OriginalScientificArticle HealthTourismandPhysicalLiteracy:AQualitative ExplorationofElderlyVisitors’Experiencesafter RehabilitationatSlovenianHealthResorts KatjaKokot UniversityofMaribor,Slovenia katja.kokot1@um.si MajaTurnšek UniversityofMaribor,Slovenia maja.turnsek@um.si Thepromotionofphysicalliteracyisanopportunitytomultiplysignificanthealth benefits in an ageing society. In Slovenia, health resortsare one of the most com- monprimeareasforhealthenhancement,offeringnumerousservicesforindividu- alstoimprovetheirhealthandforminganimportantpillarofthesocialtourismand healthcaresector.Theaimofthisresearchistoexploretheroleofmedicalrehabil- itationatSlovenehealthresortsintheprocessesofincreasingthephysicalliteracy oftheirpatients.Twenty-onesemi-structuredinterviewswereconductedwithpre- viousguestsofSlovenehealthresortswhohaveundertakenmedicalrehabilitation. Theanalysisindicatesthatthemostcommonapproachisprovidinglecturesabout physicalactivityfollowedbygrouporindividualphysicalregimesorganisedforpa- tientswithsimilarhealthconcerns.Theseactionstargettwodimensionsofphysical literacy: the competence and the knowledge/understanding dimension. However, theeventualomissionofprescribedphysicalactivityfollowingtherehabilitationis anissueconcerningthemotivationdimensionofphysicalliteracy,whichshouldthus beaddressedmoreinthefuture.Thefindingscontributetounderstandingtherole ofmedicalrehabilitationatSlovenehealthresortsbyapplyingthephysicalliteracy modelforolderadults.Thestudyprovidesvaluableinsightsregardingthelong-term benefitsofrehabilitationatthehealthresortsonindividuals’levelofphysicalliteracy. Theresultsarehelpfulforboththetourismandmedicalsectors. Keywords:healthresorts,physicalliteracy,healthtourism,rehabilitation,health literacy,elderly https://doi.org/10.26493/2335-4194.15.81-94 Introduction As health resorts are an essential part of the Slovene tourist industry, and also owing to the ageing of the European population, it is essential to learn more aboutthefuturerolehealthresortsmayplayintheac- tiveageingprocess.AccordingtoGerlingetal.(2010), ageingaffectsthequalityoflifeinthreedifferentways: cognitiveimpairments,aresultingdeclineinexisting motor skills and a negative impact on motor learn- ingofnewskills.Asof2014,Sloveniawasbelowthe averageoftheActiveAgeingIndexfortheEuropean Union(unece&dgempl,2015).AsEurope’spopu- lationisgettingolder,Sloveniafacesasimilarproblem; forexample,only42ofSlovenesbetween65and74 AcademicaT uristica,Y ear15,No.1,April2022 |81 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy yearsdonothavemobilityproblems,andonly26.1 aged 75 years or more (Ministrstvo za javno upravo Republike Slovenije, n.d.a). When creating physical exerciseprogrammesforseniors,itisvitaltoaddress thefactthat54.5ofSlovenesaged55ormorenever exercise or play sport, and 50 do not even partici- pate in light physical activity such as gardening(Eu- ropean Commission, 2018). The term ‘physical liter- acy’ describes the motivation, confidence, physical competence, knowledge, and understanding that in- dividuals develop to maintain physical activity at an appropriate level throughout their lives (Whitehead, 2010).Physicalactivityhasbeenconsistentlydemon- stratedtogenerateconsiderablehealthbenefits,such as reducing the likelihood of cardiovascular disease, diabetes,andcancer(Warburtonetal.,2006).Devel- oping and maintaining physical literacy is consistent withthegoalofhealthyageingandoptimisesoppor- tunitiesforgoodhealthatallstagesoflife.Hence,the promotionofphysicalliteracyhasbeenidentifiedasa pivotalopportunitytogeneratesignificanthealthben- efitsinadults(Almond,2013).Furthermore,improv- ingindividuals’physicalliteracymayhavethepoten- tialtoreducefinancialexpensesinhealthcaresystems (Wangetal.,2005). Healthresortsaresuitablelocationsforphysicallit- eracy improvement during medical rehabilitation. In addition, a thermal environment is an optimal place for promoting health education and patients’ well- beinginacomfortablesetting.Manycountriesinthe eu, including Slovenia, have already emphasised the potentialhealthresortshaveforactiveageingofthelo- calcommunity(Blainetal.,2016;Lindneretal.,2021). InSlovenia,certifiedhealthresortsarenotonlypartof theeconomicsectorbutalsopartofthepublichealth- caresector.Therefore,healthresortshaveapotentially significant role in increasing the physical literacy of theolderSlovenepopulation,predominantlythrough publicly financed rehabilitation treatment. However, research surrounding the question of whether reha- bilitationservicesandthecorrespondinginformation exchangewithmedicalpersonnelinfluencethelevelof physical literacy among the visitors has not yet been conducted.Furthermore,researchingphysicalliteracy in the health tourism sector can offer great potential regardingthe necessary innovative changesin future offersofthehealthresorts. CombiningtheTourismIndustrywiththePublic HealthCareSector According to Mueller and Kaufmann (2001), health tourismisthesumofrelationsandphenomenaresult- ingfromthechangeoflocationandstayofpeople,un- dertakentoprovidesupport,achievebalance,andre- storephysical,mental,andsocialcomfortthroughthe useofhealthservices.Forthisresearch,thedefinition proposed by Rulle (2004, p. 20) is the most suitable: ‘This form of tourism is characterised by the aspect ofhealth.Therestorationormaintenanceofpersonal health is in the foreground. The decision to take the journeymaybeinfluencedbyconstraintssuchasill- nessortheneedforrehabilitationorbyadoctor’srec- ommendation.’Healthresorttherapyinvolvesallmed- ical activities originating and employed in health re- sortsandaimsathealthpromotion,prevention,ther- apy,andrehabilitation(Gutenbrunneretal.,2010).Re- habilitation can be defined as ‘a set of interventions designedtooptimisefunctioningandreducedisabil- ityinindividualswithhealthconditionsininteraction withtheirenvironment’(WorldHealthOrganization, 2021). The medical treatment in health resorts com- binestheeffectofnaturalhealingresourceswithmed- icalcaretofacilitatetherehabilitationprocess. In Slovenia, health resorts offer treatments that usethehealingeffectsofthermalwatersandmineral waters, followed by seawater and brine, aerosols for inhalation, healing muds and mineral peloids, peat, andthedifferentmicro-climates(Horvat,2014).Cer- tifiedhealthresortsarepartofthehealthcaresector astheHealthInsuranceInstituteofSloveniaenables and covers medical rehabilitation expenses. A simi- lar funding mechanism is also present in other Eu- ropeancountrieswith a stronghealth tourismsector such as Poland (Woźniak-Holecka et al., 2017), Ger- many(Pforr&Locher,2013),Romania(Surugiuetal., 2020), the Czech Republic (Attl & Čertík, 2011) and Slovakia (Derco, 2014). The Health Insurance Insti- tute of Slovenia often covers the cost of overnights andfoodforaparticularnumberofSloveneresidents, whichisregulatedyearly. 82 | AcademicaTuristica,Year15,No.1,April2022 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy Intheyear2017,Slovenehealthresortsrealisedre- habilitations that totalled 351,960 overnights (Skup- nostslovenskihnaravnihzdravilišč,2018)withanav- eragedurationofthetotalstayof15.1days(Ministrstvo zajavnoupravoRepublikeSlovenije,n.d.b),whichis 11.4ofallovernightsinSlovenehealthresorts(Skup- nostslovenskihnaravnihzdravilišč,2018).Medicalre- habilitationisanimportantsegmentofSlovenehealth resorts due to financial benefits; for example, Ther- manaLaško,oneoftheoldesthealthresortsinSlove- nia, generated 35.76 revenue from sales due to the contractwiththeHealthInsuranceInstituteofSlove- niain2019(ThermanaLaško,2020). PhysicalLiteracyandHealthResorts Physical literacy has become an increasingly influ- ential concept in the past few decades and is wo- ven into education, sport, and recreation policy and practice. Whitehead (2013, p. 29) proposed the def- inition of physical literacy as ‘the motivation, confi- dence, physical competence, knowledge and under- standing to value and take responsibility for main- tainingpurposeful pursuits/activities throughoutthe lifecourse.’AccordingtoWhitehead(2010), thecon- ceptofphysicalliteracycanbedepictedbysixdimen- sions:(1)motivation(desiretobeactiveandtopersist withtheactivity),(2)competence(movementcapabil- ities),(3)environment(havinganappropriateevery- daysetting),(4)senseoftheself(perceivesoneselfasa physicallyactivepersonwithappropriateexperience), (5)expressionandinteraction(beingcapableoffluent self-expressionandempathiclisteningtoothersabout andthroughphysicalactivity)and(6)knowledgeand understanding(regardingallotherabovedimensions, andincludingaclearunderstandingofthebenefitsof physicalmovementregardingthequalityoflife). Intheliterature,physicalliteracyitselfisfrequently seenastheoutcomeorendpoint,withaprimaryfocus on fundamental movement skills in school-age chil- dren, rather than as a unique and individual process thatevolvesacrossthelifecourseasconceivedinitially byWhitehead(2013)(Youngetal.,2020).Mostarti- clespertainingtophysicalliteracyinthescientificlit- eraturehavesharedinformationrelativetothesectors of youth sports and childhood education (Roetert & Policy.Themodelisarecommendedpolicyelementforactive andhealthyaginginitiativesacrosspan-governmentaland multi-sectorallevels,andnon-governmentalorganizations. Community.Contextinwhichphysicalactivitytakesplace. Includingconsiderationsofhowtheindividualissocially connected,influencedbysocio-culturalnormsand expectations,andtheindividual‘sinteractionwithbuiltand naturalenvironments. Organizational.Programs,resourcesandservicesthatoffer personallymeaningful,culturallyrelevant,andaccessible opportunitiesforphysicalactivity. Interpersonal.Aspectrumofformalandinformalpersonal relationshipsthatinfluencephysicalactivityparticipation. Intrapersonal.Themotivation,confidence,physicalcom- petence,knowledgeandunderstanding,andengagement inphysicalactivitiesasanintegralpartofone‘slifestyle. LifecourseContinuum–Cyclinginandout. Figure1 PhysicalLiteracyModelforOlderAdults (adaptedfromJonesetal.,2018,p.10) Ortega,2019).Thusfar,physicalliteracyhasnotbeen extensively investigated among the older adult pop- ulation, and consequently, older adults are often an overlookedaudienceoftheprogrammesthatpromote physicalliteracy.Fromaphysicalliteracyperspective, successful agers compensate and modify their activ- itybyoptimisingchoices,therebymaximisingsuccess andmaintaininghigherlevelsoffunctioningacrossall dimensions(Roetert&Ortega,2019).Aphysicalliter- acymodelforolderadults(seeFigure1)hasbeende- velopedbyJonesetal.(2018),pointingtotheneedto adapttheintrapersonal,interpersonal,organisational, communityandpolicyelementstothespecificsofthe olderadultpopulation(Jonesetal.,2018,seeFigure1). Themodelisoneofthefewthattakeintoaccountthe individual ororganisationallevelandapproachesthe issueofphysicalliteracyofolderadultsfromabroader holistic perspective, also incorporating the commu- nityandnationalpolicylevel.Whilethisisprimarily atheoreticalmodeldevelopedforthewholerangeof elderlyexperienceandsocialcontext,itisausefulana- lyticaltoolforanalysingandprovidingrecommenda- tionsabouttheroleofhealthresortsinimprovingthe physicalliteracyoftheirelderlypatients. AcademicaTuristica,Year15,No.1,April2022 |83 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy Alimitedamountofresearchhasinvestigatedthe role of health resorts in increasing the physical lit- eracyoftheirelderlypatients.Stevensetal.(2014) reported that physical activity counselling and pre- scriptionsdeliveredinthehealthcaresettingaremore effective if they include an assessment of individual needs, motivation and preferencesand if social sup- ports are available. A study in French health resorts (Maitre et al., 2017) investigated the level of physical activity after three weeks of thermal treatment with additional physical education sessions. The main re- sultsindicatedthattheparticipants’volumeofphysi- calactivitywassignificantlyhigherattwoweeks,two months, six months, and one year after the end of theiractivethermaltreatmentthantheirbaselinelevel. Evenoneyearaftertheendofthethermalhealth- care,64oftheparticipantsstillhadahighervolume ofphysicalactivitythanatbaseline.Theparticipants improvedtheirphysicalfitnesscomponents(i.e. bmi, flexibility), psychological parameters(i.e. global self- esteem,physicalself-worth,intrinsicmotivation,and mood states) and the intrinsic regulation of exercise behaviour. It is likely that the physical and psycho- logical status of participants at the end of the inter- ventionwasbetterandmayfurthersupporttheiren- gagementinanactivelifestyle(Kamiokaetal.,2006; Kamiokaetal.,2009;Zijlstraetal.,2005).Thestudy byMaitreetal.(2017)impliesthatcombiningphysical educationsessionswiththermaltreatmentcouldpos- itively and longitudinally affect the levels of physical activity of patients and consequently could serve as anexampleforimplementingsuchactivitiesinthere- habilitationprocess.PreviousresearchbyCarpentier and Satger (2009) similarly stresses that balneother- apy treatments combined with educative workshops impactpatients’qualityoflifeinthelongterm.How- ever,thestudyfromGayetal.(2020)showedalimited effectofaself-managementexerciseprogrammewhen addedtospatherapyforincreasingphysicalactivityin patients. These previousstudies,however,werelimited,all focusedonquantitativeassessmentoftheeffect,either with self-administered questionnaires and/or physi- calfitnesstests(measuring bmi,walktest,andother physicalmeasures/exercises).Stillmissingarequalita- tive,phenomenologicalinsightsintotheparticipants’ experiencesandmemoryofthethermaltreatmentand theirunderstandingofthelongitudinaleffectsof the treatments. An in-depth understanding of these ex- periencesisavaluableinputregardingtestingandim- provingthephysicalliteracymodelforolderadultsfor healthresorts. Consideringthesefacts,itisnecessarytoresearch this issue; therefore, the main objective of the re- search is to explore the personal experiences of pa- tients who have previously undertaken medical re- habilitation at a health resort,focusing on the health resortservicesthataffecttheirphysicalliteracylevels. Theanalysiswillserveforfutureresearchasitisantic- ipatedthathealthresortswillhaveaprominentrolein post-pandemictimes,asthe covid-19pandemicwill changetheroleofhealthresorts,strengtheningtheir preventive, therapeutic, rehabilitative, educative, and socialrole(Masiero&Maccarone,2021). Methodology Inordertounderstandtheexperiencesofrehabilita- tion patients in Slovene health resorts, we employed semi-structuredinterviewswith21previousguestsof Slovene health resorts. The condition was that they hadundertakenatleastonemedicalrehabilitationin the last four years. The interviews were conducted in June and July 2020. Snowball sampling or chain- referralsampling was used to identify potential sub- jects.The sample consists of 7 malesand 14 females, primarilyseniors,thathavestayedatatotalof11out of14accreditedSlovenehealthresorts,eitheronceor multipletimes.Detailedinformationaboutthesample ispresentedinTable1. Alltheintervieweesstayedatthehealthresortho- tels during rehabilitation, and most of them stayed therefor 14 days. The description of the average day spentatthehealthresortdidnotvastlydifferamong theinterviewees. The interviews included questions about the stay atthehealthresorts(healthcondition,duration,time ofstay),descriptionoftheirstay(dailyroutineatthe healthresort,medicaltreatmentscarriedout,accom- modationandamenities),satisfactionwiththehealth resort (amenities and personal) and still-memorised 84 | AcademicaTuristica,Year15,No.1,April2022 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy Table 1 SampleCharacteristics ()Thermalresort Healthproblems A PtujThermalSpa Legfracture BO l i m i aP o d č e t r t e kT h e r m a lS p a DolenjskeTopliceThermalSpa ŠmarješkeTopliceThermalSpa Spinesurgery Hipreplacement C TermeZreče Legfracture D ČatežThermalSpa Kneesurgery EČ a t e žT h e r m a lS p a ThermanaLaško Kneesurgery Hipreplacement F TermeMoravskeToplice Spinesurgery G RadenciThermalSpa Heartsurgery HP t u jT h e r m a lS p a S p i n es u r g e ry I TermeZreče Legfracture JT e r m e Z r e č e Talaso Strunjan Spinesurgery Arthritis K PtujThermalSpa Legfracture L TermeMoravskeToplice Spinesurgery MT ermeZreče TermeMoravskeToplice RadenciThermalSpa Kneesurgery Hipreplacement Heartsurgery NT e r m eZ r e č e K n e es u r g e r y O ČatežThermalSpa Kneesurgery P DolenjskeTopliceThermalSpa Hipreplacement Q PtujThermalSpa Hipreplacement RO l i m i aP o d č e t r t e kT h e r m a lS p a TermeMoravskeToplice RadenciThermalSpa Kneesurgery Spinesurgery ST e r m eZ r e č e ThermanaLaško Asepticnecrosis TM e d i c a lc e n t e rR o g a š k a PtujThermalSpa Colorectalsurgery Spinesurgery U TermeMoravskeToplice Arthritis Notes (1)Interviewee. received information about their health condition (knowledge,dailyroutine,andrestrictionsathome). A suitable method for analysing the transcripts seemed to be thematic qualitative content analysis (Mayring,2014).Forthepresentqualitativecontent analysis, structuring and filtering the relevant con- tentoutofthematerialasawholeandanalysingitre- gardingthecategoriesspecifiedinadvance(thematic blocs)seemedtobethemostappropriateway.Defin- ing the categories serves to filter the interviews for statements fitting into the categories. The categories weredevelopedinductively,guidedbytheconducted data. For qualitative content analysis, Atlas.ti 8 com- putersoftwarewasused,whichiscommonlyusedfor coding and analysing transcripts. In the discussion, eachquotationislabelledwithaletterthatindicates theinterviewee. ResultsandDiscussion The findings from the transcript analysis and corre- sponding discussion are divided into three partsfol- lowing the natural narrative progression of the par- ticipants’stories:experiencesbeforetherehabilitation, experiencesduringtherehabilitation,andphysicalex- periencesaftertherehabilitation.Thediscussionofthe resultsinthissectioninterconnectsthefindingswith Jones et al.’s (2018) physical literacy model for older adultstoproviderecommendationsforfurtherdevel- opmentofhealthresortsasanactivepartnerintheso- cietalstrivingforincreasingphysicalliteracyoftheel- derly. ExperiencesbeforetheRehabilitation Themajorityoftheintervieweeshaveundergonemed- ical rehabilitation as part of the post-surgical pro- gramme of re-establishing joint motion, developing muscle strength and restoring joint function. Many have had prescribed sessions with physiotherapists beforeundergoingrehabilitationatthehealthresort; however,theypreferredthetreatmentatthehealthre- sort:‘Afterthesurgery,beforeIwenttothespa,Ihad eight sessions with the physiotherapist in the health centre.[...]However,theyshowyoumoreexercisesat thespa;everythingismoreholisticIwouldsay,better definitely.’(L) Healthliteracyisa concept connectedtoan indi- vidual’sresponsibilitytounderstandandactonhealth information in everyday environments (Sørensen et al.,2012).Itisperceivedasoneofthesignificantcom- ponentsinthepreparationsofindividualsintakingre- sponsibilityfortheirhealth.Althoughthetermsphys- ical andhealthliteracydiffer in their focus, develop- AcademicaTuristica,Year15,No.1,April2022 |85 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy ing literacy skills is key in ensuring that individuals have the skills to adopt a healthy lifestyle. The anal- ysis has indicated lower health literacy levels among the respondents as their knowledge about whether theyhavetherighttorehabilitationatahealthresort varies. Some do not know they are entitled to reha- bilitationunlesstheirphysicianmentionsittothem: ‘I do not know about these laws and if you are enti- tled or not. Even before, when I had my ovaries re- moved, I did not go anywhere.However, supposedly I was entitled to rehabilitation because I was talking withmydoctorabouttheupcomingrehabilitationfor myhip.ShesaidthatIshouldknowhowitisduring the rehabilitation, and I told her that I have yet not beenatanysparehabilitation.Andshewassurprised bythisfact.’(P)Limitedhealthliteracyisalsoshown through limited knowledge about the procedures of themedicalcommission,whichisresponsibleforthe assessment of people’s applications for rehabilitation athealthresorts:‘WhenIhadahipreplacement,my surgeonwrotethatheadvisesrehabilitationinTerme 3000 thermal spa, which was written in my report. ButIgottherehabilitationatThermanaLaško.When Icameback,mysurgeonwasangryaboutwhyIwent there if he advised another spa. I said that Laško is whatIgot.AndwhenIhadkneesurgery,mysurgeon advisedthatIgotoČatežThermalSpa,andIagaingot ThermanaLaško.AndthenIthoughtthatsomething wasnotright.Icalledthecommissiontoaskwhythey wouldnotsendmetothespathatthesurgeonadvised. ThenIgottheinstructionsonhowtowritethecom- plaint.So,IsentacomplaintandgotČatežThermal SpaasIshouldhaveatthebeginning.’(E) ExperiencesduringtheRehabilitation Physicalliteracyisarguablyanantecedentofphysical activity,whilealsobeingdevelopedthroughphysical activity(Giblinetal.,2014).Physicalexercisesduring rehabilitationarecrucialinaffectingphysicalliteracy levels. However, the physical exercises at the health resortareadaptedtothepatients’physical,cognitive, andsensorylimitations.Adaptedphysicalactivitywas executeddailybyparticipatingintheobligatorygroup exercisesinthethermalpoolorthegymsupervisedby the head physician. The medical personnel not only demonstratetheexercisebutalsosupervisetheexecu- tion and warn about possible injuries: ‘In the morn- ing, from nine to twelve, there are also physiothera- pistswithyouthatshowyouhowtocorrectlyperform theexercises,andtheyalwayswarnyouifyouaredo- ingsomethingwrong.Youreverymoveissupervised, basically.’(N) Dependingontheirhealthcondition,someofthe intervieweeshadindividualisedphysicalregimeswith thephysiotherapists,whichwasgenerallyseenasben- eficialfortheirrehabilitationprocess:‘Whenyouar- rive,yougetyourtherapistfortheentireperiod.Ihad ayoungwoman;wehadalreadybecomecolleaguesin thosefourteendays,andwewereabletotalkaboutev- erythinginacompletelyrelaxedway.Ifindthisbetter thanhavingadifferentphysiotherapisteveryday.’(C) Medicalpersonnelatthehealthresortoftenstrong- lyadvisethepatientstoperformthephysicalexercises intheirfreetimeatthehealthresortaswell:‘Intheaf- ternoonwehadindividual exercises.Everythingthat wedidinthemorning,wehadtorepeatintheafter- noonalone;therewasnophysiotherapisttoguideus. One of them was there on duty, usually the head of physiotherapy,andhesometimescametoseeus,but weweremainlyalone.Usually,Iwastherefromfour to seven in the evening. So, I was in the gymnasium orfitnessuntilsevenpm.’(D)Theaimisthusthatthe patientstakeadvantageoftheinfrastructureandstrive for regular physical exercise to become a part of the patients’lifestyleasitisexpectedthatafterrepetitive exercise,patientsrealiseitsimportancenotonlyforre- habilitationbutoverallhealthaswell. Afterthemedicaltreatments,whichusuallyoccur inthemorning,thepatientshavefreetimetosched- ule as they will. The analysis indicates that most pa- tientstrytoremainactiveintheirfreetimebybeing activeinthenaturalenvironmentorusingotherser- vicesavailabletohotelguests:‘ThereIwentonshort hikes several times. Every day probably. I have bor- rowedthepolesforNordicwalkingthere.’(B)Previous researchhasshownthatvisitorswithimprovedhealth asanexpectedbenefitaremorelikelytoengageinsuch activities(Kohetal.,2010;Kucukustaetal.,2013).We mightstipulateherethattheexpectedhealthbenefits werealsothemainmotivationalfactorfortheiractiv- 86 | AcademicaTuristica,Year15,No.1,April2022 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy ityintheirfreetime.However,theinterpersonalcon- text seemed to have played the most important role here. Itisimportanttostressthatthepatientswhohad manysocialcontactsduringtheirrehabilitationwere morelikelytoengageinphysicalexerciseintheirfree time.Thisconfirmspreviousresearchconclusionsthat social capital has an important impact on the physi- cal activity of older adults (Chen et al., 2019): ‘I had freetimeintheafternoon,butluckily,Ifoundagroup ofwomen,myroommateamongthem,andwealways wenttothepoolintheafternoon,andwealwaysdid additionalexercisesinthepool.’(P) Oneoftheprocessesofincreasingthephysicallit- eracylevelsofthepatientsisalsothelecturesorgan- ised for all rehabilitation patients. Patients see these lectures as educative and the information as appli- cable in everyday life. Lectures cover vastly different topics,suchascommonmedicalprocedures,healthy diet,medicalconditions,andsuitableexerciseforthe patients: ‘There they tell which sports are most suit- able for you, which sports are the biggest burden for kneejoints,whattheyadviseyoutodo,whichsports are not advised, and so on.’ (N) With these lectures, healthresortstrytodirectlyincreasethephysicallit- eracyleveloftheirpatients;previousresearchhasalso indicated the efficiency of combining patient educa- tion with a spa treatmenton the health statusof the patients(Kamioka et al., 2006; Kamioka et al., 2009; Maitreetal.,2017;Zijlstraetal.,2005). All thepatientsstatedthatthey receivedanexer- ciseprogrammeatthespawiththemostsuitableex- ercisestoperformathome:‘Wealwaysreceiveanex- erciseprogrammeatthespa.Asinglepaper,whereall the exercises are written and shown with pictures as well,theonesthatweshoulddoathome.’(S)Medical personnelalsoprovideinformationconcerningevery- dayactivitiesthatareimportantforsuccessfulrehabil- itation, especially about how patients should behave after rehabilitation: ‘I could say that I learned at the healthresortwhatandhowIshoulddo,howtostand upfromthebed,howtoliftthings,whichmovements Icanmake,whichIshouldavoid.[...]Thephysician had said that I should avoid the movements that do notmakemefeelwell.AndthatIwasnotallowedto lift things.And thatI should avoid cycling, the most recommended is walking and the exercises they had givenme.’(F) ExperiencesaftertheMedicalRehabilitation Analysisof the transcriptsrevealedthatinterviewees couldbe dividedintotwogroups:thosewhocontin- uedwithexercise,whichhasbeenadaptedduetotheir health concerns, and those who omitted the exercise oncethepainhadreceded.Itisassumedthatthefirst groupalreadyhadhighlevelsofphysicalliteracybe- foretherehabilitation;however,theirknowledgehas expanded,whichisvisiblebytheirappropriatemodi- ficationoftheexercisesaftertherehabilitation. Patientsareinstructedtokeepperformingsuitable physical exerciseat home afterleaving the healthre- sort.Someinterviewees,especiallythosethathadre- cently returned from the health resorts or those that still endure pain due to their health condition, fol- lowtheseinstructionsastheyseehowregularexercise benefits their health condition: ‘The most I remem- beraretheexercises,Istillperformthem,andthisis visibleonmymusclemass.’(N) Alarming information is that quite a few inter- viewees have admitted neglecting the physical exer- cise, especially those whose rehabilitationtook place a longer period ago: ‘I must admit, and I think that the same things can be said for other people as well, that I do these exercises for maybe three weeks and then theygoto oblivion.’ (S) The reasonsfordiscon- tinuingthephysicalexerciseareusuallylack oftime, equipment,ormotivation:‘Ihavemanystepsatwork, andthatisenoughforme.[...]Theyhavealsoadvised goingtofitnesstoperformtheexercises,butIdonot havemoneyortimeforit.’(D)Thesefindingsimpli- cate that the motivation dimension did not develop tosuch anextentasit didforsome patients,andthe strength of the habit of physical exercise diminishes overtime.Whilepatientswerestayingatthehealthre- sort,theywereengaginginphysical exercisebecause it was expected of them; therefore,the rehabilitation served as external regulation. The environment also playsavitalroleincontinuingtheexercisesoncethe patientsleavetheresortaspeopleathomeusuallydo not have suitable equipment. Additionally,the home AcademicaTuristica,Year15,No.1,April2022 |87 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy environmentisnotasmotivatingasthehealingenvi- ronmentatthehealthresort.Itis,however,visiblethat theintervieweesareawareoftheneedforperforming thephysicalexerciseandthebenefitstheywouldgain. Thus, the knowledge and understanding dimension hasevolvedduringtherehabilitation:‘Iamawarethat I should perform these exercises as they specifically target the knee, but so far there is no need for this’ (D). Theanalysisrevealedthatpaincouldalsobeamo- tivatorforstartingto exerciseagain:‘When it strains me,thenIexercise[...]EvenifIgoforawalkinthe morning, it is a little better. Now, when I feel that it startstohurtmeagain,Idosomeexercise,andithelps.’ (D).Incontrast,theabsenceofpain,whichisthepri- marygoalofmedicalrehabilitation,affectsthecontin- uanceofphysicalactivityasitwasbeforethemedical procedure:‘Iamalsoaswimmer.Beforetheproblems withmykneestarted,Iwentswimmingeverydayfor thelastsixyears.Ihavereallymissedit.Icouldn’tgo swimmingforalongtime.ButIhavetobecarefulnow asIamnotallowedtobendmylegs;Imustswimwith straightlegs.Itwasalittleharderatfirst,buteventu- ally,Igotusedtothis.’(N) Furthermore, the analysis revealed that only one healthresortinvitesthepatientstoanadditionalmed- icalexaminationaftertherehabilitation.Thepurpose ofthisexaminationistheobservanceoftheirrehabil- itation process over a more extended period. ‘When youfinishyourrehabilitation,afteronemonth,Ithink [...] I even had an appointment, you could go back thereforacheck-up[...]AsIheard,theyputyouin one room, and then they force you to perform some exercises to see your improvement in comparison to theresultswhenyoufirstcamethere.’(E) Manyintervieweesadmittedthateventhoughthey discontinuedtherecommendedphysicalexercise,they remainedphysicallyactiveinotherways.However,the choiceofsportsthattheyperformhaschangeddueto theirhealthcondition:‘Ialsochangedthesportsactiv- ities,nowIcycleandplaytenniswhilepreviouslyIwas playingbasketballandfootball,butnowthesetwoare toostrainingforme.’(L)Encouragingisthefactthat especiallythepeoplewhohavealreadybeenphysically active before the rehabilitation continued this habit andalsoincludedthenewexercisesthattheyreceived atthehealthresortandincorporatedthemintotheir daily exercise regime that targets other parts of the body:‘Ihavealsobeenpreviouslygoingtothework- outforosteoporosisandcoronarydiseases,soInotdo onlyexercisesforthekneebutalsofortheupperpart ofthebody.Itrytocombinetheseexercisesintheway Ifeelithasthemostpositiveeffectonmycondition.’ (O)Thisbehaviourindicatesthehighlevelsofphys- ical literacy among some patients. For the execution ofcombiningdifferentexercises,highlevelsofalmost alldimensionsofhealthliteracyareneeded,especially thehigh-levelcompetenceandwell-establishedsense ofself. Limitations Thefirstlimitationofthestudyisthereflectionofthe smallsampleandasnowballsamplingtechnique.Sec- ondly,duetothecharacteristicsofthesample,which consistedmainlyofolderadultsthathaveundertaken medicalrehabilitationatthehealthresort,thefindings andproposedimprovementsmaybe relevantonlyto this particular population. Additionally, most of the patientsofthehealthresortsdonothavehighmedical knowledgelevels,which mayreflectthebiased opin- ions,whichcouldhavebeenexpressedintheintervie- wees. Duringthetimeoftheresearch,theSlovenetour- ismindustrywassignificantlyimpactedbythe covid- 19crisis.Consequently,theremightalsobealimitation inthepotentiallygreaterfocusoftheintervieweesto- wardsmoresocially desirableanswersin theformof expressing one’s concern for health and physical ac- tivity due to the general concern over health in the covid-19crisis.Futureresearchshouldconsiderhow thesetrendswillshiftandtheroleofinterpersonalin- fluence,forexample,viafocusgroupsinspecifichealth resorts,whichwaspreventedduetocurrentcovid-19 measures. FutureRecommendationsandResearch Encompassingallfindingsfromthisstudy,thephysi- calliteracymodel forolderadultswasappliedtothe case of medical rehabilitation at Slovenian health re- sorts (see Figure 2). As rehabilitation at the health 88 | AcademicaTuristica,Year15,No.1,April2022 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy Policy Community Organizational Interpersonal Intrapersonal LifecourseContinuum HealthInsuranceInstituteofSlovenia asfundingmechanism. Naturalandbuiltenvironmentatthe healthresort. Physicaleducationaspart ofrehabilitation. Socialcontactsatthehealthresort (personnel,family,otherpatients). Improvedmotivation,competence, knowledgeandunderstanding. Activeageingpolicy(cooperationbetweenHealth InsuranceInstituteofSloveniaandhealthresorts). Localenvironmentthatencouragesphysicalexercise(e.g., opengyms)andpromotinglocalhealthpromotionevents. Obligatoryandtailoredphysicaleducation atallhealthresorts. Organizedpublicgroupactivitieswithtailored promotionforolderadults. Additionalfollow-upexaminations,healthcoaching andgamificationforolderadults. Possiblefutureinnovationdirections Figure2 PhysicalLiteracyModelforOlderAdultsbyJonesetal.(2018)AppliedtotheRehabilitationProcesses atSloveneHealthResorts resort is not enough to improve physical literacy, it is crucial to highlight possible solutions for positive long-termbenefitsaftertherehabilitationexperience. This issue shouldbe theobjectiveof interjoiningthe efforts of stakeholders from the tourism, healthcare and local development sector. Innovative solutions thatwill targettheimplementingofexerciseindaily habits,takingintoconsiderationthedifficultiesofthe oldergeneration,areneeded.Herewediscussfivein- terrelatedareasconnectedtothedomainsofthephys- ical literacy model for older adults for the future of innovative development of health resorts in collab- oration with the public health care system and local governance. First, intrapersonal elements of the model are re- lated to the definition of physical literacy by White- head(2010).Theanalysisoftranscriptsindicatesthat, primarily,thecompetencedimensionofphysicalliter- acyis targetedas patientslearn,practice,andpartic- ipatein physical activitiesthatarebeneficial fortheir rehabilitation, and additionally, the participants re- ceive information about suitable exercise and sports options. The educational lectures also targetthe mo- tivationandunderstandingdimensionsincetheben- efits of physical exercise are heavily implied (White- head,2010). Thefactthatmanyintervieweesgraduallyomitted their physical activities in their everyday lives repre- sentsanimportantchallengetofurthertargetthemo- tivationdimensionofphysicalliteracy.Aspatients,the intervieweessawphysicalexerciseasanobligationas partoftherehabilitationprocess.Atthehealthresort, itwasassociatedwithapartoftheroutineprescribed byaphysician,andtherewasastrongsocialelement toparticipation.Incontrast,physicalactivityathome wasseenasaworkorpersonalcareexperience,and therewerevariousnegotiatingconstraints. A possible solution for extending the motivation that could lead to implementing an exercise habit is additionalfollow-upexaminationsthatwouldinform thepersonabouttheresultsoftheirrehabilitation.If the participation in this examination was somewhat connectedtotheadditionalofferofthehealthresorts (for example, a short package including some thera- pies),thehealthtourismindustrywouldbenefitfrom thisaswell. Apossiblefuturesolutionisalsotheintroduction of extensive health coaching otherwise used to pro- mote healthy behaviour and achieve health-related goals (Palmer et al., 2003). Health coaching can be used in both a rehabilitative (Kivelä et al., 2014; De- jonghe et al., 2017) and preventive setting (Olsen & Nesbitt, 2010). Some patients expressed satisfaction withindividualphysicalregimes,especiallywhenthe sametherapistsupervisedthemduringtherehabilita- tion. Therefore, the individual approach is preferred AcademicaTuristica,Year15,No.1,April2022 |89 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy among the elderly population. Health coaching has alsoadaptedtothedigitalera,meaningthatthecoach- ing is executed through mobile apps, often with the optionforuserstochoosetheirhealthcoachesbased on personality matching and expertise from health coachbiographies(Duschaetal.,2018)andsupported by remote activity monitoring with technology solu- tions(Kitsiouetal.,2017).Tailoringcoachingstrate- gies is crucial for the long-term effect of coaching as many factors influence an individual’s motivation (Beinemaetal.,2021). Another future direction is increasing intrinsic motivation via various elements of making the exer- cise afun activity, such asgamificationin the health tourism industry. Gamification reinforces and im- proves behaviours and user capacities, focusing on learning and health (Kasurinen & Knutas, 2018). In the context of digital health, gamification is typically employedinhealthandwellnessappsrelatedtoself- management, disease prevention, medication adher- ence,medicaleducation-relatedsimulations,andsome telehealthprogrammes.Gamificationcouldpositively affecthealthandwell-being,especially whenapplied inaskilledway(Johnsonetal.,2016),evenonseniors (Koivisto&Malik,2020;Martinhoetal.,2020).Al- thoughgamificationisapossible solutionforengag- ingpeopleinphysicalactivity,itisimportanttoadapt games to the older population’s needs, the predomi- nantsegmentsofusersatthehealthresorts(Gerling &Masuch,2011). Second,interpersonalelementsthatinfluencephys- icalliteracyareformalandinformalpersonalrelation- shipsoftheelderlypopulation,bothformedwithinthe rehabilitationexperienceandbeforeandafter.Social benefitswereasignificantelementforparticipantsto engageinphysicalactivityatthehealthresortduring their free time. The majority of participants in this studywerevisitinghealthresortswiththeirfamilyor friends or have developed a social relationship with otherpeoplealsoundertakingtherehabilitation. Enjoymentandsocialinteractionorenablingpeo- ple to perceive their physical activity experiences as leisure might be the key to increasing participation inphysicalactivity.Facilitatingincidentalphysicalac- tivity associated with but not the focus of a pursuit appearstobeanessentialdimensioninachievingthis (Sibsonetal.,2010).Consequently,localandregional communities should further aim to provide multiple socialgatheringsthatconnecteldersandatthesame time incorporate physical activity tailored to their needs, such as public group exercises and organised hikes(Wardetal.,2020).Manyassociationsorganise such activities in Slovenia, yet the older population often does not know about these options, especially thosewith lowertechnologicalliteracylevels.There- fore, the goal should be creating such activities and findingtherightpromotionchanneltoreachthede- sired audience. This could also be an opportunity to establishfruitfulcooperationsbetweenhealthresorts, thehealthcaresystemandlocalmunicipalitiesinaway thateachpartnerprovidessuitableresources(forex- ample,knowledgeorfinancialresources). Third,theorganisationalcomponentofthemedi- calrehabilitationatthehealthresortistheeducational lectures organised for all the patients. Our findings currentlyindicatethatsomehealthresortsdonotof- ferthese lecturesat all, while othersprovide lectures thatcovervastlydifferenttopics.Someofthemaretar- getedtothegeneralpublic,andtheprovidedinforma- tion tends to be directly helpful for all the listeners, whileothersmaynotbehelpfulforallofthevisitors even though it expands their general health knowl- edge(forexample,apersonwithaskindisorderlisten- ingtoalectureaboutthereplacementofheartvalves). Thesolutiontothisissuecouldbechangingthesub- ject according to the current audience (such as con- tentspecificallydesignedforpatientswithlocomotory problems)or putting morefocus on contentapplica- ble forallguests(such asahealthydiet).Despite the factthateducationisoneofthebasicservicesincluded in rehabilitation treatment,and as such, should be a mandatorycomponentofanytreatment,itiscurrently consideredonlyasasupplementtothebasicservices. Therefore, medical treatment with a focus on health promotionmight,andshouldbe,acrucialcomponent of the continuum of medical therapy (Gutenbrunner etal.,2010). Fourth,communityelementsofthehealthresorts relatedtothephysicalliteracymodelforolderadults arethebuiltandnaturalenvironment.Ahealingand 90 | AcademicaTuristica,Year15,No.1,April2022 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy easily accessible environment was a vital contributor toparticipatinginphysicalactivityduringrehabilita- tionattheresort.Theoptionsforphysicalactivityin thehealthresortswereaccessible,andtheywereeasy andconvenientforpeopletouseandengageinphys- ical activity. The naturallandscape andits developed components(i.e.availabilityofwalkingpoleshire,use of walking paths, availability of walking tours) and theirpromotionatthehealthresortwereallmanaged toencouragephysicalactivity. To extend the habits connected to physical exer- cisetotheperiodafterrehabilitation,thecommunity- level government should focus on providing a local environment that encourages physical exercise, and is readily available and appropriate for older adults. Building open gyms and other similar facilities and healthprogrammesthatwouldbefreeforeverybody could stimulate the older population to use these fa- cilities. First, they wouldbe close to their home, and second,usagedoesnotmeananyadditionalexpenses. Additionally, such facilities are often already suitable for the needs of elders and allow them to adjust the intensitytotheircondition. Finally,as medical rehabilitationis funded by the Health Insurance Institute of Slovenia, it is a vital, if notthemostimportant,partofthepolicydomainof thephysicalliteracymodel.Thefindingsofourstudy suggest that certain services that are part of medical rehabilitation at the health resort contribute to the higherphysicalliteracylevelsofthepatients.However, thisisnottheprimarygoalofrehabilitation.Whilethis system is beneficial and has existed in Slovenia for a longtime,itishighlystrainedduetothelargershare oftheolderpopulation.Applicationoftheprocedures of curative medicine in the healthsystem due to the lengthening of life expectancy might not be enough. Forthatreason,applyingawiderangeofhealthpro- motion activities on this basis appears to be an es- sential element of the national health policy to limit the risk of disease. Most importantly, health resorts mightprovehighlybeneficialinthepromotionofac- tive ageing long before there is the need for curative medicalrehabilitation–anareawheretheHealthIn- suranceInstituteofSloveniaandSlovenianhealthre- sortsshouldbuildstrongcooperationinthefuture.An importantdirectionmightbethenewinnovativeap- proachoftheso-called‘tourismcoupons’introduced bytheSlovenianMinistryofEconomicDevelopment andTechnologyasoneofthemeasuresforsupporting thetourismindustryatthetimeofthe covid-19pan- demic.In2020,adultSloveniancitizensreceived200 eur couponstospendattourismfacilities,healthre- sortsincluded;in2021,eachadultwaseligiblefor100 eur. Future analysis of the role of these coupons for Slovenianhealthresortsisneeded. Conclusion Overall, this study provided many insights into the perceptionof rehabilitationatSlovenehealthresorts. Thefindingscanbeapplicabletothefieldofhealth tourism and can be used in the medical and health- carefieldsofresearch.Furthermore,theseresultscan alsobeappliedtorehabilitationpatientsandself-paid servicesofhealthresorts(suchasvarioushealthpack- ages)asthetargetpopulationdoesnotvastlydifferen- tiate.The covid-19pandemicaffectedtheperceived health-relatedriskoftravelling(Turnšeketal.,2020) andcausedredefiningprioritiesofthepopulation andhighlightedhealth-relatedissues.Theongoingre- search by the Slovenian National Institute of Public Healthshowsthatthe covid-19pandemicnegatively influences the daily physical activity of Slovene citi- zens(NationalInstituteforPublicHealth,2021).The findingsofthisresearchsignificantlycontributetothe understandingofphysicalliteracy,whichwillbemore actualinthenearfutureasindividuals’physicalliter- acylevelsarecrucialforestablishingahealthylifestyle. This research, conducted qualitatively, provided insights into the phenomenon of medical rehabilita- tionat healthresortsanditslong-termeffectiveness. Consequently,itsfindingscouldserveasthebasisfor creatingaquestionnaireasaquantitativemethodthat would allow us to gather information from a large audienceandperformstatisticalcorrelationanalyses. Furthermore,togainmoreinsightfulresultsaboutthe researched phenomenon, a future study should fur- ther involvethe longitudinal aspect, for example,via thediarystudymethod,inordertogainmoreaccurate informationasinthepresentstudy,theaccuracyofthe resultsheavilyreliesonthememoryoftheguests. AcademicaT uristica,Y ear15,No.1,April2022 |91 KatjaKokotandMajaTurnšek HealthTourismandPhysicalLiteracy Theresearchhashighlightedmanyopenquestions thatshouldbeaddressedinthefuture.Thefirstishow to secure the individualisation of physical education atthehealthresortsbasedonpatients’healthcondi- tions. The current findings imply that some patients received information that cannot be applied in their everyday lives due to their health status. Additional research is needed to be able to fully understand the roleandeffectofthelecturesreceived.Anotheropen questionhasarisenafteranalysisofthetranscriptindi- catedthatthepatients’levelofphysicalliteracybefore the rehabilitation might affect their physical activity afterreturningto the home environment.While this researchhasnot measuredtheir level of physical lit- eracybeforetherehabilitation,itwouldbesuitableto include thismeasurementinfuture researchtomake more reliable conclusions. Finally, the role of the so- called ‘tourism coupons’ for the Slovenian health re- sortvisitorsshouldbeanalysed,andthestudyoftheir futureimplementation,withpotentialcooperationof theHealthInsuranceInstituteofSlovenia. References Almond,L.(2013).Whatisthevalueofphysicalliteracyand whyisphysicalliteracyvaluable?JournalofSportScience andPhysicalEducation,65,35–42. 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