1.Introduction

Health tourism is currently one of the fastest growing and emerging types of tourism, attracting increasing attention (^{de la Hoz-Correa, 2018}) and relevance in the tourism industry in the world (^{Majeed, 2018}). The phenomena of Hydrotherapy / SPA and tourism, coming from past times, with all its range of activities, have reached great strength in the present (^{Leandro, Nogueira, & Carvalho, 2015}). SPA tourism constitutes a tourist product away from mass tourism or overtourism (^{Fletcher R, 2019}). 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. Tourism experiences connected to water correlate positively with the perception of the quality of life, satisfaction, and loyalty of people both towards the experience and towards the destination (^{Campón-Cerro, Di-Clemente, Hernández-Mogollón, & Folgado-Fernández, 2020}). Health tourism in the EU is still a largely understudied and undocumented field in academic and professional literature (^{Mainil, 2017}). In Portugal, the “2027 Tourism Strategy” highlighted the thermal activity as a means of economic development of the country's regions (^{Araújo, 2017}). With regard to sustainability, the National Territorial Cohesion Plan includes as a measure “Revitalize spas and thermal tourism programs in Portugal” (^{Portuguese Republic, 2016}).

The industry's success is based on service and is directly linked to people's performance and their ability to deliver a unique customer experience that exceeds their expectations (^{Thavamin, 2016}). The new challenges arising from the pandemic require tourist units to adapt to this context, (^{Dryglas, 2020}), (^{Sigala, 2020}), (^{Boonon, Hongmo, Chandramani, Kongthing, & and Swangkong, 2020}). The success of a company´s competitive strategy depends on how it relates to its environment (^{Porter, 1980}). Fit drives both competitive advantage and sustainability (^{Porter, 1996}). All this uncertainty poses a tremendous challenge for strategy making. Sustainable competitive advantage no longer arises exclusively from position, scale, and first-order capabilities in producing or delivering an offering. Instead, it stems from the four organizational capabilities that foster rapid adaptation: the ability to read and act on signals of change; the ability to experiment rapidly and frequently; the ability to manage complex and interconnected systems of multiple stakeholders; the ability to motivate employees and partners (^{Reeves, 2011}).

Training can be assumed as the formal or informal process of acquiring knowledge or adopting attitudes and behaviors that are relevant to professional and personal activities (^{Camara, Guerra, & Rodrigues, 2013}). Recruitment and selection, training and skills development, performance management and evaluation, as well as Safety and Hygiene at Work are considered by the top managers as the most important (^{Costa, Oliveira, & Oliveira, 2021}). In Such a fast-moving, reactive environment, when predictions are likely to be wrong and long-term plans are essentially useless, the goal must be to engineer flexibility. Accordingly, planning cycles may shrink to less than a year or even become continual. Companies that correctly match their strategy-making processes to their competitive circumstances perform better than those that don´t. An adaptive strategy is more flexible and experimental and works far better in immutable environments that are unpredictable (^{Reeves M. L., 2012}). We can classify the situation as conducive to emerging strategies, these being the ones that most often generate radical innovations, emanating from organizations that emphasize experimentation and organizational learning, behaving like adaptive systems (^{Mintzberg, 1985}). The environment is also favorable to the emergence of innovations to improve product performance (^{Christensen, 2014}). Sanitation is the foremost concern (^{Tang, 2021}), complementing efforts adapting facilities to attract and accommodate commercial guests and international tourists (^{Smith, 2021}). The pandemic and the social disintegration it unleashed forced companies to accelerate digital media (^Kotler, 2021).

In Portugal there are 47 thermal establishments in operation, mostly concentrated in the North and Center of the country. Regarding the number of clients, the well-being and leisure theme was concentrated in the most marked share (66% of the total). 69% of customers looking for spas for treatments are 65 years or older. The foreign market accounts for 12.4% of global demand for the thermal units, with Spain, France and the United Kingdom taking the top spots (^{Turismo de Portugal} - Direção de Gestão do Conhecimento, 2021).

On 11 March, ²⁰²⁰, WHO declared pandemic situation (^WHO, 2020). Initial containment measures prevented the exponential growth of the epidemic curve (^{Breitenbach, 2020}). Social distancing measures had an immediate impact on the demand for tourism. Uncertainty, fear and lack of confidence may lead to a protracted crisis in the sector, which is a major concern for a country where tourism-related activities account for 8 per cent of GVA and 9 per cent of employment (^OIT, 2020). The various countries looked for lessons and looked at the implications for each other (^{Sakellarides, 2020}). All thermal establishments took the initiative to suspend activity in the second week of March 2020. After Lockdown units needed to adapt to restart. WHO has issued guidelines for post lockout phase (^WHO, 2020). The National Authorities did the same for general activities as well as for thermalism (^{Direção-Geral da Saúde}, 2020). These recommendations have been detailed and focused on various areas of their facilities, such as the admission of users; suspension of treatments; maximum frequency indicators of clients per treatment period/area. The hygiene procedures of the facilities and equipment. The hygiene protocol (pre and post-treatment) and the recommendations of social conduct of the spa were also reinforced. The spa units resumed activities between 06/15 and 08/11, 2020, with the intensification of hygiene and cleaning precautions recommended by the General Health Directorate (DGS, 2020) of Portugal, in order to minimize the risk of contagion by COVID-19.

Based on quarantine measures, travel bans and border closures in most of Europe, which accounts for 50% of international tourism, developments in Asia and the Pacific, and the patterns of previous crises (2003 SARS and 2009 global economic crisis) the World Tourism Organization (^UNWTO) estimates that international tourist arrivals could decline by 20% to 30% by 2020 translating into a loss of $300 to $450 billion in international tourism receipts (exports) - almost a third of the $1.5 trillion generated globally in the worst case scenario (UNWTO, 2020). However, a crisis scenario also enables the emergence of new opportunity scenarios, with the adoption of sustainable tourism development policies and solutions (^{Pinos Navarrete & Shaw, 2021}). The current pandemic can generate a situation that allows the adoption of other tourism development models that are closer to the sustainability capacity. In this way, the challenges facing the sector, such as tourism massification (^{Hall, 2009}), can be approached as an opportunity to promote tourism destinations that are weakened or undervalued. In this context, some research questions arise, which we seek to answer in our study with the aim of highlighting the role of spa tourism in health in Portugal within the current conjuncture of a global pandemic by Covid-19, analyse consumer behaviour as well as identifying suggestions for future research.

- What is the importance of providing security and confidence for the visit of units?

- Are there any differences in approach between public and private entities?

- Was there any difference between territories?

- What are the impacts in terms of training and skills development of Human Resources?

- What are the impacts in terms of marketing?

The objective for this work is to analyze how these units adapted to the current situation. Considering in terms of supply, the objective was to consider different perspectives. That is, not only if the adaptations were those resulting from the legislation in force, but in what dimensions they were made. Few studies have focused on the problems experienced in the spas in Portugal during the pandemic. In our analysis, we used a hypothetical-deductive process to verify possible answers to our questions (^{Coutinho, 2013}). This model defines the use of hypotheses as a decisive factor in solving the problem being investigated.

H1 - The adaptations were made by all units, providing security and confidence for the visitors.

H2 - Different territories act differently.

H3 - Human resources had to adapt to respond to new challenges.

H4 - Units carried out marketing efforts as consumer behavior changed due to the pandemic. The adaptations made will be permanent and intrinsic to the activity in the future.

2. Methods

Qualitative research is usually the preferred methodology when the content of the research is based on words, arguments, and the points of views of participants or interviewees (^{Orfy, 2010}). Also, bearing in mind that the topic is still new and evolving, it was deemed that adopting this approach would enhance the emergence of concepts and conclusions out of compiled data through the various stages of the research. We used mixed data-collection method with newspaper clippings, on-line resources and interviews published on the internet and newspapers. For the qualitative phase, the data were studied using both an inductive method and a content analysis method.

Figure 1: The structure of the resarch 

In the first phase of the article, a bibliometric analysis was performed, checking the articles published in the SCOPUS, WoS and Google Scholar databases (collected on 11/04/2021) through co-word analysis. From a series of options to choose the articles that guide the values and procedures in the areas of the SPA and health tourism, the keywords of “health tourism; covid-19; public health; Personnel Management; marketing; thermalism”, were used in the box “All”, adding to search “and”, which resulted in 2014 articles. For bibliometric analysis, study of the measurement of scientific and technological progress which consists of the quantitative assessment and analysis of intercomparisons of scientific activity, productivity and progress (^{Garfield , 2000}), VOSviewer (version 1.6.10, Leiden University, Leiden, Netherlands) was used to map and process the articles due to its reliability and adequacy in bibliometric analyses. In order to analyze the research interest in published articles, we investigated the title, abstracts and keywords of the articles included in our research in the SCOPUS, Web of Science and Google Scholar databases through co-word analysis. Co-occurrence analysis gives a graphical view of the interconnection of key terms in documents (^{Lind, 2000}). For the qualitative phase, the data were studied using both an inductive method and a content analysis method (^{Crowe; Inder & Porter, 2015}). In this way, researchers, academics, managers and others can benefit from the results arising from the evaluation in this area of research. The co-word study investigates the co-occurrences of keywords and identifies the relationships and interactions between the researched themes. It also emphasizes research trends and the most influential authors. The analysis creates a map that suggests the strength of the association between keywords in textual data. VOS Viewer software is an open-source tool used in co-word analysis to investigate the links between research teams and the most visible journals considering the number of published articles and the most used keywords in research (^{Centre for Science and Technology Studies,} 2021). The number of co-occurrences of two keywords corresponds to the number of publications in which the two terms occurred simultaneously (Van ^{Eck & Waltman, 2014}). The VOSviewer software, used for this analysis, offers an option to create a text file to perform vocabulary control - the thesaurus, i.e., it is possible to perform term substitution and exclusion (duplicity) (^{Hipp & Grupp, 2005}). This is a qualitative interpretation of the keywords included by the authors in the metadata of each document.

In the different stages that constitute a research project, one of the most tormenting for researchers is the selection of the most appropriate data analysis technique. The most known technique, and certainly the most explored by researchers, is Content Analysis (^Amado, 2017). In the instances of newer problems for which understanding needs to be developed, qualitative methods can offer critical insights (^{Strauss, 1998}). Given the circumstances, it was felt appropriate to take a qualitative stance of research (^{Kaushal, 2020}). In the next phase of the research, the sample consisted of 21 surveys (44.68% of the establishments in Portugal) using judgmental sampling, non-probability sampling based on representing samples of samples from the population of interest (^{Malhotra, 2017}) with individuals in senior positions because they have responsibilities during adversity, as they are faced with the immediate challenge of responding during adversity. The responses were transcribed without any alteration, only concealing the identities and the establishment belonging to the respondents before data analysis. It was deemed necessary to sample individuals in senior positions, because they are met with the immediate challenge of answerability during adversities. This also restricted the sample size, yet non-probabilistic nature of sampling rendered in the selection of most suitable candidates (^{Lee, 2014}). For the purpose of content analysis responses were read and re-read several times, by peers, to interpret variations and discern similarities and differences in the content. These variations and similarities resulted in several underlying sub-themes (^{Mazaheri, 2013}). Through the WebQDA software, the responses were coded/labelled to uncover the similarities, which turned out to be helpful in containing them under manageable heads. Encoding helped give the accumulated content some level of logic, and condensation brought precision. (^{Thyme, 2013}). The analysis was made considering public statements by representatives of 21 thermal units in mainland Portugal published in the media during the period of analysis (March 2020 to October 2020) (^{Grimmer, 2013}). Data analysis performed by WebQDA is like the basic structure of content analysis: it organizes the material to be analyzed (pre-analysis), codes and categorizes the studies and performs inferential interpretations based on the treatment of results. The public information sources were transcribed and, later, skimming was conducted in order to highlight the nuclei of meaning associated with the empirical categories already detected. The results found with the empirical categories were confronted with the analytical categories previously delimited by the theoretical referential concerning the health literacy construct. The amount of data collected and the need to discuss them with robustness required a software approach to support qualitative analysis, which provided the researcher more control over the material of analysis and more resources to answer the questions. Regarding the analysis of written productions, the data analysis procedure followed assumed an inductive character, and the categories were defined as the data were analyzed (^{Denzin & Lincoln}, 2003; ^{Richardson, 2003}). It was imperative to utilize an inductive approach, presenting observations and hypotheses to be tested in order to reach concrete results. We used Free Codes and Tree Codes. Each code lends itself as a coding category. In the case of tree codes, a category can be subdivided into other categories helping to organize the processes of processing and analyzing the data. (^{Machado, 2020})

3. Analysis and Results Discussion

A co-word analysis considers the dynamics of a field and identifies changes in a subject area. A search in the Scopus and Scholar Google databases for the keywords “thermalism, covid, sustainability” resulted in 104 articles. Three main clusters of terms were generated. The structure of the clusters was the following: Cluster I (4 items) cover issues related to the experience at the destination, Cluster II (4 items) contains thermal units issues and Cluster III (3 items) considers marketing issues (Table 1).

Table 1 Clusters of Keywords 

Figure 1 shows the keyword network for thermalism, based on co-occurrence. The main keywords used in the articles were Holistic experience; integrated model; management; tourist destination; Balneotherapy center; instrument; quality; self-monitoring; Impact; promotion; social media. Three main groups of keywords were detected by analyzing the co-occurrence of articles published on this subject (Figure 2).

Group 1 (green) is the largest, grouping 36% of the analyzed keywords. Group 2 (red) has the same percentage. In group 3 (blue), the percentage is 28%.

Figure 2: The structure of the clusters, developed by the authors in VOS Viewer software 

In Group 1, the proposition of the spa being a source of healing, translates the holistic experience that many seek. Certainly, the temperature of the waters, its components have several therapeutic functions (^{Maraver, 2003}). Although the healing effects are minimum and the benefits may be specific to certain cases one cannot disregard the gains regarding relaxation, healthy lifestyle and beauty treatments (^{Dryglas & Rózycki, 2017}). Group 2 (red) has a focus on quality, even presenting it as a key element for the demand for spa resorts (^{García-Altés,} 2005). Wellness and health are reflected within the context of quality and translate the demands of this audience (^{Erfurt-Cooper, 2009}). Marketing marks group 3 where one takes into account the high values that often restrict the demand for these spa resorts. In counterpoint, there is a growing demand for these types of establishments leading to supply management and the search for new treatments (^{Sziva et al., 2017}). Therefore, traditional patients become customers because they do not only use mineral-medicinal waters, but also demand other treatments that do not exclusively depend on this type of spa water.

Considering WebQDA analysis, we verify the current word cloud, where safety and treatments were considered as key elements. This analysis considered textual fragments that composed the corpus of research and whose presence or frequency of appearance brought meaning to the object of study (Figure 3).

Figure 3: Wordcloud, developed by the authors in WebQDA software 

H1 - The adaptations were made by all units, providing security and confidence for the visitors.

One of the most important ways to question the data is the use of arrays (^{Costa, 2018}). We analyze these key elements by region and by property, crossing the content analysis categories and subcategories with similar parameters. We considered the variables as type of entity, guidelines, security and trust. (Table 2)

Table 2 Type of Entity. 

Several adaptions were made, such as: prior appointment for consultations and treatments (^{Matrajt & Leung, 2020}), increased spacing between treatments (^{Ribeiro & Leist, 2020}) to give more time to disinfection; reduction of some treatments to reduce the risk (^{Singhal, 2020}). Portugal was the first European country to receive the "Safe Travel" award by the World Travel and Tourism Council. The Clean&Safe label, awarded to more than 9000 establishments, aimed to reassure visitors. As for the type of entity, there was no relevant distinction between the public and the private sector.

H2 - Different territories act differently.

The combination of health and well-being services with heritage elements, associated with the therapeutic use of water, can be complemented with the enjoyment of the environment and the rural landscape.(Table 3)

Table 3 Region 

All regions have behaved similarly in terms of complying with health organization guidelines, wearing masks, and seeking to give the customer more safety and confidence (^{Ivanova et al.,} 2020). The demand for destinations outside coastal areas, in contact with nature and in smaller tourist accommodation units, proves to be a trend that tends to persist. In this sense, there are strong opportunities to position themselves as healthy and wellness destinations. National tourism will gain emphasis, which will stand out against international tourism, with tourists preferring to travel within their own country (^{Brito-Henriques et al., 2020}). Domestic tourism will gain emphasis, which will bounce back against international tourism, with tourists preferring to travel within their own country (Brito-Henriques et al., 2020).

H3 - Human resources had to adapt to respond to new challenges

In early March 2020, the Spa prepared contingency plans, where procedures for action, prevention, care and surveillance were defined.(Table 4)

Table 4 Personnel Management 

Human Resources had to initiate on-the-job training. Human resources were essential for adapting spas to ensure strict safety and hygiene rules, as well as respect for physical distance. Currently, more than having technical skills, it is necessary to have socio-emotional skills, as feelings of fear, insecurity, anger, anxiety, and helplessness in the face of this virus are dealt with daily, including other personal and professional frustrations that impact behaviours and attitudes (^{Carballo et al., 2017}). The inclusion of human resource training promotes benefits among all involved, from customers (greater satisfaction and quality regarding the product and service provided), the organization (financial returns, competitive advantages, reduction of occupational accidents), as well as the employee (motivation).

H4 - Units carried out marketing efforts. The adaptations made will be permanent and intrinsic to the activity in the future, as consumer behavior changed due to the pandemic.

In terms of marketing and innovation, the biggest references are at the product level. (Table 5)

Table 5 Marketing 

Consumer behaviour changed due to the pandemic, and everyone needed to adapt to the circumstances as everybody is more cautious about the public health conditions of each site and the hygiene levels of the facilities. During this Covid-19 period, the sanitary conditions of the units are the main concern, as well as comfort, hygiene and hospitality, in an attractive environment, which allows the achievement of unique and personal experiences (^{Napierała et al., 2020}). We also see the use of influencers at marketing efforts. With the great impacts on companies due to the pandemic, it is necessary to reinvent oneself as an organization and adapt to this moment. With a totally challenging scenario, creativity is essential to circumvent the difficulties in the business (Kotler, 2017). ^{Xu and Lee (2020}) argue that the attributes on which customers tend to reflect their satisfaction in spa hotels correspond to the room, staff and service, location and access. ^{Miles et al. (2012}) further state that perceptions of cleanliness are associated with more positive perceptions of service quality and higher levels of satisfaction. Taking marketing as an example, at the North of Portugal a new brand was created: "Termas do Porto and North of Portugal". This is a product structured in a scenario in which the context of “health crisis favors the search for thermal treatments, wellness programs and the promotion of healthy lifestyles”, as well as for the promotion of health through the strengthening of the immune system. There are also innovation projects that will allow the creation of a range of products that are 100% Portuguese, innovative and sustainable, which will bring even more notoriety to the destination and to Portuguese thermalism in general.

4. Conclusion

Portugal has abundant thermal resources, in addition to a long tradition in their use. Following guidelines from health authorities the thermal units have adapted to reopen and resume operation. Measures were taken to ensure: easy access, in all areas, to the alcohol-based solution; prior booking of appointments and thermal treatments in person, in order to avoid having users in the waiting room; Removal of magazines, brochures and other objects from the waiting room that can be handled by several people; Reduction in the number of spa users so that the recommended physical distance of at least 2 meters between them is maximized; Organize schedules and circuits in order to avoid crossing people; Ensure adequate ventilation of all spaces; Reinforce cleaning and disinfection services in spaces and objects of greater contact and circulation. As well as other specific measures, such as, workers must travel with clothing and shoes for exclusive use.

The natural resources and cultural elements of the territory are crucial in developing this segment of the tourist market. Strategically, all the features that have made Portugal the best destination in the world for three consecutive years, at the World Travel Awards, are intact. The interest in health services for disease prevention, strengthening immunity and promoting healthy behaviors and lifestyle has seen a large increase and managers believe that it will continue to grow exponentially in the coming years. Sectors that used to work in physical interaction were forced to rethink their strategies, and the pandemic became a global accelerator of digitalization.

Enhancing thermalism is a necessity, with the priority of implementing programs to combat seasonality, articulating the development of health tourism with the improvement of quality of life, as consumers are increasingly looking for more sustainable experiences, rooted in authenticity and nature and that link them to the well-being of other people and the planet.

Most patients fully recover of Covid-19, but according to World Health Organization data, about 10% show systemic, respiratory, neurological, vascular, cardiac and gastrointestinal complaints (^{World Health Organization}, 2022). The spa and thermal units can respond to these sequelae, because are health care providers in most of the areas concerned, being prepared to care for patients in the current context. Results have confirmed that with safety and confidence, thermalism has a role in the future. The current context of the Covid-19 pandemic favors the use of spas for their curative aspect related to lung problems, post-disease. There are several opportunities for hydrotherapy and research associated with the sector. It is important to draw new lines connected to its potential role in accelerating healing and prevention of coronavirus. It is recommended that existing safety measures against Covid-19 be preserved to ensure the safety of guests and encourage sustainable development of spa regions. It is of great importance to conduct studies that can outline a governance model to increasingly ensure that spas are able to function, even in the face of crises such as the pandemic. However, the present research is not without limitations. The study focuses on spas located in some of the most expressive tourist destinations in Portugal and, therefore, the conclusions should not be extended to hotels in general. It is recommended to apply the methodology employed to other contexts, such as the restaurant sector, which was also greatly affected by the pandemic.