic corridors can cooperate with Thailand, Mekong sub-region countries, and a group of countries with potential in trade, investment, education, public health, agriculture, and tourism with convenient transportation (Buddhabhumbhitak et al., 2019;Somnuke et al., 2023).In addition, these areas are centers for meetings and cooperation between the lower northern provinces, related provinces, and related countries (Nonsiri and Choesawan, 2020).If considering the tourism resources of the five lower northern provinces, it is found that there are possibilities conducive to supporting health tourists; however, there are many differences, especially the availability of natural resources as an important part of healthpromoting tourism (Strategy Development Unit: Northern Province, 2021;Thaihealth, 2022).The wellness tourism in Thailand is part of the application of wisdom based on traditional healthcare science as part of health services.As a result, health services in Thailand are diverse and outstanding.In other words, the wellness tourism is accepted and known by health tourists around the world.The wellness tourism in Thailand includes a holistic healthcare approach, Thai Hermit Datton Massage, rejuvenation of mind and body along with healthcare, detoxification, and caring for food according to the household elements; thus, the wellness tourism services have a specific context that can support the needs of all levels, from high-end to general users.Therefore, the wellness tourism can be included as part of the group's guided tours and package tours, or additional services of accommodation, such as spa, resorts, and retreats, etc. (Panyaatisin and Prasitthrathsint, 2021).For the wellness tourism operation, important factors which make tourists choose to use health tourism in Thailand are as follows (Lee-Anant, 2022).The first point is service standards consisting of the quality of personnel, equipment, facilities, communication technology, and advanced medical technology, as well as the matter of prices that can be selected according to a variety of budgets.With the promotion and efficient supervision from government, the wellness tourism can provide the highest level of safety to service users.The second point is that the good atmosphere and surroundings of the landscape make service users feel comfortable and relaxed.The third point is that Thailand is a country that can offer healthcare services along with other tourism sectors, with treatment costs that are less expensive than international treatment standards; therefore, after treatment, tourists can still afford to travel more than to other countries (Bureau of Sanatorium and Art of Healing, 2021;Suksri and Samkhuntod, 2021;Panyanak, Chaisaengpratheep and Masuak, 2022;Klangnurak and Jaronenwisan, 2023).
In addition to the themes identified related to the development of a wellness tourism program, the participants in the workshop developed a preliminary one-and two-day exemplar of a travel plan for tourists.This will need additional fine tuning, but it included the following highlights shown in Table 2.
Challenges faced during this study included the data can be used as information for the development of the area and a model for development guidelines for other areas in the lower northern region for subdistrict health promotion hospitals, sub-district administrative organizations, and private sectors in these areas; therefore, they can extend the development of a health promotion model program for health tourism.The data can be used to develop principles of the health promotion for community leaders, people, entrepreneurs, and other stakeholders in these areas.
Limitations of this study included length of time to conduct the stages of the study which was often impacted by the continued pandemic.The group of 40 for the workshop could not represent all sectors of the workforce that were present in the larger group of 90 participants so the transferability of their findings may not hold true for all sectors of the workforce.
Another limitation is the lack of funding at this stage to support marketing experts and advertising campaigns to move the wellness program forward.

Conclusions
In conclusion, the development of a wellness tourism program was deemed feasible by key stakeholders from nine provinces in lower north Thailand.A community-based participatory action framework that integrated the critical aspects of empowerment theory allowed a group of Thai people to engage in collective action to overcome the economic and health related negative impacts of Covid-19.Rather than wait for government action, they were able to take charge of their local situation and move forward with a plan that outlined the key characteristics that would be required for a successful wellness tourism program in their region.More work needs to be done in terms of developing and implementing a cohesive a marketing strategy to promote the plan and to receive targeted government financial support to further develop the program.This is to ensure that the social and economic inequities caused by Covid-19 are addressed in a manner that promotes health and reduces disparities among the Thai people in these provinces.Future recommendations include continued partnering with the stakeholders and securing government grants to aid in this evolving process.Future research needs to include an evaluation of the wellness program after two years -using follow up interviews with key stakeholders and comparing quantitative economic and tourism data per-pandemic, during pandemic years and after implementation of the wellness tourism program during the ongoing pandemic era

Table 1 .
Demographic Description of study participants