Climatic Elements as Development Factors of Health Tourism in South Serbia

Abstract

The area of Southern Serbia is the most undeveloped tourist area and is marginalized in relation to the total tourist traffic of Serbia. With the purpose of health tourism development, special attention in this paper is focused on five spas and four mountain tourist destinations of South Serbia. The interaction of climatic elements is key for outdoor tourist activities, thus the potential of health tourism is presented through the results of the tourism climate comfort index (TCCI). According to TCCI values calculated for one climatological period 1991–2020, the spa tourist destinations of South Serbia are generally favorable during May, June and September. Four studied mountain destinations have favorable TCCI values generally during June, July and August. Spatio-temporal analysis utilizing ESRI ArcMap software showed that the most favorable conditions for health tourism development occur during spring and autumn for spas (May and June) and during summer for mountain destinations (July and August), which coincides with the ideal TCCI values. MatLab software through linear regression showed that in the period of 2010–2020, a negative tendency of tourists’ number in Vranjska banja spa and Niška banja spa is noticed, and a positive tendency for Prolom banja spa and Sijarinska banja spa. The paper also highlights the perspectives of other tourism forms of development in South Serbia.

1. Introduction

According to the definition of the United Nations World Tourism Organization (UNWTO), health tourism is one of the tourism forms implying tourists travel to use natural resources, the primacy of climate and mineral waters (spa places), in order to improve their general, mental and physical health. However, numerous authors in their tourism studies point out that this definition is very narrow because it highlights the climate and mineral springs as the main factors in health tourism development. In addition to climate and mineral resources, the development of health tourism can be influenced by mountains, lakes, rivers, forest ecosystems and other natural attractions. Certain types of health tourism are medical and wellness and spa tourism. Medical tourism implies traveling to access medical treatments and provide medical assistance in the treatment of diseases. Wellness and spa tourism is focused on the prevention and improvement of the general health of tourists using medicinal (curative) and other tourist content [1].

According to Kaspar, health tourism is the sum of all relationships and phenomena resulting from the short-term change in the location of people’s residence (staying in a place that is not their place of permanent residence or a place where they work) in order to promote, stabilize and, if necessary, return to physical, mental and social well-being through the use of health services [2].

Alfier emphasizes the inextricable connection between health and tourism, stating that health is one of the oldest, strongest and most permanent motives for travel, and that tourism, in almost all of its forms, more or less always has a health function [3].

Basically, health tourism implies touristic travel and activities of individuals in order to satisfy physical, emotional, psychological and intellectual health, which increases satisfaction with life, happiness, social and emotional well-being. With intensive urbanization, industrialization and increasingly frequent stressful situations that people encounter in everyday life, people are showing a more pronounced aspiration to escape to nature, relax and use health tourism products [4].

Goodrich and Goodrich [5] and Hall [6], point out in their research that health tourism arose as a result of certain tourist centers (mountain, seaside, spa) attempting to attract tourists intentionally by promoting their health services, in addition to already existing tourist content.

The SPA center became a common synonym for spas, which is basically an acronym of Salus Per Aqua (health with the help of water), whereby the accent is on the use of healing water and mud (peloid) for medicinal (curative) purposes. Smith and Kelly [7] emphasize that the most important thing for the development of health and wellness tourism is to present to the tourist the overall natural beauty and highlight the health characteristics and services of the tourist destination. Goeldner [8] distinguishes five basic components of health tourism, where each of them determines the specificity of the tourist market, namely: activity in the sun and entertainment; involvement of healthy activities (walking, hiking, swimming, cycling), but health is not the main motive of these activities; traveling, the main motive of which is health due to change of climate; traveling because of saunas, massages and other activities that are applied in spas (spa centers); health treatments.

For Mueller and Kaufmann [9] wellness and spa tourism is a subcategory of health tourism, which they define as a set of all relationships and phenomena arising from the travel of people whose main motive is to preserve and improve their general health. They require a comprehensive service package that includes professional knowledge, fitness, cosmetic care, healthy nutrition, relaxation or meditation, physical and mental activity and education.

At certain tourist destinations, the improvement of health tourism content is of crucial importance. A touristic offer and the potential of health tourism would attract tourists and make the destination competitive. Strategically, it would be more important to target a group of older tourists burdened with stress, who want to escape from everyday urban life, improve their physical and mental health, and at the same time have free time and financial resources for wellness and spa relaxation. Lee, Han and Ko [10] concluded in their research that tourists cited as the most important factors of health tourism healthy organic food prepared in a traditional way, and physical activities associated with walking and hiking (on forest trails and routes), mountain climbing and with swimming. In the same research, the authors point out that health tourism is very important for the proper development of the so-called “social health”, which means that tourists who use the health tourism program feel very comfortable and happy in the group of tourists they are traveling with, establish close social relations with them and, through conversation and laugh, strengthen their mental health.

There are two types of health tourism consumers who have a similar or the same way of meeting their health needs. The first type represents, in the narrower sense, health tourism consumers (traditional spa tourism) who basically need natural medicinal springs, medical infrastructure and professional staff to meet their health needs. The second type represents, in a broader sense, health tourism consumers (preventive tourism) who, in addition to natural medicinal springs, require other types of activities to preserve, improve and promote their health. The second type of health tourism consumers are more mobile, play sports and recreation, often visit local manifestations and cultural and historical monuments and are interested in local traditions and gastronomy. Based on the above-mentioned, Hrabovski Tomić [11] defines health tourism as “a form of tourism that is undertaken with the aim of promoting, stabilizing and, if possible, restoring physical and mental well-being with the help of natural medicinal (healing) factors, health services, sports, recreational and wellness content, implying that the consumers do not have a permanent residence in that location”.

In Serbia, the development trend of health tourism has been linked to classic spa tourism for decades. In addition to the medical components paid for by the state health system (treatment and rehabilitation (rehabilitative, curative and preventive)), health tourism (in Serbia) implies the components of relaxation and recreation, entertainment, sports and healthy food that are also consumed by healthy people who pay for spa vacations on their own [11].

Despite numerous definitions from authors who have been researching health tourism as one of the biggest phenomena of the tourism industry for decades, they generally agree that the climate is the main factor for choosing a health tourism destination. The first research about the climate role in the tourism development of a certain destination appeared in 1923 in the works of Houghten and Yaglou [12], in the studies of Bedford in 1968 [13], then in the studies of Fanger [14] in 1973. According to their research on the influence of solar radiation, insolation, air temperature and wind on human metabolism, the first coefficients and indexes indicating the climate influence on people (humans) were defined. Based on them, further research on the climate impact on humans and on tourism development was later built on.

Lin et al. consider that the relationship between climate, weather and tourism demand is underexplored and pointed out that several recent studies had investigated climate as a basic factor for attraction and repulsion of a certain tourist destination. Their empirical results discovered tourists’ shifted behavior after the emergence of the COVID-19 pandemic underlining a preference for visiting tourist destinations with greater climate differences and the adaptation of modern tourism markets to tourists with pronounced anxiety [15].

Yang et al. emphasize the essential importance of combining microclimate with fresh air in tourist offers creation on the market, especially in severely air-polluted areas such as China. In a practical sense, the redistribution of the microclimatic factors would represent an important indicator of the health tourism market creation and development [16].

Fadafan et al. created a naturalness map for ecotourism development for one region of Iran using the Geographic Information System (GIS). The approach developed in their study is flexible because the criteria were based on topographical and climatic conditions [17].

Schmude et al. examined six spa and health Alpine destinations and concluded that they are extremely heterogeneous destinations where health tourism plays a role with varying intensity. They underline that each destination must clearly define individual measures and directions of future tourism development in order to establish a recognizable touristic offer. In this way, the tourist destination would get a position on the market based on its health care competence while adding health methods to the touristic offer (forest bathing, yoga, anti-stress courses). They also tackled marketing and concluded that it should be focused on the tourist destinations development based on scientific studies and evidence-based research [18].

Mieczkowski [19], de Freitas [20] and Mills, Roth and Lecomte [21] introduced parameters for the determination and evaluation of the human’s body subjective feelings, i.e., the comfort index that is applicable to different tourist destinations.

The tourism climate comfort index is a very effective method for the assessment of the climate elements’ competence as a condition for tourism development. Competence is based on the comfort and feeling of the human body’s pleasantness to certain climatic conditions with outdoor activities [22].

Yang et al. also give a multidimensional index that connects the fresh air index with the natural microclimate comfort index from transdisciplinary and multidisciplinary perspectives [16].

Gao et al. point out air quality for the tourism climate suitability assessment of Chinese coastal cities. They developed a coastal tourism climate index including five variables—thermal comfort, sunshine, precipitation, wind and air quality. This study gives theoretical direction for sustainable tourism marketing and management in Chinese coastal cities and suggests future research on climate assessment for destinations with serious air pollution [23].

Lukić et al. highlight the fact that climate affects the appropriateness of tourist destinations and the estimation of tourists’ flow because the climate creates different conveniences for the tourists’ activities. They made the tourism valorization of climate importance using the tourism climate index and tourism climate comfort index. The tourism climate index valorizes climate according to the two bioclimatic and three individual climatic elements. The tourism climate comfort index gives information about when the climate is most favorable [24].

The purpose of this paper is to investigate the health tourism potential for five spas and four mountain tourist destinations in South Serbia (Prolom banja spa, Sijarinska banja spa, Niška banja spa, Vranjska banja spa, Bujanovačka banja spa and Vlasina Lake, mountain Kukavica, Suva Mountain and mountain Besna Kobila) through the results of Tourism Climate Comfort Index (TCCI). This paper also examines the tourism development trend and tourist traffic in South Serbia for Prolom banja spa, Sijarinska banja spa, Niška banja spa and Vranjska banja spa.

2. Materials and Methods

2.1. Case Study Region

The spatial framework in this paper is South Serbia, with an area of 263.942 km², which spreads between the state border with the Republic of North Macedonia in the south, mountains Bukovik, Poslonjske and Mojsinjske in the north, the Jastrebac Mountain in the northwest, the state border with the Republic of Bulgaria in the east, to the Kopaonik slopes and the border with Kosovo and Metohija in the west. As stated by defined borders, South Serbia is located between 43°47′11″ and 42°15′20″ north latitude and 20°58′22″ and 22°31′60″ east longitude. According to the determined coordinates and mathematical geographical position, South Serbia spreads in the central part of the Balkan Peninsula and includes the upper and middle parts of the South Morava River basin and the upper part of the Rasina River basin. Administratively, South Serbia is divided into four districts: Nišava, Toplica, Jablanica and Pčinja District. The geographical position of South Serbia is presented in Figure 1 [25].

There are numerous natural resources (mountains and mineral springs) on the territory of South Serbia, representing the basis for the development of health and medical (SPA) tourism. However, despite the exceptional natural potential, tourism development has been unfairly neglected in the area of South Serbia, and so far, no serious research on the influence of climatic elements on tourism development has been undertaken. Assuming that climatic elements (air temperature, relative humidity, precipitation, insolation and cloudiness) are key factors for a person’s pleasant feeling at the destination, in this paper climatic elements are analyzed for the period 1991–2020, with the aim of a properly defined strategy for future tourism development and recognition of South Serbia as a destination with serious potential for the development of health tourism.

For the purposes of this paper, in order to facilitate the analysis of the influence of climatic elements on health tourism development, the research of the tourism climate comfort index for 5 spas (Vranjska banja spa, Niška banja spa, Sijarinska banja spa, Bujanovačka banja spa and Prolom banja spa) and 4 mountain (Kukavica, Besna Kobila, Suva Mountain and Vlasina Lake on the Vlasina Plateau) tourist destinations in Southern Serbia were undertaken.

Vranjska banja spa is located at 42°33′11″ north latitude and 21°59′19″ east longitude at 400 m above sea level and is framed by the range of mountains Besna Kobila, Veliki Pešter, Patarica and Srpska Čuka. Administratively, it belongs to the municipality of Vranje (Pčinja District). Vranjska banja spa has an exceptional traffic and geographical position because it is 2 km away from the international road E-75 which connects Belgrade with Thessaloniki. Vranjska banja spa boasts four large hyperthermal sources of geothermal water of different temperatures and compositions, with a total yield of 6–44 L/s and this makes it the hottest spa in Serbia and Europe only to be matched by the Icelandic geysers. The two hottest springs in Vranjska banja spa are named “Velika česma” having water temperature of 92 °C and a flow rate of 35 L/s and “Hot Spring” having a water temperature of 82 °C and a flow rate of 60 L/s. In addition to these, there are also: “Gvožđeviti izvor” with a water temperature of 61 °C and “Izvor u potoku” with a water temperature of 86 °C. Aside from water springs, there are also wells, namely A-1, A-2, VG-2 and VG-3. According to tests conducted so far, the total yield of wells totals up to 60 L/s. The water temperature of the VG-2 well is 95 °C with a yield of 27 L/s. In 1985, a temperature of 99 °C was measured at the seventh meter of a well. It is estimated that the total yield of the source of hyperthermal waters of Vranjska banja spa totals 80 L/s. According to their chemical composition, all sources are alkaline-saline, dominated by sodium carbonate, and almost all of them have neutral reactions. The gas composition is dominated by nitrogen, with over 70% [26,27].

Bujanovačka banja spa, also known as Bujanovački kiseljak, is located at 42°27′10″ north latitude and 21°45′05″ east longitude and belongs to the municipality of Bujanovac (Pčinja District). It is located between the Kozjak and Rujen mountains at 395 m above sea level. It is 3 km northeast of Bujanovac and 13 km south of the town of Vranje. The geothermal waters of the Bujanovačka banja spa are colorless, with a temperature of 32–44 °C, and a yield of 5–6 L/s. According to the chemical composition of the waters of the Bujanovačka banja spa, they are sulfurous and belong to the category of sodium-hydrocarbonate fluoride, sulfate and carbonic acid waters. The medicinal waters of the Bujanovačka banja spa are used by bathing, sprinkling or after certain cooling, drinking for the treatment of gynecological, rheumatic, cardiovascular diseases, digestive organs and digestive tract and neurological diseases, conditions manifested after surgical procedures, dermatological diseases (eczema and psoriasis). In addition to the thermal mineral healing springs, the Bujanovačka banja spa is known for its healing mud (peloid) of volcanic origin and natural healing gas [26,27].

Prolom banja spa is located in the south of Serbia at 43°02′10″ north latitude and 21°24′03″ east longitude at an altitude of 550–668 m, at the foot of the Radan Mountain. Administratively, it belongs to the municipality of Kuršumlija (Toplica District). Prolom banja spa has a moderately continental climate with subalpine variations because it is surrounded by mountains with an average height of up to 1000 m. Therefore, Prolom banja spa is both a balneological and climatological place. Natural mineral water with a temperature of up to 29 °C and a yield of up to 11 L/s contains ozone and silicic acid, with a pH value of 8.5–9, thus it belongs to the group of highly alkaline waters. Prolom banja spa water is bottled and used for drinking in the treatment of chronic diseases of the kidneys, urinary tract, stomach, gastritis and intestines [26,27].

Sijarinska banja spa is located in the south of Serbia at 42°46′23″ north latitude and 21°36′05″ east longitude. It is located at the foot of the Goljak mountain at an altitude of 520 m. Administratively, it belongs to the municipality of Medveđa (Jablanica District). Sijarinska banja spa is located on the banks of the Jablanica River and has 18 sources of mineral water whose temperature ranges from 32–72 °C. Sijarinska banja spa is renowned and famous for its hot water geyser, which erupts every 10 min and ejects a jet of hot water at a height of 8 m. The mineral water of Sijarinska banja spa is used in the treatment of the musculoskeletal system, lung and gynecological diseases, pancreatic diseases and diabetes, neuroses and psychological diseases [26,27].

Niška banja spa is located at 43°17′37″ north latitude and 22°00′09″ east longitude at an altitude of 248 m. Administratively, it belongs to the Nišava District. Koritnik, 808 m high, rises above Niška banja spa, which is a branch of Suva Mountain. It is 9 km from the city of Niš and is located not far from the main road Niš-Sofia. There are 5 sources of medicinal water in Niška banja spa with a temperature of 39 °C to 28 °C, namely: “Glavno vrelo” with a flow rate of 50 L/s, “Suva banja” with a variable flow rate of 14–48 L/s, “Školska česma”, “Banjica “ and “Pasjača”, of which “Glavno vrelo” and “Suva banja” are hot radioactive springs. Indications for treatment in Niška banja spa are: severe cardiovascular diseases, rehabilitation after orthopedic procedures, diseases of the respiratory system, sterility and conditions after damage to the central nervous system. Treatment in Niska banja spa is carried out by bathing in warm radioactive water, inhaling and drinking mineral water with the use of kinesis and electrotherapy and peloid (mud) therapy [28].

The Vlasina Lake is located in the central part of the Vlasina Plateau at 42°42′00″ north latitude and 22°20′00″ east longitude. It was created in 1949. when the “Vodojaža” dam was built on the Vlasina River. At the highest water level, the lake’s altitude is 1213 m. Extreme water amplitudes of 10 m occur when water is released from the lake for the operation of the “Vrla I-IV” hydropower plant system, the surface of the lake is 16.5 km² with an average depth of 10.4 m. The Vlasina Lake administratively belongs to the municipality of Surdulica (Pčinja District) [29].

Mountain Kukavica is located at 42°47′28″ north latitude and 21°56′47″ east longitude. With the highest peak of Vlajna at 1442 m above sea level, the mountain Kukavica extends along the left bank of the South Morava River and belongs to the group of Old Boulder Mountains. The valley of the Golema reka divides the mountain into two parts, the northern part, which is impassable and uninhabited, and the southern settlement, which is suitable for the construction of mountain lodges, ski and recreational trails, etc. Mountain Kukavica administratively belongs to the municipalities of Vladičin Han (Pčinja District), Leskovac and Vučje (Jablanica District) [29].

Suva Mountain is located 43°10′57″ north latitude and 22°10′16″ east longitude. Suva Mountain belongs to the Carpathian-Balkan group of mountains. It is found in altitude zones from 250 m to 1810 m above sea level. At the foot of Suva Mountain are 6 basins, which highlights the possibility for mutual development of sports-recreational, mountain and health tourism. Suva Mountain administratively belongs to the 5 municipalities: Niška banja, Gadzin Han (Nišava District), Bela Palanka, Babušnica (Pirot District/ East Serbia) and Vlasotince (Jablanica District) [29].

Mountain Besna Kobila is located at 42°31′46″ north latitude and 22°13′50″ east longitude and belongs to the Rhodope mountain system, thus exhibiting great tourist potential for the development of health tourism. The entire mountain is spread over the territory of the Pčinja District, where it administratively belongs to the municipalities of Vranje, Bosilegrad and Surdulica. Mountain Besna Kobila, with the highest peak of the same name at 1922 m, is the highest mountain in Southern Serbia, and is characterized by vertical climatic zoning. The foothills and lower parts of the mountain are under the influence of a moderate continental climate, while the higher parts and peaks of the mountain are under the influence of a mountain climate. At the foot of the mountain, there are only a few small rural settlements: Kriva Feja, Ploča, Musul and Crni vrh, which are mostly inhabited by Serbian elderly people. Above the village of Kriva Feja there is the mountain lodge Besna Kobila [29].

2.2. Climate as a Development Factor of Health Tourism in South Serbia

Climate is one of the most important natural–geographical elements for the development of health tourism. Having in mind that the climate is affected by the relief that changes with the increase in absolute elevation, data in the literature highlight terrains in the range from 300 m to 800 m above sea level as suitable for health tourism development [30].

The area of South Serbia is characterized by a very divided relief, alternating between plains and basins (valleys) from 300 m to high mountain peaks over 1900 m above sea level. Such a complex composition of the terrain had an influence on the forming of the climate with several varieties. The largest part of South Serbia is characterized by a temperate continental climate, while in its southwestern parts varieties of continental and Mediterranean climates occur. The main characteristics of this climate are warm and dry summers, with mild and snowy winters, which is of great importance for the development of several forms of tourism. South Serbia has an average of 123 rainy and 43 snowy days. Average air temperatures vary depending on elevation. The warmest month is July with an average air temperature of 22 °C for elevations below 300 m, and 11 °C for elevations above 1000 m. Terrains up to 1000 m above sea level receive an annual amount of precipitation from 540 mm to 820 mm, terrains above 1000 m above sea level from 950 mm to 1000 mm, while some mountain peaks receive over 1500 mm of precipitation, mostly in the form of snow. Insolation in the area of South Serbia ranges from 1500 to 2200 h per year, and the dominant wind is southern with an intensity slightly less than 3 Beaufort [25,31].

2.3. Methodology

Mieczkowski was the first person who defined a generally accepted formula for calculating the tourism climate comfort index for outdoor activities [19]. However, the authors [32] gave a new formula that is more favorable to climate comfort for inhabitants of temperate climates. According to them, the tourism climate comfort index is calculated according to the following formula:

TCCI = T_m + 0.5 A_Tm + 0.1(S_m − U_m) − n_rd

(1)

where: T_m—mean monthly air temperature (°C), A_Tm—monthly amplitude of air temperature (°C), S_m—monthly insolation or duration of sunshine (hours), U_m—average monthly air humidity (%) and n_rd—number of rainy days in each month [32].

Based on the presented formula, the same authors established a new scale of tourism climate comfort index shown in

Table 1. Scale of tourism climate comfort index [32].

Value of Index	Rating	Description	Purpose
below 0	VERY UNFAVORABLE	unpleasant and unfavorable	“snow“ activities
0–20	UNFAVORABLE	partly pleasant and favorable	excursions
20–30	FAVORABLE (between 24 and 28 VERY FAVORABLE)	pleasant and favorable	all tourism activities (except snow and extreme activities)
30–40	UNFAVORABLE	partly pleasant and favorable	recreational water activities (coastal, lakeside, spa tourism)
over 40	VERY UNFAVORABLE	unpleasant and unfavorable	sunbathing, bathing (coastal tourism)

.

The main advantage of TCCI is providing an objective and simple overview of the relationship between climate conditions and tourist activity. The application of TCCI in temperate climate zones is very effective for the planning of tourist activities where the high frequency of extreme climatic phenomena is not expressed [32].

TCCI values have a pleasant or unpleasant effect on the human body during health tourism activities. For this reason, the values of TCCI can be used in determining strategic guidelines for the development of health tourism, thus structuring mountain and spa climatic health resorts, pedestrian health stations and rehabilitation centers.

According to the definition of the World Meteorological Organization (WMO), one climatic period lasts 30 years. For this reason, the climatological elements data for the area of South Serbia for the period 1991–2020 were considered in this paper. At the studied tourist destinations in South Serbia, there are temporary meteorological stations, so additional climatological elements data were obtained by using PVGIS-SARAH2 (Photovoltaic Geographical Information System). PVGIS is an important tool that estimates the dynamics of the correlations between solar radiation, climate, atmosphere, the earth’s surface, and photovoltaic technology [33,34], but also gives elevation (altitude) and air temperature values for specific locations [35].

In order to observe more clearly the distribution of TCCI values with the increase in elevation for 5 spas and 4 mountain destinations in South Serbia, a spatio-temporal analysis for 4 seasons was performed, which is represented by a map created in ESRI ArcMap software.

Geostatistical CoKriging analysis utilizing ESRI ArcMap software was used to create the map showing TCCI values trend according to elevation for all four seasons for 5 spas and 4 mountain tourist destinations in South Serbia. The term kriging is closely related to the correlation of two different variables, where in our case a correlation (geostatistical analysis) was performed between the TCCI values according to elevations with the input of coordinate points for 5 spas and 4 mountain tourist destinations in South Serbia. In this way, a spatio-temporal image of the distribution of TCCI values for South Serbia was obtained for the period 1991–2010, i.e., for one climatological period of 30 years.

For the presentation of the tourist traffic flow at the tourist destinations of South Serbia, MatLab software R2013a was used. Matlab is powerful software package for scientific computation tasks and visualization. Linear regression is performed using the built-in Matlab function “fit”. In our case, using linear regression we were able to infer the trend in the number of tourists in the period from 2010 to 2020, for Vranjska banja spa, Niška banja spa, Sijarinska banja spa and Prolom banja spa. The reason for this is the unavailability of official statistical data on tourist traffic for the other studied tourist destinations of South Serbia, more specifically for Bujanovačka banja spa and mountains Kukavica, Besna Kobila and Suva Mountain. This represents a serious limitation for further research and the analysis of the possible future tourist development of the South Serbia area.

Local development of South Serbia can be additionally improved by linking health tourism with renewable energy usage [36]. In order to consider the potential of 5 spas and 4 mountain destinations in South Serbia as possible sustainable tourist destinations, their photovoltaic (PV) potential was estimated by using Global Solar Atlas [37].

3. Results and Discussion

3.1. Theoretical Implications

The literature review in this paper showed that in scientific circles interested in studying the TCCI influence on meeting human tourist needs, their choice of destination and, in general, the development of tourism has occurred for a long time. In accordance with similar research, our work deals with the presentation of TCCI results for five spas and four mountain tourist destinations in Southern Serbia using the meteorological data of the Republic Hydrometeorological Service of Serbia and PVGIS, with the application of ESRI ArcMap and MatLab software packages for spatio-temporal analysis and linear regression. In this way, our study represents empirical research created by the mutual integration of wider methodological approaches. Thus, the importance of favorable TCCI values of the studied destinations of Southern Serbia was highlighted, all with the aim of tourism development and their inclusion in the tourism market of Serbia and the region.

Schmude et al. point out that the study of changes in climatic elements is very important for the beginning of the valorization of destinations that are still in the shadow of tourist flows [18]. Guided by their perception of the touristic development of health destinations, in our work we approached empirical research on the influence of climatic elements through the TCCI results for the health tourism development in five spas and four mountain destinations in Southern Serbia. Given that the studied destinations are still outside the intensive tourist flows in Serbia and the region, and the work is based on empirical research, we can freely promote them in terms of marketing as ideal for a combination of health and tourism offers based on the combination of the use of healing water, mud, walking along mountain paths of health, etc.

3.2. Practical Implications

Based on the definition of the area, subject, goal and time frame of the research, the results of the obtained values of the tourism climate comfort index for five spas and four mountain tourist destinations in South Serbia are presented (

Table 2. Tourism climate comfort index for 5 spas and 4 mountain tourist destinations in Southern Serbia for the period 1991–2020.

Tourist Destination	Elevation (m)	Month
		I	II	III	IV	V	VI	VII	VIII	IX	X	XI	XII
Prolom banja spa	560	−11.21	−5.82	4.51	12.19	22.06	28.25	39.64	40.02	29.75	17.29	0.24	−9.11
Sijarinska banja spa	520	−12.13	−6.74	3.58	11.27	21.14	27.33	38.72	39.10	28.83	16.37	−1.16	−10.03
Niška banja spa	248	−13.67	−6.01	4.41	12.45	19.90	24.91	33.99	34.19	23.86	13.54	−3.84	−14.17
Vranjska banja spa	400	−10.62	−3.57	7.36	15.31	24.21	33.36	45.04	44.34	31.92	18.97	0.29	−11.91
Bujanovačka banja spa	395	−11.41	−4.37	6.56	16.11	25.01	34.16	45.84	45.14	32.72	19.77	1.09	−12.71
Vlasina Lake	1191	−17.85	−12.32	−2.47	7.53	18.52	25.33	34.14	32.28	11.98	0.32	−8.98	−16.04
Mountain Kukavica	990	−14.80	−12.48	0.89	6.54	17.53	23.83	30.83	28.98	10.05	5.15	−2.02	−15.33
Suva Mountain	860	−14.64	−11.95	1.53	7.12	18.32	24.18	31.38	28.55	9.32	4.14	−5.64	−13.67
Mountain Besna Kobila	1310	−18.23	−19.98	−9.34	−1.02	9.24	16.24	25.11	26.66	7.66	2.58	−4.46	−17.93

). By a precise input of the coordinates in PVGIS-SARAH2, the altitudes of the studied tourist destinations were determined [35]. However, in order to encourage the tourism valorization of South Serbia, for the mountain tourist destinations that are discussed in this paper, we have defined the closest altitudes of those places that have the most predispositions for the development of health, rural, mountain and sports-recreational tourism (touristic spots). The Vlasina Lake is in the village (settlement) of Vlasina Rid at 1191 m above sea level, which administratively belongs to the municipality of Surdulica (Pčinja District). Vlasina Rid is currently the only settlement in the vicinity of Vlasina Lake and the Vlasina Plateau that has the largest number of tourist accommodation capacities. For the mountain Kukavica, the villages of Srneći Dol and Kostomlatica in the municipality of Vladičin Han (Pčinja District) were defined as tourist spots. Their average elevation is around 990 m. Suva Mountain is one of the most undeveloped mountain tourist centers, although at its foothill there are numerous settlements that could become serious tourist destinations, namely: Sopotnica, Veliki Vrtop, Gornji Dušnik, which administratively belong to the municipality of Gadžin Han (Nišava District). Their average elevation is 860 m. For the mountain Besna Kobila, as a tourist spot, we have defined the village of Kriva Feja (Pčinja District) at 1310 m above sea level, with the Mountaineer Lodge in immediate proximity.

Based on the obtained data on climatological elements for a thirty-year period and the application of Formula (1), the results of the tourism climate comfort index for five spas and four mountain tourist destinations in Southern Serbia are presented in the following (Table 2).

For an easier perception of tourism climate comfort index values trends given in Table 2, the following TCCI trends are presented graphically for five spas and four mountain tourist destinations in Southern Serbia (Figure 2).

According to the results from Table 2 and Figure 2, it can be concluded that the tourism climate comfort index values are negative from November or December to February for spa tourist destinations, and from March or April for mountain destinations. Despite the negative values of the TCCI, all studied destinations have exceptional conditions for the development of health tourism in combination with mountain trails, wellness and spa services in spa centers, relaxation and anti-stress treatments. Depending on the TCCI in the studied tourist destinations of South Serbia, in addition to health tourism, which is primary, other forms of tourism can be developed, which will be proposed in the following text. When we compare the TCCI values from Table 2 with the TCCI scale given in Table 1, for spa tourist destinations, the tourism climate comfort index values range between 20 and 30 generally in May, June and September, which represent months with very favorable and comfortable conditions for people and outdoor activities, while the values in July and August are generally between 30 and 40 which represent months with partly pleasant and favorable conditions for tourist activities on the water. In May, the TCCI value for Niška banja spa is 19.90, which is very close to the threshold value of 20. In June and September, TCCI values for Vranjska banja spa (33.36 for June and 31.92 for September) and Bujanovačka banja spa (34.16 for June and 32.72 for September) are slightly higher than the threshold value of 30. TCCI values of up to 20 occur in spa centers during the spring and autumn months when the conditions are favorable for the development of excursion, hiking and picnic tourism. There is an interesting deviation at Prolom banja spa, Vranjska banja spa and Bujanovačka banja spa in July and August with TCCI values over 40 when there are unfavorable conditions for outdoor activities and direct exposure to solar radiation. These TCCI values affect the reduced feeling of pleasantness and comfort, which is of great importance for planning tourist movements due to worsening summer conditions. It can be observed that the TCCI is increasing in the first half of the year for all destinations, reaching peak values in July and August. It is evident that the Bujanovačka banja spa and Vranjska banja spa have the highest TCCI values in almost every month of the year. In addition to that, the order of other destinations sorted by TCCI value is more-or-less the same for each month (monthly values). The exception is Vlasina Lake sharing 5th and 6th place in July and August, but the last place in October and November.

TCCI values for four studied mountain destinations of South Serbia are between 20 and 30 generally during June, July and August, making the mountains pleasant and stimulating destinations with ideal climatic conditions for the development of health tourism, relaxing and strolling (walking). In June, only Mountain Besna Kobila (16.24) has the TCCI value lower than 20. In July, TCCI values for Vlasina Lake (34.14), Mountain Kukavica (30.83) and Suva Mountain (31.38) are higher than 30, and in August, only for Vlasina Lake (32.28). In the winter months with negative TCCI values, it is possible to develop sports and recreational activities on the snow in the mountains, which is an interaction with health tourism. Vlasina Lake is the highest lake in Serbia and in addition to the extraordinary conditions for health tourism, it is possible to develop bathing and nautical tourism in combination with water sports in July and August when the TCCI values are above 30.

It is very important to note that TCCI values between 24 and 28 imply the most favorable conditions for outdoor tourist activities and at the same time comfortable feeling for tourists [32]. Based on this statement, and according to the analysis from Figure 2, it can be concluded that the most favorable conditions at the spa tourist destinations of Southern Serbia generally occur in May, June and September. Sijarinska banja spa (27.33) and Niška banja (24.91) have the most favorable conditions in June, and Vranjska banja spa (24.21) and Bujanovačka banja spa (25.01) in May. The most favorable climatic conditions on the Suva Mountain (24.18) and at Vlasina Lake (25.33) are in June, and on the mountain Besna Kobila in July (25.11) and August (26.66). For all tourist destinations in South Serbia, it is noted that the most favorable TCCI values are in June, hence it can be concluded that in June, the first maximum of comfort occurs. In addition to June, favorable TCCI values occur in August and September, thus the second comfort maximum is registered in August and September.

Empirical research of TCCI for tourism development of the Danube region in Serbia [24] largely coincided with our empirical research of TCCI for Southern Serbia. According to both studies, the maximum TCCI values on the TCCI scale (Table 1) occur during summer, when conditions are favorable for outdoor tourist activities (water activities, swimming, sunbathing, lake activities, nautical and spa tourism), and the most optimal values of this index and comfort feeling usually occur in spring and May. In our research, negative TCCI values are in November, December, January and February, and in [24] research, negative TCCI values occur in November, December and January. In this regard, the Danube region has favorable climatic conditions for the development of many forms of tourism, but as it is a plain terrain, it is not possible to develop winter/ski tourism, which is not the case with Southern Serbia, keeping in mind that in our work we studied four mountain destinations. In Southern Serbia, in contrast to the Danube region, it is possible to develop winter sports and recreational tourism, because the negative TCCI values in the winter months on the mountains indicate the existence of snow cover that remains for a long time.

The results of empirical research on TCCI values for the territory of Serbia from 2016 [32], TCCI values for the Danube region in Serbia from 2021 [24] and our latest TCCI values results for South Serbia from 2022 can be of great help in creating a tourism development strategy, building tourist infrastructure, finding proper direction towards the affirmation of tourist resources for the purpose of sustainable development and creating strong marketing in order to create competitive tourist destinations on the market.

Yang et al. consider that the redistribution of microclimatic factors would represent an important indicator of the creation of the health tourism market [16]. Such a new understanding could easily be applied to the area of South Serbia, which is territorially small with a characteristic microclimate and at the same time with preserved primary natural resources, given that it has not yet entered mass tourist flows as a destination. From that point of view, it is still possible to shape the destination of South Serbia according to the modern tourist demand for new and specific forms of tourism, i.e., it is possible to simultaneously develop health, ecological, mountain, hunting, swimming, nautical tourism and camping. For the above-mentioned reasons, our work represents the basis and example for future interdisciplinary and multidisciplinary research of new and specific forms of tourism in undiscovered destinations in Serbia and the Balkan Peninsula.

TCCI values during the year for five spas and four mountain tourist destinations in Southern Serbia are directly related to the increase in elevation, which can be clearly seen in Figure 3.

Figure 3 clearly shows that the most favorable conditions for health tourism development occur during spring and autumn for spa destinations (May and June) and during summer for mountain destinations (July and August), which coincides with the ideal TCCI values (between 24 and 28) from Table 2. Keeping in mind that Prolom banja spa is located at a higher elevation than other spa destinations in South Serbia, certain characteristics of a mountain tourist center can be observed during the winter for Prolom banja spa. Vranjska banja spa, located at the foothill of the mountain Besna Kobila, shows similar characteristics. If an interaction between outdoor sports and recreational activities with wellness and spa services in hotel complexes were created, during the winter months Prolom banja spa and Vranjska banja spa would represent a serious competitive tourist destination in the South of Serbia with an emphasis on health tourism.

In order to properly understand and analyze the TCCI values of tourist destinations, it is very important to determine their tourist traffic, or perform a comparative analysis to confirm for which TCCI values tourist traffic decrease or increase. Thus, tourism development creators and tour operators could express seasonality and announce which seasons are the most favorable for certain forms of tourism [38]. Guided by this, in our work we analyzed tourist traffic using linear regression, but only for four spa destinations in Southern Serbia with available statistical data.

Although the obtained TCCI values for five spas and four mountain tourist destinations in Southern Serbia (Table 2) show exceptional opportunities for the development of health and other forms of tourism, statistical data on tourist traffic in this area show tourist stagnation and an unbalanced flow. The unfavorable trend of tourism development in Southern Serbia can be clearly seen in Figure 4, where the linear regression of tourist traffic for Vranjska, Niška, Prolom and Sijarinska banja spas is presented.

Linear regression on the example of four spa destinations in Southern Serbia (Figure 4) proved that tourist traffic is not always necessarily conditioned by favorable TCCI values. Blue circles represent the data points, while the red line is the corresponding linear approximation. A negative tendency of the number of tourists in Vranjska banja spa and Niška banja spa over the last decade can be observed, and a positive tendency for Prolom banja spa and Sijarinska banja spa. The dependency is closest to linear for Vranjska banja spa and farthest for Prolom banja spa, where we observe large fluctuations in the number of tourists over the years. Additional regression data is shown in

Table 3. Coefficients of determination with confidence intervals for linear regression for 4 spa destinations (Vranjska banja spa, Niška banja spa, Prolom banja spa and Sijarinska banja spa).

	Vranjska Banja Spa	Niška Banja Spa	Prolom Banja Spa	Sijarinska Banja Spa
p1	−447.2	−813.3	169.9	235.9
p1 (conf. int.)	(−598.8, −295.6)	(−3720, 2093)	(−259.9, 599.8)	(31, 440.8)
p2	904,800	1,651,000	−327,200	−468,700
p2 (conf. int.)	(599,400, 1,210,000)	(−4,205,000, 7,508,000)	(−1,193,000, 538,900)	(−881,600, 0–55,870)
R2	0.8319	0.0426	0.0816	0.4298
p-value	0.0000912	0.542	0.394	0.0285

. The regression equation is $Number\_of\_tourists=p_1\cdot Year+p_2$.

According to these values, we can see that there is a significant dependence (with 95% of confidence) for Vranjska banja spa and Sijarinska banja spa (p-values are smaller than 0.05).

Although the Vranjska banja spa has approximately 2 months with the most favorable TCCI values, conditions for tourist activities and comfort feeling, it records a negative tendency of tourist visits and a drop in tourist traffic, from 6262 tourists in 2010 to 1536 in 2020 [39], which represents a drop of 75.4%. Niška banja spa recorded 21,049 tourists in 2010, and 1377 tourists in 2020 [39], which represents a drop of 93.4% (the largest drop in tourist traffic for the entire studied period). Such a sudden drop in tourist traffic in the studied destinations is not due to the COVID-19 pandemic. Even more, in Serbia, since 2020, tourist traffic has grown by 63% compared to the years before the pandemic. The reason for this drastic drop in tourist traffic is the inappropriate privatization of foreign investors in already-existing over-extensive hotel accommodation facilities, which were destined to be completely closed. Especially in the Pčinja District, the existing structure of accommodation capacity is beyond all modern tourist flows, which cannot boast either quality or quantity. It is the first and basic indicator that shows that this part of Southern Serbia is the least valorized in terms of tourism compared to competing tourist destinations in Central and Western Serbia. Without sufficient accommodation capacity or developed tourist infrastructure and superstructure, any tourism development is not possible, regardless of exceptional tourist values [40]. When it comes to Niška banja spa, apart from the Special Hospital and Hospital for Cardiovascular Diseases, tourist accommodation takes place in the city of Niš, which is 9 km away.

On the other hand, Prolom banja spa and Sijarinska banja spa (Toplica and Jablanica District) each have one month close to or with ideal TCCI values (between 24 and 28) and both record an increase in tourist traffic by about 10% during the observed period, which is a consequence of the enrichment of tourist content at the destination itself. Due to bad weather conditions and unfavorable TCCI values for outdoor tourist activities during the winter months, Prolom banja spa and Sijarinska banja spa had to enrich the tourist content within their accommodation complexes in the form of wellness and spa services, numerous events, congress gatherings and gastronomic competitions. In this way, Prolom banja spa and Sijarinska banja spa increased the number of tourist visits and evened out tourist traffic throughout the whole year.

In addition to health tourism potential, South Serbia has good photovoltaic potential. Four spa and four mountain destinations in South Serbia have favorable mid-range photovoltaic power output (PVOUT) values (between 3.5 kWh/kWp and 4.5 kWh/kWp). Only one spa destination (Sijarinska banja spa) has a lower PVOUT value (3.4 kWh/kWp) that is still acceptable for PV development [37].

The usage of PV technology, as one of renewable energy technology, can make a noticeable contribution to spa and mountain destinations of South Serbia to become sustainable tourist destinations and upgrade local community development.

4. Conclusions

Health tourism is one of the largest tourism forms in recent years and it basically implies tourist travel and activities of individuals in order to satisfy physical, emotional, psychological and intellectual health, which increases satisfaction with life, happiness and social and emotional well-being.

Although the territory of South Serbia has numerous natural resources representing the basis for health and medical (spa) tourism development, spa resorts and mountain centers have not been used and valorized according to their health tourism potential. Staying at these destinations and health tourism are offered to guests as a complementary form of tourism due to the lack of marketing, accommodation capacity, medical equipment and professional medical and tourist staff.

The South Serbia area is characterized by a complex composition of the terrain, thus in the studied area, the climate has several varieties. The greatest part of South Serbia has a temperate continental climate, while in its southwestern parts varieties of continental and Mediterranean climates occur. The prime features of the South Serbia region climate are warm and dry summers, and mild and snowy winters, which is of great importance for the development of several forms of tourism.

In the studied area of South Serbia, special attention in this paper was focused on five spas and four mountain tourist destinations: Prolom banja spa, Vranjska banja spa, Niška banja spa, Sijarinska banja spa and Bujanovačka banja spa, mountain Kukavica, mountain Besna Kobila, Suva Mountain and Vlasina Lake on the Vlasina Plateau.

For the assessment of the climate element competence as a condition for tourism development, the tourism climate comfort index was introduced and calculated for five spas and four mountain tourist destinations in South Serbia. TCCI values were calculated for one climatological period 1991–2020, and it was concluded that spa tourist destinations of South Serbia are favorable generally during May, June and September. It was also concluded that mountain destinations of South Serbia have favorable TCCI values generally during June, July and August.

According to spatio-temporal analysis (presented in Figure 3) using ESRI ArcMap software, it can be concluded that there is a balanced relationship between the obtained TCCI values and altitude for the studied South Serbia destinations. The most favorable conditions for health tourism development occur during spring and autumn for spa destinations (May and June) and during summer for mountain destinations (July and August), which coincides with the ideal TCCI values.

According to the MatLab software R2013a linear regression results, it was concluded that in the period of 2010–2020, a negative tendency of the number of tourists in Vranjska banja spa and Niška banja spa are noticed, and a positive tendency for Prolom banja spa and Sijarinska banja spa.

Southern Serbia, as a destination that offers excellent opportunities for the development of health tourism, must present an original tourist offer on the market. In this regard, it is necessary to connect the health and medical functions of the spa and mountain centers of Southern Serbia with sports-recreational, excursion, congress, and event tourism. Additionally, the systematic development of the link between health tourism and renewable energy sources, such as PV technology, would make significant contribution for South Serbia to become a sustainable tourist destination.

Although the study and presentation of only nine destinations in Southern Serbia do not seem representative, this paper represents the foundation of future tourism research in this area. In addition to studying the health tourism potential of Southern Serbia based on TCCI values, future research should be also focused and based on the results of TCCI values for the development of other forms of tourism (sports, recreation, hunting, fishing, hiking, bathing, nautical tourism, etc.). As we mentioned earlier, the TCCI values have a great influence on the comfort feeling of the human body, and also on the choice and efficiency of outdoor activities, thus they represent a decisive factor for choosing a travel destination. In this way, it would also facilitate the understanding of climate change’s influence on tourism development.

The limitation of this paper is tourist traffic analysis only for four South Serbia tourist destinations (spa) out of nine for the period 2010–2020 due to availability limitations of statistical data. Thus, it was not possible to create a clear picture showing if the favorable TCCI values on the studied mountain destinations (and one spa destination) coincide with the values of the highest tourist traffic during the year, i.e., the seasonality of these destinations cannot be clearly defined.