The Impacts of Tourism Stays on Residents’ Self-Reported Health: A Pan-European Analysis on the Role of Age and Urbanization Level

It is an interesting and generally scientifically sound text.

The Abstract and Introduction are legible and accurate.

From the point of view of the research problem adopted, it seems to be important to address the issues of the motives for practicing tourism. Concentration on, for example, urban tourism does not contribute much to the subject of health. The key types of tourism that should constitute the basis for undertaking research are forms of health and recreational tourism, incl. spa tourism. I believe it is important to ignore these forms in terms of the research undertaken.

We wish to thank the Reviewer for her/his time and feedback. We have clarified that we are addressing a specific aspect of the relationship between tourism and health, which is the health outcomes on residents. We have explained why this aspect is as important as other forms of health and recreational tourism. Regarding tourism types, we are focusing on all forms of tourism (e.g. all stays in tourism accommodation establishments), based on Eurostat data. Given that we are analysing health impacts for residents, we believe that all kinds of tourism, and not just health or spa tourism, can produce impacts on residents’ health. However, based on the Reviewer’s comment we have given more relevance in the discussion that it is urban tourism specifically that seems to be disruptive for residents’ health (388-394, 510-511).

The methodological issues were presented quite well. There are significant doubts that the analysis is limited to airports where Ryanair air operations are performed. In addition, it should be noted that these are not air deductions belonging to this carrier, which is what the text says. If the issue of accessibility to air transport was found to be relevant to the scope of the research, then the entire airport network should be looked at. In the analyzed countries, in terms of access to the services of a selected carrier, this network is very diverse, which significantly distorts the effect of the study.

We wish to clarify that the Ryanair airports variable was used exclusively in the instrumental variable estimations, to further corroborate causality of tourism stays on health status. We needed an indicator that would theoretically predict tourism stays without being associated with health. We chose to focus on Ryanair airports because of several reasons: 1) because compared to the general number of airports per km2 it is even less likely to predict health. This is because low-cost carriers, as opposed to general airlines, are likely to increase tourism flows in a region, thus opening a new market. Also, low cost carriers are unrelated with health as they are not an indicator of economic development as a whole, and therefore of the quality of healthcare of a region (while the total number of airports might be a proxy of economic development and hence be related with health).

2) we focused on Ryanair airports only, instead of including several low-cost carriers, because of availability of data (we could not find the indicator for other low cost carriers).

We acknowledged this limitation in lines 656 and following.

Taking into account the above remarks, further work on the text should concern the following parts of the text: theoretical, methodical, research, discussion and conclusions.

We have made additions to the theoretical introduction, methodology, research and discussion, and conclusion.

Contribution to literary studies is rather modest. They should be significantly developed.

We have integrated and clarified the contribution to literary studies in the discussion (381-386; 405-407; 501-514)

line 163 - should be North Macedonia.

Edited

lines 285-286 - should be Ryanair. 

Edited

Introduction:

·       Paragraph (lines 61-79): here is the “heart” of your literature review, so expand it and give more details.

We wish to thank the Reviewer for her/his time and feedback.

We have expanded the paragraph, adding more details on the evidence on the health and quality of life outcomes of tourism for residents (70-103).

·       Paragraph lines 121-127: “The proposed analysis assessed…….The time frame of this study is 2013-2018.” Move this paragraph to Materials and Methods section.

·       Paragraph moved to the Methods section

Materials and Methods

·       Please define this concept/names: DEGURBA, NUTS1, and 95 NUTS2

·       Added in section 3.1

·       Above table 3: provide the significance of β and SE.

·       Added

Discussion

·       This section needs a deep organization. The results and the discussion are mixed. You should move some parts to the results section. For example, I think paragraph Lines 312-327 belongs to the results section.

·       We have reorganized the section, making some changes in structure, restating our hypotheses, simplifying lines 312-327 (now lines 375-378).

·       Delete the paragraph lines 433-445; it is unnecessary.

·       Deleted

·       Create a new section: 6. Practical Applications and Limitations, after the conclusion.

·       We have created a new section (5), as suggested. We have titled it Policy suggestions and limitations, as we believe that our recommendations are more policy related, than practical suggestions.

It is a nice research paper with a good design and convincing results. Nevertheless, some issues should be addressed.

-         The differences between countries could be very important given that data are at the regional level. Or at least the differentiation between Western, Eastern, Northern and Southern Europe would be beneficial to draw some more comprehensive conclusions 

We thank the Reviewer for her/his comments. During the analysis stage, we had performed the models adding a further level (country), to control for differences between countries. Adding this fourth level did not change our results, hence for simplicity we decided to keep the 3-level model. This is because differences between countries are indirectly controlled for by differences between NUTS regions. We have added this clarification in section 291-293.

-         When discussing the relation tourism-development not only direct effects but also the spillover effects should be taken into account. Other indirect effects should also be taken into account. The noise, grime, waste and environmental pollution effect should be detailed more.

We have integrated the introduction section (133-135) and discussion (392-394), informed by the suggestion.

-         The effects of the economic crisis (2008-) have to be taken into account as in the reference period 2013-2018 some of the European regions have not yet recovered. Therefore, the evolution of tourism was affected by it.

Thanks for raising this point. We have acknowledged the limitation that the results might also be influenced by the 2008 economic crisis (lines 658-662).

We believe that controlling for time, regional variation and regional GDP, and employing instrumental variable estimation have partially overcome this limitation.

-         One of the indicators is named Poverty deprivation, which seems to be nonsense (is either poverty OR deprivation).

Thanks for this observation! We have renamed the indicator as poverty rate.

-         Why only Ryanair airports? Why not all airports or all low-cost airports? It seems very limiting.

We wish to clarify that the Ryanair airports variable was used exclusively in the instrumental variable estimations, to further corroborate causality of tourism stays on health status. We needed an indicator that would theoretically predict tourism stays without being associated with health. We chose to focus on Ryanair airports because of several reasons: 1) because compared to the general number of airports per km2 it is even less likely to predict health. This is because low-cost carriers, as opposed to general airlines, are likely to increase tourism flows in a region, thus opening a new market. Also, low cost carriers are unrelated with health as they are not an indicator of economic development as a whole, and therefore of the quality of healthcare of a region (while the total number of airports might be a proxy of economic development and hence be related with health).

2) we focused on Ryanair airports only, instead of including several low-cost carriers, because of availability of data (we could not find the indicator for other low cost carriers). We have acknowledged this limitation in lines 656-658.

-         The rate of tourist stays per 1000 residents has some drawbacks and disadvantages in rural areas. An idea could be to find specific thresholds for urban areas and different ones for the rural areas

We agree with the point raised by the Reviewer. We believe that by controlling for DEGURBA classification, we have partially controlled for this. We have acknowledged this as a limitation in lines 652-656, leaving the identification of a specific threshold as a suggestion for future research.

-      Keywords – rural development and urban development – to be reconsidered

Keyword removed

-      The Conclusions should be revised in order to become more clear and comprehensive (should include the most important ideas of the study and the answer/final assessment of all 3 hypotheses)

We have revised and expanded the conclusions, which now include the assessment of all hypotheses and a more comprehensive summary of the study.

-         Small errors that have to be corrected. See p2, line74 that (doubled); page 5 line 243-244 “estimations were estimated”; page 7 line 271 “population in good or very good health”.

Edited

The paper entitled “Impacts of tourism stays on residents’ self-reported health: a pan-European analysis on the role of age and urbanization level” aims to study of the effects of tourism stays per 1,000 residents (as a measure of tourism pressure) on self-perceived health at regional level, based on data from Eurostat, the EU-SILC (European Union Statistics on Income and Living Conditions survey), and the LFS (Labor Force Survey). The time frame of this study is 2013-2018. 

I found the choice of the research topic very interesting and timely current due to the deterioration of the health of the population as a result of the lockdown caused by Covid-19. The reduction in tourism has had a very negative impact on the wellbeing of both urban and rural populations. So far, there have been few studies that analyze potential tourists in terms of gender, age, and place of residence. This study fills that gap.  

 The research hypotheses are correct. 

 After reading the paper, I have comments and suggestions to improve the paper as follows: 

We thank the reviewer for her/his comments and positive feedback.

In  Materials and Methods, to better understand the research course, I propose to construct a scheme of the research procedure in the form of a figure. 

We have included a figure representing the conceptual model in Section 2. we hope this clarifies the research course.

The Results were presented and described in a very good manner and are very interesting. They contribute to the value of this paper.  

In the Discussion Section, the authors should compare their project and results with results from similar conducted research on this topic from around the world. 

We have integrated the discussion section, adding comparisons to previously conducted research (381-386; 405-407; 501-514).

In the Conclusion Section, the authors should discuss and explain the findings and results of the paper more. It also important to describe the results of the paper in greater detail in this section. Recommendations are also lacking. What are the benefits of this research?   

We have created section 5 on policy recommendations, and integrated our suggestions for policy. We have clarified in the conclusions that the research highlights the potential side effects of tourism growth, related to tourism-led gentrification and increased living costs, precarious labor, and conflicts related to public space. We stress the need for equitable housing and labour policies, for healthier and more equitable cities in the post-Covid-19 era.