Health Seeking Behaviour in Stress Management : A Case Study of French Tourist Community in Kangra , Himachal Pradesh

Various studies have demonstrated that stress originates severe health problems and disturbs the normal metabolism. Health seeking behaviour of people in India is closely interwoven in the diverse geography and socio-cultural background. Codified system of ayurveda possesses symbiotic relation with the medical lore and acknowledges social and ecological factors along with mental makeup of the patient. It is technical but not reductionist and provides a meticulous account of the endemic flora-fauna and the changes in environment that could affect health. The study aims at evaluating the cause and stress management strategies among the medical tourists of France who visited Kangra in Himachal Pradesh for ayurvedic treatment during April 2015 to December 2015. The case study is set out to investigate the relational and individual benefits of Ayurvedic treatment in combating stress among French tourist community at Namlang Himal Health Resort situated at Bir village of Kangra district of Himachal Pradesh. Purposive sampling technique is used to select (N = 25) French tourists using both qualitative and quantitative data. The results indicate the benefits of the Ayurvedic treatment along with natural diet among medical tourists. Lack of concentration, loneliness, Insomnia and elevated blood pressure were experienced by 93 per cent, 92 per cent, 90 per cent and 45 per cent of the French tourists respectively. Anxiety, frustration, depression and impatience are some emotional stress felt by approximately 45 to 82 per cent of the respondents. Overall the medical tourists have shown significantly reduced psychological distress, physical and emotional stress. About 50 per cent reported excellent results and rest reported the treatment as satisfactory. The current case study provides reducing stress and enhancing psychological well-being in the sample. Integrated medical system (inclusion of modern and ayurvedic health systems together) is the need of the hour to combat lifestyle disease as well as promote medical tourism in hill region of Kangra.


Introduction
The health issues arise when there is an imbalance between an individual and environment; these imbalances include abilities and demands, needs and opportunities, goals and actualities, desires and resources, reality and fantasy [1]. While dwelling specifically on Indigenous Knowledge and the age old system of Healing Practices, it may relevantly be noted that disease and health have been one of the fundamental concerns of man since times immemorial. Every society has developed its own responses and methods for coping up with diseases and ailments; and eventually a body of its own medical system whereas the economic and time considerations of modern medical health care delivery often limit doctors' capacity to address the spiritual and emotional needs of their patients [2]. Presently 50 percent of the health burden is due to non-communicable diseases such as cardiovascular diseases, diabetes mellitus, hypertension, depression, obesity, stroke, cancer etc. Sedentary lifestyle, diet, obesity, lack of exercise, and stress are contributing factors in the causation. Stress has been observed as worldwide epidemic throughout the world and about 90 per cent of visit to physicians have been associated with it. It has detrimental impact on the physical, emotional and psychological wellbeing of an individual. Various studies have reported stress as the most common health problems caused due to long working hours and overburden of work. Anxiety, frustration, anger and feelings of inadequacy, helpless or powerlessness are emotions often associated with stress. Stress is derived from the word "stringere" which means "to be drawn tight". Stress can be defined as a physical or psychological stimulus that can produce tension or physiological reactions that may lead to illness [3].

Niche (medical) tourism: ayurveda and yoga (drugless therapy)
India with 1.25 billion people are served by merely 4.5 million doctors and thus health inequity exists. Here the doctor to patient ratio is one per 1,200 [4]. Indigenous healing rooted inexperience is still important in regions where bio -medicine may be too expensive or inaccessible. People are particularly interested to experience health benefits and rural tourism due to calm weather, lush green forests and peace. Studies on tourism suggest that tourism industry can also help promote peace and stability in developing country like India by providing jobs, generating income, diversifying the economy, protecting the environment, indigenous health services and promoting cross -cultural awareness [5]. Herbs, health, tourism and rural livelihood have always been inter linked and provide promising future. The popularity of traditional healing system has increased considerably in the past one decade. The demand from the urban population and developed world had alarmingly increased the over -exploitation of forest resources. The impact of globalization on indigenous cultures and traditional health practices can be seen as the increasing interplay of cultures. Holistic and preventive healthcare has received global acceptance where the focus is on wellness culture. Dharamsala (Kangra) Health Seeking Behaviour in Stress Management: A Case Study of French Tourist Community in Kangra, Himachal Pradesh

Abstract
Various studies have demonstrated that stress originates severe health problems and disturbs the normal metabolism. Health seeking behaviour of people in India is closely interwoven in the diverse geography and socio-cultural background. Codified system of ayurveda possesses symbiotic relation with the medical lore and acknowledges social and ecological factors along with mental makeup of the patient. It is technical but not reductionist and provides a meticulous account of the endemic flora-fauna and the changes in environment that could affect health. The study aims at evaluating the cause and stress management strategies among the medical tourists of France who visited Kangra in Himachal Pradesh for ayurvedic treatment during April 2015 to December 2015. The case study is set out to investigate the relational and individual benefits of Ayurvedic treatment in combating stress among French tourist community at Namlang Himal Health Resort situated at Bir village of Kangra district of Himachal Pradesh. Purposive sampling technique is used to select (N = 25) French tourists using both qualitative and quantitative data. The results indicate the benefits of the Ayurvedic treatment along with natural diet among medical tourists. Lack of concentration, loneliness, Insomnia and elevated blood pressure were experienced by 93 per cent, 92 per cent, 90 per cent and 45 per cent of the French tourists respectively. Anxiety, frustration, depression and impatience are some emotional stress felt by approximately 45 to 82 per cent of the respondents. Overall the medical tourists have shown significantly reduced psychological distress, physical and emotional stress. About 50 per cent reported excellent results and rest reported the treatment as satisfactory. The current case study provides reducing stress and enhancing psychological well-being in the sample. Integrated medical system (inclusion of modern and ayurvedic health systems together) is the need of the hour to combat lifestyle disease as well as promote medical tourism in hill region of Kangra.
has become a potential destination for ayurveda and yoga tourism and the ecology with diversified forms of health care system called Complementary and Alternative Medicine (CAM). It is remarkable that Complementary and Alternative Medicine (CAM) is used by one out of two European Union citizens. Throughout the European Union people are evidently seeking natural methods of healing and increasingly favors the provision of CAM within existing healthcare systems of Europe (Figure 1a and 1b), [6]. Indian Himalaya has always been a source of ayurveda since time immemorial. During last couple of years, the rapid erosion of traditional knowledge and medicinal plants is noticed. At the same time, the growing globalization of ayurveda and herbal medicine is also in fire. The study aims at determining the cause and stress management strategies among the medical tourists of France who visited Kangra for ayurvedic treatment during April 2015 to December 2015. 25 French tourists from Namlang Himal Health Resort situated at Bir, Baijnath block of Kangra district in Himachal Pradesh were selected. These tourists visit the resort for ayurvedic treatment as well as recreation and adventure sports events. Some are particularly interested to learn ayurveda and health rejuvenation techniques. Namlang Himal Health Resort is taken for this particular study purposefully because it is owned by French women of repute among tourists. French nationals prefer this place both for medical and recreational tourism.

Study area
Nestled in Western part of HP in the lap of majestic Dhauladhar, area-wise Kangra is the fourth largest district and is home to more than a fifth of the state population. The district lies in the western part of Himachal Pradesh and located between latitudes 31° 41''00" N to 32° 28' 05" N; and longitudes 75° 35' 34" E to 77° 04' 46" E, in the lower foothills of the Himalaya. The Dhauladhar range adjoins the district on one side. Kangra district lies in the southern escarpments of the western Himalaya. All the three mountain ranges of Himalaya; passes through it, Shivalik to Dhauladhar range. Kangra district presents an intricate mosaic of mountain ranges, hills and valleys. The district has a mountainous terrain with highly undulating landforms. The climate of the district varies from sub-tropical in low hills and valleys to sub humid in the mid hills and temperate in high hills. The altitude varies from about 500 to 5,500 m above mean sea level, hence possesses a mosaic of physiographic, sources of persistent perennial streams and agro -ecological conditions. The district receives annual average rainfall of about 205 cm that goes up from 100 cm in southern parts to 250 cm in north -eastern parts of Dharamshala and Palampur. River Beas and its tributaries constitute the main drainage system in the district. Purposive sampling method has been used to select 25 French medical tourists from Namlang Himal resort. Semi-structured questionnaire is used to collect relevant data on the causes of stress, pre and post health history and their socio-economic background. Intensive research method, unstructured interview, ethnographic technique and case study have been used to analyse the health status of medical tourists. Health impact assessment was also done to reveal pre and post health status of the medical tourists. Descriptive and inferential statistics have been used to analyze the data using SPSS software and diagrams and tables are created using MS Excel. Factor analysis using SPSS is used to present significant group of herbs used in stress management.

Case study of Namlang Himal resort at Bir village
The director of the resort is a French woman of 70 years old. She wants to provide permanent employment to the local population. She has maintained self -sufficient resort system. 12 months salary is given to the employees even during non -tourists seasons. There are 24 permanent employees in total at Namlang Himal Resort. For construction work total four workers from local area permanently work. One watchman, two receptionists, two worker for room services, five staff for ayurvedic centre including doctor, six personnels in restaurants, four workers are employed in organic garden. 85 per cent of the workers belong to the Baijnath block of Kangra including 40 per cent female staffs while rest staffs are from Tibetan community of Bir. Most of the workers belong in the working age group of 20 -40 years. There has been a hike of 10 per cent salary every six months. She also sells tour package mainly to the French people. It includes Himachal Pradesh Tour package (Kangra valley, Chamba Valley and Kullu Valley) and for 10 days INR 30,000 are charged from the tourists. It includes Laddakh, Zanskarrange, Himachal Pradesh, Rajasthan, Bihar, Uttar Pradesh, West Bengal, Arunachal Pradesh, Assam and Sikkim tour package. The other tour package includes South India and North India such as Rajasthan, Kerala, Tamilnadu and Karnataka respectively in which foreigners show great interest. The total cost for the North India package includes INR 66,000 per two visitors and for more people the rates are flexible and less. She has her own contacts, guide contacts and she provides guide job to some local and Tibetan people residing in Baijnath region. Foreign tourists are not much interested for Himachal tour package due to lack of advertisements at international level. March to May is peak season including October and November. On an average most of the medical seekers (ayurvedic treatment) and adventure tourists (trekking/paragliding) stay for about 10 -15 days in the resort.
On an average INR 1,500 is spent by tourist son ayurvedic treatment. She promotes ayurveda in France as well as other countries by her unique resort based ayurveda service. On an average 80 tourists visit the resort every year since 2008 having slight decrease now due to Euro crisis. On an average, INR 1,000 is spent on food and accommodation in the resort except treatment. For instance in October 2015, individual visitor pays INR 15,000 for 15 days and for the month of October, total earning was INR 1,68,000. She has an innovative entrepreneurship and wants development of tourism in the Mid Himalaya region. Trekking should be promoted by the government efforts; there is an urgent need of lodges, restaurants and other facilities in the trekking routes. There is good demand from tourists but lack of proper planning in the region is the main bottleneck for untapped tourists place like Rajgunda (having lush green bed of grasses and surrounded by mountains), Barot Valley (fishing). There is also urgent need to protect the wildlife of the region.
French tourists have good paying capacity as 47 per cent had an income level between 50,000 -0.1 million. Per day expenditure for medical tourists at Namlang Himal includes INR 1,500 for Ayurvedic treatment, INR 1,500 for food and accommodation at the same resort. From 25 visitors during October 2015, the resort on an average earned INR 70,000 -75,000 per day. The visitors include both medical and paragliding tourists including students of ayurveda from France. 98 per cent of medical tourists were female. They were from various profession including doctors, nurses, and technical professionals. Recently in 2015, there held world paragliding, first ever in South Asia with participation of 130 pilots from 35 countries. This major event also attracts tourism in the region. The French tourists said that they come here due to calmness of place and all facilities at one place especially ayurveda treatment (Figures 2-6).

Socio-economic profile and health seeking behaviour of French tourists at Namlang Himal resort
The medical French tourists stay at Namlang Himal Health Resort whenever they visit Himachal Pradesh. About 80 per cent French tourists have invested money as sponsors to build Namlang Himal Health Resort. Each person owns an accommodation facility at the resort for their lifetime. Most of them reported that they feel happy to have another home (India) away from their home at France. 47 percent of them belong to middle age group i.e., between 40 -50 years while one third out of the total visitors belongs to age group of 50 -60. This age group shows that most of them are also in their working age groups at various occupational levels and they want to invest in their future wellbeing. It is also evident from their occupational, social and economic profile that their stress level is high due to several    reasons. Due to stress and depression they wish to move towards nature and health rejuvenation. Another important aspect emerging is that people all across globe are moving away from material life towards peaceful lifestyle seeing health and mental wellbeing. 20 per cent have high income profile which they most willingly invest for their healthy future.
90 per cent female mostly in the middle age group are suffering from stress, anxiety or other health issues due to occupation and marital status. Single female are more likely to suffer from stress and anxiety due to loneliness, and fear for future. Live in relationship is also considered by majority of the tourists as the cause of their stress. There is no sense of commitment in the relationship and thus emotional strength is missing from that particular relationship. Single women as well as men also feel burden of occupational stress like late working hours, aggressive work culture, target based results and overall fast pace of life. It result into insomnia (disturbed sleep), negative effect on biological cycle, body pain, headache, anxiety, depression etc. Psychological stress followed by loneliness (92 per cent) and Insomnia (90 per cent) are among the major types of stress suffered. Divorced female are also suffering from stress due to work pressure and excessive worries for their children. Psychological pressure is considered one of the major reasons for stress which varies from person to person. Release of emotional stress is better among female compared to males which helps in their health. Three out of sixteen are yoga instructors which show their inclination towards Indian traditional system of medicine. They consider yoga as drugless therapy which may also include natural products as diet therapy while performing yoga. The popularity of ayurvedic spas and yoga studios at France motivate them to feel the essence of the health system of another continent. They reported that there is huge lack of Indian system of medicine like ayurveda and yoga. They wish to receive original quality yoga and ayurveda and for that reason they visit India. Some of them also came to study ayurveda in order to popularize it in France.
In order to understand the health impact of ayurveda treatment pre and post case studies have been taken. Health and dietary habits are closely linked. Gradually it has been observed that non vegetarian diet increases cholesterol level as well as hard to digest which ultimately becomes the cause for several health issues. 100 per cent of them are non-vegetarian with majority of them on red meat. Their lifestyle is highly influencing their health status with late working hour. Irregular diet, fast food, irregular and late night sleep etc. are some of the major lifestyle pattern seen among the patients pre Ayurvedic treatment.
Several diseases like PNS hypertrophy, Acromegaly, arthritis Parkinson, low immunity and weakness are some major health challenges suffered by the patients. Their pre -ayurvedic treatment includes modern high dose medicine. Modern medicine and side effects are interrelated phenomena which were experienced by almost all patients. Long duration of treatment from modern medicine did not provide relief from health issues. Post Ayurvedic treatment is a combination of rejuvenation therapy, diet therapy, medicinal plants, yoga, Panchkarma and indigenous spa (Abhyanga, shirodhara, Shodhan etc.,). They were kept under full diet control which is the prime requirement of ayurveda to attain good health because 'food is medicine' as written in ayurvedic texts. Ginger honey lemon tea, boiled cereals and other herbs are included in their routine is fixed early in the morning till dinner by ayurvedic doctor at the resort. The ayurvedic doctor also reported that about 90 per cent patients (both male and female) cry hard after they go through the treatment and release their emotions due to soothing impact of the treatment which he considers good for their health. Patients also reported excellent experience of the ayurvedic treatment which they have never experienced earlier and they also promised to strictly follow the directions of the Ayurvedic doctor. After the completion of their treatment they are advised to take at least 6 months course of the Ayurvedic medicines which they happily agree and take away medicines with them (Tables 1-4).

Faith healing and ayurveda tradition
The therapeutics teams applied in Ayurveda consist of spiritual measures (Daivavapasrayachikitsa), pharmacological therapies

Unfriendliness in society 65
Relationship issues 87 Family issues 56 Occupational/work issues 93 Divorce 90 Multiple pressure including social, economic status 46

Source: Primary survey, 2015
Note: Study*: Some Foreign tourists seek training in Ayurveda for about a month or two or sometimes 6 months to practice Ayurveda in their own country due to its popularity among Europeans (Yuktivyapasraya) and Non-pharmacological psychotherapies (Satvavajaya). Tulsi, Amlaare commonly found plants is considered divine and anti-oxidants which existed in socio-cultural religious system of the Indian society since time immemorial [7,8]. Ayurveda and faith healing complement each other in stress management. Indigenous health knowledge is not restricted to medicine man only but it was also diffused in the society in the form of local health tradition. Himachal is predominantly an agrarian state where livestock has major role to play in the livelihood pattern and due to hilly terrain, health requirements of livestock pose great challenge among the residents. Earlier about a decade ago there were many rural based knowledgeable human as well as veterinary health practitioners in Kangra district. People revealed application of locally available medicinal plants on the wounds removes several health issues of the livestock. Many different kinds of medicinal plants from the hills of Dhauladhar are still known to some Gaddi community in the study villages with their use in human and veterinary health care but fast erosion of knowledge on indigenous health practices is noticed [9]. There are about 50 per cent Gaddi workers in Namlang Himal Resort including both men and women providing ayurvedic services like Panchkarma. The livelihood security of the local Gaddis depends on the resort. Knowledge of systems and medicament of Ayurveda is documented in Sanskrit, Hindi and ten regional languages of India. There are over 4,29,246 and 78,5185 registered practitioners of Ayurveda and Ayurveda, Unani, Siddha and Homeopathic (AYUSH) respectively in India with over 22,000 government dispensaries, 3000 hospitals and 9000 drug manufacturing units [10]. Popularity of ayurvedic treatment is noticed in the study area where total number of patients who received treatment from Ayurvedic College Paprola situated in Baijnath block of Kangra was recorded 79,871 in 2013 while it was 89,084 in 2014.The role of traditional healing system and now Ayurvedic hospitals and private clinics cannot be undermined today in an era of globalization. Medical tourism has positive impact on the local economy and economic security of the local people due to increasing demand of Ayurvedic products in the region (Figure 7).

Commonly found medicinal plants used in stress management at Kangra valley, Himachal Pradesh
Herbal home remedies form the base of ayurveda in India. The importance of some common home remedies used in Indian kitchens in maintaining healthy lifestyle is notable. Factor analysis indicates some important group of herbs. Trigonella foenum graecum L has got a high factor loading and high mean which means it plays an important role as herbal remedy but due to lack of awareness and other reasons, its use has become reduced. Another factor anti-allergic remedy available in the household is Phillanthus emblica L has got high factor loading and high mean which means it is widely preferred as herbal medicine in the region. Phyllanthus emblica L and Trigonella foenum graecum L are stress busters and should be a part of our daily diet as suggested by the Ayurvedic practitioners [11]. Ayurveda is just not only a medicine but a way of life in India such as use of common herbal plants in daily diet. Giloye is abundantly found in all parts of Kangra. Recently use of Tinospora cordifolia Willd. (Giloye) has increased due to its benefit in joint pains. It has become one medicine for recently deadly disease called Chicken Guinea which struck Delhi and most parts of North India. Whereas, Ocimum sanctum L (Tulsi) and Centella asiatica L (Mandukparni) paste is considered most effective in stress management and it has been applied as required (Tables 5 and 6).

Pulse diagnosis and purification (Shodhan): an integral part of ayurveda in stress management
In Ayurvedic treatment for stress management, pulse diagnosis and shodhan are important methods used by Ayurvedic doctor in the study region. Pulse diagnosis is an examination technique in which   the doctor directly palpates the pulses on both wrists of a patient to evaluate the properties and condition of the pulses. The most representative method of diagnosis involves palpation and is known as pulse diagnosis. A patient's condition and disease are diagnosed according to the palpation of the pulse, a treatment plan is chosen, and the effectiveness of the selected treatment is determined by comparing the pulses before and after the treatment. Optimal effect of medicinal plants in traditional medicine can be best achieved with the careful study of patient's health condition according to traditional methods of diagnosis. The use of Amla against excessive pitta (fire element inside the body), is an example of this case. Pulse diagnosis is more than recording the pulse beat. The vital energy or life force circulates throughout the gross and subtle channels of the body and the practitioners of traditional medicine can feel this flow of vital life energy with the help of pulse diagnosis. Pulse diagnosis enables the ayurvedic doctor to feel the way the blood circulates from the heart, including the health of the various tissues and organs, and by detecting symptoms of imbalance or disease in the body at different stages of disease [7,12].
Purification or Shodhan is defined as the treatments by which the disease causing factor i.e., imbalance (Doshas) are expelled out of the human body. The impurity and imbalance is removed by its regular practice. This treatment modality is popularly known as Panchkarmaas it consists of following 5 major treatment procedures: namely Basti, Vaman, Virechan, Nasya and Raktamokshan. Nasya treatment includes expelling the vitiated doshas through the naso-salivary secretions. Raktamokshan treatment procedure expels the vitiated doshas by letting of impure blood in small amount from the body. The Panchkarma treatment is reported to be beneficial for the medical tourists of Namlang Himal Health Resort [13,14].

Conclusion
The relationship between health and socio-economic aspects is strong. On an average most of the medical tourists spend INR 1,500 per day on ayurveda treatment. The total earning of Namlang Himal Health Resort was INR 1,68,000 during peak tourist season. From 25 visitors during October 2015, the resort on an average earned INR 70,000 -75,000 per day. The stay and treatment cost is also optimal and satisfactory as reported by most of the medical tourists.
Among medical tourists, 90 per cent female mostly in the middle age group are suffering from stress, anxiety or other health issues due to their lifestyle. Single female are more likely to suffer from stress and anxiety due to loneliness, and fear for future. Lack of concentration, loneliness, Insomnia and elevated BP were experienced by 93 per cent, 92 per cent, 90 per cent and 45 per cent of the French tourists respectively. anxiety, frustration, depression, impatience are the emotional stress felt by approximately 45 to 82 per cent of the respondents.
Their lifestyle is highly influencing the health status with late working hour. Irregular diet, fast food, irregular and late night sleep etc., are some of the major lifestyle pattern seen among the patients pre ayurvedic treatment. Several diseases like PNS hypertrophy, acromegaly, arthritis Parkinson, low immunity and weakness are some major health challenges. Their pre-ayurvedic treatment includes modern high dose medicine. Modern medicine and side effects are interrelated phenomena which were experienced by almost all patients. Long duration of treatment from modern medicine did not provide relief. Post Ayurvedic treatment is a combination of rejuvenation therapy, diet therapy, medicinal plants, yoga, panchkarma and indigenous spa (abhyanga, shirodhara, shodhan etc.,). The diet therapy in ayurveda helps attaining good health which was prerequisite in the treatment. The ayurvedic doctor also reported that about 90 per cent patients (both male and female) release their emotions as a result of the treatment. Patients also reported excellent experience of the treatment which they have never experienced. About 50 per cent reported excellent results and rest reported the treatment as satisfactory. In conclusion, there is good demand from tourists but lack of proper planning in the region is the main bottleneck for untapped tourist location. Medical and adventure tourism in the mid Himalaya region should be promoted by the government and there is an urgent need of lodges, restaurants health resorts and other facilities in the trekking and recreational routes. Working professionals are more susceptible to occupational stress because of intense work load and they are facing with a variety of stress due to long working hours, relationship issues, loneliness and other emotional setbacks. It is recommended that respondents should adapt a positive ways of managing stress by meditating and natural way of life as human beings can manage stress by following healthy lifestyle following ayurveda and yoga.