Tourist arrivals and overnight stays in Slovenia from 2008 to 2017. Data taken from the SURS—Statistical Office of the Republic of Slovenia.
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\r\n\tThe aims of this book are to present the updates and advances in the field of resuscitation including AHA guidelines, latest evidence for the airway protection equipment, the role of AED in cardiac arrest, latest advances and the evidence including ongoing updated research including return of spontaneous circulation and post resuscitation care and support including neurological and hemodynamic stability.
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\r\n\tThe content of this book will be focused on latest research in the field which will create a concise updated information for medical, nursing and paramedical personnel. Furthermore, the book will also touch upon controversial topics in resuscitation and will try to bring out latest evidence intending to solve the controversies in the field of resuscitation. This book will be an excellent extract of all available updates and ongoing research for a complete knowledge of resuscitation.
Cerebral palsy (CP) is a neurodevelopmental condition comprising a group of permanent disorders of movement and posture that are attributed to nonprogressive disturbances of the developing brain [1, 2]. In children, CP affects approximately 2.1/1000 worldwide, making it the most common physical disability of childhood. Although some children might outgrow their CP symptoms due to the maturation of neurons, lesions within the central nervous system often compromise motor development severely through time. The classification of CP often differs according to the gestational age at birth, age, and the distribution of lesions. However, classifications are normally registered using two categories, extremity location and neurologic dysfunction. If extremities are involved, diagnosis is subjective to monoplegia, hemiplegia, diplegia, or quadriplegia. If neurologic dysfunctions are involved, it is subjective to spastic, hypotonic, dystonic, athetotic, or a combination [3]. While commonly diagnosed, it is often shown that CP affects many aspects of a child’s health. Common health problems associated with CP are excessive drooling, respiratory issues, nutrition, sleep, and poor oral hygiene. With almost one-third of children with CP having difficulties with chewing and swallowing, it is important to note that oral health is a primitive underlying factor for the majority of these complications.
\nOral health in children with CP is impacted significantly by their neuromuscular and neurodevelopmental disabilities, leading them to have a higher risk of dental disease due to the greater difficulty for these individuals to perform or receive effective oral hygiene and oral care [4, 5, 6]. Specific attributions can be made to the high prevalence of orofacial motor dysfunction, which can lead to poor oral hygiene, and increase dental biofilm formation and retention [7]. Factors such as food consistency and snacking between meals have also been reported to contribute to the high incidence of dental diseases, like dental caries and periodontitis [8]. Nevertheless, dental caries is one of the most common chronic diseases in childhood. Dental caries are defined as one or more decayed, missing, or filled teeth for permanent teeth. Dental caries can also develop at any tooth site in the oral cavity. Hence, with the combined characteristics of poor oral hygiene and orofacial impairments, children with CP make seamless dental caries inhabitants. Several studies have examined caries rates in individuals who have CP [9, 10, 11]. However, most of those studies were conducted on highly selected children (e.g., children attending clinics or rehabilitation centers) and in high-income countries. A study from England did not find any significant differences in the levels of decayed, missing, and filled teeth between children who had CP and a control group of children without disabilities. They did find, however, that the children with CP had more untreated decay than children without a disability. Emphasizing the notion that oral health considerations were avoided or even worse, not accessible, which embarks the path of irreversible dental damage and further consequential health issues impacting overall quality of life. For this reason, society must change its outlook on the correlation between healthcare and oral health status for this population.
\nThe concept of oral health-related quality of life (OHRQoL) is defined as the impact of oral health or disease on an individual’s daily functioning and well-being. In the United States Surgeon General’s report on oral health, they attribute OHRQoL as, “a multidimensional construct that reflects (among other things) people’s comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction with respect to their oral health” [12]. Previous studies have in fact demonstrated that dental diseases and disorders have a negative impact on an individual’s OHRQoL and the quality of life (QoL) of their parents or caregivers. Therefore, improving and understanding the factors contributing to the OHRQoL should be the goal for all children with dental disease including children with CP. For these reasons, the motivating factors of dental caries will be explored in order to identify modifications to the oral hygiene behavior and appropriate diet for children with CP. By pinpointing these improvements, a prospective outlook can be set on the impact training and reorganization of preventative dental care can provide for this challenged population.
\nOral health pertains to the teeth, tongue, gums, and their supporting tissue, but also the upper and lower jaw, chewing muscles, throat, salivary glands, and lips that allow us to explore our five senses [12] through speech, facial expressions, food, smell, or touch. With these valuable assets being compromised under the CP population, it is very common for one to not understand or assume responsibility of a standard oral routine; but it is for this same reason that this specific population must be inspected more heavily. Thus, early oral health preventive care and routines must be explored in order for this population to subside in the category of prevalent dental caries.
\nStudies have shown that the prevalence of caries experience was higher in individuals who cleaned their teeth less than once a day than those whose teeth were cleaned at least once a day [13]. For this reason, tooth brushing twice a day can provide an effective maintenance of the oral cavity. Alongside with fluoride-containing toothpaste, it is shown to decrease the presence of plaque. Plaque being a microbial biomass is composed of resident bacteria from saliva. If a tooth surface is covered by dental plaque, the metabolic activity alters the chemical dissolution of the tooth surface [14]. Therefore, brushing is essential to disturb and remove plaque in efforts of decreasing the rate cariogenicity.
\nTooth brushing and flossing also eliminates the quantity of food debris, which if not removed can lead acid erosion to breakdown enamel and dentin, leaving teeth sensitive and discolored. Being that these are the major factors that promote the increase of dental caries, there are no parts of a tooth that are necessarily, “more or less susceptible.” However, the idea of susceptibility is one parent of children with CP must acknowledge that no matter the age, classification of CP, or dietary regime, lesion formation and progression of dental caries can be controlled.
\nThe presence of fluoride within a child’s oral practice is essential in the prevalence and severity of dental caries. Fluoride’s attraction to calcium inhibits and even reverses the potential of dental caries to form by disrupting demineralization and enhancing remineralization of teeth. Remineralization of teeth increases the acid resistance of the enamel surface structure, thus preventing the change in pH levels, which are primarily responsible for tooth erosion and the creation of new lesions. Fluoride can be integrated in three main functions, community water fluoridation, pastes, and mouthwashes. Frequent consumption of water containing fluoride can permit a consistent barrier for dental caries to occur among the CP population, with minimal dietary efforts needed. Daily toothpaste use alongside with tooth brushing can provide a direct dosage of fluoride for the enamel to combat acid erosion. Studies relating dental caries risk factors attributed difficulty in the application of fluoride to the oral reflexes, such as biting and vomiting and intraoral sensitivity [7, 15]. As a result, it is advised that parents aide their children in the process of tooth brushing, by altering the child’s orofacial position to decrease the probability of these refluxes, thereby promoting the ability to apply the daily dosage of fluoride on all teeth. Antimicrobial products although not noted as often can also be utilized in low concentrations to diminish the role of bacteria within the oral region. With minimal bacterial growth, oral cavities will be less prone to metabolize fermentable carbohydrates. Counteracting the microbial environment will thus set additional inhibitors that these dental caries agents will try and override. Finally, mouthwashes containing low concentrations of fluoride (0.05% neutral sodium fluoride or 0.1% stannous fluoride) and antimicrobial agents can provide an effective mean in increasing salivary production, which will allow a continuous aqueous flow to protect the oral cavity throughout the day.
\nDisease preventative measures can be performed within one’s home; however, it can also be supported by seeking a professional opinion, at least once a year. Seeking an oral health professional that is an approved medical practitioner in one’s estate can provide the family and child with CP, a clear, understandable, and personalized protocol to be followed if the oral health evaluation is not up to par. Oral health practitioners can provide insight on the severity of the dental caries present, and the following steps to be considered if a stronger optical concentrated treatment is needed. Specifically, in low-income and middle-income countries (LMIC), parents and physicians must work together in reassuring the child of an oral evaluation as governmental and service providers are limited in their capacity to quantify current and future resources of this population. This phenomenon has been evaluated by studies in Brazil, Bangladesh, and Japan. Determinations were made on the effects of oral health care access and dental caries progression in LMIC [3, 13, 16]. Results displayed that progression of dental caries was reduced once handicapped children participated in the funded rehabilitative programs of oral health professionals [16]. Practitioners should be specifically trained and equipped to handle CP-related orofacial impairments in order to provide the patient the least amount of discomfort and pain as possible.
\nThe role of oral hygiene in the prevention and decrement of dental caries within the CP population can be reviewed by three major provisions, daily tooth brushing, use of fluoride-containing products, and scheduled dental visits. The combination of tooth brushing and fluoride toothpaste can provide an effective barrier to the ubiquitous degradation of plaque and cariogenic bacteria. Scheduled dental visits can provide a professional review of the child’s current oral health status and can deliver an incentive to change oral health behavior if dental examinations are abnormal. Overall, efforts should be emphasized that the role of oral hygiene plays a significant role in the prevalence of dental caries, and caregivers should focus on providing a primal example of daily oral health routines to combat this notion.
\nChildren with CP experience varying degrees of motor impairment as quantified by the gross motor function classification system (GMFCS), which classifies children with CP based on functional abilities and limitations [17]. GMFCS is a classification system intended to enhance communication between families and professionals when describing a child’s gross motor function and can be useful when setting goals and making management decisions. The GMFCS levels range from level I of “Walks without limitations” to level V of “Transported in a manual wheelchair.” Motor impairment results in difficulty in performing and receiving oral hygiene, which among other factors, such as feeding problems and reduced access to oral health care, increases caries risk. The GMFCS has not traditionally been used to inform dental professionals in their evaluation of dental caries risk and management decisions for children with CP; however, it has recently been identified that children with CP with severe motor impairment are at high risk for dental caries. As a result, this section will focus on motor impairment and its association with worse OHRQoL of children with CP.
\nMotor impairment in children with CP can be communicated in a variety of ways making it difficult to gather information from the literature on the impact of motor impairment. It is commonly described by some combination of location, type, and severity and falls along a continuum with the most severe presentation being of the “quadriplegic spastic type characterized by stiff hypertonic muscles and motor deficits in all four limbs.” Location is often described as tetraparesis/tetraplegia/quadriplegia, triplegia, diparesis/diplegia, monoplegia, or hemiparesis/hemiplegia and type is often described as spastic, athetoid, ataxic, hypotonia, or mixed. Recent studies in Brazil found a relationship between increased motor impairment and increased caries experience in children with CP. It has been found that “individuals with mild to moderate mobility disability (GMFCS levels I, II and III) had a 4.2-fold greater chance of having teeth with cavities and those with severe motor impairment (GMFCS levels IV and V) had an eightfold greater chance of having cavities in comparison to individuals without motor impairment” [18]. As a result, attributed difficulty in providing oral hygiene to children with CP can be claimed by the “differences in intraoral sensibility, presence of involuntary physical movements and/or oral pathological reflexes and spasticity in masticatory muscles” [15]. For these reasons, attention must be paid forward in the act of involving primary caregivers in the instrumental role of oral hygiene practices, as they are the main source to provide consistent care and additional oral health care for these children with CP.
\nThe OHRQoL instrument has been used in several studies to obtain data from primary caregivers or parents, to reference the effect of their child’s current oral health on their daily lives, (i.e., “how often have you had mouth sores because of your teeth/mouth?”). These data points also include the parents’ concerns about their child’s oral health in regards to being upset, having disrupted sleep, or taken time off work. Studies using this paradigm concluded that compared to children with GMFCS I-III, the group of children with increased motor impairment of GMFCS IV-V had worse outcomes for having difficulty saying words, having trouble sleeping, having difficulty eating, drinking or chewing firm foods, taking longer to eat a meal, and feeling terrible or frustrated. Furthermore, children were more likely found to feel upset, shy, and avoid smiling or laughing. These main concerns were the elements that resulted with statistically significant differences between the two groups, ranging from 5.2 to 9.1 times more prevalent in the group with increased motor impairment. These components narrate the children’s emotional reactions to their oral condition and in particular reflect on their self-esteem, social, and emotional well-being. Having difficulty drinking, eating, or chewing firm foods reflects upon the domain of physical functions while feeling upset and shy reflect upon the individual’s social and emotional experience. Concurrent studies in parts of world such as Brazil and Japan also have found that parents of children with CP had greater distress, uneasiness, and lower quality of life, which implicates the attributed complications of motor and orofacial impairments in the performance of quality oral hygiene and life for families worldwide [3, 16].
\nIt is well defined that the health-related quality of life (HQoL) and oral health-related quality of life (OHRQoL) between children with CP are often intertwined. The prevalence of motor deficiencies associated with CP contributes to the inability for this population to perform daily movements and thus making it incapable for children to perform self-care functions such as maintaining adequate oral hygiene, thereby moving the subjective responsibility of oral hygiene, feeding, and overall lively independence to the caregiver. This manner of consistent dependence significantly impacts the physical, social, and emotional well-being of both a child and their caregiver. As a result, an assessment will be made to discuss oral health’s multidimensional impact on the livelihood of families. Distinguishing these traits will provide children and families with CP better modus to achieve optimal health.
\nIn summary, motor deficiencies associated with CP contribute to gross limitations in a child’s ability to perform activities of daily living, namely self-care functions such as maintaining adequate oral hygiene. Improving OHRQoL should be the goal for all children with dental disease including children with CP. Understanding the impact of factors contributing to OHRQoL will help to inform management in this population. Although often segmented from the physical diagnosis of motor and orofacial impairments, OHRQoL emphasizes the importance of defining appropriate treatment goals and outcomes in order to provide care that focuses on a person’s social, emotional, and physical experience. A child simply cannot experience these factors separately. Therefore, they must function in unity for proper medical and dental treatment measures to be obtained. With this in mind, good quality of life can be provided for all CP patients.
\nMotor and orofacial impairments significantly impact the capability of children with CP to smell, taste, and chew their food. Children with increased motor impairments of GMFCS IV-V have worse outcomes in difficulty eating, drinking, and chewing firm foods, thereby subjecting parents and guardians to administer alternative food consistencies and frequent snacking between meals for nourishment. However, several studies have reported that these factors contribute to the high incidence of caries and periodontal disease in those with CP [13]. Thus, elements of dietary control and feeding habits will be investigated to deduce the cause of the high dental caries incidence, in order to determine which oral hygiene practices and nutrition should be suggested for this population to obtain an optimal level of oral health.
\nTo subject to a higher standard of oral health, it is important to understand the specific roles of sensory and saliva functions in food consumption. Deficiencies in high-density sensory nerve endings in the craniofacial tissues affect the sensory functions of children with CP. The impact of these craniofacial tissues thereby restricts the movement of the tongue, jaws, and oral-facial muscles [12]. The modulation of these muscles thus affects the salivary glands. The production of saliva in these salivary glands is an essential guard against tooth decay. Saliva flushes out sugars and remaining food particles from the oral cavity and by eliminating these bacterial food sources, the oral cavity will host limited acid diffusion and tooth erosion [19]. In patients with CP, saliva production can sometimes be the only factor contributing to an easier way of chewing and swallowing food. Thus, saliva production within CP patients, especially those with more severe motor dysfunctions, must be monitored in order to create an easier pathway for food to be consumed. To increase saliva production, a child must drink water frequently, chew on sugar-free gum (if capable), and decrease active mouth breathing.
\nStudies have shown that dental caries incidence within this population can be attributed to food impaction, cariogenic foods and drinks, and sweetened medications [20]. Impaction of food indicates that nominal salivary production is not sufficient enough to keep the oral cavity clean of tooth demineralization. Commonly in CP children, food impaction can be due to “poor masticatory muscular control, which encourages food stagnation in the buccal and labial sulci and poor manual dexterity” [21]. Affirming that oral hygiene efforts including daily tooth brushing and flossing must be used in order to remove any food particles that can harbor within teeth. Removal of these food particles can prevent food from degrading and fostering acidic compounds, which could then lead to acid production. If foods and liquids are composed of acidic compounds, such as foods with high sugars and carbohydrates, cariogenicity is more likely. Therefore, a decreased intake of foods and liquids prevalent in saccharides could provide children with CP a lower plaque count. Additionally, sweeten medications referred for controlling seizures and other medical problems often contain saccharides and artificial flavors. These medications like the anticonvulsant, carbamazepine, are highly viscous and used at night thereby setting the perfect environment for dental caries to form [22]. Digesting these medications at night without the subsequent oral practice of tooth brushing enables the acidic compounds to form around teeth. As a result, parents must take into account that night medication must be considered after brushing and before going to bed, in order to maintain a proper oral hygiene routine.
\nDiet and nutrition is essential in the regulation of good oral health and the promotion of overall systemic health. Unfortunately, in children with CP, malnutrition is often encountered due to a child’s frequent pain in the teeth and mouth, difficulty in eating and drinking. Malnutrition alters homeostasis, which can lead to the dental disease progression, reduce the resistance to the microbial biofilm, and reduce the capacity of tissue healing [21]. Deficiencies of vitamin A, vitamin D, vitamin B, iron, and protein can be responsible for enamel hypoplasia, hypomineralization, salivary gland hypofunction, delayed tooth eruption, and dental caries. Consuming foods that are rich in these nutrients are consequently essential in order to defend the oral cavity against infection and its ability to buffer plaque acids. Appropriate nutrition for children with CP should be considered depending on their personalized health deficiencies. Being that a majority of children with CP are dependent on nonsolid food intake, parents must be aware that the physical consistency, sequence, and frequent feedings are associated to the development of dental caries. The high and frequent sugar intake constructs this population to be highly susceptible to food cariogenicity. Thus, parents should be able to associate that a frequency in snacking of more than one time/day increases the dental caries experience [13]. If the child is dependent on nonsolid food intake, these products must have minimal refined sugars. Snacking in between meals should be minimized to decrease the anaerobic metabolism of sugars. Nevertheless, snacking should be used as an additional source of nutritional intake, not as a primary source. If a child possesses signs of nutritional deficiencies and eating disorders, early clinical signs can be noted with inflammation of the lining of the oral cavity, oral lesions, or sore throat [21]. In summary, a substantial diet filled with a variety of vitamins, minerals, and proteins should be consumed regularly in order to prevent a delay in tooth development, which could later be responsible for an increased caries experience.
\nThe incidence of dental caries in this population can be attributed to the direct relationship between motor impairment and poor feeding habits. Children classified with CP are more prone to have trouble drinking, eating, or chewing firm foods, thus leaving food to be caught in between teeth more frequently. To diminish dental caries susceptibility, improvements must be made in the nutrient intake and oral hygiene practices in this population. By changing this behavior, CP children can reduce frequent dental pains and improve their OHRQoL.
\nThe World Health Organization has indicated that an individual who is “cured” cannot be categorized as one who is doing “well” [12]. As a child with CP, quality of life is significantly impacted by an inability to eat, be independent, or socialize. These qualities are often exacerbated if the child is at high risk for dental caries, due to the concerns of one’s smile and appearance. These elements thus relate the child’s emotional reaction to their oral condition and in particular reflect on their social and emotional well-being and self-esteem. Having difficulty in drinking, eating, or chewing firm foods reflects upon the domain of physical functioning, while feeling upset and shy reflect upon the individual’s social and emotional experience, thereby leaving a negative impact on the OHRQoL of children with CP. As children with CP who have more severe functional mobility limitations (GMFCS IV and V) have greater caries experience, these children are more likely to be at high risk for poor OHRQoL [11]. Concurring studies in Brazil address these issues in a population as early as preschool children [11]. As a result, children with CP with more severely impacted OHRQoL are consequently subjected to a poorer well-being. Suggesting that inclusion of OHRQoL measures can provide a more comprehensive assessment of the impact on overall health status.
\nParents and caregivers are indispensable members of the medical team as they provide daily support for children with CP. On the other hand, this indispensability of caregivers comes at health cost. The need for subsequent care in regard to hygiene, clothing, food, and rehabilitation leads caregivers to be physically and mentally tired 8. Studies have found that the quality of life within the parental population of children with CP is in fact worse than those of non-CP children [12]. Data suggest that parents of children with CP demonstrate higher levels of distress due to their children’s oral health status than parents of children without CP. Additional studies indicate that parents of children with CP had greater uneasiness regarding their child’s oral health than those parents of children without CP, and a study in Hong Kong found the same association with parents of preschool children with CP [1, 23, 24]. Parents and caregivers of children with CP may be more likely to experience frustration or difficulties supporting their children’s daily oral hygiene activities due to complications related to intraoral sensibility, presence of involuntary physical movements and/or oral pathological reflexes, spasticity in masticatory muscles, and the presence of residual food common to many children with CP [12].
\nIndividuals with CP and their families whom have a poor OHRQoL are subjective to a poorer quality of life. The deficiency of neurological and motor development in children places a dependent responsibility among parental figures. This dependent responsibility can consequently lead to an irritable and counterproductive environment for the promotion of oral health. Efforts should be made to develop an effective oral health promotion program for children with CP. Health programs should abide by the significant relationship between health care professionals, caregivers, and the child with the disability. In turn, the prioritization of this relationship can motivate the caregivers to modify their oral health experience, improve family dynamics, and subsequently improve their overall quality of health.
\nGeneral rehabilitative efforts among the CP population are often used in order to improve children’s health, education, and future employment. Yet, the severity of oral conditions in this population demonstrates the need for interventional dental therapy for a holistic rehabilitation effort to be performed. Involvement of evidence-based techniques such as risk assessments, preventative, and restorative treatment thus can provide a beneficial provision in the incidence of dental caries within this population. Utilizing a combination of these factors can then create a favorable oral environment and substantially reduce caries risk and progression.
\nAn assessment of risk factors associated with caries activity is necessary in order to explore and understand the oral capacity of children with CP. Being that the prevalence among dental caries has declined, but not specifically in the CP population, has lead researchers to investigate which risk assessments should more often be considered 15. Studies have shown that no singular oral examination can be indicative of dental caries status, thus a multifactorial analysis must use combining laboratory examination and observations for a cohesive diagnosis. Characteristics that place a child at high caries risk includes consumption of sugary food or drinks, poor oral hygiene, caries experience of the caregiver, poor resource settings, cavitated or noncavitated carious lesions, missing teeth due to caries, and inadequate salivary flow [25]. Since children with CP often experience frequent consumption of cariogenic nonsolid foods, inadequate practice of oral hygiene in the household, severe motor disabilities (GMFCS level IV-V), and low-quality dental care, it is subsistent for this population to face a high risk for dental caries [12, 13, 26]. Although the susceptibility for this population is high, preventative and restorative measures can still be announced and evaluated in the means of reducing the patient’s risk in developing an advanced disease or arresting the disease process.
\nChildren with CP and their caregivers must be willing to participate in daily tooth brushing and flossing. Tooth brushing twice a day can provide an effective maintenance of the oral cavity [13]. Through removal of plaque daily should markedly reduce the increment of new carious lesions. Improving oral measures at home can also provide a change in the presence of tooth erosion, plaque, malocclusions, dmft, and DMFT in this population [15]. An intensive oral hygiene instruction followed by periodic reinforcement will need to be provided to the caregivers and CP children. If a child is incapable of performing this action, it is up to the parents/caregivers to supervise this practice into completion.
\nTopical fluoride preventive agents such as mouth rinses, varnishes, gels, foams, and paste have been systematically reviewed by the Australian Dental Association (ADA) as a safe clinical means to reduce or arrest the development of caries. These treatments can be provided at home or professionally in accordance to the ADA clinical recommendation and practitioner’s professional judgment [25]. Integration of fluoride in the oral hygiene of children with CP can provide an effective barrier to the demineralization process often caused by food deposits and harboring bacteria.
\nFeeding conditions for children with CP are impaired due to the lack of neurological and muscular development. Eating efficiency is thus represented to be poor since aspects of oral skills are also impaired. Difficulty to perform normal deglutition in the tongue, lips, and cheeks prevent food to be consumed properly, leaving residual food to inhabit the mouth [27]. To minimize food cariogenicity, parents are advised to eliminate frequent snacking and nonsolid foods rich in carbohydrates. Future evaluations should be considered in the eating efficiency in this population to provide a better nonsolid supplement for standard nutrition. Several sugar substitutes may be required to provide a broad range for stability, taste onset, and sweetness intensity. Such changes could potentially have a major public health impact in reducing dental caries in CP children.
\nThe use of dental questionnaires can provide primary caregivers a means of interpreting their children’s pain and discomfort, if the child has a limited capacity to self-report. Behaviors can be annotated with questionnaires such as the oral health-related quality of life (OHRQoL), early childhood impact scale (ECIS), family impact scale (FIS), and the child perception questionnaire (CPQ) [11, 13, 28, 29]. Although these questionnaires have been used as an additional means in their prospective studies, their singular results have repeatedly coincided with identifying the nominal risk or presence of dental caries in the CP population. Consequently, making it a functional and easy-to-use instrument to alert parents and physicians alike of the child’s dental discomfort or well-being [30].
\nIf the progression of dental caries is not controlled, lesions can be formed. In this event, “anatomical grooves, or pits and fissures on occlusal surfaces of permanent molars can trap food particles and promote the presence of bacterial biofilm” [25]. As a result, secondary preventative measures should be taken in order to inhibit the progression of these carious lesions. This management may include topical applications of fluoride varnish, excavation of undermined enamel, dentine conditioning, or temporary fill glass ionomer cement. The aim of lesion management will prepare the oral environment for caries arrest, bacterial infection reduction, and prevent food impaction in open cavities.
\nPhysicians can educate and motivate patients by monitoring them on a regularly basis. Frequent evaluations can so be utilized to cease, prevent, and reverse dental caries from occurring. Oral hygiene instruction and coaching can also be used to train children with CP how and why it is important to have an oral hygiene routine, in the case that the caregiver is unenthusiastic.
\nDental therapy for the physically and mentally impaired should be a part of the normal rehabilitation process. Specifically, in children with CP, their extensive sensitivity for dental caries emulates the level importance of clinical dental evaluations in a rehabilitative program [15]. Programs must consider that oral health in this specific population is a major determinant of their physical, social, and mental well-being. If it is impacted, it can secondarily affect their motivations to integrate into society as a whole. For these reasons, rehabilitation programs should consider the efficacy and economic cost of comprehensive care, as it must be accessible to all families. Ignorance to this measure would thus extend the gap of hosting an equal opportunity for quality oral and general health for children and families with CP.
\nIn summary, efforts should be made to develop oral health initiatives for children with CP. The rudimentary neurological and muscular impairments default this population to be highly susceptible candidates for oral health diseases like dental caries. Children with more severe functional motor impairment might have a higher risk of experiencing dental caries, which could be attributed to difficulties in performing adequate oral hygiene. Therefore, the role of oral hygiene must be emphasized in the household of these families in order to treat the prevalent risk factors. To reduce dental caries susceptibility, improvements such as minimal snacking and carbohydrate intake must be made to mend OHRQoL and frequent dental pain. Prioritization should be given by oral health rehabilitation programs to abide the relationship between the physician, caregiver, and the child with the disability to recuperate family dynamics and subsequently improve their overall quality of health. By pinpointing these improvements, a prospective outlook can be set on the impact training and reorganization of preventative and restorative dental care can provide for this challenged population.
\nWe would like to acknowledge Penelope Subervi, Biomedical Engineering from the University of Rochester for drafting the manuscript as a part of her internship program at the School of Dentistry, The University of Sydney.
\nNone of the authors reported any conflict of interest.
Although tourism is generally understood as people traveling for pleasure, it is nevertheless a complex activity that involves a number of issues that intersect over several branches in the economic and social sectors [1]. Defined by the World Tourism Organization (UNWTO) [2] as “a social, cultural and economic phenomenon which entails the movement of people to countries or places outside their usual environment for personal or business/professional purposes”, tourism today is recognized as one of the world’s largest economic sector, supporting more than 313 million jobs in 2017 and generating 10.4% of global GDP [3]. Considering the predictions of increased global growth and the unique connectedness of tourism sector, it is clear why UNWTO has recognized tourism as one of the drivers for realization of the sustainable development goals [4] and even dedicated a separate website to the promotion of the idea and mission [5]. It has long been established that short-term market success might in fact lead to the deterioration of the destinations and therefore natural environment. Sustained market competitiveness requires a balance of growth orientation and environmental commitment at an acceptable rate of return to all industry partners involved in the marketing of a destination [6]. For this reason, it is critical for future of the tourism development to adapt marketing in tourism to preserve both natural and cultural heritage. In achieving this, the appropriate use of the key enabling technologies plays the crucial role.
In this book chapter we introduce the largest government-sponsored research project in Slovenian tourism called Tourism 4.0, together with the main marketing challenges of the project itself and solutions developed in it. Slovenia is a small country located in the south of Central Europe with a long history of tourism. For instance, records of people traveling to the spas of Rogaška Slatina go back to the middle of the seventeenth century [7], while modern cave tourism in Postojna began in 1818 [8]. Hence, it is not surprising that the Tourism 4.0 partnership has been established here. Its ambition is to create a testbed in order to transform the tourism industry into an innovation-driven economy by enriching tourism experiences with the use of technology and data. The term originates from the modern paradigm in industry, known as Industry 4.0 [9] and aims to improve the added value to tourism through innovation, knowledge, technology and creativity. This is planned to affect every field around it by creating an ecosystem, in which physical and digital space, infrastructure, personnel and technology behind it merge into one seamless experience of many personalized outputs. The knowledge, expectations and experiences of tourists, defined as Tourist 4.0 in the project frame, will be utilized to build the new services and products to rise up the satisfaction with the experiences of all stakeholders in the tourism ecosystem.
By uniting managers of physical spaces in the ecosystem (towns, municipalities) with leading Slovene research and educational institutions, as well as technology experts and developers, a collaborative ecosystem is being created, which treasures the history and knowledge of tourist business and at the same time transfers it into the digital world. The result will be a new format of dynamic collaboration system among all tourism stakeholders sprouting a new generation of tourist applications and services, which are built on real tourist needs and wishes by using the key enabling technologies from Industry 4.0 harmonized with the Tourism 4.0 principles.
Subsequent to this introductory section, the following chapter is organized as follows: Section 2 provides the description of the future tourism we want to create with Tourism 4.0, in Section 3 the implementation and ambition of the project is shared, Section 4 discusses the marketing challenges as well as introduces the Twirl marketing model of a paradigm shift and in the last section the chapter is reviewed.
Tourism is ought to be an enjoyable experience for visitors, while at the same time providing a substantial source of income for many destinations and even entire countries. Unfortunately, several studies, even dating back to the 1960s [10, 11] and 1970s [12, 13, 14], have indicated the existence of many worrisome consequences of tourism. The areas negatively affected have found out to be [15, 16]:
Environmental—increased consumption of electricity and water, extra waste production, overcrowding, reduction in accessibility, increase in population density, etc.
Economic—increase in real estate and land price, shift from market prices to higher tourist prices [17], employment fluctuation, economic dependence on a single industry, etc.
Social—illegal goods and people trafficking, excessive commercialization, loss of cultural identity, etc.
Since the number of annual international tourists travels has more than doubled in the last 20 years (to over one billion, shown in Figure 1) reaching 1323 million in 2017 [18], it is essential to ensure sustainable growth of tourism in order to avoid the deteriorating effects on both the social and natural habitat.
Number of international tourist travels over the last decade. Source: World Tourism Organization, Yearbook of Tourism Statistics [19].
Many cases of extreme ramifications of tourism can put pressure on resources and the host communities, hence leading to a decline in the quality of living. All of this brought about the issue of overtourism, defined as “the excessive growth of visitors leading to overcrowding in areas where residents suffer the consequences of temporary and seasonal tourism peaks, which have enforced permanent changes to their lifestyles, access to amenities and general well-being” [20].
In 2017, Slovenia recorded more than 4.9 million tourist arrivals and almost 12.6 million overnight stays, which is 13% more than in 2016 [21]. As shown in the Table 1, the growth is continuous for 4 years already, with this tendency expected in 2018 and also predicted for the near future. By making a total contribution to 11.9% of GDP in 2017, with a forecast of rise to 14.5% in 2028 [22], tourism is becoming a more and more important economic activity.
Year | Tourist arrivals | Overnight stays | ||
---|---|---|---|---|
Total | Foreign | Total | Foreign | |
2008 | 3,083,713 | 1,957,691 | 9,314,038 | 5,351,282 |
2009 | 2,984,828 | 1,823,931 | 9,013,773 | 4,936,293 |
2010 | 3,006,272 | 1,869,106 | 8,906,399 | 4,997,031 |
2011 | 3,217,966 | 2,036,652 | 9,388,095 | 5,463,931 |
2012 | 3,297,556 | 2,155,612 | 9,510,663 | 5,777,204 |
2013 | 3,384,491 | 2,258,570 | 9,579,033 | 5,962,251 |
2014 | 3,524,020 | 2,410,824 | 9,590,642 | 6,090,409 |
2015 | 3,927,530 | 2,706,781 | 10,341,699 | 6,614,443 |
2016 | 4,317,504 | 3,032,256 | 11,179,879 | 7,342,118 |
2017 | 4,948,080 | 3,586,038 | 12,591,562 | 8,572,217 |
Tourist arrivals and overnight stays in Slovenia from 2008 to 2017. Data taken from the SURS—Statistical Office of the Republic of Slovenia.
The rapid rising of numbers put Slovenia ahead of new challenges. While each destination has to constantly strive to improve and innovate in order to stay competitive, local communities (not just tourist service providers and the government) must play a key role in the future development of tourism. Another issue in need to be addressed is the fact that there has been a lack of research in Slovenian tourism [23]. Existing studies pointed toward outdated business methods, lack of cooperation between public and private sector tourism managers, a low level of awareness by the government on the importance of responsible tourism practices as a major impediment in improving competitiveness [23, 24]. Fortunately, in the last years this attitude is changing and in 2017, the efforts of Tourism and Hospitality Chamber of Slovenia in the area of sustainable tourism have finally been recognized and included in the development areas of the smart specialization strategy [25]. With this action, the tourism industry has been set up alongside health and medicine, circular economy, factories of the future and others as a prospective field justified for government co-financing on research and development projects. The specific objectives aimed to be achieved are: an increase of energy efficiency in tourist facilities for 20% by 2021; an increase in the number of the fast-growing companies in tourism from 29 in 2015, to 50 in 2021; a raise in the level of knowledge and quality in Slovenian tourism and a raise in the added value in tourism for 15%.
Accordingly, the prevailing approach needs to change. Therefore, the aim of Tourism 4.0 is to develop a model of collaboration that minimizes the negative impact of tourism, while at the same time improving the overall experience. This goal will be obtained by using the concepts and tools provided by smart tourism [26, 27, 28, 29]—a phenomena describing the convergence of information and communications technology (ICT) with tourism experience, expanding them even further, and integrating them into a platform that will involve all stakeholders active in the tourism sector: the local community, government, tourist service providers and of course tourists—presented in Figure 2.
The core of the Tourism 4.0 concept is to integrate all the stakeholders (local community, tourists, tourist service providers and government) in the sector within a collaborative innovation process centered around the local community.
The main ambition is to build an interactive platform based on the state-of-the-art technology infrastructure, guaranteeing the sustainable development of services and products, accessible to everyone at any time. It will facilitate the tourist’s integration into the destination, increase the quality of the experience and support individual’s interaction to develop tailored products and services. In other words, we want to foster the leap that was enabled by high technologies from Industry 4.0 at products level, by implementing them in tourism services.
For successful implementation of the project goals, the platform will integrate four main pillars or modules, which are at the same time different areas of research for understanding the tourism ecosystem:
Technology module. With the use of cutting-edge technologies enriched tourist experiences will be delivered. This includes:
Internet of things (IoT) for enabling networks of smart device for monitoring and collecting information;
High-performance computing systems (HPC) with artificial intelligence (AI) for the purpose of solving most complex challenges involving data;
Virtual and augmented reality (VR and AR), which can elevate or enhance the overall experience;
Blockchain solutions for a safe and transparent way of delivery.
Innovation module. Research and development of practices and methodologies dedicated to the creation and diffusion of innovation in the ecosystem with the aim to raise the level of competences among all stakeholders.
Ecosystem module. Understanding the tourism ecosystem and all its stakeholders in both the physical and digital world in order to create the space for the new generation of tourism.
Application module. Enabling systems and applications that improve and enrich the real and digital experiences in tourism with the focus on mobility and services (and processes behind) for persons with the purpose of holidays, leisure or recreation, business, health, education or other.
In the Tourism 4.0 ecosystem the local community is in focus while Tourists 4.0 are very active participants in all processes. They have a direct impact on their own experience and act also as co-creators of the tourist offer. With this in mind, we should not forget that the change is only possible by data sharing of all stakeholders of a given ecosystem, thereby acting as a driver for all of the processes on the platform. Furthermore, the data need to be analyzed, if they should be turned into useful information that can be used for strategic decisions and marketing purposes, such as people flow management.
After the initiative was launched by the company Arctur, lack of readiness level to embrace the use of the key enabling technologies, especially by small and medium enterprises in the tourist sector, has been identified. As a consequence, the partnership for Tourism 4.0 has been established to enable collaboration of any stakeholder in the world to participate in research or development of tourism of the future. It brings together a consortium of highly relevant industrial organizations, top research organizations in tourism and the leading research organizations in computer and informatics technology.
The partnership is growing continuously and already boasts with a number of prominent members, such as Slovenian Ministry of Economic Development and Technology as well as Ministry of Public Administration, Tourism and Hospitality Chamber of Slovenia, Association of Towns and Municipalities of Slovenia, University of Ljubljana, University of Maribor, University of Primorska and many partners joining from all over the world. Not only research, also projects focused on validation and deployment of the technologies are planned in order to transform Slovenia into a testbed, Tourism 4.0 Living Lab Slovenia. Further activities in the area of Alps, Danube, Balkans and Mediterranean are set to spread the concepts to an international level.
Sustainable tourism [30, 31, 32] is at the core of Tourism 4.0 that is aspiring to using technology to encourage a positive environmental, social and economic impact and collaboration between all stakeholders in the ecosystem. Following the slogan of Slovene tourism: ‘Green, active, healthy’, new ways of motivating not only individual tourists but all stakeholders will be studied in order to encourage as much of positive contribution as possible for the local environment while traveling and visiting places. This will be achieved by establishing a system of motivation and rewarding for positive behavior i.e. behavior with positive impact on social, environmental and economic elements in a destination—both from tourists and other stakeholders. In this way tourism truly becomes the driver of the sustainable development of the whole society. These are heavily dependent on the quality and intensity of communication, if they are to be reached. For this reason, marketing has a key role in this endeavor since reshaping of the tourism ecosystems with the focus on the local community will not just happen even though this is a crucial step toward the tourism of the future.
The model, that has been so far only theoretically constructed, is named Collaboration impact model (CIM). For its implementation certain tools need to be developed to help with collection, understanding and integration of data. This includes data such as weather prediction, traffic density, number of tourists in a defined area, energy consumption in tourism, etc. In an interactive way, through gamification, we want to reduce the negative and encourage the positive behavior and promote positive attitude to inspire more responsibility among citizens of the globe. The CIM model will use the data of the ecosystem to help tourists with suggestions for tourist activities. When using this model, the tourists will receive real-time information and recommendations based on their own profile, which will help them decide, for example what places to visit or what activities to partake in. Furthermore, users will be able to switch between their own avatars since interest of tourists vary significantly according to their purpose of traveling, which is not limited to for business and pleasure only.
Collaboration impact model is supported by several technological solutions. The most impactful one is the creation of digital tokens, a boosting and rewarding tool of the positive impact accomplished through collaboration within the ecosystem T4.0. In our proposed system, they are named after the model and thus called collaboration impact tokens (CIT). The currency will be needless to say developed on the basis of the blockchain technology. These tokens will be awarded to stakeholders of the tourism ecosystem as incentives for performing certain actions that are beneficial to the local economy and environment. They could help preserve and promote cultural heritage, reduce the consumption of natural resources and support an effective dispersion of tourism.
Examples of CIT awarding are shown in Figure 3. However, there are many more. With this mechanism, responsible development of ecosystem is enabled by encouraging positive attitudes, using of more ecologically-friendly transportation and stimulating a more favorable allocation of tourists. The latter is a pressing issue as more and more destinations are struggling with negative consequences of overtourism. In the next step, we plan to go further and integrate attitudes that encompass most different aspects of society and include them in the rewarding system. For example, visiting elderly people and spending time with them for few hours or reporting a damaged public trash bin to the municipality could be encouraged by incentives in the form of tokens. We believe that step by step with the technological development as well as by raising awareness through strategic communication rewarding positive impact on wider society will become the norm.
Examples of methods and actions with which a tourist can earn the collaboration impact token—CIT and the attitudes we want to promote.
Anyhow, visitor management techniques can also be applied to select or deselect tourists, control their flows and influence their behavior through promotion and education [33]. With the help of internet of things, it is possible to monitor and thus measure many human activities. The most common example in the tourism sector is the water and energy consumption of each accommodation. Many hotels collect such data but they do not use them. In accordance to our collaboration impact model, the tourists, who exhibit ecologically conscious behavior, i.e. consume less than average consume of water and energy of tourists in that specific area, would receive a reward in the form of CITs. The received tokens can be used for purchase of other tourist products or services. In addition to increasing the sustainably driven attitude preserving the environment is this beneficial for the local economy. Another example of desirable behavior is visit during the low tourist season or places in the touristic periphery. An additional issue of significant importance due to the size of its impact is the mobility. Here good behavior is determined and rewarded by the use of public transport or sharing services besides renting a bike or an electric car. The underlying idea is that tourists are awarded and thus motivated to exhibit behavior with a positive impact more often.
The most important aspect of the collaboration impact token is the assignment of dynamic values according to location and time of its use. For an illustration, we examined the number of tourists’ overnight stays for each municipality in Slovenia in 2017 and normalized it to the municipality’s population density (residents/km2), as seen in Figure 4. The discrepancy can be noticed immediately. Some areas experience a much higher tourist density than others, with some parts already experiencing overtourism. The value given in the calculation is dependent on:
visits to the geographic area—lower in the red and higher value in the green areas;
tourist season—low season means higher value;
strategic development level of the region—higher value in less developed regions;
etc.
The number of tourists overnight stays in 2017 for each municipality normalized by its population density (i.e. residents/km2). The data is taken from the SURS—Statistical Office of the Republic of Slovenia.
As the example of the calculation demonstrates, the use of public data can already enable the first insight into understanding of tourist flows. Building an award-based collaboration ecosystem that helps to manage issues of people flow within a destination, region or even a country is very rational and strategic since it also supports less developed regions in establishing their touristic sites. By implementation of the CIT that provides instant award in discounts, tourism of the beaten path can rise significantly. This does not only reduce the unbearable crowds of tourists in one spot of a destination, but above all immensely improves the tourist experience.
It is the lack of capital, technology and marketing and management expertise that restrains the growth of tourism in many less developed regions in the world [33]. An adoption of societal marketing strategies will thus have to take place, where increased visitations are not the primary concern and visitors are not treated like any other commodity. This will include monitoring of both the tourist and host satisfaction for the purpose of optimizing the of tourism impact on the environment and consequently increasing the benefits for the local community [34, 35]. Since monitoring is dependent on data, access to them is increasingly relevant to the tourism sector as well. It allows for the provision of evidence-based decisions and the development and analysis of future scenarios, which infuse the whole sector with additional efficiency and productivity to face its current challenges. In addition to accessibility, green mobility and connectivity has been identified as a priority area for facilitating the flows of movement, and easing the negative impact of tourism on local environment, along with reducing the effect on climate change.
Moreover, the prevalence of smartphones and mobile devices are swiftly changing the face of technology use for destination marketing as people now have access to the virtual world in palms of their hands [36]. More importantly the new technology enables smaller and peripheral destinations to compete on equal footage with larger and more central ones. The gained competitiveness lies in reduced dependency on intermediaries for the distribution of tourism products. As a consequence, the providers of tourism services are able to improve their negotiation power, which fosters the development of a healthier distribution mix. As aforementioned, this is of even greater importance for remote, peripheral and insular destinations where local principals and authorities have a great dependency on tourism for their income but lack expertise and resources to undertake comprehensive marketing campaigns [31].
Only an advanced ICT infrastructure enables a more dynamic, less rigid, and fast interaction within organizations and between organizations at the tourist destination, which empowers stakeholders through the creation of a technological infrastructure for increased communication and collaboration [34]. Tourist destinations are now, more than ever, building competitive tourist places using state of the art business models. However, without a proper information environment these business models are often subjected to failure. The T4.0 platform facilitates the just-in-time information exchange between various stakeholders from different places or markets using the key enabling technologies available at this time (illustrated in Figure 5). This way, the platform reduces the information and choice overload, which currently presents one of the key barriers in conducting tourism business. What is more, various tourism providers can use the platform to share their services, products or information to users at all levels of the industry (e.g. G2C, B2B, B2C, C2C).
The enabling technologies for project Tourism 4.0.
The Tourism 4.0 platform actually enables the communication between stakeholders and collaboration within the ecosystem where users are involved in the development of new tourist products and provide free access to the collected data, thereby encouraging innovation through the use of modern technology. In the implementation of technological solutions of Tourism 4.0, local communities play a vital role, thus we are putting them at the center of the ecosystem of future tourism. As already presented in Figure 2, the Tourism 4.0 platform is envisaged toward four main target audiences:
The providers of tourism services and packages (e.g. local tourist organizations and tour operators). The interest of this group is in the direct access to their target audiences, which will be enabled through the platform. There is a number of niche web (and mobile) platforms that almost proverbially offer only one solution to the end user (e.g. only hotel reservations, only attraction tickets, etc.). Contrarily, the Tourism 4.0 platform will gather together a number of various but complementary proposers of tourist services that will be interested to promote through the platform due to the considerably reduced margin for the referred business.
The tourist. They will be encouraged to use the platform mainly because of its all-in-one portfolio and also its embedded features. The combination of an all-encompassing offer, accompanied by AI will enable the platform to produce a tailored offer to the user. The AI will have an overview of the interests and preferences of the end-user and the services at offer. By combining the two, the user will get offered first the most interested services for her or him in that moment followed by services listed accordingly to their relevance for the user.
Local inhabitants. Through the collaborative platform, it will be possible to measure, monitor and manage the impact that tourists have on the local environment. This can be used to control the quality of living of the population and the quality of the tourist experience of the guests. In a second step also measuring of attitudes of local inhabitants are planned to be included in order to incentives all stakeholders to strive for the positive impact.
Government. Providing a collection and aggregation of data that can help in understanding and development of appropriate policy regulations, which are not only able to react to disruptions but even boost innovations.
In understanding the ecosystem in such way, a question emerges on who is the consumer in this new paradigm of tourism, as every stakeholder is collaborating, profiting and co-creating. These are the challenges that need to be embraced by the marketing specialists in the near future.
Actually, from the technological and business aspect, tourism and e-tourism have always been in the background, in the sense that tourism was predominantly following innovation. In the latest technological wave, many of the most prominent startups and corporations of the new generation are strongly attached to tourism, mainly through sharing economy. Sharing economy is just the beginning of a trend that indicates how the technology allows the sharing of tangible and intangible elements of all kinds of user experiences, in tourism as well. The tendency will continue with the intensive incorporation of all other current trends (AI, VR, AR, IoT, Smart Mobility, Blockchain, etc.). It will not only be about new ways of sharing and building up these elements. For the economic sector, it is important that these elements are appropriately used in new, innovative business models. Therefore, the technological project outcomes will be adopted to the new and innovative business models in tourism in general, as well as in the areas of destination management and event management.
Here are some examples of the use of the key enabling technologies in tourism that will transform the tourism business in near future:
Virtual reality could help potential visitors to decide which destination they prefer to visit;
Augmented reality could enable a completely new touristic experience that is either historically informative or adventurous in nature;
Combination of external data such as weather forecast with travel information would implement an automatic rebooking of a trip in case of a rainy day.
Such and similar future applications could become a new income stream in tourism, especially in relation to natural landmarks since most of them can be experienced for free. We do not promote limited access to nature because access to it should stay free of charge. On the other hand, interactive experience offered via augmented reality app could be payable and the income acquired could be spent on preserving the nature in a given destination. This way we would not rely solely on demand management for sustaining tourism resources with effective marketing, which can channel tourist flow to places that are more impact-resilient, such as urban and seaside built environments rather than to more fragile wilderness areas [33]. With the income from the enriched tourist experience national parks and heritage sites would be able to invest into preservation of natural environment in addition to managing the ever increasing demand.
In fact, the sustainability of local resources is becoming one of the most important elements of the destination image, as a growing section of the market is not prepared to tolerate over-developed tourism destinations and diverts to more environmentally advanced regions. The degree of consumer satisfaction will depend on the assessment of the perceived overall experience of the destination versus anticipated expectations and perceptions [34]. Smart tourism will become the driver of social change due to its high innovation potential and above all impact on economic, cultural and natural environment. As explained, marketing has a crucial role here. Not only in promoting sustainability in tourism but also in marketing in an attractive way of less popular tourist destinations. Inefficient use of many tourist facilities (hotels, for example, often have annual bed occupancy rates of 50–60% in most countries), indicates that the effective marketing of these tourist resources is of great significance in reducing resource wastage as well [33]. Challenges and opportunities are many, especially because throughout the world tourism services are offered by small and medium tourism enterprises, which tend to be family managed. Hence, the challenge for destination management organizations is to provide leadership in the development of innovative products and create local partnerships for the delivery of seamless experiences [34]. The collaboration impact model can provide that but marketing and communication experts will need to develop new strategies to make better use of the new tools with the purpose of optimizing the positive impact of tourism while increasing the benefits of the local community.
In marketing of new concepts, such as a new paradigm, the first issue everybody is facing is how to build trust and rise interest for complex and new solutions since trust and perceived risk are shown to be direct antecedents of intention to transact, suggesting that uncertainty reduction is a key component in consumer acceptance [37]. Hence, it is crucial to be aware of the lack of readiness level of the target groups in terms of lack of skills and lack of processes, in which research and development spirit could fit into strategies and implementation of changes.
To address this, the Twirl marketing model of a paradigm shift, presented in Figure 6, has been developed that shows in which process the appropriate target groups were identified and how the nature of communication has been growing into collaboration. In this process the communication starts with the informative phase addressing a broad public. It is upgraded in the second step with educational dimension that focuses on a smaller target group, which is then in the third step reduced to the key persons of each specific target group. With them conversations take place in order to find the possibilities to embrace the new concepts. This leads to collaboration, with which the amount of people reached via informational, educational and conversational communication raises again. In the best case, such organic growth occurs through community building. This is the reason for establishment of the Tourism 4.0 partnership, which is open to new interested stakeholders.1 In addition, an online form is available on the website, where anyone can share their idea or solution in the field of Tourism 4.0 and are later connected to potential partners.
Twirl marketing model of a paradigm shift.
How does the Twirl marketing model of a paradigm shift prove to work in practice? In the informative phase all available tools to spread information are used, such as digital presence (website with news section for updates, social media, newsletter, etc.) and participation or organization of events with good media coverage or specific to the topic performed. This enables the reach of the appropriate target groups. Tourism 4.0 as a new paradigm has been presented both at events organized locally and around the globe, in China and Mexico for example, but always accompanied with good national media coverage.2 The goal was to awake interest and give it relevance through international dimension. In the second phase, education in the form of presentations at conferences, forums3 and fairs were given in order to provide knowledge of the paradigm shift and its necessity while getting experts and policy makers in the tourism sector acquainted with the Tourism 4.0 objectives. To achieve this, concrete examples of technologies were presented in the form of vivid storytelling.4 The play of concepts around marrying tourism with technology has been created to help novices with low to limited knowledge of technology to embrace the new concepts and possibilities they bring. From persons targeted during the education phase some individuals, small groups and organizations showed interest for a further conversation, which is the activity of the third phase of the Twirl marketing model of a paradigm shift. This phase includes personal conversations with tourist organizations and institutions and service providers. At the same time, deep conversations will take place through an extensive survey conducted as a part of the
Only after informing the public, educating specific target groups and conversing with key decision makers an inclusive collaboration at a local or global level is possible. In the marketing model of a paradigm shift after performing the first ‘round of process’ further marketing strategy builds on an eternal interviewing of all communication methods from the first three phases for multiplication of collaboration. However, the precondition remains the trust of all stakeholders, which is being built by interaction that hopefully grows into collaboration. This interactivity is enabled by the modern tools for tourism marketing and management that can re-engineer the entire process of developing, managing and marketing tourism products and destinations as well as provide the competitive advantage with the ability to re-develop the tourism product proactively and reactively [39].
Therefore, the next step of the Tourism 4.0 project marketing strategy is testing of above-mentioned solutions with a series of products at TRL 6–8 stage.6 The goal is to test the prototypes in operational environment to support commercial activity in ready state in environments called living labs, where future reality and future tourism in it are simulated. Imagine a playground in which technology service providers can test their gadgets with tourists, who want to be part of such a testing experience accepting the violations of their privacy. At the same time, public decision makers can learn from the reality and adapt the legislation accordingly. Students, waiters and all other personnel in contact with tourists get the possibility to train how to deal with crypto tokens while children will be educated about their water consumption and challenges that we as citizens of the world are facing and how to behave to minimize our negative impact. Key to the marketing a paradigm shift is to understand that the marketing process needs to address all stakeholders. To mention the most crucial fact, we are aspiring to facilitate the break down the silos mentality where stakeholders do not wish to share information and provide feedback with one another. Such trials will connect consumers (both local community and tourists) and tourist providers, (local) government as well as high-tech companies in order to unify the dispersed ideas, experiences, knowledge and expertise with the intent of integrating them in a collaborative manner around the Tourism 4.0 platform and later used in real business environment.
With more than one billion persons traveling yearly around the world, a small change in this sector has a huge impact on the whole society. The new paradigm, Tourism 4.0, build around technologies from Industry 4.0 can path the way of transformation not only in tourism, but also as driver of the UN sustainable development goals. In Slovenia, the biggest research project on tourism in the history of the country called Tourism 4.0, which has already grown into a Tourism 4.0 partnership, gathering academia, business and public partners, is focused on defining the ecosystem, in which these changes could take place. Hence, the main objective is the development of a platform for a new form of active cooperation system among the local community, tourists, tourist service providers and the government.
The system aims to encourage positive behavior among all stakeholders in order to maximize positive impact on the local environment through the collaboration impact model. For its implementation certain tools need to be developed to help with collection, understanding and integration of data. This includes data such as weather prediction, traffic density, number of tourists in a defined area, energy consumption in tourism, etc. In an interactive way, through gamification, encouragement of the positive behavior and promotion of positive attitude to inspire more responsibility among citizens of the globe is foreseen. Digital token, to mention the most impactful one, is a boosting and rewarding tool of the positive impact accomplished through collaboration within the T4.0 ecosystem. The so-called collaboration impact tokens (CIT) is a currency developed on the basis of the blockchain technology. These tokens will be awarded to stakeholders of the tourism ecosystem as incentives for performing certain actions that are beneficial to the local economy and environment. In addition to gamification and incentives, social marketing strategies promoting sustainability and positive impact will be used.
The Tourism 4.0 ecosystem is built around the problems and wishes of local inhabitants and in only in the second step around those of other stakeholders. Hence, we are facing the shift from tourist-centered focus to a tourism-centered focus around the local community. During the development of such an ecosystem a question emerges about who is the consumer in this new paradigm of tourism as every stakeholder is collaborating, profiting and co-creating. As the right answer due to the collaborative nature of the Tourism 4.0 ecosystem is everyone, the Twirl marketing model of a paradigm shift emerged. The model leads to collaboration through the process of finding the right partners that bring new collaboration and help spreading the messages and ideas of the paradigm shift. This occurs by first addressing the broader public, educating the appropriate target groups via innovative marketing tools and event presentations at various conferences, forums and fairs, where interested individuals and organizations are found. This leads to personal conversations with them aimed at finding common goals and their implementation into strategies and actions plans. In this way an environment in which collaboration can emerge and grow is created. And this is the beginning of the story of a new paradigm shift which might have or not, depending a lot on communication and marketing experts, a huge impact on our future.
To conclude, such an ecosystem does not only provide immense opportunities for technological innovation and new business models but also represents an extremely rich environment for identifying and studying new interaction paradigms and forms of value (co-)creation. The stakeholders interact with information and with technologies in new ways that have yet to be identified and understood, the challenges that need to be embraced by the communication and marketing specialists in the near future.
This work is carried out within the framework of the research project Tourism 4.0—enriched tourist experience (OP20.03536), co-funded by the Slovenian Ministry of Education, Science and Sport and the European Regional Development Fund. The consortium is led by Arctur company and includes top experts from three Slovenian universities: the Faculty of Tourism Studies—Turistica (University of Primorska), the Faculty of Tourism (University of Maribor) and the Faculty of Computer and Information Science (University of Ljubljana). We would also like to acknowledge the ongoing support from the Association of Municipalities and Towns of Slovenia (Skupnost občin Slovenije—SOS).
The authors do not declare any conflict of interest.
The authors of this chapter would like to thank Dejan Šuc for providing the graphic designs.
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\n\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
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\n\n2. STATEMENTS OF CONCERN
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\n\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n3.2. CORRIGENDUM
\n\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\n\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\n\nPolicy last updated: 2017-09-11
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