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Tourism Management 28 (2007) 625629

www.elsevier.com/locate/tourman

Psoriasis treatment via doctor shes as part of health tourism: A case

study of Kangal Fish Spring, Turkey
Murat Sayilia,, Hasan Akcaa, Teoman Dumanb, Kemal Esenguna
a
Department of Agricultural Economics, Faculty of Agriculture, Gaziosmanpasa University, 60240 Tokat, Turkey
b
School of Tourism and Hotel Management, Gaziosmanpasa University, Zile, 60400 Tokat, Turkey
Received 5 May 2006; accepted 30 August 2006

Abstract

Spa (thermal) tourism is gaining increasing importance in health tourism. Turkey has numerous thermal sources that have been used to
cure a number of common diseases. Among these thermal sources, Kangal Fish Spring has a unique nature with its doctor sh known to
cure psoriasis. To date, a number of studies analyzed Kangal Fish Spring as a thermal source with its water and sh characteristics but no
research to the authors knowledge has been conducted to analyze the springs demand and destination characteristics. In Turkey,
research about thermal health centers and their visitors, is fairly limited from a tourism experience point of view. The current paper
reports a case study of psoriasis treatment by doctor sh in Kangal Fish Spring as part of health tourism in Turkey. The paper describes
Kangal Fish Spring as a health tourism destination and investigates socio-economic and visitor characteristics of the people visiting
Kangal Fish Spring. As part of the study, 104 visitors to the destination were surveyed and visitor perceptions about the destination and
visitor characteristics were reported. The paper concludes with a discussion about the future of the destination and health tourism in
Turkey.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Psoriasis treatment; Kangal Fish Spring; Spa tourism in Turkey

1. Introduction are Pamukkale, Denizli; Afyonkarahisar; Balkesir and

Turkey is rich with spa (thermal) sources. According to
the Turkish Health Tourism Association, there are more
than 1800 hot springs in Turkey and only 6% of these are
used for touristic purposes. Among the 40,000 beds offered
to tourists in thermal destinations, only 15,000 of them can
be categorized as accredited facilities. According to the
Turkish Ministry of Culture and Tourism, the majority of
demand for health tourism in Turkey is inbound. On the
other hand, outbound demand for health tourism exceeds
10,000 clients every year. Despite having rich thermal
sources, the use of these for health tourism is very limited.
Among the better-known thermal destinations in Turkey
Corresponding author. Tel.: +90 3562521616 2266;
fax: +90 3562521488.
E-mail addresses: muratsayili@yahoo.com (M. Sayili),
akcahasan@yahoo.com (H. Akca), tduman@gop.edu.tr (T. Duman),
esengunkemal@yahoo.com (K. Esengun).
Kzlcahamam, Ankara.
One of the main motives for thermal tourism is to
improve health. Throughout history, hot springs in Turkey
have been used to cure a number of skin, bone and internal
diseases (Ulker, 1984). The water characteristics of
different thermal sources differ widely and each are known
to cure various and differing diseases. Among the many
spas in Turkey, Kangal thermal springs in Sivas province
possesses a unique characteristic because of its ability to
treat psoriasis. The current research investigates Kangal
Fish Spring and its visitors as part of Turkish health
tourism. Studies explaining tourist proles (demographic,
economic, and lifestyle factors), economic contribution to
the local area, problems faced by the health centers, and
determinants of duration of stay at the spa have been fairly
limited. Therefore, the aims of this study are to (i) analyze
visitors socio-economic characteristics, (ii) explain the
factors determining duration of stay at Kangal Fish Spring,

0261-5177/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tourman.2006.08.010
 ARTICLE IN PRESS
626 M. Sayili et al. / Tourism Management 28 (2007) 625629
(iii) identify marketing problems and (iv) propose solutions
for the springs.
2. Health tourism, Kangal Fish Spring and doctor sh
A literature search shows that research exploring the
relationship between health and tourism is limited (Hunter-
Jones, 2005; Connell, 2006). Health tourism is broadly
dened as people travelling from their place of residence
for health reasons (Ross, 2006). Yet, in recent years, health
tourism has received growing attention due to its economic
importance (Garcia-Altes, 2005). In Turkey, the numbers
of both foreign and domestic patients seeking medical
treatment in health centers have been increasing annually.
However, the majority of studies on health tourism focus
on health centers and tend to be descriptive in nature, e.g.
illustrating their services.
Kangal Fish Spring as a thermal health center is one of
30 spas certied by the Turkish Ministry of Health.
Certied thermal health centers allow patients with various
diseases to enter a suggested treatment program. This
program at Kangal Fish Spring includes a 21 d treatment
for psoriasis. Psoriasis is a common and chronic skin
disease whose origin is still unknown. As part of its
treatment, various drugs have been developed and tested
but as yet no drug has been able to completely cure the
disease (Ozcelik et al., 2000).
Spa and climatic procedures have been the means of
treatment for various diseases for a long time. In this sense,
positive results are likely to be achieved through natural
ultraviolet effects of selenium in the water at high altitudes
and the cleaning of scum by the sh at the hot spas. With
these treatment factors, the spa is a candidate for becoming
an internationally accepted and signicant center for health
care tourism.
As already stated Kangal Fish Spring is famous for
curing psoriasis and it is also used as a summer resort by
local people. This health center is 13 km away from Kangal
County, 96 km from Sivas City and 450 km from Ankara,
the capital city of Turkey. Road and train connections
offer access to the treatment center. Public buses and
minibuses between Kangal County and the spa are
available for visitors.
According to local history the medicinal power of the
spring was rst noticed in the early 1900s by a shepherd
who healed his wounded feet in the spa water. The spa has
also a mystic reputation because there is no information
about how the sh had come to the region. The spas public
pools were built in 1963. Currently, modern facilities can
be found at the spa that serve national and international
tourists. The water of spring, with a pH of about 7.2, is
isothermal and maintains a temperature of about 35 1C
throughout the year (Ozer, Akpinar, & Akcay, 1987). The
thermal water is rich in calcium, magnesium, and selenium
(1.3 ppm) and are suitable for bathing. Although the spa is
famous for its psoriasis treatment, the spa water is also
known to be benecial to a number of other diseases such
as rheumatic disease, neurological disorders (neuralgia,
neuritis, paralysis), orthopaedic and traumatological se-
quelae (fractures, joint trauma, and muscle disease),
gynaecological problems (by lavage), skin diseases, uro-
lithiasis (by drinking) and psychosomatic disorders accord-
ing to a report dated March 2, 1967 from the Physical
Therapy and Hydrology Clinic of Faculty of Medicine,
Ankara University, Turkey (Undar, Akpinar, & Yaniko-
glu, 2006).
Previous research on the spa sh show that two different
types can be found in the pools. Both are members of the
Cyprinidae family and are adapted to live in hot waters
(Ozer et al., 1987). The so-called striker, Cyprinion
macrostomus macrostomus, has a terminal mouth, is 15 to
20 cm in length, and is covered with relatively large scales
that have 6 to 8 irregularly arranged lateral spots of various
sizes. The second sh Garra rufa obtusa, the licker, has a
crescent-shaped ventral mouth and a maximum length of
19 cm. Its body is also covered with large scales (Undar
et al., 2006). An immature form of the strikers is called the
Jabber. Jabbers lose their lateral spots during matura-
tion. Both types of sh are omnivorous and feed on
phytoplankton and zooplankton (Halver, 1972). Spa pools
contain small amounts of plankton (Ozer et al., 1987). This
is known to slow the growth of the sh and to make them
aggressive and predatory (Akpinar & Aksoylar, 1988).
When there are diseased individuals in the pools, schools of
sh nibble on the diseased skin, which is a more easily
obtained food source (Ozer et al., 1987).
Despite the high temperature of the water these sh can
live in the pools. The scarcity of natural food sources in the
pools means that human skin is an attractive and easily
obtainable food source for these sh (Ozcelik et al., 2000).
An advised 21-d healing program at the health center
includes drinking at least 3 glasses of healing water before
breakfast, entering the pools after breakfast, starting
therapy through soaking in the water rich in minerals
and sh, abstaining from alcohol during the therapy,
taking no medicine against psoriasis during the cure,
entering the pool twice a day for a duration of 8 h/d.
C. macrostomus and Garra rufa, two types of sh found
in the spring, are known to cure skin diseases such as acne,
eczema and psoriasis. Spa treatment for such diseases are
generally seen as the last hope for individuals where
modern medicine has been unsuccessful (see Kangal Fish
Spring website, /www.balikli.orgS).
3. Material and methods
3.1. Research area and data collection
The spring area contains one hotel, two motels and an
additional 50 tents catering for camping and caravan based
tourists. The hotels and motels have 137 rooms (134
standard rooms, 3 suits) with 300 beds. The spring includes
5 olympic size pools and 16 private baths.
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Qualitative and quantitative methods were used during
the research process. Notes were taken after observing the
site and its facilities. Also, personal interviews were
conducted with the spa managers and visitors to obtain
detailed information about the site and visitor experience.
Quantitative methods included a survey of spa visitors.
Survey data were obtained from 104 people visiting
the Kangal Fish Spring via self-administered surveys in a
3-month period from June to August 2004. Convenience
sampling was used for data collection. Sampling was
conducted on both weekdays and weekends. Respondents
were approached and requested to complete the survey in
the accommodation facilities. In the year 2004, 291 foreign
and 2183 domestic visitors were accommodated at the
spring. Therefore, about 4% of the total number of visitors
were surveyed through the research process.
3.2. Instrumentation
The questionnaire consisted of questions related to
socio-economic characteristics and perceptions of visitors
about the destination. Questions about socio-economic
characteristics of visitors included gender, age, education
level and annual household income. Visitor perception and
destination selection questions were about reasons for
visiting the sh spring, an evaluation of spring facilities,
information sources about the spa and the adequacy of
these sources for information gathering. The collected data
were analyzed with the SPSS package software.
4. Results
The socio-economic characteristics of the visitors are
shown in Table 1. The majority of the visitors to the spring
were males. Nearly, two-thirds of the respondents had high
school or lower education levels. Around half of the
respondents were aged between 25 and 45. As far as
household income is concerned, more than one-third of the
visitors had annual revenues of between $4001 and $8000.
Government ofcials and self-employed respondents con-
stituted around half the sample.
Table 2 shows travel behavior and visitor perceptions
about the spa facilities and advertising. More than three-
quarters of the respondents visited the spa for psoriasis
treatment. Going on picnics, curiosity about the sh and
visiting the area were other reasons for visiting the spa. The
great majority (97.53%) of the respondents believed that
the treatment would be positive if they followed the
procedures exactly as advised by the medical practitioners.
Of the respondents, 13.5% stated that they found spa
facilities to be extraordinary, 9.6% rated them as
perfect, 42.3% as good, 26% as normal and 8.6%
as ordinary. More than half of the respondents stated
that this was their rst visit to the spa. Daily visitors
constituted 17.3% of the respondents. Nearly 42% of the
sample stayed between 15 and 21 d. In order to get a
positive result from the treatment it is advised that patients
should stay 21 d at Kangal Fish Spring. More than two-
thirds of the respondents (67.3%) stated that the advertis-
ing of the Kangal Fish Spring as a tourism destination and
health center was inadequate. The most widely used
information sources by the respondents are media (radio,
TV, newspaper, magazine, etc.) and friends and relatives.
Nearly half of the sample used their private vehicles as the
means of transportation because the spa is located in
the rural area of Kangal County. Generally people visited
the spa with other individuals or their families. The
majority of the respondents stated that they would
recommend the spa to other patients who had psoriasis.
Three-quarters of the visitors came to the spring from
other Turkish provinces. The proportion of foreign tourists
was 11.5%. As for visitor expenditures, on average daily,
visitors spent $83.11 on transportation, entrance fee and
food, while visitors who stayed at accommodation at the
spa spent $61.72 per day for transportation, accommoda-
tion, entrance fee and food.

Table 1
The socio-economic prole of visitors

Characteristics Number % Characteristics Number %

Gender Annual household income (US$)

Male 86 82.69 Less than $4000 22 21.15
Female 18 17.31 $4001$8000 38 36.54
Total 104 100.00 $8001$12000 18 17.31
Age (Year) $12001 and over 26 25.00
Less than 25 24 23.08 Total 104 100.00
Between 25 and 35 30 28.85 Profession
Between 36 and 45 23 22.11 Government ofcials 26 25.00
Between 46 and 55 18 17.31 Self-employed 27 25.96
56 and over 9 8.65 Labor 19 18.27
Total 104 100.00 Tradesman 8 7.69
Educational level Student 8 7.69
High school or lower 67 64.42 Retired 8 7.69
College 29 27.89 Housewife 6 5.77
Postgraduate 8 7.69 Farmer 2 1.93
Total 104 100.00 Total 104 100.00
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Table 2
Travel behavior and visitor perceptions about Kangal Fish Spring

Variables Number % Variables Number %

Reasons for visiting the spa Advertisement of the spa

Health (to cure psoriasis) 81 77.88 Adequate 19 18.27
Other (picnic, curiosity, etc.) 23 22.12 Inadequate 70 67.31
Total 104 100.00 No idea 15 14.42
Perceptions about treatment Total 104 100.00
Believe to be positive 79 97.53 Information sources (a)
Believe to be negative 2 2.47 Media 68 65.38
Total 81 100.00 Friends & relatives 57 54.81
Evaluation of spa facilities Poster & brochure 2 1.92
Extraordinary 14 13.46 Internet 5 4.81
Perfect 10 9.62 Advice of the doctor 2 1.92
Good 44 42.31 Means of transportation
Normal 27 25.96 Private vehicle 48 46.15
Ordinary 9 8.65 Other 56 53.85
Total 104 100.00 Total 104 100.00
Past visits to the spa Travel party
Yes 45 43.27 Individual 36 34.62
No 59 56.73 Family 48 46.15
Total 104 100.00 Friends and relatives 20 19.23
Duration of stay Total 104 100.00
Daily visit 18 17.31 Recommendation to others
27 25 24.04 Will recommend 95 91.35
814 17 16.34 Will not recommend
1521 44 42.31 No idea 9 8.65
Total 104 100.00 Total 104 100.00
a
More than one answer.

A series of further qualitative and quantitative analyses
were conducted to determine visitor motivations and the
reasons for duration of stay at the spa. Qualitative analysis
included data from personal interviews with service
suppliers and visitors. Quantitative analysis included
regression analysis where duration of stay was used as a
dependent variable. Overall, the results suggest that
treatment for psoriasis is the main motivator for the
majority of visitors. The spa is the only alternative for
psoriasis treatment through natural means in Turkey and
this seems to be the most important determinant of
destination attractiveness. Furthermore, the levels of total
expenditure for the spa visit, household income, past
experience and travel distance were positively related to
duration of stay at the spa.
5. Discussion
The current study deals with a novel tourism product,
which offers an alternative treatment for psoriasis patients.
With this feature, Kangal Fish Spring is unique among
other health tourism destinations. Despite the increasing
popularity of health tourism in the past decade, the
academic tourism literature lacks destination and visitor
specic studies that can be used for planning and market-
ing of these destinations (Connell, 2006). As such, most
studies about spa destinations in Turkey have dealt with
water qualities and the nature of medication offered in
these spas. To this end, the current study looks at visitor
and destination characteristics of a specic health tourism
destination from a marketing perspective.
Overall, research results suggest that Kangal Fish Spring
attracts two main types of visitors. First are the treatment
seekers who make up the majority of demand for this
destination. The second group of visitors visits the spring
for short-term recreation purposes. It seems that recreation
seekers short-term visits satisfy their curiosity and relaxa-
tion needs. This group of visitors come to the spring from
short distances and make more frequent visits to the spring
when compared to other visitors, who travel further.
Treatment seekers, on the other hand, visit the spring for
longer periods of time and their motivation for visiting the
spring is much more specic. These visitors seem to know
what they are looking for and they have detailed ideas
about the services they are receiving. Media and word of
mouth are the two main sources of information for these
visitors. Due to the unique nature of the destination, most
visitors are prepared to recommend it to others.
When compared to many tourism destinations, which
have difculties in identifying target markets, Kangal Fish
Spring has the advantage of two specic target markets for
marketing the destination. As marketing efforts should be
directed towards treatment seekers, current marketing of
the destination appears to be too general and far from
being proactive. Destination managers and the majority of
visitors nd present advertisements of the spa inadequate,
probably due to the lack of target marketing plans for the
destination. For a more successful marketing of the
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M. Sayili et al. / Tourism Management 28 (2007) 625629
destination, word of mouth advertising and personal
marketing efforts through other medical facilities where
psoriasis treatment is supplied should be given more
priority. More effective word of mouth advertising is
possible through visitor satisfaction studies, the results of
which can be used to improve services and facilities to
create higher levels of visitor satisfaction. For example,
some respondents note that professional guides giving
extra information to visitors and speaking foreign
languages are very limited in number. Also, destination
management should provide better transportation means
for visitors from remote parts of Turkey and overseas as
the destination is located quite far from Sivas city center.
6. Conclusion
Health tourism through spas is potentially one of the
strongest areas of Turkish tourism supply. Yet, market
research about spa destinations is very limited. Although
top government tourism ofcials argue from different
viewpoints that health tourism is one of the strengths of
Turkish tourism for future investment, the marketing of
health tourism destinations is not effective in creating
demand for these destinations. In this research, destination
and visitor characteristics to Kangal Fish Spring were
investigated. Future studies about spa tourism should
focus on target market characteristics and factors affecting
629
visitor satisfaction. Studies such as these will help destina-
tion management in marketing efforts; especially in the
case of Kangal Fish Spring.
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