Health Promotion International, 2020;35:50–69

doi: 10.1093/heapro/day103
Advance Access Publication Date: 18 December 2018

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Article

Blue care: a systematic review of blue space

interventions for health and wellbeing
Easkey Britton1,*, Gesche Kindermann1,2, Christine Domegan1,3, and
Caitriona Carlin1,2
1
Whitaker Institute, National University of Ireland – Galway, Galway, Ireland, 2Applied Ecology Unit,
Centre for Environmental Science, National University of Ireland – Galway, Galway, Ireland and 3J.E.
Cairnes School of Business & Economics, National University of Ireland – Galway, Galway, Ireland
*Corresponding author. E-mail: [email protected]

Summary
There is increasing interest in the potential use of outdoor water environments, or blue space, in the
promotion of human health and wellbeing. However, therapeutic nature-based practices are cur-
rently outpacing policy and the evidence base for health or wellbeing benefits of therapeutic inter-
ventions within blue space has not been systematically assessed. This systematic review aims to ad-
dress the gap in understanding the impacts of blue space within existing interventions for targeted
individuals. A systematic review was carried out, searching Google Scholar, SCOPUS, PubMed, etc.
through to August 2017. Only blue space interventions were included that were specifically
designed and structured with a therapeutic purpose for individuals with a defined need and did not
include nature-based promotion projects or casual recreation in the outdoors. Thirty-three studies
met the inclusion criteria and were assessed. Overall, the studies suggest that blue care can have di-
rect benefit for health, especially mental health and psycho-social wellbeing. The majority of papers
found a positive or weak association between blue care and health and wellbeing indicators. There
was also some evidence for greater social connectedness during and after interventions, but results
were inconsistent and mixed across studies with very few findings for physical health. This is the
first systematic review of the literature on blue care. In summary, it has been shown that mental
health, especially psycho-social wellbeing, can be improved with investment in blue spaces. Key
areas for future research include improving understanding of the mechanisms through which blue
care can improve public health promotion.

Key words: blue space, blue health, nature-based therapy, intervention, systematic review

INTRODUCTION As the above statement from the World Health

Organisation (WHO) highlights, water environments are
Most of the earth’s surface is covered by water, and essential to promote health. Nevertheless, global evidence
most of the human body is composed of water—two of disconnect and detachment from our natural surround-
facts illustrating the critical linkages between water, ings is growing as the world’s ecosystems increasingly
health and ecosystems. (WHO, 2017) come under threat from human pressures (Levin and Poe,

C The Author(s) 2018. Published by Oxford University Press.

V
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Systematic review of blue space interventions for health and wellbeing 51

2017), with economic and social goals attained at the cost The link between nature, health and wellbeing
of future health (Kite-Powell, 2008). Freshwater, coastal While there is some conceptual ambiguity of terms such as

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and marine ecosystems have been identified as suffering ‘blue space’, ‘health’ and ‘wellbeing’ (Bragg and Atkins,
more rapid degradation and biodiversity loss than any 2016), a systematic review requires definitions of terminol-
other ecosystems (MEA, 2005; Whitmee et al., 2015). ogy. Blue space could be described as a ‘threshold concept’
With over one-third of the world’s population living (Meyer and Land, 2003) and is often assumed under the
around coastal ecosystems (Neumann et al., 2015) atten- umbrella concept of green space or green infrastructure
tion has more recently begun to focus on blue space and where the assumption is that these spaces will ‘improve en-
promoting human health (Domegan et al., 2016; Grellier vironmental conditions and therefore citizens’ health and
et al., 2017). Within academia there is growing interdisci- quality of life’ (EC, 2016). Blue space is largely defined in
plinary interest in and recognition for the benefits provided the academic literature to include all visible outdoor sur-
by specific water environments, or ‘blue space’ (Korpela face waters (White et al., 2016; Grellier et al., 2017), how-
et al., 2010; Depledge et al., 2013; Wheeler et al., 2015; ever, blue space is sometimes still subsumed under ‘green
Bell et al., 2015, 2018). This systematic review builds on space’, in particular riparian areas (Haeffner et al., 2017).
this evidence to look at the use of blue space in therapeutic Foley and Kistemann’s [(Foley and Kistemann, 2015), p.
interventions for the promotion of health and wellbeing. 157] definition emphasizes the health enabling qualities,
The WHO define health as ‘a state of complete physical, ‘where water is at the centre of a range of environments
mental and social wellbeing and not merely the absence of with identifiable potential for the promotion of human
disease or infirmity’ yet public and political discourse is pre- wellbeing’. In this paper, blue space is used to refer to all
occupied with disease (Yach et al., 2004; Kim et al., 2013; visible, outdoor, natural surface waters with potential for
South, 2015). Within the UK, and indeed globally, the the promotion of human health and wellbeing. This
growing interest in the therapeutic potential of nature-based excludes outdoor swimming pools, garden ponds and
interventions at a policy-level (Bragg and Atkins, 2016) fountains, however, it can include modified and artificially
seems to be driven by a global health crisis, in particular the constructed spaces that still contain natural surface water
rise of non-communicable diseases (Kickbusch, 2015). The such as a canals, dammed lakes or urban streams/rivers. It
WHO reported that 88% of deaths in the European region is evident that there is much overlap between blue and
were caused by non-communicable diseases (WHO, 2016) green spaces, however, authors have argued that blue
such as obesity, type 2 diabetes and mental illness often at- spaces offer very different sensory experiences and are
tributed to increasing sedentary lifestyles, poor diet, an age- used in different ways with different outcomes and bene-
ing population and social isolation in developed nations fits that are often overlooked and remain poorly under-
(Bragg and Atkins, 2016). This crisis is further aggravated stood (Haeffner et al., 2017).
by overburdened and underfunded public health care sys- A term increasingly used in environmental policy and
tems (Kaplan and Porter, 2011; Kirwan et al., 2017). The management is ‘nature-based solutions’ (NBS). NBS are
issue of mental health is especially acute, with a rising sui- defined by the European Commission (EC) as ‘instru-
cide rate and lack of funding for services highlighted in the ments inspired by nature and using the properties and
UK (Mental Health Taskforce, 2016). Public health author- functions of ecosystems to enhance ecosystem services
ities are beginning to recognize the importance of proximity and multiple health benefits’ [(Haase et al., 2017), p. 42].
to, and contact with, natural environments ‘as an upstream The concept of nature-based therapy is defined by the
health promotion intervention for populations’ [(Maller Green Care Coalition in the UK as, ‘nature-based therapy
et al., 2006), p. 45]. Although public health interventions or treatment interventions specifically designed, struc-
delivered at the individual or community level can be tured and facilitated for individuals with a defined need’
equally successful in changing the behaviour of a large pop- [(Sempik and Bragg, 2016), p. 100]. These terms are
ulation (Sniehotta et al., 2017) they cannot be seen in isola- emerging and evolving and encompass any intervention
tion from other environmental factors which could exert a that uses or learns from nature to improve health or man-
greater influence on behaviour change (Graham and White, age illness. The term ‘blue care’ is used in this paper to re-
2016). Challenging these preoccupations is one of the key fer to blue space interventions (BSI), pre-designed
goals of an emerging number of research initiatives, collab- activities or programmes (typically physical) in a natural
orative research projects such as ‘NEAR Health’ and ‘Blue water setting, targeting individuals to manage illness, pro-
Health’ are building an evidence base that will begin to mote or restore health and/or wellbeing for that group.
qualify how important natural environments, and uniquely There is a growing body of international literature
aquatic environments, are for human health and wellbeing. exploring how engagement with nature can assist both
52 E. Britton et al.

in promoting and restoring health (Maller et al., 2006; This systematic review assesses existing peer-
Coombes et al., 2010; Lovell et al., 2014; Sandifer et al., reviewed journal articles to identify and evaluate:

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2015). However, a specific focus on blue space for
• Types and characteristics of BSIs—including use of
health and wellbeing has only emerged in more recent
validated methods and measures.
years (Foley and Kistemann, 2015). To date, only one
• Range of mechanisms, barriers or enablers associated
systematic review has focused exclusively on blue space
with access to blue care.
(Gascon et al., 2017), and one scoping review on urban,
• Range of the health and wellbeing outcomes measured.
freshwater blue space (Völker and Kistemann, 2011).
Gascon et al. (Gascon et al., 2017) synthesized current Furthermore, the aim of this systematic review is to
epidemiological evidence from 36 quantitative studies help provide evidence that can inform researchers,
on the health benefits of blue spaces. The review found policy-makers and practitioners in the design and deliv-
that overall there were potential health benefits of living ery of blue care for health promotion and restoration.
near or deliberately visiting blue space, primarily on
mental health and the promotion of physical activity.
However, the authors highlighted that better methodo- METHODOLOGICAL APPROACH
logical approaches, sampling strategies (randomized
Search strategy
controls) and documented procedures, including evalua-
From the initial search (Step 1 in Figure 1), several
tions are required to advance our knowledge on the
terms were identified (outlined below). The search in-
topic (Gascon et al., 2017). To our knowledge, no sys-
cluded keywords, topic, title, abstract words.
tematic review has been carried out that examines the
Literature searches included simultaneous computer-
benefits of therapeutic interventions in blue space.
ized searches of online databases (Step 2, Figure 1). In
The recognition of the importance of the value of na-
addition, in a process of chain-referral sampling,
ture and place as a determinant of wellbeing presents an
authors’ publications, articles citing papers and refer-
opportunity to struggling healthcare systems seeking new
ence list checking were carried out to obtain access to
and cost-effective services (Bragg and Atkins, 2016). The
more material. Based on recommendations by Hartig
recent and rapid proliferation of NBS and interventions,
et al. (Hartig et al., 2014) a combination of nature (in-
such as the ‘green gym’ (Yerrell, 2008) and ‘blue gym’ ini-
cluding blue space) terms, health and wellbeing terms,
tiative (Depledge and Bird, 2009) in the UK, is out-pacing
interactions, interventions and outcomes, sample,
policy and knowledge base. This creates challenges to un-
study type, behaviours, etc. were used (Supplementary
derstanding and assessing their impact for public health
Appendix S1).
benefit (Raymond et al., 2017). Better understanding of
potential approaches and pathways are needed to gain an
evidenced-based knowledge of the benefits of blue care. Exclusion/inclusion criteria
Two of the review authors (Carlin and Britton) co-
Aims of the systematic review developed inclusion and exclusion criteria and were veri-
This evidence review aims to address the gap in under- fied by another review author (Kindermann) to see if the
standing the health benefits of blue space within existing criteria were clear and applicable. Inclusion and exclu-
interventions for targeted individuals. It systematically sion criteria set out in Steps 3 and 4 (Figure 1) were ap-
identifies, summarizes and synthesizes studies that have plied. Searches were restricted to articles in the English
examined the benefits, if any, of blue care for attaining language. Study populations in both urban and rural
or restoring psychological and/or physical health and spaces were permitted and an unlimited, global geo-
wellbeing. This review examines the design, structure, graphic scope, including all target populations was ap-
benefits and outcomes as well as the mechanisms of in- plied. Only studies with a nature-based therapy or
tervention provision. Much of the literature on blue treatment intervention specifically targeted, designed or
space is highly heterogeneous, varied in disciplinary ori- structured for individuals or a voluntary group were in-
gin, with authors approaching the study design using cluded. The study did not have to explicitly define ‘blue/
different methods and conceptualizations of blue space green’ spaces. However, studies had to address outdoor,
for health and wellbeing (or none at all) (Gascon et al., natural (i.e. non-manmade), blue space (e.g. rivers,
2017). As this is a recently emerging body of work and lakes, coasts, sea, etc.) in relation to health and/or well-
the available evidence remains highly heterogeneous, a being (including studies where improving individual psy-
narrative synthesis approach is used, which is textual chological, social and/or physical wellbeing was the
rather than statistical (Lovell et al., 2014). primary goal of the intervention).
Systematic review of blue space interventions for health and wellbeing 53

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Fig. 1: Summarized overview of the literature search and selection process.

Data extraction and collation bias, are likely to be greater for non-randomized studies
The research team adapted and co-developed a checklist compared with randomized controlled trials (RCTs)
of 60 questions (see Supplementary Appendix S2) from a (Cochrane, 2017). A quality appraisal tool was not applied
previous desk-based study by one of the authors (Carlin for similar reasons. However, RCTs pose a challenge in the
et al., 2017). The Cochrane, Campbell and PRISMA context of public health as they are often difficult to apply
guidelines were used to ensure a systematic and consistent in ‘real world situations’ [(Rütten et al., 2019), p. 4], an is-
approach was applied by all three researchers in retriev- sue the authors return to in the discussion.
ing information to assess quality and decide on inclusion/
exclusion from review (Cochrane, 2017). This included
the recording and evaluation of details. Data were RESULTS
recorded using a structured template and ENDNOTE X7
Study characteristics
was used to manage bibliographical information.
Following the selection criteria of Steps 4 and 5
(Figure 1), 33 studies were included in the final selection
for this systematic review. These were published from
Data analysis
2004 to 2017, with the majority of studies published in
The authors reviewed the data extracted independently to
the last 5 years (Table 1).
ensure all researchers were extracting the same information.
The data were reviewed in the light of verification feedback.
A narrative synthesis approach was adopted by the authors Study aims
and included a combination of vote-counting methods fol- The aims of the studies (Table 1) can be categorized as
lowed by thematic analysis. While the Cochrane Review (i) evaluating or assessing the effectiveness of a BSI for
guidelines set out a need to assess risk of bias in all included treating, reducing or alleviating symptoms of specific
studies (Cochrane, 2017) this review deliberately did not as- conditions [e.g. post-traumatic stress disorder (PTSD),
sess the risk of bias or ‘internal validity’ in the intervention addiction], and/or (ii) investigating or exploring the
studies. The authors recognize that there is a risk of bias wellbeing (physical, mental, psychosocial) impacts and
with all included interventions, which were all non-random- outcomes of a BSI, and/or (iii) studies that focused more
ized studies and potential biases, including in particular se- on understanding the impact of the BSIs on participants
lection bias (the samples were self-selected) and reporting perceptions, values and beliefs.
Table 1: Study design characteristics
54

Author(s), year, Aims of Study Sample Age/gender of Health characteristics of Health outcome Validated tools/measures Study design
country size participants participants measured methods

Rogers et al., Assess ocean therapy for war veter- 11 18þ (majority 24– PTSD, depression Mental health, None Pre–post, uncon-
2014, USA ans seeking treatment for PTSD. 30 years), M, F PTSD trolled study,
(n¼3)
Berger and Tiry, Explore experiential approach to na- NS NS, Adults Emotional and psychiat- Mental health None Experimental,
2012, Israel ture therapy for mental health ric difficulties (include Qual.
issues. depression)
Godfrey et al., Evaluate wellbeing outcomes of surf- 136 8–18, youth (plus Social exclusion, mental Psycho-social Stirling Children’s Pre–post, Quant.,
2015, UK ing intervention for youth. parents and health issues; sensory wellbeing, Wellbeing Scale, questionnaire
referrers), M, F issues. behavioural (SCWBS)
Caddick et al., Investigate wellbeing outcomes of 16 27–60, adult, M PTSD Wellbeing, PTSD None Qual., interview,
2015, UK surfing for combat veterans PO
experiencing PTSD.
Clapham et al., Understand health benefits of surf 17 5–17, youth, M, F Mixed disabilities (physi- Physical, Brockport Physical Pre–post, Quant
2014, USA programme for youth with cal, cognitive, psychosocial Fitness Test (BPFT)
disabilities. behavioural)
Dustin et al., Explore therapeutic benefits of river 13 NS, Adults, M, F PTSD PTSD None Qual.
2011, USA running for veterans with PTSD (n¼3)
Tardona, 2011, Investigate wellbeing impacts of kay- 129 9–17, youth, M, F NS Wellbeing, None Qual., NS
USA aking as a nature-based activity (17%) behavioural
for inner-city youth
Carin-Levy and Investigate psychosocial benefits of 3 33–53, adult, M Amputees and SCI QoL, psychoso- None Post, Qual.,
Jones, 2007, scuba diving for individuals with cial, physical interviews
UK acquired physical impairments impairments
Casey et al., 2009, Understand meaning and value of en- 6 NS, adults, M. F SCI: quadriplegic, SCI None Post, Qual.,
Ireland gaging in kayaking as a leisure paraplegic interviews
pursuit for adults with a SCI.
White et al., 2016, Evaluate effects of sail training for 11 26–61, adult, M, Addiction (drugs and Recovery from None Pre–post, Qual,
UK adults recovering from drug and F (n¼3) alcohol) drug and alco- interviews
alcohol addiction hol addiction
Mowatt and Impact of therapeutic fly-fishing in- 67 NS, adult PTSD PTSD None Qual., self-reflec-
Bennett, 2011, tervention on PTSD symptoms of tive letters
USA war veterans

(continued)
E. Britton et al.

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Table 1: (Continued)
Author(s), year, Aims of Study Sample Age/gender of Health characteristics of Health outcome Validated tools/measures Study design
country size participants participants measured methods

Nielsen and Investigate psychosocial impact of 6 43–75, adult, F Breast cancer Psycho-social None Qual. Interviews
Mitchell, 2002, dragon boat racing (DBR) as post
Canada cancer rehabilitation both physi-
cally and emotionally.
McDonough Explore changes in body image and 14 46–60, adult, F Breast cancer Body image, social None Pre–post, Qual,
et al., 2008, social support experienced by support, breast interviews
Canada breast cancer survivors during a cancer
novice season of DBR
Parry, 2008, Understand contribution DBR makes 11 40–60s, adult, F Breast cancer Women’s health, None Qual., interviews
Canada to women’s health and breast can- breast cancer
cer survivorship
Sabiston et al., Explore breast cancer survivors 20 42–70, adult, F Breast cancer Social support, None NS
2007, Canada experiences of participation, moti- physical self-
vation, social support, and physi- perception,
cal self-perception related to their breast cancer
participation in DBR
Mitchell et al., Investigate the psychosocial impact 10 35–70, adult, F Breast cancer Psycho-social, None Pre–post, mixed,
2007, Canada of DBR participation on women breast cancer questionnaire,
treated for breast cancer. interviews
Parry, 2007, Investigate broader health benefits of 12 40–60s, adult, F Breast cancer Broader health, None NS
Canada participation in DBR breast cancer
Systematic review of blue space interventions for health and wellbeing

Unruh and Elvin, Explore impact of DBR on psycho- 3 50s, adult, F Breast cancer Psych. wellbeing, None NS
2004, Canada logical wellbeing from point of breast cancer
view of breast cancer survivors.
Armitano et al., Explore benefits of surfing for youth 16 5–18, youth, M, F Cognitive and learning Physiological, BPFT Pre–post, Quant,
2015, USA with disabilities by assessing for disabilities [Down disabilities
physiological improvements. Syndrome, Autism
Spectrum Disorders
(ASD), Microcephaly,
Global Developmental
Delays, Dandy-Walker
syndrome], heart
defects,
hypothyroidism

(continued)
55

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Table 1: (Continued)
56

Author(s), year, Aims of Study Sample Age/gender of Health characteristics of Health outcome Validated tools/measures Study design
country size participants participants measured methods

Cavanaugh and Determine benefits and outcomes of 11 10–16, youth, M, ASD Psycho-social, so- Social Skills Improvement Pre–post, mixed,
Rademacher, 2-day surf camp on social compe- F (n¼3) cial skills, self- System; Piers-Harris multiple meas-
2014, USA tence, social skills and self-concept concept, ASD Children’s Self-concept ures/scales
of students with ASD Scale; Parent
Perceptions of surf
camp curriculum;
SURF Skills
Observation Checklist
Colpus and Show the positive effects surfing has 72 8–17, youth, M, F Mental health issues, so- Mental health, so- Wellbeing scale (0–10) / 6 Pre–post, mixed,
Taylor, 2014, on young people with varying cial/personal develop- cial needs measures scale, focus
UK mental health conditions, personal mental issues groups
and social needs.
Lopes, 2015, Demonstrate how surfing can be 321 8–66, all ages, M, Physical (SCI, amputees) Physical and men- None NS
Portugal used to promote physical and F and cognitive disabil- tal wellbeing,
mental health, social interaction ity, visually impaired social interac-
and inclusion of persons with dis- tion, disabilities
abilities, regardless of age or
disability.
Hignett et al., Evaluate the impact of a surfing pro- 58 13–16, youth, M, At-risk youth, behaviou- Physiological, Physiological indicators Pre–post, mixed,
2017, UK gramme aimed at at-risk youth. F (n¼10) ral issues, learning dif- anti-social be- (HR, SBP, DBP), self- interviews,
ficulties. Physically haviour, well- reported wellbeing questionnaire
aggressive behaviours being, (BHPS-Y);
connectedness Connectedness
(adapted Inclusion of
Nature in the Self-INS
Scale); teacher ratings
of Social and
Emotional Aspects of
Learning (SEAL)
questionnaire.
Capurso and Investigate the impact of a sail train- 147 13.18 (mean age), Chronic disease or physi- Self-concept MCSC scale Quasi-experimen-
Borsci, 2013, ing on self-concept of adolescents. youth, M, F cal or cognitive tal, pre-during-
Italy disability. post (3 months),
Quant, scale
McCulloch et al., Investigate purposes, beliefs and ben- 325 14–21, young NS Social impacts, so- Self-assessment scale for Pre–post (3
2010, multi- efits of participation in sail adult, M, F cial confidence social confidence months),
E. Britton et al.

country

(continued)

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Table 1: (Continued)
Author(s), year, Aims of Study Sample Age/gender of Health characteristics of Health outcome Validated tools/measures Study design
country size participants participants measured methods

training for youth, especially the Mixed, inter-

social nature of the experience. views, scale
Bennett et al., Understand participants’ perceptions 28 22–50, adult, M, PTSD, traumatic brain Combat-related None Qual., focus
2014, USA of programme for veterans with F (n¼8) Injury, hearing and vi- disabilities groups
combat-related disabilities. sual impairments
Vella et al., 2013, Evaluate effectiveness of a fly-fishing 74 22–64, adult, M, PTSD, major depressive Psychological PCL-M—degree of PTSD Pre-during-post (6
USA programme in reducing the psy- F (n¼5) disorder, traumatic (mood, stress, symptoms; Brief weeks), Mixed
chological concomitants of stress brain injury sleep), PTSD Symptom Inventory
among a sample of veterans with (BSI); PANAS—mood;
PTSD. PSS - stress; Pittsburgh
Sleep Quality Index
Ritchie et al., Examine qualitatively how OALE 43 12–18, adoles- NS Resilience and None Qual. journals,
2015, Canada promoted resilience and wellbeing cents, M, F other aspects of interviews, fo-
for First Nations youth from one (n¼5) health and cus groups.
community population. wellbeing During-post
(3 months).
Ritchie et al. Evaluate the impact of an OALE on 73 12–18, adoles- NS Resilience and Resilience (RS-14); Mixed. pre–post
2014, Canada the resilience and wellbeing of cents, M, F other aspects of Mental Component (1 month, 1
First Nations adolescents from one (n¼16) health and Score; Physical year), compari-
reserve community. wellbeing Component Score; Self- son group,
esteem Scale; questionnaire
Systematic review of blue space interventions for health and wellbeing

Flourishing Scale; Scale

of Positive and
Negative Emotion
(SPANE); Satisfaction
with Life (SWL)
Hayhurst et al., Examine potential for resilience to be 272 16.55 (mean age), NS Resilience, self-ef- Resilience Scale (RS-15); Mixed model de-
2015, NZ enhanced in a group of youth par- adolescents, M, ficacy, social ef- Self-Description sign 22 (time
ticipating in a developmental F (n¼72) fectiveness, Questionnaire III; Self- of resilience as-
voyage. belonging efficacy and Social ef- sessment: use of
fectiveness scales; control group);
Sheldon and interval, pre–
Bettencourt’s 3-item in- post
clusion scale; Weather
rating.

(continued)
57

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 58 E. Britton et al.

M, male; F, female; NS, not specified; PTSD, post-traumatic stress disorder; ASD, autism spectrum disorder; Qual., qualitative design; Quant., quantitative design; pre–post, pre-test–post-test design; OALE, outdoor adventure leader-
post (3 months)
Study participants

Mixed, case study

Mixed model de-
sign (sexself-
esteemtime);

Quant. Pre–post
interval, pre–
Taking all 33 studies combined, there were a total of
Study design

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approach
2031 participants. However, there were high levels of
methods

variation in sample size ranging from studies with as few

as one participant (Fleischmann et al., 2011) to over 300
(McCulloch et al., 2010). Participants were primarily
Validated tools/measures

self-selected. The majority of studies recruited adults

Questionnaire (SDQ);
Strength and Difficulties
Questionnaire (SDQ

Physical (mobility, NS (measure of opioid

(n ¼ 18), followed by youths (n ¼ 12) (defined as pre-

Youth experiences
teen and teen, <18 years), one study recruited ‘young

use over time)

Self-Description

adults’ (14–21 years) and one study included a mix of all

survey
ages. Very few studies included participants aged over
65 years. Most studies included both male and female
III)

participants (n ¼ 20), however, the majority in these

mixed studies were predominantly male. Some notable
psychological.
balance, pain)

exceptions included studies assessing sailing interven-

Health outcome

Psycho-social

tions in New Zealand, where the majority of the partici-

wellbeing
Self-esteem
measured

pants were female (Grocott and Hunter, 2009; Hayhurst

and

et al., 2015). Seven studies included women only, three

were male-only, and two studies did not specify gender
(Table 1). Participants were primarily recruited via
pression, opiate use for
Health characteristics of

brain injury, mild de-

organizers or practitioners delivering the intervention

Amputee, burn injury

(n ¼ 18), followed by local community networks

(n ¼ 11), advertising methods (n ¼ 10) and healthcare
severe pain

providers (n ¼ 6). In six studies participants were medi-

participants

cally prescribed or referred by their healthcare provider

(Figure 2a). Participants in other studies may also have
NS

NS

been through professional medical referral procedures,

however, this was not clearly stated.
The health characteristics of study populations var-
15–18, adoles-

10–16, adoles-
Sample Age/gender of

cents, M, F

cents, M, F

21, adult, M
participants

ied (Figure 2b) with needs ranging from the physical to

(n¼119)

cognitive and psycho-social (Table 1). A large propor-

tion of the studies included participants with multiple
disorders or with a mix of health issues (n ¼ 13). Mental
health issues were the most prevalent (n ¼ 17) yet the
193
size

types of issues were very diverse and often overlapping.

48

Specifically, these ranged from behavioural and social

social and emotional skills and be-
creased in at-risk youth and learn-
self-esteem following a 10-day de-

Assess surfing as a multimodal treat-

problems, typically among youth (n ¼ 4), addiction

Matos et al. 2017, Assess if behavioural problems de-
velopmental voyage (short-term

ing enhanced in self-regulation,

Assess global and domain specific

(n ¼ 1), depression or a major depressive disorder

(n ¼ 4), PTSD (n ¼ 6), cognitive disabilities (mixed or
longing through surfing.

ment for patients with

unspecified) (n ¼ 6), Autism Spectrum Disorder (ASD)

and long-term effect).

(n ¼ 2), traumatic brain injury (n ¼ 3). Physical disease

and disability included recovering breast cancer survi-
polytrauma.
Aims of Study

vors (n ¼ 7), heart defects (n ¼ 1), spinal cord injury

(n ¼ 3), amputees (n ¼ 3), visual and/or hearing impair-
ment (n ¼ 2), chronic disease (unspecified) (n ¼ 1). Seven
studies did not specify the health characteristics of the
Table 1: (Continued)

participants prior to the intervention.

Hunter, 2009,
Author(s), year,

et al., 2011

ship experience.
Fleischmann
Grocott and

Portugal

Study measures and design

, USA
country

NZ

The primary aim of these studies was to explore and as-

sess the various health and wellbeing outcomes and
Systematic review of blue space interventions for health and wellbeing 59

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Fig. 2: Results (numbers of studies) from analysis showing the recruitment procedures used in the studies (a), health characteristics
of study population (b), type of blue space setting where interventions took place (c) and physical activities in blue care (d).

benefits of a particular BSI, mostly pilot interventions only two used a comparison/control group (Ritchie
with small sample size. The primary health outcome et al., 2014; Hayhurst et al., 2015). The research process
assessed was mental health and/or psycho-social well- and intervention content were primarily pre-determined,
being, with one study measuring physical health exclu- rather than co-created with participants.
sively (Armitano et al., 2015). The majority of the
studies were qualitative (n ¼ 15), followed by a mixed-
method design (n ¼ 9) and five were quantitative General characteristics of interventions
(Table 1). A mix of methods and tools were used includ- Interventions ranged from a single day activity to 6
ing semi-structured interviews (n ¼ 13), questionnaires months for a single participant in a surf therapy inter-
(n ¼ 12) and other mixed methods (participant observa- vention (Fleischmann et al., 2011). Almost one-third of
tion, field journals, focus groups, participant letters, studies (n ¼ 10) did not specify the duration of the inter-
practitioner reports), as well as validated and non- ventions (Supplementary Appendix S3). These interven-
validated measures and scales (Table 1). Only 14 out of tions were typically designed, led and facilitated by
the 33 studies used validated measures to assess health outdoor/adventure educators and providers, often
and wellbeing outcomes. A varied mix of validated out- within a charitable organization aimed at providing a
come measures were used to evaluate the effects of the type of ‘eco-therapy’ for specific groups. The main pur-
intervention on mental health. Various physiological pose of the interventions was health promotion, restora-
indicators and measures such as the Brockport Physical tion and awareness (Table 1). There was little or no
Fitness Test were used to assess physical health inclusion of participants in the design of these interven-
(Table 1). The majority of studies did not clearly report tions. The few exceptions (n ¼ 4) where the intervention
outcome measures or use any validated measures was designed in response to the needs and aims of the
(n ¼ 19). Most studies were used a pre-post design and group were Berger and Tiry (Berger and Tiry, 2012) for
60 E. Britton et al.

those with psychiatric disabilities, Ritchie et al. (Ritchie 397]. Berger and Tiry (Berger and Tiry, 2012) chose
et al., 2014, 2015) with Aboriginal adolescents in methods according to needs and aims of the group who

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Canada, and Nielsen and Mitchell (Nielsen and were coping with emotional and psychiatric difficulties,
Mitchell, 2002) with breast cancer survivors. Only seven highlighting the potential for creative processes to help
studies listed funding sources for the interventions. adults better engage with nature as well as how nature
These were primarily a foundation/charity or local au- can spark greater creativity. In Lopes (Lopes, 2015), the
thorities, and two were funded by the Big Lottery Fund intervention was based on hydrotherapy but applied to a
(in the UK). coastal environment rather than indoor pool setting. In
Matos et al. (Matos et al., 2017), ‘Surf-Salva Camp’ tar-
geted ‘at-risk youth’ in Portugal and included psycholo-
Setting and type of activity
gists and surf instructors in its design and delivery. The
The majority of interventions took place in marine or
majority of the studies tended not to set specific targets
coastal (n ¼ 19), followed by freshwater (n ¼ 14) envi-
but instead created a process whereby participants could
ronments; two included a mix of green and blue spaces
experience respite from their symptoms. Caddick et al.
(Berger and Tiry, 2012) and wetlands, marsh and near-
[(Caddick et al., 2015), p. 80] describe surfing as ‘a vehi-
shore (Tardona, 2011) (Figure 2c). Three studies did not
cle for pursuing pleasure and escaping pain rather than
define the type of outdoor blue space. Details about the
for loftier notions of psychological growth and develop-
blue space setting or the natural environment were lim-
ment’, and Godfrey et al. [(Godfrey et al., 2015), p. 26]
ited in all studies and completely lacking from eight
state that surfing provides ‘a chance to forget rather
studies (Figure 2c). The interventions took place in a
than focus on problems’.
mix of both urban and rural environments. However,
Very few studies (n ¼ 4) assessed the effect of blue
the majority of studies do not clearly situate the inter-
space activities on nature connectedness (in relation to
vention in any setting (n ¼ 12). Seven interventions took
the aims/objectives and measures used). For those that
place in what authors describe as ‘wilderness’, seven in
did, the intervention was designed in response to the
urban/semi-urban areas (e.g. city beaches, lakes) or a
characteristics of the local natural environment (Berger
mixed urban/rural setting, and five took place out at sea.
and Tiry, 2012). Caddick et al. (Caddick et al., 2015) fo-
None of the studies provided a clear definition of blue
cused specifically on the effects that surf had on veter-
space. The studies were primarily carried out in devel-
ans’ wellbeing, in particular the sensory and embodied
oped countries in Europe (n ¼ 11), the USA (n ¼ 10),
experiences veterans had while in the sea. Similarly,
Canada (n ¼ 8), New Zealand (n ¼ 2), one in Israel and
Lopes [(Lopes, 2015), p. 6] highlighted the influence of
one multi-country study (including Europe, USA,
specific qualities of blue space in functional rehabilita-
Australasia). There is greater emphasis on active experi-
tion, including how, ‘the absence of gravity in saltwater
ences and physical activities rather than more passive ac-
improves mobility, which improves cardio-respiratory
tivities in the interventions. The highest number of
function and is an integral muscular workout’. Hignett
interventions were delivered through surfing (n ¼ 11),
et al. (Hignett et al., 2017) included a specific measure
followed by seven studies on Dragon Boat Racing
of nature connectedness. However, it was not assessed
(DBR), five on sailing, three fly-fishing and kayaking,
in relation to a health or wellbeing outcome.
two on canoeing, one located at the beach (as well as a
forest park), swimming (as part of a kayaking interven-
tion), and another on scuba diving (Figure 2d).
Outcomes and benefits
Studies appraising mental health and psycho-social well-
Function and purpose of interventions being outcomes (the most common health outcomes
In over half (n ¼ 17) of the studies, intervention aims assessed) showed some improvement overall. The most
and objectives were not clearly stated. Many of the pro- commonly assessed wellbeing indicators included self-
grammes focused on the skills required to learn a new esteem, self-efficacy, social confidence, resilience and
physical activity such as surfing or sailing with little other psychological indicators (e.g. stress, mood) using
modification or therapeutic addition. However, several self-report measures. Enhanced social relationships were
studies emphasized a therapeutic approach such as also reported and pro-social behaviour (Supplementary
ocean therapy based on principles of occupational ther- Appendix S3). Improvement in environmental connect-
apy where, ‘participation in meaningful activities within edness and the effect on health and wellbeing outcomes
the natural environment is both part of the therapeutic was less definitive. Environmental connectedness is
process and a desired outcome’ [(Rogers et al., 2014), p. linked with psychological restorativeness, although few
Systematic review of blue space interventions for health and wellbeing 61

large studies have explored what and how environmen- increased resilience and self-esteem were maintained 5
tal qualities affect these outcomes (Wyles et al., 2017b). and 3 months, respectively, following sailing interven-

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Hignett et al. [(Hignett et al., 2017), p. 12] found that tions. Ritchie et al. (Ritchie et al., 2014), who used the
‘Surprisingly, there was no direct improvement in con- same validated measure of resilience as Hayhurst et al.
nectedness to nature or the beach as a result of the study (Hayhurst et al., 2015), found that resilience (defined in
overall’. Bennett et al. (Bennett et al., 2014) referred to the study as, ‘the ability to successfully cope with change
the importance of the physical setting for restoration, in- or misfortune’, p. 2526) reverted back to pre-
cluding the sound of the river but did not provide any intervention levels after 1 year.
details on the quality or characteristics of the natural
setting. Hayhurst et al. (Hayhurst et al., 2015) did not
Barriers and adverse effects
consider nature connectedness, but included a weather
The studies were evaluated to identify any barriers or
rating scale as part of a mix of measures assessing the ef-
adverse effects (Supplementary Appendix S4). Barriers
fect of sail training on the resilience of young people.
are defined here to mean any factor that may inhibit or
Only six studies considered or assessed some aspect
reduce a person’s ability to access or participate in BSIs.
of physical health outcomes. Three surfing interventions
These barriers were identified and categorized by the re-
with participants with mixed cognitive and physical dis-
view authors. Fourteen studies were identified as refer-
abilities measured physical health outcomes using the
ring to some form of barrier in the description of the
Brockport Physical Fitness test. However, the primary
study. Barriers ranged from various access issues and
benefits reported in each study were mixed. Armitano
lack of resources and equipment, to fears and stigma as-
et al. (Armitano et al., 2015) reported improved numer-
sociated with personal abilities, level of fitness, environ-
ous areas of physical fitness (upper-body strength, core
ment, social and cultural norms and diagnosis of illness,
strength, cardiorespiratory endurance). In Fleischmann
and level and appropriateness of training for those deliv-
et al. (Fleischmann et al., 2011) specific features such as
ering blue care. Thirteen studies did note some adverse
response to waves (movement) and skills required to
effects. Adverse effects are any perceived negative effects
surf (balance) were attributed to enhanced vestibular
experienced by those participating in the study during or
balance, as well as pain reduction and subsequent re-
after the intervention. These included feeling ‘emotion-
duced dependency on narcotics attributed to the psycho-
ally low’ during or post-intervention as identified by
logical effect of surfing. All seven studies on DBR found
participants suffering from PTSD in a surf therapy pro-
no negative physiological effects for participants recov-
gramme (Caddick et al., 2015), by some survivors of
ering from breast cancer and some improvements in self-
breast cancer in DBR (Sabiston et al., 2007;
reported body image. There was a significant drop in
McDonough et al., 2008; Parry, 2008) and post-sailing
heart rate among vulnerable youth after surfing, suggest-
voyages (Capurso and Borsci, 2013; White et al., 2017).
ing improved fitness (Hignett et al., 2017).
Gender-based barriers (Tardona, 2011), seasickness and
The short-term benefits of the interventions were
discomfort caused by poor weather conditions and tired-
well reported. However, very few studies considered the
ness or fatigue post-activity were also identified.
long-term effects. Just over half of the studies used pre-
post design, of these, only three assessed participant’s
experiences during the intervention. Five studies consid- DISCUSSION
ered longer-term effects, at 3 months (Grocott and
This review systematically identified and synthesized
Hunter, 2009; McCulloch et al., 2010; Capurso and
studies that examined BSIs for promoting or restoring
Borsci, 2013), 5 months (Hayhurst et al., 2015) and 1
psychological and/or physical health and wellbeing. In the
year after the intervention (Ritchie et al., 2014), with
following section, the implications of the design, struc-
contrasting results. Capurso and Borsci (Capurso and
ture, function and outcomes as well as the mechanisms of
Borsci,2013) found that although self-concept (defined
intervention provision are discussed. Furthermore, the
in the study as, ‘a multidimensional and context-
authors highlight limitations and gaps with recommenda-
dependent learned behavioural pattern that reflects an
tions for further study and research as well as implica-
individual’s evaluations of past behaviours and experi-
tions for health promotion, policy and practice.
ences, influences an individual’s current behaviours, and
predicts an individual’s future behaviours’, p. 16)
increases after sailing it reverts back after 3 months. Study and intervention design
Hayhurst et al. (Hayhurst et al., 2015) and Grocott and The studies included in this review were highly heteroge-
Hunter (Grocott and Hunter, 2009) reported that neous, varied in disciplinary origin, with different
62 E. Britton et al.

approaches to study design and/or use of methods. They to consider how to build capacity after funds and exper-
lacked conceptualizations of blue space and were limited tise is withdrawn (Poland et al., 2009). Furthermore, the

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in their use of validated measures. Social mixing in most ethical implications of this, although beyond the scope of
of the interventions (i.e. participants with differing abili- this paper, deserve further investigation. As recommended
ties or diagnoses, etc.) poses a challenge for research, es- in other reviews on health-based interventions (Lefebvre
pecially where the emphasis is on clearly defined and Flora, 1988; Campbell et al., 2000; Poland et al.,
interventions and homogenous study populations within 2009) better means of evaluating the impact of nature-
the medical literature (Sempik and Bragg, 2016). In the based programmes on public health are needed.
context of BSIs, the weakness of RCTs is that, ‘most There was very weak involvement of participants’
RCTs focus on outcomes, not the process involved in perspectives in the design and delivery of interventions,
implementing an intervention’ [(Oakley et al., 2006), p. and participants’ perceived experience of blue space was
413] and therefore fail to account for how social and en- often lacking. Studies provided limited details regarding
vironmental processes influence behaviour (Duane et al., participants’ attitudes towards particular environments
2016). Furthermore, while RCTs would be desirable in or how they might have previously engaged with nature.
this area of research, it is questionable how feasible Evidence reviewing effective health-based interventions
implementing one would be considering: (i) blinding emphasizes the need for greater engagement with partic-
participants to an intervention arm especially when the ipants in the design and delivery as well as an under-
activities they are undertaking are potentially coordi- standing of how participant expectations and individual
nated by specialist organizations, (ii) the ethics of allo- needs measure against actual outcomes (Poland et al.,
cating participants to a control arm who may stand to 2009; Rütten et al., 2019). Some studies in this review
benefit from the intervention arm and (iii) the financial did engage in a more collaborative process that included
resources often available to, e.g. surf schools or similar, health professionals, outdoor educators and researchers
who are likely to be delivering the intervention. in the design. By working together, community members
Consequently, it may be sensible to expect and accept a can gain a sense of ownership that will sustain their in-
lower standard of evidence from such intervention stud- terest and commitment to the intervention and make it
ies, at least at present. more likely that the intervention will be integrated into
Recruitment of participants lacked an even spread existing community structures (Bryant et al., 2009). The
across socio-economic groups, age (elderly) and nationali- increasing tendency to engage participants in both the
ties. In most cases contextual information regarding par- conceptualization of interventions and the interpretation
ticipants was not provided. Notably absent were studies of their outputs is seen as a move towards validation
from Latin America, Africa, Middle East and Asia. The based on reality (Domegan et al., 2017; Rütten et al.,
review also highlights a lack of consideration of wider 2019). Studies show that co-created interventions can
community, social support networks and services in inter- lead to more sustained outcomes and greater participa-
vention design and delivery. Poland et al. (Poland et al., tion (Duane et al., 2016). However, participants may
2009) argue, that in addition to addressing the needs and not always know what intervention components may be
capacities of people, health interventions need to address successful at affecting outcomes; e.g. they may exhibit
local contexts in order to assess the circumstances in affective forecasting errors (Wilson and Gilbert, 2005).
which outcomes are achieved and the comparability of Only one study included a long-term follow-up (Ritchie
such findings. The duration of interventions (dosage) var- et al. 2014) to assess the potential for sustained health
ied greatly. This review has identified that duration of an and wellbeing benefits (i.e. >6 months), but a tendency
intervention is a knowledge gap in relation to sustained to focus on short-term outcomes is typical of health-
health outcomes. In Fleischmann et al. (Fleischmann based interventions in general (Nutbeam, 1998;
et al., 2011), a dramatic and sustained reduction in opioid Campbell et al., 2000). This could be due to a lack of
use occurred after a 6-month surfing intervention. funding for longer-term evaluations or the lack of theo-
However, the majority are short-term or one-off pilot retical explanations of behavioural maintenance as op-
interventions (limited by funding) with little discussion of posed to behavioural initiation (Kwasnicka et al., 2016).
longer-term healthcare promotion and provision for par-
ticipants. In typical medical trials, longer-term provision
of interventions rely on robust evaluations in order to se- Activity and setting
cure further funding and staff time. This in turn can be The interventions in these studies were not designed
translated into applications for larger trials which explic- with the intention of conducting research nor were the
itly outline mechanisms of health benefits. There is a need activities developed for any purpose other than the
Systematic review of blue space interventions for health and wellbeing 63

treatment, therapy or recovery of participants. Greater advocated (Nutbeam, 1998; Domegan et al., 2016;
collaboration between researchers, practitioners and Komro et al., 2016; Wong et al., 2017). Furthermore,

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community, as in Ritchie et al. (Ritchie et al., 2015), swimming is usually more accessible in non-natural
could help build a more coherent evidence base and environments (e.g. swimming pools), which might ex-
communicate effectiveness to policy-makers (see Rütten plain why it does not appear as often as, e.g. surfing
et al., 2019). Further experimental and controlled inter- which can only really be practiced at the coast. A com-
ventions could be designed to help inform policy and parison of the various mechanisms with which people
practice [see, e.g. (Wyles et al., 2017a,b)]. The impor- engage with blue space, in both complex and controlled
tance and impact of the physical setting on health out- interventions is an area for further study. Blue care de-
comes and determining what proportion of the health sign could benefit from a better understanding of how
benefit is attributable to the natural environment as op- environmental preferences and characteristics, such as
posed to other factors was poorly considered in the stud- wildlife and perceived biodiversity, can enhance well-
ies. The types of activities used to deliver BSIs were being (Wyles et al., 2016, 2017b; Carlin et al., 2017;
typically classified in the action-sports sector or requir- Cracknell et al., 2017; White et al., 2017). In addition,
ing learned skills, with a tendency to emphasize the why preference is given to some activities (e.g. surfing)
immersive and experiential qualities of these activities in over others (e.g. swimming or walking), needs further
blue space. Notable absentees from the type of activities investigation. Studies by Ritchie et al. (Ritchie et al.,
used in blue care include activities that are typically 2014, 2015) uniquely included a cultural component of
more accessible such as walking, running or even swim- nature connection and its relevance for the learning and
ming (Foley, 2015). These are activities which require change process that occurred in response to the interven-
very little in the way of resources or indeed funding. tion, as well as how this might intersect with other deter-
Unlike green care interventions (Sempik and Bragg, minants of health such as gender, race and ethnicity.
2016) passive and conservation-based activities and Further evidence is needed to comprehend the drivers
approaches are somewhat lacking in blue care. The em- and components of a successful BSI, such as the differ-
phasis on more physically challenging interventions that ence between settings and activities across interventions.
might act as a barrier for some, could explain a lack of
inclusion of elderly participants. However, this also
points to a larger issue of (mis)perceptions and stereo- Function and outcomes
typing that persists in public policy, practice and re- Overall, positive outcomes were identified for health
search around ageing and the outdoors (Wheaton, and wellbeing, especially mental health and psycho-
2017). The specialization of these interventions both in social wellbeing in the short term. Some interpersonal as
terms of activity type, volunteer/practitioner training well as individual effects were evident with a number of
requirements, equipment, suitable environments, target studies placing strong emphasis on social connection,
group, can, as Hignett et al. (Hignett et al., 2017) com- sense of belonging, and interaction with others who
mented, lead to an exclusionary attitude and belief that have shared life experiences, as well as the connective
it’s ‘not really for us’. The ethical implication of this properties of water environments. The findings suggest
merits further study. That said, studies do exist on walk- how activities in blue space, rather than particular quali-
ing interventions in blue space [e.g. river paths (Marselle ties of blue space, might contribute to rehabilitation and
et al., 2013)], however, these often do not have popula- health promotion (Lopes, 2015; Fleischmann et al.,
tions with a defined need participating. 2011). Water can be particularly therapeutic, altering
The authors acknowledge that there is an extensive bodily sensations and levelling the playing field, e.g.
body of research on the topic of water-based or hydro/ with participants feeling equal to non-disabled divers
aquatic therapy, as well as cryo-therapy (e.g. cold-water (Carin-Levy and Jones, 2007). The number of studies
immersion) and increasing uptake of ‘wild swimming’, assessing the physical impacts of blue care were very
especially for women (Smolander et al., 2004; Thorsby, limited in comparison to mental health, unsurprising
2013). However, these experimental studies are typically given that the majority of populations included in the
carried out indoors, or in man-made settings where envi- studies were characterized with mental rather than phys-
ronmental factors can be controlled or are studied as ical health issues. However, this raises the question of
recreational activities for general health promotion. This why these population groups are not more targeted for
tension between controlled experiments and more com- these interventions. Perhaps another reason might be the
plex, community interventions is highlighted elsewhere difficulty in designing controlled or clinical interventions
in the literature, with no single methodology being in an outdoor, natural water setting with physical tests
64 E. Britton et al.

measured more effectively when designed as experi- the intervention process. This perhaps highlights the
ments in controlled environments, typically indoors need for training to facilitate nature encounters for

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(Smolander et al., 2004; Collier et al., 2015). The find- health and wellbeing across sectors in outdoor public
ings emphasize a multi-dimensional view of health with spaces (Maller et al., 2006).
participants experiencing positive changes to sense of
self, health and wellbeing, as illustrated in the following
quote from a participant in a scuba diving intervention Limitations of the studies
[(Carin-Levy and Jones, 2007), p. 10], ‘Diving turns me The review process identified some of the following limi-
back into a human being, I go down there and I’ve got tations of the studies. Due to the small sample size of
the freedom and I’m back to being a person’. However, nearly all the studies as well as self-selection bias, lack of
not all experiences were positive. Participant selection control groups or long-term follow-up, the risk of bias
bias could favour those who had more positive experien- was moderate to high for all studies and limits the trans-
ces, especially in qualitative studies where a small num- ferability of the findings. To some extent, as most of this
ber of participants from a large sample might only be research has only emerged in the last decade, this is to be
interviewed [e.g. White et al. (White et al., 2016) only expected. There was a notable lack of diversity in partic-
interviewed 11 out of the 100 participants on sail train- ipant selection and/or poor description of participant
ing trips]. characteristics in some studies, with the majority of par-
A number of studies (n ¼ 9) did not clearly specify the ticipants being Caucasian, well-educated and from mid
aims of the interventions they were assessing. to high income backgrounds. Another common limita-
Interventions designed without clear aims or objectives tion was the risk of gender bias. Additionally, poor con-
hinder the ability to understand or evaluate the impact. sideration was given to the potential gendered effects of
Although beyond the scope of this paper, the number and interventions, e.g. the increased likelihood of female par-
range of barriers and adverse effects highlights the com- ticipants dropping out of the surfing intervention pro-
plexity of blue care design and delivery. Challenge can be gramme as noted by Godfrey et al. (Godfrey et al.,
an important factor for enjoyment and quality of life en- 2015). A lack of validated measures might suggest a lack
hancement. For example, self-reported feelings of tired- of available tools for assessing health/wellbeing out-
ness, cold, body aches were also considered factors that comes. However, it is more likely that there are too
led to a sense of self-efficacy and perseverance (Ritchie many to choose from and that there is instead a lack of
et al., 2015), and challenging activities were linked to measures specifically designed to meet the particular
greater sustainable wellbeing (Hignett et al., 2017). needs of a target population and place (Linton et al.,
However, the ‘mood-dip’ identified by some studies can 2016). Given that BSIs offer an alternative to more med-
be caused by perceived discrepancies between personal icalized interventions some participants may feel uncom-
experience during an intervention and the social require- fortable with being evaluated by measures that are
ments or demands of daily life after an intervention overly focused on the health issue or ‘problem’.
(Capurso and Borsci, 2013). This highlights the need to Despite the importance of understanding connected-
better understand the barriers to engaging with blue space ness to nature as a prerequisite for health outcomes
for wellbeing (Pitt, 2018). There is also a need for a con- (Schultz, 2002), it was given very little attention within
textually sensitive and process-oriented approach with the studies. A consistent lack of description of setting
process evaluations—measuring more than ‘what’ characteristics or the natural environment as a ‘subject’
worked well; but also evaluating ‘how’ and ‘why’ success was evident across all of the studies despite nature/water
or indeed failure happened (Oakley et al., 2006; Rütten being mentioned frequently by participants as beneficial
et al., 2019; McHugh et al., 2018). Further research is for their overall sense of wellbeing. Some exceptions
needed on how unintended consequences might be identi- were Tardona (Tardona, 2011), who made reference to
fied and the longer-term impact of BSIs. participants’ appreciation of the natural environment
A key consideration for public health promotion is and the calming effect of water as well as noting biodi-
how participants are referred or gain access to interven- versity and environmental characteristics, and the influ-
tions. For example, in this review, to qualify for a BSI ence of climatic/weather conditions (both positive and
those suffering from PTSD required a clinical diagnosis. negative). The how and why a particular nature setting
This poses a barrier for a mental health issue that is stig- was selected would strengthen the interpretation of in-
matized and often goes unreported or untreated. tervention outcomes (Poland et al., 2009).
Furthermore, studies lacked a thorough description of The conceptual ambiguity of terms such as ‘blue
practitioner roles, levels of expertise and skills used in space’, ‘health’ and ‘wellbeing’ invites both narrow and
Systematic review of blue space interventions for health and wellbeing 65

vast definitions and exacerbates a lack of coherence CONCLUSION

and common language for nature-based providers,
This is the first systematic review of the literature on

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researchers and policy-makers, an issue highlighted in
therapeutic BSIs and it shows that interventions are di-
a report by Natural England (Bragg and Atkins,
verse in study population, setting and activity. The ma-
2016). Ambiguity around the use of ‘wellbeing’ and
jority of studies included adults (although not elderly)
associated terms (e.g. self-esteem, resilience) in a
often with multiple disorders, predominantly psycholog-
place-based context persists. BSIs would benefit from
ical. The studies were primarily in developed countries
a common language to describe subjective wellbeing
and the emphasis was on active (rather than passive) ac-
across nature and health research, policy and practice.
tivities with marine or coastal settings favoured.
There is an historic and recent precedent for the inclu-
Findings suggest how activities in blue space, rather
sion of common set of cognitive and experiential com-
than particular qualities of blue space, might contribute
ponents of subjective wellbeing (Linton et al., 2016).
to rehabilitation and health promotion. Many of the
This would allow comparability and harmonization of
interventions resulted in significant positive effects for
findings, and as a consequence have greater relevance
health, especially psycho-social wellbeing benefits, with
for policymakers. However, as identified in a recent
relatively few findings for physical health. This review
review of wellbeing in the UK, wellbeing measures are
illustrates that blue care has the potential to improve
often highly individualized and fail to account for the
mental health for diverse groups, but more research is
socio-ecological factors of disadvantage and social in-
required, and we call for further investigations into BSIs.
equality (Mansfield et al., 2018). Furthermore, as
In particular, more rigorous pilot interventions co-
highlighted by Ritchie et al. (Ritchie et al., 2015),
designed in collaboration with population groups, pro-
dominant, individualized measures of wellbeing fail to
fessionals, policymakers and researchers are needed to
account for indigenous models of wellbeing embedded
evaluate outcomes.
in a socio-ecological context.
With a lack of longitudinal studies, it remains
Studies could also benefit from drawing on a more
untested whether the benefits associated with participa-
inter-disciplinary framework such as a complex systems
tion in blue space are sustained, as well as how this rela-
approach taking a non-linear perspective (Savigny and
tionship to blue space could vary across the lifecourse
Adam, 2009). Briefly, a ‘system’ is a set of elements—
(Pearce et al., 2016). The evidence is highly heteroge-
e.g., people, organizations, etc.—interconnected in such
neous in study design, method and measurement with
a way that they produce their own pattern of behaviour
high risk of bias making it difficult to determine the im-
over time (Meadows, 2008; Domegan et al., 2017). It
pact of blue care on health and wellbeing. The design
assumes multi-causality at work between the diversity of
and delivery of BSI’s would benefit from a more detailed
blue-green forces and health with dynamic interactions
evaluation of outcomes. Studies would benefit from
and feedback muddying the waters. In contrast, linear
both broad and in-depth understanding of the associa-
interventions within the epistemology of classical science
tion and evidence between blue space and health out-
are not sensitive enough to the dynamics and complexi-
comes. We advocate a complex systems approach that
ties of nature-based messy or ill-structured problems. In
considers the complexity of multiple stakeholder groups
this non-linear setting, stakeholders and their engage-
and how they simultaneously affect and are affected by
ment are central to success of messy or ill-structured
an intervention. As discussed, a contextually sensitive
problems (Jonassen, 2003). The boundaries of blue
approach that considers participation, process evalua-
space and nature-based issues are diffuse (Hisschemöller
tions and dynamic understandings with multiple stake-
and Gupta, 1999). Outcomes are best seen as an interac-
holders is needed. There is a tendency to count only the
tive process with a multitude of stakeholders who are in-
‘good interactions’, however, this review also
terrelated, not independent (Bryson, 2004). This
highlighted potential for negative experiences and a
translates into a system of stakeholders; a dispersed
need to unpack potential risks and trade-offs for vulner-
spectrum of individuals and groups with common inter-
able groups. The rapid proliferation of nature-based
ests, extending beyond a traditional participant inter-
interventions threatens to out-pace the knowledge base
vention focus. That said, with this complexity, there is
of meaningful and appropriate strategies for public
the risk that it becomes more difficult to develop process
health benefit. This review highlights the need to im-
evaluations which accurately evaluate the contributions
prove our understanding of complex nature-based inter-
of the setting, activity, role of participant and
ventions for health outcomes. Investment in further
researcher.
research is needed to understand the general significance
66 E. Britton et al.

of blue space for public health and the potential for em- Capurso, M. and Borsci, S. (2013) Effects of a tall ship sail train-
bedding blue care within existing health promotion ing experience on adolescents’ self-concept. International

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FUNDING tional science perspective. Canadian Journal of
Occupational Therapy, 74, 6–14.
This study is part of the NEAR Health project, funded Carlin, C., Cormican, M. and Gormally, M. (2017) Health
by the Environmental Protection Agency (EPA) and the Benefits from Biodiversity and Green Infrastructure.
Health Service Executive under Grant Award No. 2015- Synthesis Report (2014-HW-DS-1). Prepared for the
HW-MS-2. Environmental Protection Agency. https://www.epa.ie/pubs/
reports/research/health/EPA%20Research%20Report%20
195_webFinal.pdf, last accessed 9 September 2018.
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the experience of kayaking for persons with spinal cord in-
Supplementary material is available at Health jury. Irish Journal of Occupational Therapy, 37, 29–36.
Promotion International online. Cavanaugh, L. K. and Rademacher, S. B. (2014) How a
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