Measurement and Evaluation of the Development Level of Health and Wellness Tourism from the Perspective of High-Quality Development

Abstract

In recent years, with the dramatic surge in the demand for health and elderly care services, the emergence of the health dividend has presented good development opportunities for health and wellness tourism. However, as a sector of the economy, health and wellness tourism still faces numerous challenges in achieving high-quality development. Therefore, this paper focuses on 31 provinces in China and constructs a multidimensional evaluation index system for the high-quality development of health and wellness tourism. The global entropy-weighted TOPSIS method and cluster analysis are used to conduct in-depth measurements, regional comparisons, and classification evaluations of the high-quality development of health and wellness tourism in each province. The research results indicate that: (1) From a quality perspective, the level of health and wellness tourism development in 11 provinces in China has exceeded the national average, while the remaining 20 provinces are below the national average. (2) From a regional perspective, the current level of high-quality development in health and wellness tourism decreases sequentially from the eastern to the central to the western regions, with significant regional differences. (3) Overall, the development in the 31 provinces can be categorized into five types: the High-Quality Benchmark Type, the High-Quality Stable Type, the High-Quality Progressive Type, the General-Quality Potential Type, and the General-Quality Lagging Type. (4) From a single-dimension analysis perspective, there are significant differences in the rankings of each province across different dimensions. Finally, this paper enriches and expands the theoretical foundation on the high-quality development of health and wellness tourism; on the other hand, it puts forward targeted countermeasures and suggestions to help promote the comprehensive enhancement of health and wellness tourism.

1. Introduction

In March 2021, the European Commission announced the official implementation of the “Healthy EU Plan 2021 to 2027” to provide guarantees for promoting population health (https://health.ec.europa.eu/, accessed on 11 November 2023). In January 2023, the United Nations pointed out in the “World Social Report 2023” that the number of people aged 65 and above is expected to more than double by the middle of this century and that support should be provided to the global aging population (https://desapublications.un.org/, accessed on 12 November 2023). In the context of “enlarged health” and “population aging”, health and wellness tourism is a new format for the development of leisure tourism and has become a fashionable industry for the experience economy, leisure economy, and in regard to health and wellness.

The social demand for health and wellness tourism has unlimited potential and countries are actively taking measures to promote the high-quality development of health and wellness tourism. In order to promote the recovery of tourism and move towards the “Medical Center of the World”, in May 2020, the Tourism Authority of Thailand, the Ministry of Public Health, and other government departments, jointly launched the “Amazing Thailand Safety and Health Label Certification (SHA)” with private tourism organizations, establishing safety and health standards for Thailand’s tourism industry (https://www.tatnews.org/, accessed on 13 November 2023). The German National Tourist Office (DZT) has formulated a realistic inbound tourism recovery strategy, focusing on the development of digital tools, and its “Open Data and Knowledge Graph Project” began implementation in 2021 (https://www.germany.travel/, accessed on 14 November 2023). In November 2022, the World Tourism Cities Federation released a statement saying that Malaysia will promote healthy lifestyles and “eco-sustainable tourism” (https://cn.wtcf.org.cn/, accessed on 15 November 2023).

With the development of China’s economy and society, people’s living standards have gradually improved, and the national focus on health and physical fitness has continued to increase. Meanwhile, China has an aging society and the problems presented by aging are becoming increasingly severe. In July 2023, the China Tourism Academy pointed out in the “China Elderly Residential Health and Wellness Development Report” that aging will become a basic national condition for a long period in the future. According to the UN’s predictions, the number of elderly people over 65 in China will increase by 112.3% between 2020 and 2050, and the provisions in terms of elderly health and wellness tourism urgently need to be upgraded (https://www.mct.gov.cn/whzx/zsdw/zglyyjy/202307/t20230704_945588.html, accessed on 16 November 2023). At the policy level, in August 2022, the General Office of the Central Committee of the Communist Party of China issued the “14th Five-Year Cultural Development Blueprint”, which emphasized, in particular, the close relationship between tourism and modern lifestyles. It advocated for the acceleration of the development of health and wellness tourism and leisure vacation tourism and committed to establishing national health and wellness tourism demonstration zones (https://www.gov.cn/, accessed on 17 November 2023). In October of the same year, the 20th National Congress of the Communist Party of China emphasized positioning high-quality development as the core task of building a modern socialist country and clearly stated that achieving such a high standard of development is the fundamental requirement for practicing modernization that integrates Chinese characteristics. However, despite the rich experience accumulated in the field of health and wellness tourism throughout its long-term practice, the vision of high-quality development pursued has not yet been fully realized, urgently requiring joint efforts both within and outside the industry to advance it to a higher level of maturity. Based on this, this paper takes 31 provinces in China as the research object, using the global entropy-weighted TOPSIS method and cluster analysis to measure, compare regions, and classify and evaluate health and wellness tourism data from 2016 to 2022, aiming to address the following three questions: First, is there an imbalance in the development of health and wellness tourism among the provinces in China? Second, what are the development advantages and challenges faced by the provinces along the path to high-quality development? Third, how can existing policies be formulated or adjusted to promote a comprehensive upgrade of health and wellness tourism?

2. Literature Review

2.1. Connotations of High-Quality Development and the Construction of Multidimensional Indicators

Since the concept of “high-quality development” was proposed, scholars have begun to explore its connotations in-depth and have constructed corresponding indicator systems for measurement [1]. The core of high-quality development is to pursue high efficiency, fairness, and green sustainable development, aiming to meet people’s growing need for a better life [2]. Theoretically, it reflects the quality state of economic development, guided by new development concepts. Innovation is the core driving force of high-quality development, enhancing industrial competitiveness and the quality of economic growth through technological and institutional innovation. Coordinated development aims to reduce regional and urban–rural gaps, achieving regional coordination and integrated development. Green development emphasizes the balance between economic growth and environmental protection, promoting green technologies and industries to achieve ecological civilization. Shared development focuses on social fairness and inclusive growth, striving for equal access to public services and the improvement of people’s well-being [3]. Currently, scholars are exploring the construction methods related to evaluation indicator systems for high-quality economic development from various perspectives [4]. For example, one study constructed an action logic framework for high-quality development based on the characteristics of spatiotemporal evolution and safeguarding mechanisms [5]. Alternatively, a high-quality development evaluation index system consisting of 21 indicators was proposed, based on four dimensions: output scale, operational quality, social contribution, and green development [6].

However, existing research is still insufficient in regard to integrating the emerging field of wellness tourism into the high-quality development framework. Given the significant role of high-quality development in driving industrial integration through innovation, promoting local economic development, protecting the ecological environment, and enhancing people’s well-being, this paper will explore how wellness tourism can be integrated into the high-quality development framework in regard to the following four dimensions based on an in-depth review of the relevant literature: Firstly, from the perspective of innovation, wellness tourism needs to continuously introduce new concepts and technologies in the development of products and services to enhance tourists’ experiences and satisfaction [7]. Secondly, in terms of coordinated development, wellness tourism must be aligned with regional economic development, social development, and ecological environmental protection, forming a pattern in terms of multiple stakeholder participation to maximize comprehensive benefits [8]. Green development, as one of the core requirements of high-quality development, emphasizes that wellness tourism should focus on environmental protection and resource conservation. This can be achieved through promoting green buildings, eco-friendly transportation, and sustainable operations to realize a positive interaction between the ecological environment and tourism [9]. Finally, the dimension of shared development requires that wellness tourism benefit a broader social group, especially focusing on vulnerable groups and impoverished areas. Through tourism development, employment can be promoted and income distribution can be made fairer, in order to truly achieve common prosperity [10]. By analyzing the above four dimensions, this paper aims to enrich and improve the theoretical framework on high-quality development, providing a theoretical basis for the high-quality development of wellness tourism.

2.2. Research on Health and Wellness Tourism

The China Aging Office and the “Health and Wellness Blue Book” define “health and wellness” as health, wellness, and elderly care [11]. In the Blue Book of Health and Wellness published in 2017, health and wellness are defined as activities that combine the external environment to improve people’s physical and mental well-being, helping them achieve optimal health. The “National Health and Wellness Tourism Demonstration Base” (LB/T051-2016) further clarifies the concept of health and wellness tourism, stating that it should include forms and functions, such as longevity, a healthy diet, and physical and mental cultivation, to optimize tourists’ physical and mental state [12].

Research on health and wellness tourism mainly focuses on the following aspects. First, analysis involving multiple perspectives: health and wellness tourism, as a multifaceted concept, is related to multiple industries, involving components such as hot springs, spas, medical tourism, body and mind care, diet, exercise, the natural environment, culture, spiritual practices, and special events. The intersection and integration of these industries has become an important feature in the development of health and wellness tourism [13]. Second, research on resource and spatial distribution: tourism resources exhibit significant agglomeration effects and spatial imbalances in different regions. For example, the spatial distribution of tourism resources in China is strong in the southeast and weak in the northwest [14]. This regional distribution pattern not only reflects the differences in the distribution of natural resources, but is also closely related to the level of regional economic development and infrastructure construction. The regional agglomeration effect of health and wellness tourism is mainly concentrated in economically developed, well-equipped, and resource-rich areas. These areas not only have superior natural conditions, such as hot springs, forests, and climate advantages, but they also have well-developed medical services and recreational facilities, thus attracting a large number of health and wellness tourists [15]. For example, the East China region and the southern coastal areas have become important regions for the development of health and wellness tourism, due to their abundant hot springs and favorable climate conditions [16]. Third, taking the demand for health and wellness tourism as a starting point, there is research on the motivations and functions of health and wellness tourism [17,18]. Health and wellness tourism integrates the need for physical health, beauty, longevity, awareness enhancement, emotional well-being, and connections with the community, environment, or religion [19]. In fact, there are potential contradictions in health and wellness tourism motivations, as tourists seeking a better quality of life are also looking to meet their health needs in various areas, from physical to psychological, and from spiritual to cultural [20]. The overall vision of health and wellness tourism has changed from a narrow perspective focused on physical health and well-being to a broader view of holistic wellness [21], for the convenience of reading, an explanatory table is presented (

Table 1. Visualization table on health and wellness tourism research.

Topic	Author	Content
Definition of health and wellness tourism	Zhou M et al. (2023) [11]	Health and wellness are defined as health, wellness, and elder care. Health and wellness tourism should include forms and functions such as longevity, a healthy diet, and self-cultivation to optimize the physical and mental state of tourists.
Multidimensional perspective research	Dini M and Pencarelli T (2021) [13]	Health and wellness tourism intersects and integrates with multiple industries, including components such as hot springs, spas, and medical care.
Research on resource and spatial distribution	Zhang X et al. (2023) [14] Xiong N et al. (2022) [15] Ta M et al. (2019) [16]	Tourism resources exhibit spatial distribution imbalances across different regions; The regional agglomeration effect of health and wellness tourism is mainly concentrated in economically developed areas with well-established infrastructure, rich natural resources, and comprehensive medical services and recreational facilities.
Research on the demand for health and wellness tourism	Lee J and Kim J (2023) [17] Gan T et al. (2023) [18] Wang K et al. (2020) [19] Sirgy J (2019) [20]	Motivations for health and wellness tourism; Functions of health and wellness tourism; Vision of health and wellness tourism.

). The above research mainly focuses on the integration of multiple industries, resource distribution, and regional agglomeration, lacking discussion on how to achieve optimal resource allocation through coordinated development. This paper will provide targeted policy recommendations by analyzing the spatial distribution and coordinated development of health and wellness tourism resources, in detail.

2.3. Research on Health and Wellness Resources

The research on health and wellness tourism resources in the existing literature mainly focuses on the development and utilization of natural resource types that are closely related to tourism resources, such as forests [22] and hot springs [23], and the evaluation of health and wellness resources [24]. These studies usually explore how to enhance tourists’ health and wellness experience through the use of natural resources and assess their value and potential in terms of health and wellness tourism. However, in the research on health and wellness resources, scholars focus more on the current status of elderly care services [25], namely the introduction, selection, and influencing factors of elderly care models. Although these studies provide basic information for understanding the current status of elderly care services, there is relatively little in-depth discussion on the relationship between elderly care models and the integration of medical and elderly care [26], as well as innovative research on elderly care models in the new era [27]. Therefore, this paper takes a multidimensional approach to comprehensively explore the high-quality development level of health and wellness tourism.

In summary, although the existing literature on health and wellness tourism covers multiple aspects, such as definitions, resource classification, supply and demand relationships, and spatial distribution, there is still a research gap in regard to how to integrate health and wellness tourism into a high-quality development framework and promote the sustainable development of health tourism through innovation, coordination, green development and sharing concepts. This paper aims to address these gaps by developing a more systematic and scientific evaluation index system to provide theoretical support and practical guidance for the comprehensive and healthy development of health and wellness tourism.

This study makes three key contributions: Firstly, it identifies and quantifies the imbalance in health and wellness tourism development across China’s 31 provincial-level administrative regions, using the global entropy-weighted TOPSIS method and cluster analysis. Secondly, it develops and optimizes a high-quality development index system encompassing four dimensions: innovation, coordination, green development, and shared development. Lastly, it compares and analyzes real-world data to assess the progress and challenges in each region on the path to high-quality development, providing clear development directions and improvement strategies for health and wellness tourism.

3. Research Methods and Data Sources

3.1. Data Sources

The data selected in this article are panel data for 31 provinces in China from 2016 to 2022 (excluding Hong Kong, Macao, and Taiwan). The data mainly include per capita GDP, the abundance and scale of health and wellness resources, the number of health and wellness cities, the number of distributed health and wellness institutions, tourism transportation, accommodation facilities, landscape facilities, the urbanization rate, the green coverage rate in built-up areas, and environmental sound quality, etc. To ensure the accuracy and consistency of the research data, this research mainly collected publicly published statistical data, such as data from the “China Statistical Yearbook”, “China Tourism Statistical Yearbook”, and other data (see Appendix A for details), as well as provincial and regional statistical yearbooks, and annual national economic and social development statistical reports. For some of the missing data, an interpolation method was adopted to supplement and improve it.

3.2. Index Construction

The construction of the evaluation index system for the high-quality development of health and wellness tourism is based on theoretical discussions and empirical studies by scholars at home and abroad, in reference to the related research results [10,28,29,30]. The system includes 21 indicators across four dimensions, namely innovation, coordination, green development, and shared development (

Table 2. Evaluation index system for high-quality development of health and wellness tourism.

Target Layer	First-Level Indicators	Second-Level Indicators	Attribute	Weight
Innovation	The input from the health and wellness industry	The abundance and scale of health and wellness resources	Positive	0.0223
		Number of practicing (assistant) physicians per 10,000 people	Positive	0.0273
		Market value of listed companies in the health and wellness industry	Positive	0.1804
	The output from the health and wellness industry	Per capita GDP	Positive	0.0291
		The output value of the health and wellness industry	Positive	0.1514
Coordination	Industrial integration degree	Integration with agriculture	Positive	0.0517
		Integration with business	Positive	0.0314
		Integration with the service industry	Positive	0.0198
		Integration with the medical industry	Positive	0.0359
	Coupling coordination degree	The proportion of the tertiary industry in terms of GDP	Positive	0.0201
		Urbanization rate	Positive	0.0083
Green development	Natural health and wellness environment	Green coverage rate in built-up areas	Positive	0.0101
		Average annual temperature	Moderate	0.0116
		PM2.5 concentration	Negative	0.0021
	Humanistic health and wellness environment	Number of health and wellness cities	Positive	0.0634
		Environmental sound quality	Positive	0.0808
Shared development	Health and wellness tourism facilities	Tourism transportation	Positive	0.0139
		Accommodation facilities	Positive	0.0454
		Landscape facilities	Positive	0.0280
	Health and medical facilities	Number and distribution of health and wellness institutions	Positive	0.1345
		Number of medical and health institutions	Positive	0.0325

), and their definitions (

Table 3. Explanation of evaluation indicators for the high-quality development of health and wellness tourism.

Second-Level Indicators	Index Interpretation
The abundance and scale of health and wellness resources	The number of national forest parks, wetland parks, and ocean parks in 31 provinces
Number of practicing (assistant) physicians per 10,000 people	The number of practicing (assistant) physicians at the end of the year/the number of permanent residents at the end of the year/10,000 (ten thousand people)
Market value of listed companies in the health and wellness industry	The market value of 46 health and wellness listed companies (billion CNY)
Per capita GDP	Total GDP/annual average population (CNY)
The output value of the health and wellness industry	In relation to 46 listed health and wellness companies and their total operating income (billion CNY)
Integration with agriculture	Agricultural investment/total investment in all industries (%)
Integration with business	Business investment/total investment of all industries (%)
Integration with the service industry	Service industry investment/total investment of all industries (%)
Integration with the medical industry	Medical industry investment/total investment of all industries (%)
The proportion of the tertiary industry in terms of GDP	The added value of the tertiary industry/GDP (%)
Urbanization rate	The urban resident population at the end of the year/total regional population at the end of the year (%)
Green coverage rate in built-up areas	The green coverage rate in built-up areas (%)
Average annual temperature	The average annual temperature in 31 provinces (°C)
PM2.5 concentration	The PM2.5 concentration in 31 provinces (μg/m3)
Number of health and wellness cities	The number of health and wellness cities in 31 provinces (units)
Environmental sound quality	The average sound level of regional ambient noise (A)
Tourism transportation	The road network density in built-up areas (km/km2)
Accommodation facilities	The number of five-star hotels in 31 provinces (units)
Landscape facilities	The number of 5A-level scenic spots in 31 provinces (units)
Number and distribution of health and wellness institutions	The number of nursing homes (units) with a rating of above three stars in 31 provinces
Number of medical and health institutions	The number of medical and health institutions in 31 provinces (units)

). The data on the various indicators for 31 provinces, from 2016 to 2022, were analyzed, and the weight of each indicator was determined using the global entropy method.

3.3. Research Methods

From the perspective of high-quality development, the global entropy-weighted TOPSIS method and cluster analysis method were chosen to measure and evaluate the development level of wellness tourism, based on the following considerations: The global entropy-weighted TOPSIS method can objectively determine the weight of each indicator, avoiding the subjectivity of manual weighting and ensuring that the results of the evaluation are scientific and stable; the cluster analysis method can effectively identify the differences in wellness tourism development between different regions, providing a scientific basis for regional development. In contrast, other researchers often use methods such as fuzzy comprehensive evaluation, the Analytic Hierarchy Process (AHP), and grey systems theory, each with their own advantages and disadvantages. The fuzzy comprehensive evaluation method can handle fuzziness and uncertainty in complex systems, but still has some subjectivity in regard to weight determination; the AHP is systematic, but computationally complex, and is easily influenced by expert experience; grey systems theory is suitable for small samples but has limitations in terms of weight determination and interpretation of the results. Overall, the global entropy-weighted TOPSIS method and cluster analysis method are highly applicable and practical in measuring and evaluating the development level of wellness tourism when multiple dimensions and indicators are involved. They can objectively and scientifically determine the weights of the indicators and effectively identify regional differences.

3.3.1. Global Entropy-Weighted TOPSIS Method

• Construct a global entropy value evaluation matrix

The $m$ evaluation indicators of $n$ provinces to be evaluated in each year form a cross-sectional data table $X^T$. The $T$ cross-sectional data tables $X^T$ in $T$ years are sorted based on time to form a global entropy evaluation matrix $X$.

$$X=\left(X^1,X^2,X^3,X^4,\cdots ,X^T\right),X^T=X_{ij}\left(t\right)$$

(1)

Among them, $X_{ij}\left(t\right)$ is the data of the $j$ th evaluation index of province $i$ in year $t$,$t\left(t=1,2,\cdots ,T\right)$ is the year, $i\left(i=1,2,\cdots ,m\right)$ is the number of samples, and $j\left(j=1,2,\cdots ,n\right)$ is the number of indicators.

2.

Dimensionless data

In view of the differences in the dimensions of each indicator, the indicators are first normalized and then weighted. The objective weight of the indicators is calculated using the entropy method, and the range method is used to make the data dimensionless.

When the indicator is a positive indicator, its standardized formula is:

$$r_{ij}={\displaystyle \frac{x_{ij}-x_j^{\min }}{x_j^{\max }-x_j^{\min }}}$$

(2)

When the indicator is a negative indicator, its standardized formula is:

$$r_{ij}={\displaystyle \frac{x_j^{\max }-x_{ij}}{x_j^{\max }-x_j^{\min }}}$$

(3)

When the indicator is a moderate indicator, its standardized formula is:

$$r_{ij}=1-{\displaystyle \frac{\left|x_{ij}-d_i\right|}{\max \left|x_{ij}-d_i\right|}}$$

(4)

($d_i$ is the determined standard value)

Among them, $r_{ij}\in \left[0,1\right]$, $x_j^{\max }$, $x_j^{\min }$, respectively, represent the standard value, maximum value, and minimum value of the $j$ th evaluation index of province $i$.

3.

Calculate the probability of the impact

$$y_{ij}=r_{ij}/{\displaystyle \sum _{i=1}^n{r}_{ij}}$$

(5)

4.

Calculate the information entropy

$$e_j=-{\displaystyle \frac{1}{\ln n}}{\displaystyle \sum _{i=1}^n{y}_{ij}}\ln y_{ij}$$

(6)

5.

Determine the indicator weights

$${\omega }_j=\left(1-e_j\right)/{\displaystyle \sum _{j=1}^p\left(1-e_j\right)}$$

(7)

6.

Construct a weighted matrix

Perform vector normalization on the processed data:

$$b_{ij}={r_i}_j/\sqrt{{\displaystyle \sum _{i=1}^m{r_{ij}}^2}}$$

(8)

The method’s biggest feature is that after normalization, the sum of the squares of the same attribute value for each scheme is 1. The weights are multiplied by the normalized matrix to get the weighted normalized matrix $c_{ij}={\omega }_j{b}_{ij}$.

7.

Determine the best solution $C_j^{+}$ and the worst solution $C_j^{-}$

Assume that the $j$ th attribute value of the best plan $C^{+}$ is $C_j^{+}$ and the $j$ th attribute value of the worst plan $C^{+}$ is $C_j^{-}$.

$$C_j^{+}=\max c_{ij}j=1,2,\cdots ,n$$

(9)

$$C_j^{-}=\min c_{ij}j=1,2,\cdots ,n$$

(10)

8.

Calculate the Euclidean distance

The Euclidean distance between plan $c_{ij}$ and the best plan $C_j^{+}$ is $d_i^{+}$, and the Euclidean distance between plan $c_{ij}$ and the worst plan $C_j^{-}$ is $d_i^{-}$.

$$d_i^{+}=[{\displaystyle \sum _{j=1}^n(C_{ij}-\underset{i}{\max }}\{c_{ij}\}{)}^2{]}^{1/2}$$

(11)

$$d_i^{-}=[{\displaystyle \sum _{j=1}^n(C_{ij}-\underset{i}{\min }}\{c_{ij}\}{)}^2{]}^{1/2}$$

(12)

9.

Calculate the composite index

$$C_i={\displaystyle \frac{d_i^{-}}{d_i^{+}+d_i^{-}}}$$

(13)

3.3.2. Cluster Analysis

This article aims to conduct an in-depth analysis and comparison of the high-quality development levels of health and wellness tourism in China’s 31 provinces, as well as their similarities and differences. Using SPSS version 27.0 software and using the four core dimensions of innovation, coordination, green development, and shared development, as the basis for classification, a systematic cluster analysis was conducted on China’s 31 provinces and classified into different development categories (Figure 1).

4. Comprehensive Index Analysis of the High-Quality Development of Health and Wellness Tourism

Firstly, using the indicator values of 31 provinces as original data, the weight of each indicator was determined through the global entropy-weighted method. Secondly, the TOPSIS method is used to calculate the indices of the four main dimensions. Finally, the average values of these dimensional indexes were used as the basic data and the entropy-weighted TOPSIS method was applied to calculate the weight of the standard layer and the comprehensive index for the high-quality development of health and wellness tourism in 31 provinces (

Table 4. Comprehensive index for high-quality development of health and wellness tourism from a structural perspective.

Province	Composite Index	Ranking	Area	Province	Composite Index	Ranking	Area
Zhejiang	0.2203	1	East	Henan	0.0417	17	Central
Guangdong	0.1585	2	East	Hubei	0.0391	18	Central
Shandong	0.1040	3	East	Jiangxi	0.0374	19	Central
Shanghai	0.0995	4	East	Chongqing	0.0355	20	West
Jiangsu	0.0868	5	East	Tianjin	0.0350	21	East
Hainan	0.0800	6	East	Guangxi	0.0336	22	East
Anhui	0.0714	7	Central	Jilin	0.0323	23	Central
Beijing	0.0661	8	East	Liaoning	0.0317	24	East
Sichuan	0.0595	9	West	Gansu	0.0296	25	West
Fujian	0.0582	10	East	Shanxi	0.0293	26	Central
Hebei	0.0565	11	East	Inner Mongolia	0.0263	27	Central
Guizhou	0.0476	12	West	Tibet	0.0243	28	West
Hunan	0.0446	13	Central	Xinjiang	0.0219	29	West
Heilongjiang	0.0439	14	Central	Ningxia	0.0213	30	West
Yunnan	0.0438	15	West	Qinghai	0.0167	31	West
Shaanxi	0.0437	16	West

).

According to the data in Table 4, the average high-quality development index for wellness tourism from a structural perspective is 0.0561. At the provincial level, the top 11 regions have surpassed the national average in terms of high-quality wellness tourism development, becoming demonstration areas for high-quality wellness tourism. Notably, Zhejiang, Guangdong, and Shandong have comprehensive indices exceeding 0.1001, well above the national average, with Zhejiang leading with 0.2203. In contrast, the wellness tourism development levels of the provinces ranked 12th to 31st are below the national average, classified as general quality development provinces. Among these provinces, Gansu, Shanxi, Inner Mongolia, Tibet, Xinjiang, Ningxia, and Qinghai have comprehensive indices below 0.0310. This indicates significant differences in the high-quality development of wellness tourism among different provinces in China.

From a regional perspective, 12 out of the 31 provinces are located in the eastern region, 9 in the central region, and 10 in the western region. According to the composite index, the average high-quality development index for health and wellness tourism in the eastern region is 0.0859, indicating the fastest development. Following closely is the central region with an average index of 0.0407, while the western region has an average index of 0.0344, indicating a relatively lower level of development. Thus, the high-quality development levels of health and wellness tourism in the eastern, central, and western regions decrease sequentially (Figure 2).

The fundamental reasons for the differences in the high-quality development of health and wellness tourism across the eastern, central, and western regions of China can be analyzed from three perspectives: the economic development level, infrastructure completeness, and local government policies. First, the eastern region has a relatively high level of economic development. Provinces like Zhejiang and Guangdong not only have a strong economic foundation, but also possess well-developed infrastructure, such as efficient transportation networks and advanced healthcare facilities, which strongly support the development of health and wellness tourism. Additionally, the local governments in these provinces actively support the development of the health and wellness tourism industry through policy measures, such as tax incentives and industry guidance funds, attracting significant private investment and further promoting high-quality development in this sector. In contrast, while the central region’s economic development is relatively lower, it still benefits from certain infrastructure and policy support. For instance, Hubei province has gradually enhanced the quality of health and wellness tourism through the support of the “Yangtze River Economic Belt” policy. However, the western region lags behind in terms of economic development and infrastructure construction. Provinces like Gansu and Xinjiang, for instance, face significant shortcomings in their transportation and healthcare facilities, which clearly hinder the development of health and wellness tourism. Additionally, local government support in the health and wellness tourism sector is insufficient, lacking systematic and long-term planning, leading to generally low indices of high-quality development in the western region. Therefore, disparities in economic development, infrastructure completeness, and local government policies across different regions have collectively resulted in an imbalance in the high-quality development of health and wellness tourism across China.

According to the degree of high-quality development of health and wellness tourism, the 31 provinces can be divided into two categories, and ArcGIS 40.8 software was used to create a spatial distribution diagram (Figure 3). As shown in the figure, the six provinces located in eastern China all show high-level development in terms of health and wellness tourism. Among the five medium and high-level provinces, three are located in the east, and one is located in the central region, and one in the western region. Among the 13 middle and low-level provinces, six are located in the center, four are in the west, and three are in the east. Among the seven low-level provinces, five are located in the west and two are located in the center. These findings reflect that the high-quality development trend of health and wellness tourism is gradually increasing from the west to the east.

5. Cluster Analysis of the High-Quality Development of Health and Wellness Tourism

This paper uses SPSS version 27.0 software to conduct systematic clustering of the high-quality development levels in terms of health and wellness tourism across different provinces. Referring to the cluster analysis dendrogram, the scores and rankings for each province in regard to the four dimensions of innovation, coordination, green development, and shared development (derived from the product of the secondary indicator weights and their standardized values) are obtained and the 31 provinces are classified into five categories (

Table 5. Cluster analysis table of health and wellness tourism development quality.

Type	Number of Provinces	Province
High-Quality Benchmark Type	3	Zhejiang, Guangdong, Jiangsu
High-Quality Stable Type	5	Beijing, Shanghai, Hainan, Sichuan, Shandong
High-Quality Progressive Type	3	Fujian, Hebei, Anhui
General-Quality Potential Type	15	Guizhou, Yunnan, Guangxi, Chongqing, Henan, Shaanxi, Hubei, Tianjin, Jiangxi, Hunan, Jilin, Heilongjiang, Liaoning, Shanxi, Inner Mongolia
General-Quality Lagging Type	5	Xinjiang, Ningxia, Tibet, Qinghai, Gansu

). Among them, the High-Quality Benchmark Type refers to provinces that excel in all four dimensions and serve as leaders. The High-Quality Stable Type refers to provinces with high overall development levels that maintain stable and balanced development. The High-Quality Progressive Type refers to provinces with strong development momentum and significant potential for improvements in certain dimensions. The General-Quality Potential Type refers to provinces with moderate current development levels that have potential for improvement. The General-Quality Lagging Type refers to provinces with low overall development levels that require significant improvement.

According to

Table 6. Criteria layer index and ranking of provinces with high-quality development of health and wellness tourism.

Type	Province	Innovation	Ranking	Coordination	Ranking	Green Development	Ranking	Shared Development	Ranking
High-Quality Benchmark Type	Zhejiang	0.1484	1	0.0492	21	0.0590	2	0.0706	4
	Guangdong	0.1019	2	0.0462	25	0.0678	1	0.0844	1
	Jiangsu	0.0604	3	0.0459	27	0.0439	5	0.0795	3
High-Quality Stable Type	Beijing	0.0465	6	0.0665	2	0.0255	15	0.0429	9
	Shanghai	0.0580	4	0.0634	1	0.0229	16	0.0368	8
	Sichuan	0.0399	9	0.0623	6	0.0314	14	0.0614	5
	Shandong	0.0554	5	0.0497	3	0.0374	19	0.0814	2
	Hainan	0.0096	8	0.0541	5	0.0333	12	0.0314	6
High-Quality Progressive Type	Fujian	0.0279	13	0.0466	23	0.0469	3	0.0493	13
	Hebei	0.0432	7	0.0542	13	0.0203	7	0.0574	19
	Anhui	0.0267	15	0.0471	22	0.0447	4	0.0366	14

, there are three provinces classified as the High-Quality Benchmark Type: Zhejiang, Guangdong, and Jiangsu. These provinces excel in innovation, green development, and shared development, while coordination is at a moderate level. This indicates that these provinces have achieved a relatively advanced level of development in wellness tourism. Despite the slow improvement pace, the results are significant, setting an example of high-quality wellness tourism development for other regions. There are five provinces classified as the High-Quality Stable Type: Beijing, Shanghai, Hainan, Sichuan, and Shandong. These provinces rank high in terms of innovation, coordination, and shared development, while green development is moderate, indicating balanced development overall. These provinces have established a solid foundation in wellness tourism development and demonstrate a stable growth trend. There are three provinces classified as the High-Quality Progressive Type: Fujian, Hebei, and Anhui. These provinces excel in regard to the green dimension, while ranking moderate in terms of innovation, coordination, and shared development. Although these provinces participated in wellness tourism relatively late, their excellent performance in regard to the green dimension has driven synchronized improvement in the other dimensions, achieving coordinated development overall.

According to the data in

Table 7. Criteria layer index and ranking of provinces with general quality development of health and wellness tourism.

Type	Province	Innovation	Ranking	Coordination	Ranking	Green Development	Ranking	Shared Development	Ranking
General-Quality Potential Type	Guizhou	0.0204	22	0.0647	4	0.0342	9	0.0232	24
	Yunnan	0.0218	21	0.0619	7	0.0381	6	0.0282	22
	Guangxi	0.0186	25	0.0466	24	0.0318	13	0.0297	20
	Chongqing	0.0261	16	0.0564	11	0.0214	17	0.0324	17
	Henan	0.0355	11	0.0567	10	0.0140	24	0.0528	7
	Shaanxi	0.0275	14	0.0672	19	0.0214	18	0.0325	16
	Hubei	0.0358	10	0.0502	17	0.0334	11	0.0413	11
	Tianjin	0.0235	19	0.0462	8	0.0167	21	0.0139	28
	Jiangxi	0.0260	18	0.0496	20	0.0340	10	0.0381	12
	Hunan	0.0428	27	0.0521	15	0.0350	8	0.0424	10
	Jilin	0.0192	24	0.0589	9	0.0125	25	0.0183	27
	Heilongjiang	0.0320	12	0.0648	14	0.0119	27	0.0207	25
	Liaoning	0.0225	20	0.0545	12	0.0191	20	0.0323	18
	Shanxi	0.0178	26	0.0514	16	0.0157	22	0.0333	15
	Inner Mongolia	0.0260	17	0.0384	30	0.0120	26	0.0246	23
General-Quality Lagging Type	Xinjiang	0.0196	23	0.0323	31	0.0104	28	0.0291	21
	Ningxia	0.0086	30	0.0454	28	0.0140	23	0.0069	30
	Tibet	0.0083	31	0.0502	18	0.0056	30	0.0053	31
	Qinghai	0.0087	28	0.0384	29	0.0055	31	0.0077	29
	Qinghai	0.0087	28	0.0612	26	0.0093	29	0.0187	26

, there are 15 provinces classified as the General-Quality Potential Type: Guizhou, Yunnan, Guangxi, Chongqing, Henan, Shaanxi, Hubei, Tianjin, Jiangxi, Hunan, Jilin, Heilongjiang, Liaoning, Shanxi, and Inner Mongolia. These provinces rank at mid-to-low levels across the four dimensions, with slow overall development. However, in recent years, Guizhou, Yunnan, Guangxi, and Chongqing have shown rapid optimization, supported by good ecological and climatic conditions, indicating significant potential for high-quality wellness tourism development. Lastly, there are five provinces classified as the General-Quality Lagging Type: Xinjiang, Ningxia, Tibet, Qinghai, and Gansu. Due to natural environmental factors, such as the altitude, climate, and water quality, these provinces rank low across all four dimensions: innovation, coordination, green development, and shared development. Therefore, the health and wellness industry in these provinces remains underdeveloped.

In summary, whether it is the overall comprehensive index analysis, or the comprehensive index cluster analysis of the four dimensions of innovation, coordination, green development, and shared development, the research conclusions further show that there are significant differences in the high-quality development of health and wellness tourism in 31 provinces in China. The results show that the high-quality development of health and wellness tourism in the southeast is the most advanced and the high-quality development of health and wellness tourism in the northwest is lacking.

6. Discussion

Currently, scholars mainly focus on the integrated development paths involving hot springs, specialty agriculture, and eco-wellness tourism, as well as the spatial distribution patterns and development levels of regional wellness tourism, and the demands and motivations of wellness tourism. Although there is limited research on the measurement and evaluation of wellness tourism development from a quality perspective, some scholars have begun to explore the high-quality development of regional wellness tourism from the perspectives of high-quality and the shared economy [31,32], and others have studied the development of wellness tourism from a digitalization perspective [33].

Firstly, in constructing the evaluation system for high-quality development, Zhang (2020) studied the high-quality integrated development of the western Sichuan region’s economy in regard to five aspects: innovation capability and technology application, multidimensional coordinated development, ecological environmental protection, social inclusion, and public services [34]. Despite the different specific subjects and contexts of the research, innovation, coordination, green development, and shared development are considered key factors in promoting high-quality development. This study provides targeted development strategies through the detailed measurement and evaluation of the high-quality development of wellness tourism across 31 provinces in China, while the study on western Sichuan explores new ideas and methods for the high-quality development of the regional economy through a comprehensive approach supported by big data.

Secondly, the above studies show that the high-quality development level of wellness tourism across 31 provinces in China decreases from the eastern to the central and western regions, with significant regional differences in the spatial distribution. This is consistent with the findings by Zhang et al. (2023) [14] and Xiong et al. (2022) [15], indicating significant spatial imbalances and clustering effects of tourism resources in different regions. The imbalance is characterized by a pattern where tourism resources are stronger in the southeast and weaker in the northwest; the regional clustering effects are mainly concentrated in economically developed areas, with well-established infrastructure and abundant natural resources. Based on this, this study uses more detailed data and application methods to further deepen the understanding of this imbalance phenomenon. This study reveals significant differences in the development of wellness tourism across the different provinces in China, which are closely related to the economic development levels, natural resource endowments, and policy support in each province.

Finally, based on the empirical results, this study systematically evaluates and categorizes the development levels of wellness tourism according to the four dimensions from a quality perspective. By comparing the indices and rankings for the provinces with high-quality development, like Zhejiang and Guangdong, with those of generally developing provinces, like Guizhou and Yunnan, it specifically analyzes the challenges and advantages faced by each province in regard to their high-quality development path. This multidimensional evaluation method not only enriches Sirgy (2019) [20] exploration of health and wellness tourism motivations and functions, but also partially addresses the lack of systematic discussion in existing research on how wellness tourism can integrate into the high-quality development framework. It also provides new perspectives and methods for future research.

7. Conclusions and Recommendations

7.1. Conclusions

This article builds a scientific and reasonable evaluation index system for the high-quality development of health and wellness tourism based on the four dimensions of innovation, coordination, green development, and shared development, and uses the global entropy-weighted TOPSIS method to evaluate 31 provinces in China, from 2016 to 2022. This study uses SPSS version 27.0 software to classify and evaluate the high-quality development level of health and wellness tourism in 31 provinces. The main conclusions are as follows:

(1)

From the perspective of the comprehensive index on the high-quality development of health and wellness tourism, the average value of the high-quality development index on health and wellness tourism in 31 provinces across the country from 2016 to 2022 is 0.0561. Moreover, 11 provinces led by Zhejiang are higher than the average and 20 are lower than the average. There are obvious developmental stages between provinces;

(2)

From the overall levels achieved in terms of the four dimensions, the development levels of health and wellness tourism in 11 provinces led by Zhejiang, Guangdong, and Jiangsu are higher than the national average and they are classified as high-quality development provinces. The 20 provinces led by Guizhou, Yunnan, Guangxi, and Chongqing are lower than the national average and belong to general-quality development provinces. Through cluster analysis, China’s 31 provinces can be divided into five categories in terms of the quality of the development in terms of health and wellness tourism: the High-Quality Benchmark Type, the High-Quality Stable Type, the High-Quality Progressive Type, the General-Quality Potential Type, and the General-Quality Lagging Type. In regard to this pattern, the eastern region plays a leading role in the high-quality development of health and wellness tourism, the central region has relatively strong development, while the high-quality development of health and wellness tourism in the western region has not yet fully emerged;

(3)

From a single perspective, in regard to the innovation dimension, Zhejiang, Guangdong, and Jiangsu have a high level of development and remain at the forefront of the country. The health and wellness industry has invested in the climate, forests, hot springs, traditional Chinese medicine, and specialty agriculture. Health and wellness resources are collected and allocated in order to carry out health and wellness service innovation and technological innovation. The output of the health and wellness industry is reflected in the output value of the health and wellness industry. Under the coordination dimension, the top three provinces in the comprehensive ranking are Shanghai, Beijing, and Shandong, which have a high degree of industrial integration and economic coordination. Under the green development dimension, Guangdong, Zhejiang, and Fujian have the highest overall development level. Relying on natural health and wellness resources and humanistic health and wellness resources, with the help of a good natural ecological environment and rich humanistic health culture, these provinces are able to fully develop health and wellness tourism. Under the shared development dimension, Guangdong, Shandong, and Jiangsu are generally at the forefront of development, and their health and wellness tourism and health and medical facilities are complete, forming a new pattern of health and wellness tourism construction.

7.2. Recommendations

Based on the above conclusions, this article makes the following suggestions:

(1)

High-Quality Benchmark Type provinces should actively fulfill their leadership and demonstration responsibilities in the field of health and wellness tourism; use their respective advantages to integrate and innovate health and wellness tourism resources; build health and wellness industry chains, such as involving medical care, services, commerce, and agriculture; and form a coordinated development pattern. At the same time, these provinces also need to explore new models that integrate health care tourism, pay attention to avoiding over-investment in infrastructure, expand and popularize health care consumption channels, and ensure that the advantages of health care resources continue to be transformed into industrial advantages. This will enhance the overall competitiveness of health and wellness tourism and promote the comprehensive development of high-quality benchmark provinces in health and wellness tourism. Taking Guangdong province as an example, its health and wellness industry started early, with mature forest health and wellness and hot spring industries, a complete service system, and widely recognized development concepts. Therefore, Guangdong province needs to gradually establish complete health and wellness product categories, evaluation and management standards, and at the same time establish a relevant talent training system. In addition, balancing the development of different industries and promoting the diversification of the health and wellness industry are also key;

(2)

For High-Quality Stable Type provinces, developing health and wellness tourism is not only their only task, but also requires deep utilization of local ecological resources and the medical environment, deep exploration of local cultural heritage, and the construction of ecological experiences involving healing and health and wellness, and health and medical care. The core, new diversified health and wellness business format takes medical health as the focus of development and is committed to building a model health and medical tourism base. Take Shanghai as an example. As one of the pioneers of domestic medical tourism, Shanghai has launched the cultivation of international medical tourism pilot institutions, aiming to create international-level medical tourism service products. Therefore, Shanghai needs to further enhance the driving role of the medical tourism industry, promote the integration and collaboration of medical resources with neighboring regions, such as Zhejiang and Jiangsu, and jointly promote the in-depth integration of medical resources and health and wellness tourism, thereby forming a good regional pattern of coordinated development;

(3)

In the process of pursuing all-round development, High-Quality Progressive Type provinces should be committed to cultivating a health and wellness industry ecosystem that is compatible with high-quality development. This requires the formation of an industry with health and wellness tourism as the core, with related industries and derivative industries around it, jointly building a diversified industrial supply network system, and promoting a cross-industry, cross-region, and cross-ownership form of health and wellness tourism. Take Qinhuangdao city in Hebei province as an example. As one of the leaders in China’s health and wellness industry, the city is gradually moving towards the goal of “global health and wellness” by leveraging its unique resources and industrial foundation. Although its health and wellness patterns continue to be innovative and relevant, and business formats continue to expand, progress in the construction of health and wellness demonstration areas is relatively slow. Additionally, the Wuyi Mountain area in Fujian province has taken advantage of its unique natural and cultural conditions to actively promote the construction of ecological health and wellness bases and strive to become a national-level smart health and wellness demonstration area. Therefore, while promoting their own development, High-Quality Progressive Type provinces should also strengthen their cooperation with other regions to jointly promote the high-quality development of health and wellness tourism and achieve a win–win situation within the region;

(4)

General-Quality Potential Type provinces should first learn from successful cases of provinces with high-quality development in regard to their development strategies, adjust their own development strategies, tap into and utilize the potential demand in the health and wellness market, and expand the scale of related services. Government agencies in these provinces should pay more attention to the health and wellness industry and formulate and implement special policies and measures to promote the development of health and wellness tourism. For example, the Henan Provincial Government has clearly proposed an action plan to “accelerate the development of health and wellness tourism” and supports the establishment of a cultural and health and wellness tourism demonstration base and a traditional Chinese medicine health and wellness tourism demonstration base. In addition, these provinces should also deeply explore and develop local distinctive ethnic resources, combine ethnic culture with the health and wellness industry, and create a unique health and wellness experience. For example, the Dongba Valley Health and Wellness Town project in Lijiang city, Yunnan province, closely focuses on the theme of health and wellness and creates a unique tourist destination for leisure and health and wellness, according to local conditions. The Shizhu Family Autonomous County in Chongqing has successfully established itself as a well-known health and wellness tourism destination by using its family culture;

(5)

General-Quality Lagging Type provinces, although the health and wellness resources are rich and varied, they have unique conditions for the development of health and wellness tourism. However, at present, the health and wellness tourism in these provinces is still in the initial stage, and the health and wellness industry are not yet mature. Firstly, these provinces should make full use of the driving force of policies to promote the launch and development of the health and wellness industry. For example, Ningxia uses its high-quality natural resources to develop desert health and wellness, driving the further development of local desert and other special health and wellness industries. Secondly, these provinces should also develop new health and wellness businesses based on their own tourism resource characteristics and tourist needs. For instance, Xinjiang, Gansu, and Qinghai have vast territories, diverse terrain and landforms, as well as rich natural and cultural landscapes, which provide good conditions for the development of high-quality tourism routes and new formats, such as Western self-driving tours.

8. Limitations and Future Implications

Although this study provides targeted development strategies by conducting detailed measurements and evaluations of the high-quality development level of health and wellness tourism in 31 provinces in China, there are still some research limitations. First, the limitation in terms of the data volume: This study examines data from 31 provinces in China from 2016 to 2022. Due to the impact of the pandemic, data updates have been delayed, resulting in a smaller data volume. Secondly, the research methods are relatively singular; in the future, multiple methods will be considered for comprehensive analysis. Additionally, this study mainly focuses on the horizontal comparison among provinces in China, with less research on the longitudinal development changes in specific provinces.

Future research can be deepened in the following directions: First, further improve and update the data sources, increase the application of real-time data and big data analysis to enhance the timeliness and accuracy of the research. Secondly, optimize the high-quality development evaluation system, and explore more scientific and objective methods for selecting indicators and assigning weights. Thirdly, strengthen longitudinal, dynamic research on specific provinces to analyze the long-term trends and changes in the high-quality development of health and wellness tourism. Finally, expand the research perspectives by incorporating emerging fields, such as digital transformation and the sharing economy, and explore their impact mechanisms and pathways in regard to the high-quality development of health and wellness tourism.