The Physical, Mental, Spiritual, and Environmental (PMSE) Framework for Enhancing Wellness Tourism Experiences and Its Validation in the Context of Kerala, India

Abstract

Wellness tourism has emerged as a thriving sector in Kerala, India, renowned for its Ayurveda treatments, yoga, and holistic well-being offerings. However, a comprehensive framework capturing the key dimensions of wellness tourism experiences remains underexplored. This study aims to validate the physical, mental, spiritual, and environmental (PMSE) framework within the context of Kerala’s wellness tourism industry. A quantitative research design was employed, utilizing data collected from wellness tourists who participated in various wellness services in Kerala. Confirmatory factor analysis (CFA) was conducted to assess the fitness of the PMSE framework. The findings reveal that mental experience and physical experience, with their respective sub-attributes, contribute significantly to the overall wellness tourism experience. The validated PMSE framework provides valuable insights for stakeholders, enabling them to enhance the quality and competitiveness of wellness tourism services in Kerala. By prioritizing the mental and physical dimensions of wellness experiences, Kerala can strengthen its position as a leading wellness tourism destination. This study advances the theoretical understanding of wellness tourism experiences and offers practical implications for destination management and service providers in Kerala’s wellness tourism industry.

1. Introduction

Wellness tourism has emerged as a thriving sector within the global travel industry (George and Henthorne 2009; Zhong et al. 2021). This niche market has witnessed rapid expansion and is poised for continued growth, outpacing the broader tourism landscape (Thal et al. 2021). Projections from the Global Wellness Institute (2018) indicate that wellness tourism will sustain its upward path, with expectations of even higher growth rates compared to the overall tourism sector. To meet the escalating demand for wellness experiences, various stakeholders, including hotels, resorts, wellness treatment centers, and specialized travel packages, are increasingly incorporating health and wellness services into their offerings (Dillette et al. 2021; Paraskou and George 2017).

The global wellness economy, a significant driver of this industry, has demonstrated impressive growth, surging at a rate of 6.6% annually. From USD 4.3 trillion in 2017, it reached USD 4.9 trillion in 2019, far surpassing the 4.0% growth rate of the overall global economy (Global Wellness Institute 2021). Forecasts suggest that the wellness tourism market will continue to thrive, with an anticipated Compound Annual Growth Rate (CAGR) of 10.17% from 2023 to 2031 (Wellness Tourism Market 2023). However, it is crucial to acknowledge the challenges posed by external factors, particularly the profound impact of the COVID-19 pandemic, which has significantly disrupted the operations of key players in both the tourism and wellness industries (Cheer 2020; Stankov et al. 2020; Sivanandamoorthy 2021).

The onset of the COVID-19 pandemic has prompted a profound shift in people’s priorities, placing a heightened emphasis on health and well-being (Markose et al. 2023; Sthapit et al. 2023). This shift has notably expanded the potential of the wellness travel market (Chen et al. 2023). Recent studies predict that the socio-cultural changes triggered by the pandemic will have a lasting impact on consumer behavior and preferences (Eichelberger et al. 2021). In response to the challenges posed by the pandemic, there is a growing recognition of the need to diversify tourism-related activities and offerings, promoting exploration of distant and untapped locations, a perspective long advocated by scholars and planners alike (Chugh 2021).

Scholarly insights suggest that the pandemic will play a pivotal role in shaping consumer behavior, fostering a positive influence on wellness tourism (Chugh 2021; Kongtaveesawas et al. 2022). This anticipation underscores the potential for a transformative period in the wellness travel sector as individuals seek safer and more health-conscious travel options. India, with its rich history of wellness practices, stands to benefit from this shift in consumer preferences.

Wellness tourism stands as a cornerstone in India’s diverse tourism product mix, prominently featuring recognized elements such as yoga, meditation, and Ayurveda (Dutt 2022). The establishment of the Ayush Ministry by the Indian government plays a pivotal role, providing a solid legal and institutional foundation for promoting alternative medical practices, including the flourishing field of wellness travel. Kerala, in particular, has carved out a niche for itself as a premier Ayurveda destination, attracting both domestic and international travelers seeking diverse treatment options (Bandyopadhyay and Nair 2019).

To further assert Kerala’s position and compete globally in the wellness tourism market, it is essential to more precisely define the characteristics that distinguish its wellness tourism experience. Despite the abundance and quality of wellness-related resources and services offered by numerous stakeholders, there is a need for a comprehensive framework that captures the specific factors required for a robust wellness tourism experience in Kerala. This study aims to investigate these factors, exploring their applicability in the context of Kerala. Leveraging existing theories, wellness attributes, and models, the goal is to shed light on how Kerala can enhance its performance and compete within the dynamic global wellness tourism market.

2. Theoretical Framework

2.1. Concept of Wellness Tourism

Over the past few decades, there has been a notable paradigm shift in the theoretical and methodological focus of tourism research, with a growing emphasis on well-being (George and Nedelea 2009; Kay Smith and Diekmann 2017). This transition has been marked by a diverse array of terminologies, including “quality of life”, “life satisfaction”, and “wellness” (Smith and Puczkó 2016). Despite this evolution, wellness tourism research remains in its infancy. The World Tourism Organization and European Travel Commission define “health tourism” as travel primarily motivated by a desire to contribute to physical, mental, or spiritual health through medical and wellness activities. However, the Global Wellness Institute (GWI) notes that the umbrella term “health tourism” encompasses modalities ranging from medical procedures to yoga retreats. In essence, “health tourism” is a broad concept encompassing travel for medical and wellness purposes to enhance overall well-being (Global Wellness Institute 2018). Wellness, as conceptualized by Smith, represents holistic health with multiple facets—physical, mental, environmental, spiritual, emotional, and social—all working in harmony to promote well-being (Kay Smith and Diekmann 2017). The intricate nature of this definition underscores the complexity of comprehending well-being and wellness. Beyond individual benefits, wellness contributes to economic growth, empowers women, supports regional products, and preserves cultural heritage. The positive impact of wellness extends beyond the individual, connecting to broader societal aspects. It aids in reviving ancient wellness practices, addressing mental health issues, supporting environmental conservation, promoting sustainable tourism, and preserving natural and cultural resources (Global Wellness Institute 2019). Furthermore, wellness is linked to increased social capital and an enhanced quality of life. Wellness travelers, driven by a holistic approach to health and well-being, expect a diverse range of medical care, encompassing both traditional and complementary therapies. Their health and well-being, as well as their behavioral intentions, are influenced by the perceived positive trade-off between their expectations and the actual experiences encountered in wellness tourism (Majeed and Kim 2022).

2.2. Wellness Tourism Frameworks

Wellness tourism has garnered significant attention in recent years, with researchers exploring various models and frameworks to comprehend its dynamics and impact on tourists’ well-being. The diverse array of wellness tourism models and frameworks discussed in the literature sheds light on the multifaceted nature of wellness tourism and its implications for tourist experiences and well-being. Researchers are continuously striving to unravel the complexities of wellness tourism by integrating concepts of sustainability, technology, and local well-being into these models, aiming to pave the way for a more holistic and enriching wellness tourism experience that benefits tourists and destinations alike. Majeed and Kim (2022) present a wellness tourism conceptual model that intricately weaves together conventional medical treatments, alternative health treatments, and tourist attractions to influence wellness tourists’ expectations, perceptions of performance, health and well-being (HWB), and behavioral intentions (Majeed and Kim 2022).

Valeriani et al. (2022) focus on a wellness tourism model in the recovery sector during the new normal period, emphasizing indicators like a high standard of sanitation, security, staycations, niche tourism, private travel tours, and virtual tourism as key components influencing the wellness tourism experience. He et al. (2023) model how the wellness tourism experience inspires tourist engagement, constructing pathways that link wellness tourism experience, inspiration, and engagement. Chen et al. (2023) introduce a chain mediation model that incorporates the stimulus–organism–response (SOR) model to investigate how the wellness tourism experiencescape influences tourists’ behavior, particularly focusing on authenticity, memorability, organizational identification, and revisit intention.

Aluculesei and Avram (2020) discuss the potential of developing rural well-being tourism in the Puglia region of Italy, emphasizing the region’s wellness tradition and the reputation of its thermal centers. Patterson and Balderas-Cejudo highlight the importance of tourism in promoting healthy lifestyles and well-being among older adults, aligning with the goals of Agenda 2030 (Schubert and Schamel 2021). In the context of sustainable tourism development, Schubert and Schamel (2021) propose a dynamic model that considers resident spillovers, aiming to balance the well-being of locals with the impacts of tourism (Li et al. 2021). Puig-Cabrera et al. (2023) explore tourism’s role in enhancing the well-being of Small Island Developing States, aligning with the objectives of Agenda 2030 (Houge Mackenzie et al. 2021).

The evolving landscape of wellness tourism is also influenced by technological advancements and changing consumer behaviors. Li et al. (2021) investigate the effects of virtual reality tourism on subjective well-being during the COVID-19 pandemic, highlighting how virtual experiences can enhance individuals’ well-being and contribute to destination recovery. Additionally, Houge Mackenzie et al. (2021) propose a conceptual model that explores how adventure sport tourism can enhance well-being, emphasizing the psychological processes that underlie well-being outcomes for adventure sport tourists.

2.3. Characteristics of Wellness Tourism in India

In 2017, India secured seventh position on the wellness destination list, investing a substantial USD 16.3 billion in wellness travel, consequently supporting 3.8 million jobs (Global Wellness Institute 2018). This remarkable investment aligns with India’s consistent growth in the tourism sector over the past decade. Notably, the emergence of health tourism has contributed significantly to this upward path. India holds second position in Asia for health tourism, trailing behind Thailand. Patients flock to India for a diverse range of treatments, encompassing traditional Ayurvedic and spa therapies along with contemporary medical procedures (Choudhary and Qadir 2022; Subathra et al. 2019). India has been transformed into a globally sought-after destination for wellness and medical care, spurred on by the growing acceptance of alternative medicine and traditional healing methods. The nation’s appeal as a wellness travel hotspot is strengthened by its diverse array of traditional medical practices, such as naturopathy, yoga, homeopathy, Unani, and Ayurveda. This rich healing tradition, combined with India’s robust tourism potential and rich cultural heritage, positions the country as an ideal location for wellness seekers from around the world (Mishra and Panda 2021). Datta (2022) highlights that India, often considered a “land for all seasons and purposes”, boasts a cultural heritage where yoga, practiced for about 5000 years, holds a significant place. The Ministry of Tourism (2020) underscores the dramatic benefits India has derived from attracting a substantial number of tourists through wellness retreats. Despite India’s success in the medical and wellness tourism sector, there remains a need for strategic measures to increase its share in the global wellness tourism market (Bhowmick 2018). Understanding the distinctive aspects of wellness tourism in various cultural contexts is crucial for positioning India effectively on the international stage.

2.4. Characteristics of Wellness Tourism in Kerala

India boasts exceptional travel destinations for wellness seekers, with Kerala standing out prominently, renowned for its Ayurveda practices (Romão et al. 2022), yoga, meditation, and backwater tourism. Recognizing the substantial potential, there is a significant opportunity to position Kerala as a premier wellness travel destination (Manhas et al. 2019). Notably, Kerala has successfully crafted a distinctive, location-based wellness brand and product, making it a standout state in this regard. Around two decades ago, Kerala identified itself as the “land of Ayurveda” (Kannan and Frenz 2019). Since then, the state has been progressively solidifying its status as a leading wellness tourist destination. Leveraging ancient medical treatments like rejuvenation therapies and panchakarma, which are among the oldest methods of medical treatment (Datta 2022), Kerala has become the preferred choice for foreigners seeking Ayurvedic experiences (Kannan and Frenz 2019). It provides services through accredited Ayurvedic wellness centers across the state (

Table 1. Accredited Ayurveda wellness centers in Kerala.

No.	Districts	Number of Accredited Wellness Centers
1	Thiruvananthapuram	19
3	Kollam	4
4	Idukki	3
5	Kottayam	10
6	Alappuzha	8
7	Ernakulam	10
8	Thrissur	17
9	Malappuram	3
10	Palakkad	1
11	Kozhikode	3
12	Wayanad	3
13	Kannur	1

Source: Kerala Tourism (2018).

). The Western world has long perceived India as a hub for enlightenment and spirituality, and Kerala’s current tourism initiatives align with marketing campaigns offering visitors not just physical relaxation but also spiritual renewal and transformation (Bandyopadhyay and Nair 2019). Remarkably, despite facing natural and man-made disasters in 2018, Kerala witnessed a 6% increase in visitor arrivals. This positive trend continued in 2019, with a remarkable 8.58% rise in foreign visitor arrivals, according to the state’s tourism data (Kerala Tourism Statistics 2019).

Key milestones in Kerala’s tourism industry have been achieved through strategic product development efforts, notably driven by the surging demand for Ayurvedic rejuvenation vacations and heritage attractions, both domestically and internationally. The expanding range of lodging options, including boutique resorts and heritage hotels, has further enriched the tourist experience. Government initiatives have played a crucial role in transforming historic structures into wellness centers, preserving a traditional ambiance. Kerala’s wellness tourism has successfully aligned itself with contemporary market demands, focusing on rejuvenation, spirituality, and culture, attracting leisure travelers from various categories (Nair and Dileep 2021).

The latest market shifts in Kerala underline a deliberate integration of wellness, medical, and cultural tourism components, aiming to provide guests with a unique and holistic experience. Noteworthy aspects of the industry include a diverse array of offerings, customized interaction zones, robust social media-driven marketing platforms, and easily accessible specialized amenities. Recent treatments are designed around the principles of “escapism”, offering comprehensive packages for rejuvenation and revitalization that harmonize the mind, body, and spirit. Kerala has pioneered the integration of wellness, hospitality, and tourism in unprecedented ways, solidifying its position as a distinguished destination for wellness travel (Dileep and Nair 2021).

2.5. Dimensions of Wellness Tourism Experience Theoretical Framework

The term “wellness” is holistic; many researchers emphasizing its multifaceted aspect, which includes “physical and mental health, as well as social and environmental” factors. It is defined as a state of “experiencing harmony in mental, Physical, spiritual, and biological health” (Kotur 2022; Liao et al. 2023). Wellness tourism has evolved from a narrow emphasis on physical health and well-being to a broader concept of holistic health (Dini and Pencarelli 2022). Rapid economic progress, combined with greater social pressure and competition, has hastened the pace of life, resulting in widespread burnout. This burnout emerges in the body, mind, and interpersonal communication, leading to an increase in persons displaying sub-health features. Wellness tourism has grown as a way of life and is a preferred choice for individuals seeking more than just leisure; it also offers opportunities for self-exploration (Dini and Pencarelli 2022; Joseph Sirgy 2019; Liao et al. 2023). Previously, wellness tourism experiences emphasized “relaxation, sensory pleasures, enjoyment, and the natural environment”. However, recent trends have seen wellness tourism evolve to offer more immersive and authentic experiences that prioritize personal growth. Wellness tourism experiences now actively or passively protect people’s health by merging their “cultural, spiritual, nutritional, physical, and environmental demands” (Global Wellness Summit 2020).

This study aims to validate the PMSE framework of the wellness tourism experience within Kerala’s wellness tourism industry, drawing on the Push and Pull Motivational Theory to provide a comprehensive understanding of wellness tourism experience dimensions. The Push and Pull Motivational Theory explains the motivations behind wellness tourism by identifying internal desires (push factors) and external attractions (pull factors) (Mai and Nguyen 2023). In the context of the PMSE framework, the physical dimension addresses push factors such as the desire for health improvement, relaxation, and physical rejuvenation, while pull factors include Kerala’s renowned wellness facilities, such as spas, fitness centers, and natural healing environments. The mental dimension captures push factors like the need for stress relief and psychological well-being, with pull factors being destinations that offer mental wellness programs such as meditation, mindfulness workshops, and mental health retreats. For the spiritual dimension, push factors involve the quest for spiritual growth, inner peace, and life purpose, whereas pull factors include spiritual attractions like ashrams, spiritual retreats, and cultural experiences. The environmental dimension aligns with push factors driven by a desire to escape urban life and reconnect with nature, and pull factors represented by Kerala’s natural beauty, eco-friendly accommodations, and activities promoting environmental conservation. By integrating these dimensions, the PMSE framework, supported by the Push and Pull Motivational Theory, offers a holistic approach to understanding the multifaceted motivations and experiences of wellness tourists, thereby enhancing the overall appeal and effectiveness of Kerala’s wellness tourism industry.

The present study was conducted in Kerala, India, a region renowned for its remarkable growth in wellness tourism, particularly in the domain of Ayurveda treatments, andoften referred to as “God’s own country” (Romão et al. 2022). The factors shaping wellness tourism experience vary place to place, and comprehensive frameworks addressing these attributes remain unexplored, especially in Kerala. Furthermore, there is a lack of a validated PMSE framework tailored specifically to the development and planning of wellness tourism in Kerala. Thus, we have undertaken the adaptation of the PMSE framework from prior studies (Kongtaveesawas et al. 2022) to assess its suitability and applicability within the context of Kerala. The aim of this study is to authenticate the PMSE framework within Kerala, while pinpointing the dominant attribute that significantly contributes to the overall wellness tourism experience. The study focuses on wellness tourists visiting Kerala, specifically those seeking wellness treatments and answers the question about the key factors that contribute towards the overall wellness tourism experience.

The research contributes to the understanding of wellness tourism in Kerala, shedding light on the factors that attract visitors seeking Ayurveda treatments. It also explores the unique positioning of Kerala as a wellness destination, emphasizing the term “wellness tourism” to distinguish itself from the conventional tourism image of India (Bandyopadhyay and Nair 2019).

3. Research Methods

This study employed a quantitative research design to validate the PMSE framework within the context of Kerala’s wellness tourism industry. Quantitative methods, specifically confirmatory factor analysis (CFA), were chosen as the right approach for several reasons, as follows:

• Objective Measurement: Quantitative approaches allow for objective measurement and statistical analysis, providing strong evidence to establish the framework’s validity in a new cultural context.
• Generalizability: The ability to collect data from a larger sample size increases the generalizability of the results, making them more applicable to the broader wellness tourism industry in Kerala.
• Framework Validation: CFA is ideally suited to validating existing theoretical frameworks, allowing us to test whether the data fit the hypothesized PMSE model.

While quantitative methods were deemed most appropriate, we did consider alternative approaches. In-depth interviews or focus groups could have provided rich, detailed insights but would have limited our ability to statistically validate the PMSE framework and generalize the findings. A mixed-method approach was considered for its potential to provide both breadth and depth of understanding. However, given our primary aim of validating an existing framework, a purely quantitative approach was more efficient and directly addressed our research objectives. While EFA could have been used to explore the underlying structure of the data, we chose CFA because we were working with an established theoretical framework (PMSE) and wanted to confirm its applicability in the Kerala context rather than explore new factor structures.

The study utilized a questionnaire adapted from Kongtaveesawas et al. (2022), consisting of 26 attributes across the four PMSE dimensions. The questionnaire included sections covering participant demographics, tourism behaviors, and the importance or expectation levels of wellness tourism experience dimensions. Both online and offline questionnaires were employed to ensure privacy and prompt responses. The survey was conducted from 1 April 2023 to 31 May 2023. We employed purposive sampling to ensure that participants had relevant experience with wellness services in Kerala. This approach was crucial for obtaining informed responses that accurately reflect the wellness tourism experience across all PMSE dimensions. Respondents were chosen from a pool of individuals with previous experience in wellness services in Kerala.

The initial sample size of 320 was determined based on the population of wellness tourists in Kerala, using Yamane’s formula (Najar et al. 2020) to ensure statistical significance. Following field editing and data screening procedures, the final sample size was reduced to 286. This sample size remains statistically robust for CFA, adhering to the general guideline of having at least 10 respondents per observed variable in the model (Hair et al. 2010). AMOS software was used for goodness-of-fit assessment and modification of the measurement model. CFA was employed to assess the fitness of the PMSE framework, providing rigorous evidence supporting the construct validity of the framework and ensuring that the identified dimensions accurately represent the wellness tourism experience. The PMSE attribute framework validation instrument exhibited a good level of reliability, with a Cronbach’s alpha of 0.73.

This study adhered to ethical guidelines, ensuring participant confidentiality, informed consent, and respectful representation of cultural practices. Participants were provided with clear information about the research purpose and had the option to withdraw at any stage without consequences.

4. Findings and Discussion

A total of 286 responses were gathered through online and offline questionnaires from wellness travelers in Kerala between March and May 2023, employing purposive sampling techniques. The data set underwent descriptive statistical analysis using IBM SPSS version 23.0 to explore its key characteristics. Following data collection, confirmatory factor analysis (CFA) was conducted using AMOS to validate the factors influencing the wellness tourism experience in Kerala.

4.1. Respondents’ Profile

Among the 286 respondents, the majority (61%) identified as male. The highest representation fell within the 26–35 age group. Notably, a significant portion (51.4%) rated their health as excellent. A considerable number of respondents had engaged in wellness services for the last two years. During wellness trips, a majority (57%) preferred stays of 3-4 nights. Independent travel was the choice for 35% of the respondents. Leisure activities were the preferred wellness activities for the majority (35%), while 23.1% opted for health and wellness activities. Noteworthy selections included natural sightseeing (14.7%) and spa experiences (11.5%). Regarding wellness tourism destinations in Kerala, Kovalamattracted the highest attention among respondents (25.2%). The average daily spending of tourists during their wellness trip typically ranged between 3001 and 5000. Most respondents provided positive ratings on the PMSE (wellness tourism experience) framework within the context of Kerala.

4.2. Descriptive Statistics

Within the framework of the wellness tourism experience under the PMSE model, this article aims to assess various dimensions including physical, mental, spiritual, and environmental experiences. The study adapted 26 attributes (Kongtaveesawas et al. 2022) applicable to wellness tourism experiences in Kerala: 10 associated with physical experience, 5 with mental experience, 5 with spiritual experience, and 6 with environmental experience. Descriptive statistics for these 26 attributes are presented in

Table 2. Mean and standard deviation values for wellness tourism experience (N = 286).

	Code	Item	Mean
Physical Experience
1	P_ex1	Availability of passive wellness tourism activities	4.26
2	P_ex2	Availability of active wellness tourism activities	4.26
3	P_ex3	The detoxification programs	4.11
4	P_ex4	The food quality and/or food service	4.20
5	P_ex5	The destination’s visual arts	4.08
6	P_ex6	Reasonable price of wellness service	4.01
7	P_ex7	Wellness amenities, products, and souvenirs	4.17
8	P_ex8	Supply typology	4.16
9	P_ex9	Hygiene policy of the destination	4.09
10	P_ex10	Accessibility of the wellness center	4.35
Mental Experience
1	M_ex1	Life progress and/or positive change	4.27
2	M_ex2	Escape from daily life and recuperation	4.19
3	M_ex3	Service care and empathy of employees	4.17
4	M_ex4	Being part of community	4.15
5	M_ex5	Understanding new things from host community	4.09
Spiritual Experience
1	S_ex1	Spirit/soul upliftment	4.19
2	S_ex2	Sharing your wellbeing travel experience with destination communities, stakeholders, and others	4.20
3	S_ex3	High level of engagement or interest in destination’s activities	4.17
4	S_ex4	The attributions of knowledge, memories, perceptions, emotions, and self-identity	4.18
5	S_ex5	To be able to recall the experience anytime you like	4.26
Environmental Experience
1	E_ex1	Wellness service, knowledgeable staff, and stakeholders.	4.29
2	E_ex2	Environmental concern and sustainable surroundings	4.27
3	E_ex2	Utility of local products and cuisines	4.21
4	E_ex3	Peaceful destination	4.23
5	E_ex4	Authentic destination	4.24
6	E_ex5	The link between wellbeing and sustainable development	4.20

Source: Primary data.

, detailing their respective means.

In the realm of physical experience, the attribute with the highest mean value is accessibility to the wellness center (4.35), indicating a strong inclination towards ease of access. Following closely are two attributes: availability of passive wellness tourism activities (4.26) and availability of active wellness tourism activities (4.26), reflecting a positive attitude towards engaging in various wellness-related activities. Transitioning to mental experience, the attribute with the highest mean value is life progress and positive change (4.27), suggesting a significant endorsement of personal growth and positivity among respondents. Moving on to spiritual experience, participants expressed agreement with the attribute “to be able to recall the experience anytime you like” (4.26), which garnered the highest mean value. This indicates a strong sentiment towards the lasting impact and recallability of spiritual experiences. In environmental experience, the attributes with the highest mean scores arewellness service, knowledgeable staff, and stakeholders (4.29), signaling a high level of satisfaction with the expertise and involvement of staff and stakeholders in providing wellness services. Following closely is environmental concern and sustainable surroundings (4.27), reflecting a positive attitude towards environmentally conscious practices and sustainable surroundings.

Overall, to further analyze these data, it is necessary to perform confirmatory factor analysis to understand the interrelationships among these items and potentially reduce them into fewer latent factors that explain the underlying structure of wellness tourism experiences.

4.3. Confirmatory Factor Analysis

CFA (confirmatory factor analysis) methodology was employed to construct and assess measurement models for four distinct dimensions, physical experience, mental experience, spiritual experience, and environmental experience, all contributing to the overall wellness tourism experience. The measurement model, depicted in Figure 1, displays coefficients in standardized form, illustrating the structural relationships among the variables. In Figure 1, ovals symbolize the latent variables or unobserved constructs, rectangles represent the observed variables, and circles depict the measurement error associated with each latent variable.

The measurement model comprises four factors: physical experience (10 items), mental experience (5 items), spiritual experience (5 items), and environmental experience (6 items). To ensure satisfactory reliability and validity, composite reliability and the average variance extracted are calculated and presented in

Table 3. Results of first-order confirmatory factor analysis of PMSE attributes towards overall wellness tourism experience.

Latent Variable	Observed Variable	Standardized Loading	Composite Reliability	Average Variance Extracted
Physical Experience	P_ex1	0.99	0.929	0.74
	P_ex2	0.96
	P_ex3	0.59
	P_ex4	0.90
	P_ex5	0.65
	P_ex6	0.87
	P_ex7	0.53
	P_ex8	0.50
	P_ex9	0.75
	P_ex10	0.61
Mental Experience	M_ex1	0.57	0.801	0.65
	M_ex2	0.98
	M_ex3	0.72
	M_ex4	0.40
	M_ex5	0.59
Spiritual Experience	S_ex1	0.84	0.878	0.75
	S_ex2	0.54
	S_ex3	0.42
	S_ex4	0.95
	S_ex5	0.98
Environmental Experience	E_ex1	0.81	0.848	0.68
	E_ex2	0.38
	E_ex2	0.88
	E_ex3	0.86
	E_ex4	0.60
	E_ex5	0.54

Source: Primary data.

.

In the measurement model, composite reliability is an essential indicator to build reliability. It offers a thorough assessment of the consistency of the concept, including its stability and equivalency. A composite reliability value of 0.70 or above, according to Chi et al. (2020), denotes favorable scale reliability and confirms the construct’s reliability. In this analysis, the values for all the variables are greater than 0.07, so it is confirmed that all the mentioned variables are highly reliable and internally consistent. The average variance extracted is higher than 0.05, indicating a good convergent validity (Naderi et al. 2019).

Table 4. Model fit description based on first-order CFA.

Model Fit	Normed Chi-Square (ᵡ2 /df)	GFI	AGFI	RMSEA
Model	2.911	0.849	0.809	0.072
Recommended value	Less than 5	0.8–0.9	0.8–0.9	Less than 0.080

Source:Primary data.

shows an acceptable model fit where the chi-square is 2.911 (<5), GFI is 0.849, which is between 0.8 and 0.9. AGFI is 0.809, which is between 0.8 and 0.9. RMSEA is 0.072 (<0.080).

The current study aimed to validate the PMSE framework in Kerala by engaging wellness tourists who have entrusted themselves to various wellness services and treatments in the region. To enhance the quality of wellness tourism services, providers can integrate this validated model along with its highly influential attributes. Despite Kerala’s strong footing in Ayurvedic treatments, there remains a need to address factors crucial for retaining tourists and ensuring their satisfaction in the region.

The findings of the first-order confirmatory factor analysis (CFA) of wellness tourism attributes contributing to the overall wellness tourism experience reveal positive relationships between the observed indicators and their respective latent constructs. Across the board, the factor loadings demonstrate significant contributions of the indicators to the overall wellness tourism experience, with values ranging from 0.38 to 0.99. Specifically, within the categorized experiences, the physical, mental, spiritual, and environmental indicators exhibit robust associations with their respective factors. In physical experience, the factor loadings range from 0.53 to 0.99, showing the strength of their relationship. Likewise, for mental experience, the factor loadings range from 0.40 to 0.98, indicating substantial contributions. The spiritual experience domain reflects factor loadings spanning a range from 0.42 to 0.95, while the environmental experience domain shows values between 0.54 and 0.88. These results underscore the multifaceted nature of wellness tourism, illustrating how various attributes contribute distinctly to the overall wellness tourism experience across the physical, mental, spiritual, and environmental dimensions in the context of Kerala.

The findings from the second-order factor analysis (Figure 2) of wellness tourism attributes influencing the wellness tourism experience in Kerala indicate consistently positive and substantial factor loadings across all the indicators (see

Table 5. Second-order confirmatory factor analysis.

SI No.	Construct	Standardized Factor Loading
1	Physical Experience	0.99
2	Mental Experience	1.01
3	Spiritual Experience	0.37
4	Environmental Experience	0.45

Source: Primary data.

). Notably, the highest factor loading is observed for the mental experience factor, loaded at 1.01. This underscores the significant contribution of mental experiences to the overall wellness tourism experience, aligning with previous research findings (Kongtaveesawas et al. 2022; Voigt et al. 2011). Mindfulness/mental experience, defined as awareness and consciousness of one’s thoughts, emerged from wellness travelers, characterized by rejuvenation, escapism, and personal growth. Many wellness tourists anticipate experiencing profound rejuvenation and relaxation during their travels (Dillette et al. 2021).

Likewise, distinct from the previous research results, the physical experience factor also demonstrates strong support in Kerala, with a factor loading of 0.99 across all ten items. This suggests that all aspects of the physical experience greatly contribute to the overall wellness tourism experience, highlighting the holistic nature of wellness tourism in Kerala. Physical experiences encompassed various elements such as the food, activities, and services offered at wellness centers. Unlike typical vacation experiences, the food provided at wellness resorts is evaluated for taste, quality, and nutritional value (Dillette et al. 2021; Lehto and Lehto 2019; Voigt et al. 2010, 2011). The analysis highlighted culinary experiences as a significant factor in enhancing the overall wellness tourism experience, serving as a vital mechanism for supporting visitors’ holistic well-being.

5. Discussion

The current study assessed the applicability of the PMSE framework in Kerala, demonstrating its effectiveness in enhancing the wellness tourism industry. This validated PMSE model offers a blueprint for redesigning and optimizing wellness tourism services in Kerala. Despite the industry’s established status, the identified factors are crucial in fostering tourist retention, thereby enabling destination loyalty.

The PMSE framework builds upon established theories in tourism and wellness studies, such as the Push and Pull Motivational Theory (Crompton 1979; Dann 1977) and the Wellness Tourism Experience Model (Voigt et al. 2011). While these theories explain tourist motivations and experiences, the PMSE framework specifically tailors these concepts to the wellness tourism context in Kerala. Our study extends these models by validating the framework in a unique cultural setting, demonstrating its applicability beyond Western contexts, where most wellness tourism research has been conducted.

One of the most noteworthy findings of this study is the significant role that culinary experiences play within the physical dimension of wellness tourism in Kerala. While food has been recognized as a component of wellness tourism in previous studies, its prominence in our findings was unexpected. This suggests that Kerala’s unique cuisine may be a more integral part of its wellness tourism offering than previously thought. Another surprising result was the relatively low importance of spiritual experiences compared to mental and physical experiences. Given Kerala’s reputation for spiritual tourism, particularly related to Ayurvedic practices, this finding challenges some assumptions about the nature of wellness tourism in the region. Furthermore, this research challenges the notion of a universal wellness tourism experience by highlighting the specific attributes that contribute most significantly to wellness experiences in Kerala, namely the mental and physical dimensions. This finding extends Kongtaveesawas et al.’s (2022) work, which found comparable results in Thailand, suggesting a potential regional pattern in Asian wellness tourism experiences. The strong correlation between mental and physical experiences suggests a more holistic approach to wellness among tourists in Kerala than has been observed in some Western contexts.

These findings have significant implications for both theory and practice. Theoretically, they highlight the need for more nuanced, culturally sensitive models of wellness tourism that can account for regional variations in how wellness is conceptualized and experienced (Liao et al. 2023). By empirically validating the PMSE framework in Kerala, our study contributes to the theoretical understanding of wellness tourism by providing a more nuanced, culturally sensitive model that can inform future research and practice in diverse settings. Practically, to elevate the wellness tourism experience in Kerala, practitioners should prioritize mental and physical dimensions equally. Key attributes within the mental experience encompass escaping daily life, recuperation, service care, and employee empathy. Meanwhile, in the physical realm, resort management attention should be given to the availability of passive and active wellness activities, food quality and service, reasonable pricing, and destination hygiene policies. The findings suggest that wellness tourism providers in Kerala might benefit from emphasizing culinary experiences and the mind–body connection in their offerings, potentially differentiating themselves from wellness destinations in other parts of the world.

6. Conclusions

This study validates the PMSE framework within the context of Kerala’s wellness tourism industry, providing valuable insights that aid effective development and planning. By evaluating the adaptation of the framework and considering feedback from wellness tourists who have experienced Kerala’s wellness tourism services, we have demonstrated the framework’s relevance and applicability in the region. The research contributes to the ongoing discourse surrounding the development of wellness tourism by offering practical guidance for researchers, practitioners, and policymakers. By adopting the guiding principles of the PMSE framework and capitalizing on the insights derived from this study, Kerala has the potential to solidify its position as a prominent player in the global wellness tourism market, offering transformative experiences for travelers seeking holistic wellness and rejuvenation.

6.1. Theoretical Contributions

Our research significantly advances the understanding of wellness tourism in diverse cultural settings. By validating the PMSE framework in Kerala, we extend its applicability beyond Western contexts, challenging the notion of a universal wellness tourism model. The study reveals a potential regional pattern in Asian wellness tourism experiences, with mental and physical dimensions emerging as particularly significant. This finding contributes to the development of more nuanced, culturally sensitive theoretical models in wellness tourism research. Furthermore, our study highlights the unexpected prominence of culinary experiences within the physical dimension, suggesting a need to reconsider the role of gastronomy in wellness tourism frameworks, particularly in cultural contexts where cuisine plays a leading role in wellness practices.

6.2. Practical Contributions

The validated PMSE framework offers substantial benefits to wellness service providers and policymakers in Kerala. By identifying the most influential attributes of wellness tourism experiences, particularly the mental and physical aspects, the framework provides a roadmap for enhancing service quality and destination appeal. Practitioners can use these insights to create targeted strategies that emphasize opportunities for mental rejuvenation, physical well-being, and culinary experiences. For instance, wellness centers could develop programs that combine traditional Ayurvedic treatments with stress relief activities, nature-based experiences, and local cuisine exploration, addressing both mental and physical wellness dimensions. Policymakers can use this framework to guide tourism development plans, prioritizing infrastructure and services that support these key experiential dimensions.

6.3. Limitations and Future Research

While this study offers valuable insights, it is important to acknowledge its limitations. Firstly, the research focused specifically on Kerala, India, and the findings may not be directly generalizable to other wellness tourism destinations. Cultural biases peculiar to Kerala may have influenced the study’s findings. Secondly, the study employed a quantitative research design, which may not fully capture the nuances and depth of individual experiences. Additionally, the study relied on a sample of wellness tourists who had previously engaged in wellness services in Kerala, potentially excluding insights from potential visitors. The lack of longitudinal data limits understanding of how wellness tourism preferences evolve over time, especially in response to global events like the COVID-19 pandemic.

Future research can address these limitations by exploring the applicability of the PMSE framework in diverse cultural and geographical settings, incorporating qualitative methods to gain deeper insights into individual experiences, and conducting longitudinal studies to track changes in wellness tourism preferences over time. Additionally, researchers could further investigate the role of culinary experiences in wellness tourism, as highlighted by our findings. Examining the use of digital technologies in creating wellness tourism experiences may also provide insights into how technology enhances or detracts from the wellness experience.