Mapping the Sustainable Development in Health Tourism: A Systematic Literature Review

Abstract

Health tourism is recognised as a growing industry. Therefore, sustainable development in health tourism is crucial not only for the well-being of patients but also for destinations and communities. In this sense, sustainable development in health tourism aims to develop solutions related to the environmental, social, and economic challenges faced by the country and the tourism sector. After the COVID-19 pandemic, health tourism has become popular, and despite the increase in research related to the theme, the existing literature is still relatively fragmented and lacks a comprehensive view. This study addresses this gap by investigating sustainable development in health tourism through a systematic literature review. Ninety-three articles were collected from the Web of Science database. After subjecting them to bibliometric analysis, it is possible to examine the topic’s current state of the art. This research permits the systematisation of the existing literature into five areas: (1) stakeholders of sustainable tourism, (2) impact of COVID-19, (3) health tourism, (4) challenges and opportunities, and (5) sustainability values. This research provides significant contributions to the field of sustainable development in health tourism. Firstly, it sheds light on aspects that previous literature has examined, offering valuable insights into the drivers of sustainable development in health tourism, thus enriching our comprehension of the subject. Additionally, the article delineates a prospective research agenda, suggesting various directions that can lay the foundation for upcoming inquiries and the development of pertinent theories for assessing the impact of sustainable development in health tourism.

1. Introduction

The importance of the health tourism industry has been rapidly increasing in recent years [1,2,3]. Health tourism emerges as a significant facet at the intersection of the pursuit of well-being and global mobility. This intricate phenomenon, where travellers seek medical treatments beyond their borders, redefines the traditional dynamics of health and tourism [2]. Health tourism represents a burgeoning market within the tourism sector, emerging as a relatively recent phenomenon in which governments increasingly invest [1]. Therefore, health tourism has an extraordinary potential that should be taken seriously [4]. In this regard, the importance of the tourism sector has increased at a high rate in many destinations [5], contributing to their economic development [6]. For UNWTO (United Nations of World Tourism and Organizations) [7], tourism represents a multifaceted social, cultural, and economic phenomenon. Individuals characterise health tourism by travelling to countries or destinations beyond their familiar surroundings for personal, business, and professional motives. Tourism generates economic activity by searching for goods and services directly and indirectly in places visited and beyond. These include job creation within tourism and its associated sectors, such as agriculture, construction, and smallholders [8]. The economic impact of tourism is an essential consideration in planning and development, as it yields considerable advantages for both the nations hosting tourists and the countries of origin for the tourists [9]. Tourism also contributes to the progression and development of the global economy, influencing employment, GDP, the balance of payments, and general economic growth [6].

However, measuring the economic contribution of tourism can be complex due to varying definitions and statistical sources [10]. According to Andrade and Velonjara [11], there is a long-term positive relation between tourist expenditure and economic growth, highlighting the importance of tourism for GDP growth. Despite the favourable impacts brought about by the tourism industry, there are adverse effects that this sector can generate [12]. One way to minimise the effects is to develop sustainable tourism [13] by achieving the Sustainable Development Goals (SDGs) [14]. The SDGs form essential components of the United Nations 2030 Agenda, aiming to realise a more sustainable and improved future for everyone. They underscore the interconnectedness of human well-being, the health of natural systems, and shared challenges across countries, encompassing aspects like peace, development, and human rights [15]. Sustainable tourism reduces environmental impacts, promotes cultural preservation, and benefits local communities [16,17,18]. It involves implementing practices such as reducing carbon emissions, managing waste, conserving natural resources, and supporting local economies and communities [16,17,18]. By adopting sustainable practices and targeting the SDGs, tourism enterprises have the potential to influence the industry’s sustained growth and sustainability and minimise its adverse environmental and community effects [16,17,18].

Effective tourism development requires a delicate equilibrium in the interactions among tourists, residents, destinations, and the organisations and companies offering tourism services [19]. In this context, holistic, sustainable tourism development encompasses the involvement of various stakeholders and underscores the significance of enhancing the quality of life for residents. [20]. The theme of Community Quality of Life (CQoL) has emerged as an essential topic in tourism development [21]. Hence, residents assume a critical role in the sustainable development journey, actively bolstering the well-being of the tourism industry and fostering community prosperity. Consequently, it is mutually beneficial for residents, the tourism sector, and tourists alike to cultivate a positive perspective and promote favourable experiences in tourism development [20].

Tourism exerts various influences on health, impacting both consumers and providers alike. Primarily, health and wellbeing constitute essential prerequisites that not only shape tourists’ decisions regarding destinations and travel arrangements—influenced by factors such as epidemiology or the presence and quality of health services in the host country, hygiene standards, water quality, and more—but also influence the wellbeing of the local population [22].

Health tourism refers to travelling across international borders to obtain healthcare services. It has proliferated in recent years due to factors such as high treatment costs in wealthy countries, long waiting lists, affordable air travel, favourable exchange rates, and the availability of well-qualified medical staff [23]. Health tourism encompasses medical tourism, which focuses on treatment, and wellness tourism, which includes relaxation, exercise, and visits to spas [24]. Health tourism has evolved into various components such as hot springs, spas, medical tourism, body and mind care, enogastronomy, sports, nature and environment, culture, spirituality, and events [25]. The industry has significant economic potential, contributing to a multi-billion-dollar global market [26].

Health tourism is a growing industry that involves individuals travelling to access health services or wellness activities in different countries. Research carried out on the topic of health tourism has explored aspects such as the application of protection motivation theory to understand the behavioural intentions of international tourists in health tourism [27]; the organisational and operational aspects of health tourism, including the level of adjustment of health tourism companies to sustainable development criteria [28]; and the transformative process and goal systems of health-seeking tourists in wellness tourism destinations [29]. Health tourism is a multidimensional field encompassing multiple perspectives and factors, contributing to its status as a booming billion-dollar business [30].

The expansion of medical tourism has led to the globalisation of healthcare, resulting in the cross-border provision of healthcare services and the growth of the healthcare sector in many countries [31]. Medical tourism positively affects the production growth of host economies, particularly in non-OECD (Organization for Economic Cooperation and Development) countries. However, considering the unfavourable indirect effect on productivity reveals an overestimation of medical tourism’s contribution to production. [32]. Furthermore, medical tourism can contribute to developing the tourism market and attract citizens concerned with maintaining or improving health and well-being and patients seeking high-quality services, thus benefiting the local economy [33]. Therefore, it is essential to recognise that health tourism impacts the local economy, and policymakers need to consider these effects and ensure that it can positively impact the local economy, attracting visitors and generating economic benefits [34].

However, there are specific regulations that apply to health tourism in certain countries and have a significant impact on the health tourism industry. In Guatemala, for example, the need for adequate public regulation of the medical tourism sector has created regulatory gaps and raised concerns about patient safety and health equity [35]. Key informants in Guatemala expressed the need for government regulation and the potential use of international accreditation to increase national regulation [36]. Similarly, the International Health Regulations (IHR) are crucial in minimising the spread of infectious diseases and have implications for travellers and travel health advisors [37]. The IHR focuses on implementing protection, control, and response measures at points of entry to prevent the spread of disease while minimising disruptions to international trade [35]. Therefore, the specific regulations and frameworks can shape the health tourism industry by ensuring patient safety, bridging regulatory gaps, and minimising the spread of infectious diseases [38].

Health tourism presents variations in motivational factors, demand dynamics, and elasticity. Ridderstaat et al. [39] identified different motivational factors for tourists visiting medical spa resorts, including treatment, prevention, and tourism. The demand for health tourism depends on several factors, such as the impact of the main visitor entry markets on health tourism expenditure [40]. Furthermore, demand for health tourism can be affected by price competition and exchange rates [41]. Elasticity in health tourism refers to the responsiveness of health spending to changes in visitor markets and other factors. Research has shown that long-term variations in visitor inbound markets can significantly impact healthcare spending [27]. Furthermore, changes in travel motivation patterns in wellness tourism indicate a greater focus on wellness aspects, reflecting different expressions of interest in wellness [42].

Another aspect is that health disasters, such as the impact of COVID-19, have devastated tourism [43,44,45,46]. For Bosone and Nocca [13], the pandemic inflicted severe adverse effects on tourism, making it one of the most impacted economic domains. Nevertheless, this disaster also opened up opportunities for new actions in tourism and sustainability management [43,44,45,46]. However, there were also positive effects on the environment associated with reduced travel, the interruption of specific activities, and limitations imposed by the government [13]. New tourism areas, such as health or medical tourism, were already growing from this crisis. Health tourism has grown exponentially in the last two decades and is one of the fastest-growing niche tourism markets [47]. The COVID-19 pandemic has brought even more significant evidence of the relevance of health and wellbeing, resulting in changes and new trends in international health tourism. Health tourism is a global trend with great potential for growth and economic development [47,48].

The study of sustainable development in health tourism has been boosted in the last few years, leading to a deeper understanding of the area. Researchers explore the opportunities and challenges associated with interdisciplinary practice in tourism research, especially in light of the impacts of the pandemic [49], address the phenomenon of tourist overcrowding or over-tourism and the importance of residents [50], and the relationship between green finance, renewable energy, and tourism for sustainable development [51].

Tourism and health tourism can be more sustainable by considering sustainable development, maximising customer satisfaction, and promoting sustainable practices. This could be completed by offering services with the best quality and reasonable prices while considering environmental and social impacts [52]. Additionally, it is essential to adopt sustainable business models that contribute to sustainability through positive effects on natural resources [53]. Digital technologies can support the design of sustainable tourist practices, guiding tourist behaviour towards sustainability. [54]. To achieve sustainable competitiveness in medical tourism, valuable, rare, and inimitable resources and capabilities should be utilised to design unique tourist experiences [55]. Challenges for the future include the need for leadership, well-defined strategy, financial support, and specific training programs in the medical tourism industry [56].

Through a Systematic Literature Review (SLR) analysis, this research contributes to the knowledge of the theme and development of sustainable development in health tourism. As expected and given the theme’s importance, this research finds multiple SLRs about the subject. Some are very recent, like the SLR developed by Rahmadian, Feitosa, and Zwitter [57], which analysed the use of Big Data in sustainable tourism and understood how it could support decision-making. The SLR of Streimikiene, Svagzdiene, Jasinskas, and Simanavicius [58] analysed the main ways and factors of strengthening tourist competitiveness by implementing economic, social, and environmental goals for developing destination territories. Vong, Rita, and António [59] conducted a systematic review in the specific context of health-related tourism but focused only on synthesising health-related crises. In this context, none of the SLRs examined the concept of sustainable development in tourism on a broader scale, explicitly analysing the context of health tourism. In this sense, this SLR formulated the following research questions (RQ): RQ1—What are the main trends in research on the literature on sustainable development in health tourism? RQ2: What is the possible future research direction?

Therefore, this systematic methodology enhances the existing literature by delineating additional streams, domains, contributions, and geographical contexts linked to sustainable development in health tourism. Additionally, this SLR offers a comprehensive framework for comprehending the processes and consequences of sustainable development in health tourism, shedding light on its influence on the progress of both organisations and nations. This framework illustrates the interconnections among the identified thematic groups. The findings of this comprehensive review can serve as valuable insights for governments, residents, tourists, and all stakeholders engaged in advancing and enhancing countries through the pursuit of sustainable development in health tourism. This study addresses a research gap that necessitates additional exploration into sustainable tourism, highlighting that this area still needs to be explored [44].

The organisation of the present research is as follows: initially, it offers a literature review on sustainable development in health tourism. Subsequently, it outlines the materials, methods, and conceptual framework employed in the study. The findings and discussions, derived from bibliometric analysis, shed light on the current knowledge in this field. The study concludes by presenting key insights and proposing a future research agenda.

2. Materials and Methods

This study uses an SLR on sustainable development in health tourism as a methodology. Embraced across various disciplines and areas of inquiry, the research methodology of SLR has experienced notable expansion and growth in recent years [60]. The SLRs adhere to rigorous pre-defined methods, facilitating the progression of knowledge, minimising the scope for bias, and ensuring the possibility of replication [60,61]. In the development of this research, the selection and compilation of representative articles from the Web of Science database occurred without temporal delimitation. This research utilises WoS (Web of Science) as it plays a crucial role in academic research by providing access to high-quality scientific information. As one of the largest and most respected bibliographic databases, WoS offers a vast collection of peer-reviewed articles across diverse disciplines, allowing researchers to gain valuable insights and track the progress of knowledge in their areas of interest. Thus, the WoS database is appreciated and recognised as a high-quality archival source for collecting materials used by several previous researchers as a robust and high-quality data source. Its scope and precision make it a reliable source for bibliometric analyses and scientific research trend studies. Likewise, integrating resources such as VOSviewer allows for a more detailed and comprehensive analysis of available data, further improving understanding of the current scientific landscape [62]. The characteristic of a user-friendly platform like WoS allowed the set research questions to be answerable in this paper. First, the research was conducted on a topic-based search of the WoS Core Collection without imposing any time restrictions, employing the specified keywords: “sustain* development” AND “tourism industry” AND “health tourism”, and it was carried out on 2 August 2023. These keywords were considered and chosen considering the objective of this study, which is the analysis of sustainable development in health tourism. The truncation (‘*’) was used to cover all fitting terms, allowing us to restrict the scope to articles that specifically address the defined words and their derivations. The search yielded 175 articles. Second, the screening process covers the research refinement procedure. The filters applied were “type of document”, “language”, and “research areas”. In this sense, the analysis was developed only with journal articles, whereas conference papers, books, and book chapters have been excluded. On the other hand, only articles written in English and from the areas of Social Sciences—Other Topics, Public, Environmental and Occupational Health, Science and Technology—Other Topics, Environmental Sciences Ecology, Health Care Sciences Services, and |Business Economics areas were chosen. After the application of the filters mentioned, the research was reduced to 93 articles. Figure 1 shows the research protocol.

To the objectives defined for this investigation, an SLR was carried out with bibliometric techniques on the theme of sustainable development in health tourism, an emerging research topic. In the initial phase, descriptive statistical analyses were conducted on the obtained articles. Subsequently, bibliometric techniques were used to enhance the advancement of scientific knowledge by delving into and analysing the factors underlying bibliographic phenomena associated with scientific interest [63]. In this sense, and to allow the mapping and processing of articles obtained in the research, the VOSviewer 1.6.13 software was used [64]. Thus, the 93 articles were the subject of different and complementary bibliometric analyses that will allow the analysis and evolution of the state of the art on the topic under analysis [65]. Thus, the bibliometric techniques were (i) co-occurrence analysis of keywords and (ii) bibliographic coupling of documents. The bibliographic coupling of documents involves grouping articles based on the shared references cited by two distinct articles [66]. In this analysis, the examination was performed on the “documents” unit using the “full count” method, with a minimum cluster size of 5. Regardless of the number of authors associated with each document, each co-authorship link offers a more accurate representation of collaborative activity [67]. The “minimum cluster size” parameter plays a crucial role in refining the clustering results to better align with the desired goals of the VOS clustering technique. By specifying a higher minimum number of items, we can enhance the quality and relevance of clustering results, ensuring that resulting clusters represent more cohesive and meaningful groups of articles [67]. The bibliographic coupling method establishes a connection between two documents if they cite the same reference item [66], thereby facilitating the identification of relationships between authors based on cited references, assisting in identifying highly influential research, and providing insights into the analysed field [68]. The software automatically identified five groups comprising just 51 articles: Cluster 1 will contain 12 items, Cluster 2 will include 12 items, Cluster 3 will comprise 11 items, Cluster 4 will form 10 items, and Cluster 5 will comprise 6 items. Articles were scrutinised to identify emerging themes in each cluster.

In recent years, co-occurrence network analysis tools have increased as they allow a clear understanding of current trends on a given topic under analysis [67]. Examining keyword co-occurrence enables us to assess their relationship, determined by the frequency with which they appear together in articles [64]. This technique allows for identifying the conceptual structure of the research field under analysis [69].

The combined utilisation of bibliometric analyses aims to offer a more holistic perspective of the structures and dynamics in the analysed literature [69]. Specifically, co-occurrence analysis scrutinises the frequency of objects appearing together relative to the total number of co-occurrences, facilitating the identification of the underlying conceptual structure within the research field [70].

3. Results

This section presents a brief and precise account of the experimental results, their interpretation, and the derived experimental conclusions.

3.1. Descriptive Analysis

The evolution of the number of citations and publications of the 93 articles obtained for analysis from 2003 to 2023 is shown in Figure 2. The data is organised chronologically, revealing the evolution of citation counts, reaching a peak in 2018 with 246 citations and in 2021 with 163 citations. The number of articles has consistently increased, with 2022 marking the highest point, featuring 30 publications.

A total of 20 (21.5%) of the 93 articles obtained in the survey have no citations, and 66 (71%) have less than ten citations. This happens because they are very recent articles; of the 20 articles without citations, 8 are from 2023, and of the 66 articles with less than 10 citations, 22 are from 2022 and 2023. The first study identified was Charlier and Bologa [71], which examined the status of the coastal zone by exploring realistic solutions to address its problems. On the other hand, it addresses the importance of the zone for environmental and economic sustainability. The most cited article is a literature review by Hens et al. [72], who examined the underlying factors that contributed to the significant transformations in Clean Production over the past quarter century.

The prominent journals contributing to the theme are in

Table 1. Prominent Journals.

Title of Journal	Number of Articles	Total of Citations (Web of Science Core Collection)
Sustainability	20	153
Current Issues in Tourism	3	136
Frontiers in Public Health	3	6
International Journal of Env. Res. And Public Health	3	36
Journal of Environmental Protection and Ecology	3	33
Marine Policy	3	39
Asia Pacific Journal of Tourism Research	2	4
Environment Development and Sustainability	2	16
Environmental Management	2	7
International Journal of Event and Festival Management	2	5
Journal of Sustainable Tourism	2	110
Tourism Review	2	31
Worldwide Hospitality and Tourism Themes	2	16

.

The rest of the articles are dispersed across 44 journals, with one per journal.

Figure 3 presents the distribution of articles by area of research. There is a concentration of articles in the areas of Environmental Sciences (46%), Green Sustainable Science Technology (33%), and Hospitality Leisure Sport Tourism and Environmental Studies, each of one (28%).

The top ten of the most cited articles are in

Table 2. Top 10.

Article Title	Authors	Journal	Total Citations (in WoS Core Collection)	Methodology
On the evolution of Cleaner Production as a concept and a practice	[72]	International Journal of Life Cycle Assessment	140	Qualitative analysis
Comparative life cycle assessment and social life cycle assessment of used polyethene terephthalate (PET) bottles in Mauritius	[74]	Journal of Sustainable Tourism	113	Quantitative analysis
The diffusion of environmental sustainability innovations in North American hotels and ski resorts	[75]	Tourism Management	109	Quantitative analysis
Corporate sustainability reporting index and baseline data for the cruise industry.	[76]	Current Issues in Tourism	89	Qualitative analysis
More than medical tourism: lessons from Indonesia and Malaysia on South-South intra-regional medical travel	[77]	Science of the Total Environment	79	Qualitative analysis
Tackling challenges for Mediterranean sustainable coastal tourism: An ecosystem service perspective	[12]	Sustainability	78	Quantitative analysis
Resident Support for Tourism Development in Rural Midwestern (USA) Communities: Perceived Tourism Impacts and Community Quality of Life Perspective	[20]	Journal of Hospitality and Tourism Management	56	Quantitative analysis
Should we cancel? An examination of risk handling in travel social media before visiting ebola-free destinations	[78]	Journal of Travel Research	52	Qualitative analysis
Medical Tourism Experience: Conceptualization, Scale Development, and Validation	[2]	Current Issues in Tourism	39	Quantitative analysis
Tourism organisations’ responses to the COVID-19 pandemic: an investigation of the lockdown period	[79]	Sustainable Cities and Society	39	Qualitative analysis

. It is possible to observe that the most cited articles are in different journals, encompassing qualitative and quantitative analyses. Given that sustainable development in tourism remains in its nascent research phase, qualitative analysis bolsters the validity and depth of research findings, serving as a critical instrument for researchers delving into the intricate realms of social, psychological, and cultural phenomena [73]. Simultaneously, the prevalence of quantitative analyses is increasing in response to the imperative to comprehend and elucidate specific phenomena, such as Sustainable Tourism Development [73].

3.2. Bibliometric Analysis

This study employed diverse bibliometric analysis techniques to offer a holistic and integrated perspective on various dimensions within the research area. All bibliometric analyses were conducted utilising the VOSviewer 1.6.13 software [64].

3.2.1. Keyword Co-Occurrence

A keyword co-occurrence analysis was performed to deepen the insights revealed by the bibliographic coupling of documents. This analysis allows for identifying the most critical concepts of sustainable development in tourism. Figure 4 shows the keyword network for sustainable development in tourism based on co-occurrence. The five main keywords used in the articles were “tourism” (23 occurrences), “COVID-19” (17 occurrences), “sustainable tourism” (14 occurrences), “sustainable development” (113 occurrences), and “impacts” (12 occurrences). Identifying eight main groups of keywords through co-occurrence analysis of the articles on this subject is possible.

Cluster 1 encompasses 17% of the analysed keywords, with “tourism” being the primary keyword due to its higher number of co-occurrences. Cluster 2 represents 16% of the keywords, with “medical tourism” having the most significant co-occurrences. Cluster 3 includes 15% of the analysed keywords, with “sustainable tourism” as the main keyword. Cluster 4 comprises 12% of the keywords, and “sustainable development” is the predominant keyword. Cluster 5, accounting for 12% of the keywords, is centred around “COVID-19”. Cluster 6, with 11% of the keywords, is characterised by the main keyword ”impacts”. Finally, Cluster 7 and 8, each representing 9% of the keywords, are associated with the main keywords “model” and “economic growth”, respectively.

The primary keywords linked to the four clusters are shown in

Table 3. Clusters of keywords.

Cluster Number	Colour	Cluster Name	Main Keywords
1	Red	Tourism	Attitudes, beach, coastal ecosystems, coronavirus, health, impact, intention, interdisciplinary research, island, ocean, perceptions, sustainability, work
2	Green	Medical Tourism	Behavioural intentions, destination, dimensions, health tourism, quality, sand, satisfaction, service, stakeholder, tourism industry, travel, wellness tourism
3	Blue	Sustainable Tourism	Behaviour, benefits, community, crisis management, destinations, governance, health crisis, perception, resilience, stakeholders, willingness
4	Yellow	Sustainable Development	Climate change, crisis, framework, management, performance, responsibility, social life cycle assessment, tourism management, vulnerability
5	Purple	COVID-19	Conservation, events, experiences, festivals, green, hospitality, industry, safety, technology
6	Pink	Impacts	Carrying capacity, challenges, environment, indicators, local development, policy, renewable energy, tourism development
7	Orange	Model	China, Delphi method, footprint, innovation, low-carbon tourism, tourism ecosystem health
8	Brown	Economic Growth	CO2 emissions, energy consumption, environmental Kuznets curve, index, lockdown, pollution

. Each cluster was named according to the keyword with the highest co-occurrences.

In Figure 5, it is possible to show the most significant keywords that emerged between 2018 and 2022, demonstrating the originality and actuality of the theme. The keywords that appeared in 2018 were “sustainability”; in 2019, the words “sustainability development” and “tourism” stood out. In 2020, the word most mentioned was “impact”; in 2021, it was “medical tourism health”. Words that have surfaced more recently in 2022 indicate a recent surge in interest in the field, with the most frequently mentioned term being “tourism ecosystem health”.

3.2.2. Bibliographic Coupling of Documents

The research was divided into clusters based on a bibliographic coupling of 93 articles to identify trends in the literature on sustainability development in health tourism. The analysis was conducted at the document level, with each cluster comprising at least five documents. This process yielded 51 papers distributed across five clusters, as seen in Figure 6.

The constitution of each cluster and respective citations, obtained through bibliographic coupling of documents analysis, can be seen in Appendix A.

The formation of five clusters has unveiled distinct characteristics in terms of the number of articles, total article citations, and research focus, affirming the broad spectrum of themes within this research domain. The diverse research emphases within each cluster prompted the assignment of descriptive names: (1) Stakeholders of Sustainable Tourism, (2) Impact of COVID-19, (3) Health Tourism, (4) Challenges and Opportunities, and (5) The Values of Sustainability.

4. Sustainable Development in Health Tourism—Main Themes

According to Figure 6, the results obtained from the bibliographic coupling of documents allow for the identification of five clusters. This section examines the primary themes addressed within each cluster by analysing the five most cited articles constituting each cluster.

4.1. Cluster 1—Stakeholders of Sustainable Tourism

Cluster 1, highlighted in red in Figure 5, is composed of 12 articles. Cluster 1 addresses the issue of sustainable tourism and local community involvement. At this point, it is essential to discuss the impact of the pandemic, the relevance of coastal ecosystems and natural resources, community involvement in tourism, and the relationship between tourism and the population’s quality of life. In this way, debates on sustainability issues in tourism increase [12,13,80]. Therefore, there are several topics analysed, including the promotion of circular and human tourism [13], addressing the challenges faced by coastal tourism in the Mediterranean [12], and the search for sustainable development in tourist resorts on small islands [80]. Sustainable tourism requires everyone, especially local populations, to be aware of the relevance of sustainable tourism for preserving their territories and local economies [12,13,80,81]. The pandemic has made this topic even more evident and urgent [13,80]. Yu et al. [20] emphasise the link between tourism and the community’s quality of life, emphasising the importance of sociocultural and environmental well-being to support tourism. COVID-19 forced a rethink of the tourist enterprise and business models, highlighting the financial, economic, social, and environmental impacts [13].

4.2. Cluster 2—Impact of COVID-19

Formed of twelve articles, Cluster 2 consists of the most recent articles, one from 2020, six from 2021, and five from 2022. Cluster 2 (green) addresses the effects of COVID-19 on the tourism industry and proposes ways for a destination to recover after a health crisis such as COVID-19 [43,44,45,46]. Due to the experience with the pandemic, the elaboration and implementation of recovery strategies for the tourism sector are crucial [43,44,45,46]. The pandemic allows investment in critical organisational capability and human capital through technology innovation, digital skills, and health protocols to build industry resilience to respond to future shocks [43]. In addition, the relevance of local development, community resilience, and cooperation between different stakeholders, especially the local communities, could be considered strategies to face the effects of future pandemics [50].

4.3. Cluster 3—Health Tourism

Cluster 3 (blue) has 11 articles addressing health tourism’s growing importance [2,3,75,82]. In addition, sustainability is a relevant topic. According to Smerecnik and Andersen [75] and Liu et al. [83], adopting sustainable practices is extremely important in disseminating environmental sustainability innovations in resorts or evaluating the utility value of forest ecosystem services. There is a common focus on the tourist experience. According to Majeed et al. [82] and Ghosh and Mandal [2], the perceptions and experiences of health tourists, whether concerning health resorts or medical tourism in general, should be considered and explored. Oltean et al. [3] broadened the focus of health tourism to include the perspectives of dental clinics and travel agencies on dental tourism. This focus on the tourist experience demonstrates the relevance of providing quality and attractive services to health tourists. In this context, health tourism can be a profitable and beneficial industry, but it needs to be managed sustainably to avoid negative impacts [3,82]. Collaboration between stakeholders, including governments, tourism companies, medical clinics, and tourism agencies, is crucial to developing a sustainable and attractive health tourism industry [3,75]. The quality of the tourist experience, the adoption of sustainable practices, and the understanding of tourists’ perceptions and motivations are critical elements for the long-term success of this industry [2,82].

4.4. Cluster 4—Challenges and Opportunities

Cluster 4, highlighted in orange in the figure and formed by ten articles, focuses on two main aspects. Firstly, it investigates the challenges of natural disasters and global health crises such as COVID-19 and Ebola. Secondly, it addresses the need for interdisciplinary collaboration to address these challenges within the tourism sector.

National disasters, ranging from economic crises and natural calamities to health-related risks and acts of terrorism, significantly impact the sustainability of the tourism sector and adversely affect the economies of affected nations [84]. Consequently, governments must adopt strict risk management measures to facilitate economic recovery [78,84,85]. However, achieving this goal requires continuous interdisciplinary cooperation and uniting social and medical sciences domains, as highlighted by Liu et al. [49].

It is crucial to emphasise that merely designing and implementing risk management systems cannot revive a nation’s appeal as a tourist destination. Governments must proactively invest and help recover the destination’s image to attract tourists [78,86]. Consequently, countries must channel their marketing efforts to leverage the vast reach of social media to neutralise any stigmas that may have arisen [78].

Furthermore, it is noteworthy that regions or countries facing a higher risk of disasters witness a growing interest in nature-based tourism [86].

4.5. Cluster 5—Sustainability Values

Cluster 5 (purple) is the smallest, formed by six articles. According to the total citation number, this cluster contains the most influential article developed by Hens et al. [72]. This cluster is noteworthy for its analysis of themes related to the evolution of the sustainability concept.

The concept of sustainability has undergone significant transformation over the past 25 years. Management reports that once solely centred around economic and environmental considerations must now incorporate the principles of corporate social responsibility. Bonilla-Priego et al. [76] and Hens et al. [72] underscored that these reports should encompass many aspects, including human rights, resource management, business ethics, and community engagement.

Nevertheless, the tourism industry has encountered numerous challenges over the years. Consequently, studies support tourism (see [1,41,45,80,81]). The objective is to develop methodologies and practices that are more sustainable and ecologically responsible, allowing the industry to confront and prevent both natural [87] and health-related crises effectively [88].

Above all, the aim is to facilitate a collaborative effort between academia and the tourism industry, emphasising the importance of raising awareness among all stakeholders within the sector.

Indeed, if residents better understand tourism and its interrelationships with other aspects of their lives, they will be more informed about the impacts of tourism. This process will help them be more involved in community issues influencing their quality of life [5]. This collaborative endeavour plays a pivotal role in assisting governments in making informed decisions aimed at establishing a sustainable tourism sector [5].

5. Conceptual Framework and Future Research Agenda

Diverse bibliometric analyses facilitate insight into trends within the literature on sustainable development in health tourism. The outcomes derived from various techniques complement and corroborate the literature’s systematisation. This, in turn, enables the formulation of an integrative framework (see Figure 7), articulating the primary themes identified in the literature.

The integrative framework illustrates how bibliometric analysis results can be systematised and interrelated. Cluster 1 investigates the field of sustainable tourism and its intersection with the involvement of various stakeholders, mainly the local community, which plays a central role. In this context, it is possible to verify the importance that residents play and influence tourism in a pandemic context (Cluster 2) or even natural disasters or terrorism (Cluster 4). On the other hand, this cluster also addresses the dynamics between tourism and the general quality of life in local communities. It is possible to see the relevance of tourism as a positive factor in sustainable development, minimising environmental impact, and contributing to the prosperity of the local community. As Pjanić [6] and Oana-Elena et al. [8] state, tourism contributes to local and global economic activity, as it benefits the nations that host tourists and the tourists’ countries of origin. This paper verified that health tourism also has a fundamental and impactful role in the growth of the health sector in many countries and sustainable development, mainly through the behaviours of citizens and patients. Thus, this study also confirms the results of Hazarika [31] and Godovykh and Ridderstaat [33]. Hence, conducting additional research involving tourists and various stakeholders would be intriguing. This research can facilitate identifying and implementing strategies and measures to foster a more circular and sustainable approach to tourism [13]. Another interesting future research to carry out would be the analysis of religious and cultural tourism’s impact on the sustainable development of rural tourism, considering different countries, regions, rights, and ages [89].

Cluster 2 addresses the unprecedented challenges that COVID-19 has had on tourism, specifically health tourism. The impact of COVID-19 on health tourism has been profound and multifaceted. With the pandemic, the health tourism sector has experienced disruptions to travel patterns, changes in consumer behaviour, and challenges for healthcare providers and destinations dependent on medical tourism revenue. Therefore, those interested in the health tourism industry need to adapt to new realities and implement innovative strategies to mitigate the impact of the pandemic. On the other hand, it also points out some more sustainable approaches and incentives the sector had to adopt. So, as the industry recovers, the emphasis on sustainability continues to grow, benefiting traveller’s health and the health of the local community and the planet. In this sense, these aspects align with what Ghaderi [50] defends, highlighting the importance of residents and cooperation between different stakeholders to develop strategies to face the effects of future pandemics. On the other hand, it is also possible to understand the importance governments, through their policies and measures, have in health tourism’s healthy and sustainable growth, minimising the negative impacts that pandemics may cause. Thus, the results confirm the studies developed by Vaidya et al. [35] and von Tigerstrom et al. [38], which state the need for adequate legislation, thus guaranteeing the safety and protection of everyone involved.

In this sense, future research should be carried out in different geographic regions to investigate the organisational, economic, environmental, social, and political aspects the tourism and hospitality sector faced and still faces due to the COVID-19 pandemic [43]. Furthermore, future research must be developed to delve deeper into the most efficient types of institutional support in rebuilding the tourism sector post-pandemic [44].

Although Cluster 4 also addresses the impact of COVID-19, natural disasters, and terrorism, it also addresses the issue of challenges and opportunities that can arise in these adversities. It is essential to consider the challenges and opportunities of the sustainable development of health tourism as these significantly influence the future of this constantly growing sector. Challenges not to be overlooked include the environmental impact, ensuring that health tourism is accessible and equitable for all, and developing ways to make services more accessible without compromising quality. As opportunities, health tourism can boost economic development in regions that depend on it, creating jobs and stimulating the growth of related sectors, cultural and educational exchange between patients and health professionals, and the contribution to the social area, supporting local communities and promoting human development through investments in infrastructure, education, and health. Therefore, interdisciplinary collaboration is crucial as one of the practices to be developed so that the tourism sector, specifically health tourism, can continue to grow. Addressing these challenges and seizing these opportunities requires an integrated and collaborative approach involving all stakeholders, including governments, healthcare professionals, patients, and the local community. In this sense, more longitudinal studies should be developed to gather information on changing opinions and perspectives of tourism organisations after crises [79]. As previously mentioned, this cluster is influenced by Cluster 1, that is, the stakeholders of tourism, especially residents. Therefore, future research should investigate approaches to engage local inhabitants in developing tourism and initiatives addressing the pandemic [49].

Cluster 5 addresses the issue of sustainability, namely the evolution of associated values. If the initial concern was economic and environmental, sustainability increasingly focuses on social issues and social responsibility. Nature plays a fundamental role in wellbeing, and health destinations are increasingly committed to preserving the ecosystems surrounding them. As Simo-Kengne [16] and Jiaqi et al. [18] refer, tourism, and therefore health tourism, associated with sustainability, must be considered a fundamental area for countries and governments in that it will contribute to the reduction in environmental impacts, the promotion, and the cultural preservation of local communities. In this sense, it is crucial to develop studies introducing innovations and theoretical advances in analysing the health of the tourism ecosystem [87].

All mentioned clusters affect Cluster 3, which addresses the issue of health tourism. According to this concept, tourists seek medical treatments or wellness but do so in an ecologically conscious and socially responsible way. This combination of sustainable and healthy tourism benefits travellers and contributes to environmental conservation and the development of local communities. As stated by Dini and Pencarelli [26], this industry has increased considerably in recent years, becoming a strategic point for global economic growth. But, more than the financial aspect, this industry must be considered by all countries and governments as fundamental as it allows the interconnection of human well-being, the health of natural systems, and challenges shared between countries such as peace, development, and human rights [19]. According to what has recently been experienced, future research should focus on the development of medical tourism in the post-corona era [1]. On the other hand, it will be interesting to conduct more longitudinal studies that track patients’ pre-, mid-, and post-medical travel experiences [77].

From the framework analysis, it is possible to perceive that although residents play an essential role, all stakeholders have a prominent role in the sustainable development of tourism, especially in the specific area of health. The combination of sustainable and healthy tourism benefits travellers and contributes to environmental conservation and the development of local communities. Only through adopting practices and measures associated with this mentality and concept can the sustainable future of health tourism be promising. Nevertheless, the current SLR highlights the imperative for additional studies on this topic, indicating that a considerable amount remains yet to be explored.

A future research agenda for each cluster is summarised in

Table 4. Future research agenda.

Cluster	Future Research Suggestions
Stakeholders of sustainable tourism	- More research with tourists and other stakeholders allows the identification and implementation of strategies and actions for more circular and sustainable tourism [13]. - Analysing the impact of religious and cultural tourism on the sustainable development of rural tourism, considering different countries, regions, rights, and ages [89].
Impact of COVID-19	- Studies in different geographic regions investigating the organisational, economic, environmental, social, and political setbacks the tourism and hospitality sector faces due to the COVID-19 pandemic [43]. - Develop studies that deepen the study of the most efficient types of institutional support in rebuilding the post-pandemic tourism sector [44].
Health tourism	- Future research should focus on the development of medical tourism in the post-corona era [1]. - More longitudinal studies that track patients’ pre-, mid-, and post-medical travel experiences [77].
Challenges and opportunities	- Longitudinal studies to gather information on changing opinions and perspectives of tourism organisations after crises [79]. - Future research should investigate ways to involve residents in tourism development and anti-pandemic initiatives [49].
Sustainability values	- Develop future studies introducing innovations and theoretical advances in analysing ecosystem health [87].

.

6. Conclusions, Limitations

Sustainable tourism development is an increasingly important topic. In turn, sustainable development in health tourism has also gained prominence in recent years, as it combines two crucial elements: health promotion and environmental preservation.

This study reveals that scientific production on the analysed topic holds promising prospects, exhibiting a growing trend. Furthermore, our observations indicate a significant concentration of publications within the field of environmental sciences, with a considerable number of papers appearing in the journal.

The main objective of this study is to use bibliometric analyses to map and examine the existing literature on sustainable development in health tourism and thus define the crucial literary works on this subject based on previous, current, and future trends within this emerging field of research. The data were collected from the WoS database, and 93 articles related to sustainable development in health tourism from 2003 to 2023 were subjected to bibliometric analysis, namely (i) co-occurrence analysis of keywords and (ii) bibliographic coupling of documents. By the co-occurrence analysis, it was possible to identify five main keywords used in the papers on sustainable development in health tourism, namely “tourism”, “COVID-19”, “sustainable tourism”, “sustainable development”, and “impacts”. Through the evolution of the keyword co-occurrence networks, it is also possible to verify that the future trend in this area will be the analysis of aspects such as footprint, green, events, challenges, ecosystem health, challenges, economic growth, and tourism development. With the bibliographic coupling analysis, five thematic groups were identified in sustainable development in health tourism, namely (1) Stakeholders of sustainable tourism, (2) Impact of COVID-19, (3) Health tourism, (4) Challenges and opportunities, and (5) Sustainability values.

With this study, it became clear that all participants, whether residents, tourists, or even the government, play a crucial role in advancing sustainable tourism (Cluster 1). In this sense, local communities become active partners in developing tourism in their regions, obtaining direct benefits from tourist activities. This can generate economic opportunities, improve local infrastructure, and reinforce cultural pride. Only with everyone’s participation can the impacts caused by tourism be minimised, contributing to the well-being of local communities and preserving residents’ quality of life. Before the COVID-19 pandemic (Cluster 2), there was already a growing awareness of the importance of adopting sustainable practices in the tourism sector, including health tourism. However, the pandemic has brought significant challenges to health tourism and, at the same time, further highlighted the importance of sustainability. Sustainable tourism development is also a necessary response to environmental challenges (Cluster 4).

In contrast to traditional practices, which often negatively impact the environment and local communities, sustainable tourism seeks to balance economic growth with environmental conservation and the well-being of communities. Thus, sustainable health tourism (Cluster 3) strongly focuses on connecting with nature and valuing local culture, as many health destinations are in stunning natural areas. This promotes physical health and strengthens people’s bond with the natural environment. Sustainable tourism represents a paradigm shift in the tourism sector, highlighting the need for more responsible practices to ensure the world’s natural and cultural beauty is available for future generations (Cluster 5). This encompasses responsible management of natural resources, biodiversity conservation, and reducing travel’s carbon footprint. It could be a more promising path towards a more ethical, conscious, and beneficial tourism sector for everyone involved.

This article contributes significantly to literature and practice. To the theory, the research contributes by mapping the state of the art on sustainable development in health tourism through the systematic organisation of pertinent themes proposing a conceptual framework. On the other hand, it presents research trends through an integrative framework. It defines possible lines of future research for each of the five most relevant areas identified by bibliometric analysis. Thus, the study presented is essential to help researchers contribute significantly to the literature. In practical terms, this study allows us to verify that all agents involved in the sustainable development of health tourism play a fundamental role in its existence and effectiveness. Governments play a crucial role in promoting the sustainable development of health tourism. Therefore, they must act as regulators, facilitators, and promoters of investments in health. Local communities and residents also have a crucial role in the sustainable development of health tourism. The involvement of local communities in sustainable tourism is essential to preserve local territories and economies, especially during challenges such as the COVID-19 pandemic. Moreover, a collaborative effort between tourism agencies, healthcare providers, residents, and clients are imperative for developing healthcare tourism and effective patient care.

Although there are many contributions, this research has some limitations. One limitation of the study is its reliance on a single database (WoS) for literature collection, potentially introducing a reductionist perspective in the systematic review.