ArticlePDF AvailableLiterature Review

Blue space, health and well-being: A narrative overview and synthesis of potential benefits

Authors:

Abstract

Research into the potential health and well-being benefits from exposure to green spaces such as parks and woodlands has led to the development of several frameworks linking the different strands of evidence. The current paper builds on these to provide a model of how exposure to aquatic environments, or blue spaces such as rivers, lakes and the coast, in particular, may benefit health and well-being. Although green and blue spaces share many commonalities, there are also important differences. Given the breadth of the research, spanning multiple disciplines and research methodologies, a narrative review approach was adopted which aimed to highlight key issues and processes rather than provide a definitive balance of evidence summary. Novel aspects of our framework included the inclusion of outcomes that are only indirectly good for health through being good for the environment, the addition of nature connectedness as both a trait and state, and feedback loops where actions/interventions to increase exposure are implemented. Limitations of the review and areas for future work, including the need to integrate potential benefits with potential risks, are discussed.
Environmental Research 191 (2020) 110169
Available online 22 September 2020
0013-9351/© 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Review article
Blue space, health and well-being: A narrative overview and synthesis of
potential benets
Mathew P. White
a
,
b
,
*
, Lewis R. Elliott
a
, Mireia Gascon
c
,
d
, Bethany Roberts
a
, Lora E. Fleming
a
a
European Centre for Environment & Human Health, University of Exeter, UK
b
Urban & Environmental Psychology Group, University of Vienna, Austria
c
Universitat Pompeu Fabra (UPF), Barcelona, Spain
d
CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
ARTICLE INFO
Keywords:
Blue spaces
Aquatic environments
Health
Well-being
Narrative review
ABSTRACT
Research into the potential health and well-being benets from exposure to green spaces such as parks and
woodlands has led to the development of several frameworks linking the different strands of evidence. The
current paper builds on these to provide a model of how exposure to aquatic environments, or blue spaces such as
rivers, lakes and the coast, in particular, may benet health and well-being. Although green and blue spaces
share many commonalities, there are also important differences. Given the breadth of the research, spanning
multiple disciplines and research methodologies, a narrative review approach was adopted which aimed to
highlight key issues and processes rather than provide a denitive balance of evidence summary. Novel aspects of
our framework included the inclusion of outcomes that are only indirectly good for health through being good for
the environment, the addition of nature connectedness as both a trait and state, and feedback loops where ac-
tions/interventions to increase exposure are implemented. Limitations of the review and areas for future work,
including the need to integrate potential benets with potential risks, are discussed.
1. Introduction
Aquatic environments pose a wide range of threats to human health
and well-being. There are an estimated 370,000 drownings globally per
year (World Health Organisation (WHO), 2014), and water-borne dis-
eases such as cholera (Ali, 2015; Nelson et al., 2015), account for nearly
2 million deaths annually, mostly among children under 5 years (WHO,
2019). Storms and oods exacerbate both issues, especially if drinking
water supplies and sanitation facilities are contaminated with polluted
oodwaters, events that are expected to increase in many parts of the
world under climate change and sea level rise (Neumann et al., 2015).
Recreational bathing waters are associated with large numbers of gas-
troenteric infections when contaminated with human or animal sewage,
with the loss of some 66,000 disability-adjusted life years (DALYs)
annually (Shuval, 2003). Chemical pollution from mining, agriculture
and industry (Landrigan et al., 2018), harmful algal blooms (Fleming
et al., 2015), and emerging threats such as pharmaceuticals (Webb et al.,
2003), and micro-plastics (Science Advice for Policy by European
Academies (SAPEA), 2019), all have the potential to undermine human
health and well-being though contact with aquatic environments (Borja
et al., 2020; Fleming et al., 2014, 2019; Depledge et al., 2017, 2019).
But we also need freshwater to live, not only for drinking but for
irrigating crops and for livestock, as well as in healthcare, sanitation,
industry and commerce (Aylward et al., 2005). Coastal and marine
waters also have considerable value in terms of their ecosystem ser-
vices, i.e. the benecial effects they have on human well-being via
‘provisioning services (e.g. sh, shellsh, seaweeds, aggregates, etc.)
and ‘regulatoryservices (e.g. water quality and climate regulation)
(Millennium Ecosystem Assessment (MEA), 2005). It is no surprise,
therefore, that most large towns and cities are sited on the coast or near
large inland water bodies in order to exploit the potential benets to
human well-being they provide (Solomon, 2010; Martinez et al., 2007).
Yet despite general recognition of these benets, research exploring
them in detail has been relatively scarce compared to ‘green spacessuch
as urban parks, woods and forests, and even private gardens (Two-
hig-Bennett and Jones, 2018; Markevych et al., 2017; van den Bosch and
Sang, 2017; van den Berg et al., 2015).
* Corresponding author. European Centre for Environment and Human Health, University of Exeter Medical School, c/o Knowledge Spa, Royal Cornwall Hospital,
Truro, Cornwall, TR1 3HD, United Kingdom.
E-mail address: mathew.white@exeter.ac.uk (M.P. White).
Contents lists available at ScienceDirect
Environmental Research
journal homepage: www.elsevier.com/locate/envres
https://doi.org/10.1016/j.envres.2020.110169
Received 21 August 2020; Received in revised form 28 August 2020; Accepted 3 September 2020
Environmental Research 191 (2020) 110169
2
1.1. Aims and scope
The aim of current paper, therefore, was to bridge this gap in the
literature and to attempt to provide a narrative overview and synthesis
of the potential benets of aquatic environments, or ‘blue spaces, for
health and well-being (Depledge and Bird, 2009; Grellier et al., 2017;
White et al., 2016). The aim was not to provide a risk-benet analysis. It
is too early to attempt such an endeavour, not least because the risks are
generally far better articulated and documented than the benets (Borja,
2020; Fleming et al., 2019). Rather, the focus was on integrating the
emerging research on the potential benets to health and well-being,
and in particular research that suggests improved access to, and safe
use of blue spaces, could play a role in tackling some of the major public
health challenges of middle to high-income countries in the 21st Cen-
tury. These include common mental health disorders such as anxiety and
depression (Bloom et al., 2011; WHO, 2013), and a lack of physical
activity (Guthold et al., 2018), that in the long-term can increase the risk
of cardiovascular disease, dementia and some cancers (WHO, 2018). It
also explores evidence suggesting that blue spaces can be used not just to
prevent disease, but to promote good psychological health and help
individuals with chronic health conditions manage their rehabilitation,
recovery or ongoing health states.
The overview and synthesis draws on a range of research method-
ologies including large epidemiological studies, visitor surveys, eld and
laboratory experiments as well as in-depth qualitative research. Because
of its breadth, it should be considered a narrative rather than systematic
review. Although every attempt was made to be inclusive, it would be
impossible in a single article of this nature to derive a single manageable
review question of the type required of systematic reviews. Rather, the
aim was to provide a broad introduction to some of the key themes
across the eld, and to signpost areas for further exploration.
1.2. Structure
To help structure the evidence, we build on several earlier models of
green space and health/well-being, to create a bespoke blue space and
health/well-being model (Fig. 1). First, we deconstruct blue space
exposure/contact into four types: a) home/work proximity; then
building on Keniger et al. (2013), b) indirect exposure (e.g. window
views or TV programmes); c) incidental exposure (i.e. exposure that
occurs even though the main activity was for a different purpose e.g.
commuting); and d) intentional exposure (deliberately spending time in
aquatic settings e.g. for work or recreation). We then extend Markevych
et al.s (2017) three pathways linking green spaces and health, to blue
spaces and health. Each pathway incorporates several sub-processes: a)
Mitigation (i.e. reduction of harm, e.g. urban heat island effect); b)
Instoration (e.g. promotion of positive outcomes such as improved mood
or greater physical activity); and c) Restoration (e.g. recovery from
depleted attentional capacity or stress). We also adopt the two sets of
effect modiers proposed (although not named) by Hartig et al. (2014):
a) Situational (e.g. access, quality, weather, culture, etc.); and b) Indi-
vidual (e.g. personal characteristics such as age, gender, SES, etc.).
As well as extending previous models to blue spaces in particular, we
make three additional contributions. First, we included ‘Planetary
health and well-being as an outcome variable. Given the well-
established links between planetary health and human health (Whit-
mee et al., 2015), evidence that blue space exposure might improve
pro-environmental behaviours (Alcock et al., 2020) suggests that this
can also have positive effects on human health and well-being. Second,
we introduce feedback loops from health outcomes to exposure and
intermediate pathways reecting interventions that may result from the
outcomes and which ultimately feedback to changes in exposure. Here,
we propose three broad types of intervention/action: a) Societal; b)
Local; and c) Personal. Finally, we include the psychological concept of
Fig. 1. A conceptual diagram of the relationships between blue spaces and health and well-being. (For interpretation of the references to colour in this gure legend,
the reader is referred to the Web version of this article.)
M.P. White et al.
Environmental Research 191 (2020) 110169
3
nature connectedness in two different ways. First, we include it as a
dispositional trait (e.g. Mayer and Frantz, 2004) that might moderate
linkages between exposure and pathways/outcomes. Second, we include
it as a state, reecting short-term changes in attitudes/feelings towards
the natural world that might result in immediate benets (Martin et al.,
2020; Pritchard et al., 2019). The remainder of the paper goes through
each section in turn.
2. Exposure, health and well-being
We begin by exploring issues of exposure (the left of Fig. 1),
including evidence of exposure-outcomes that did not consider inter-
mediate pathways.
2.1. Proximity & other exposures
Most people live relatively close to a water body of some kind. In
Germany, for instance, the average home distance to a signicant piece
of water is <1.5 km (Wüstemann et al., 2017). Unsurprisingly, people
who live closer to blue spaces tend to have greater indirect, intentional
and incidental exposure. Having a view of water from home (indirect
exposure) is directly associated with proximity, although as Nutsford
et al. (2016) point out, elevation (e.g. living on a hill or in a block of
ats) can increase blue space views while not living particularly close.
With respect to intentional exposure (deliberately visiting e.g. for rec-
reation), studies in Denmark (Schipperijn et al., 2010), England (White
et al., 2014; Boyd et al., 2018), and across 18 different countries (Elliott
et al., 2020) all demonstrate that the closer one lives to blue spaces, the
more frequently one visits, with most studies showing an exponential
decay function. Of note, visit frequencies may be moderated by
socio-economic and/or ethnic status. In one study, although lower
SES/Hispanic individuals often lived nearer to urban waterways than
higher income/white individuals, the latter tended to visit them for
recreation more (Haeffner et al., 2017). Finally, a study in Hong Kong
(Garrett et al., 2019a), a city dominated by the coast, shows that home
proximity to the coast is associated with the likelihood of blue space on
ones commute (an incidental exposure).
2.2. Proximity and health and well-being outcomes
One of the rst studies to show a relationship between living near
blue spaces and health and well-being outcomes was Brereton et al.
(2008) which found that people who lived within 2 km of the coast in
Ireland (but not 25 km) were signicantly more satised with their life
than people living >5 km away. Subsequent research has found that
living near the coast or inland water bodies is associated with better
mental health, e.g. in Canada (Pearson et al., 2019), China (Helbich
et al., 2019), England (Alcock et al., 2015; Garrett et al., 2019b), and the
Netherlands (de Vries, 2016). Several studies have also shown a positive
relationship with home proximity to water bodies and self-reported
general health, e.g. in Belgium (Hooyberg, 2020), England (Wheeler
et al., 2012, 2015), and Spain (Ballesteros-Olza et al., 2020). A longi-
tudinal study in England found that over time the same people report
better mental and general health in the years when they live close to the
coast (<5 km) versus inland (White et al., 2013b).
A systematic review of 35 different studies around the world by
Gascon et al. (2017) rated 22 of the studies to be of ‘good quality and
concluded that the balance of evidence suggested a positive association
between greater exposure to outdoor blue spaces and both benets to mental
health and well-being (N =12 studies) and levels of physical activity (N =13
studies). The evidence of an association between outdoor blue space exposure
and general health (N =6 studies), obesity (N =8 studies) and cardiovas-
cular (N =4 studies) and related outcomes was less consistent (p.1207).
Further, not all subsequent research has demonstrated a positive effect
for mental health (Gascon et al., 2018; Helbich et al., 2018), especially
for more serious conditions such as schizophrenia (Boers et al., 2018).
The lack of effects seen in some recent studies may be due to evidence
suggesting that the effects of living near blue space on health and
well-being tend to be signicantly stronger for people living in poorer
regions (Wheeler et al., 2012) or lower income households (Garrett
et al., 2019b). Studies that have not explored the modifying effect of
income may therefore be failing to reveal differences at different levels
of income. If these studies are replicated more generally in the future, it
would suggest that access to blue spaces may help mitigate chronic
socio-economic related inequalities in health (WHO, 2019).
In many developed countries, homes close to inland and coastal
waters, especially those with blue space views, tend to be more expen-
sive including in Hong Kong (Jim and Chen, 2009), the Netherlands
(Luttik, 2000), and the UK (Gibbons et al., 2014). The same applies to
hotel rooms (Lange and Schaefer, 2001), something which extends to
hospitality globally with waterfront hotels and sea views commanding
higher prices. Economists assume that people are willing to spend more
on accommodation close to blue spaces because buyers derive extra
benet or ‘utility. To the extent this is true, then this ‘hedonic pricing
approach would also suggest that well-being is gained from living or
staying near water. This is consistent with a range of studies which show
that stated preferences for landscapes are higher for those containing
water (V¨
olker and Kistemann, 2011; White et al., 2010, 2018).
2.3. Indirect & incidental exposure and health and well-being outcomes
Several recent studies have found evidence that having a water view
(over and above proximity) may play a role. In New Zealand, Nutsford
et al. (2016) showed lower rates of poor mental health among those with
a sea view, controlling for proximity (and other factors). In Hong Kong,
Garrett et al. (2019b) found general health was signicantly higher with
a sea view, but there was no association with mental health. Finally, in
Ireland, Dempsey et al. (2018) found a lower risk of depression among
those with the highest level of sea views, although no effect of coastal
proximity. Both of the latter studies were conducted with older aged
samples; and it has been argued that blue space views from home may be
particularly important to older adults with poorer mobility (Coleman
and Kearns, 2015). We expect more research in this area as innovations
in viewshedanalysis develop that take into account both elevation and
obstruction (Nutsford et al., 2016; Qiang et al., 2019), as well as street
view breakdown (Helbich et al., 2019) and even body cameras that lm
local neighbourhoods from the wearers perspective (Pearson et al.,
2017).
In terms of assessing incidental blue space exposure, we know of only
one study, the Hong Kong study with older adults by Garrett et al.
(2019b). Although having to travel through, or by, blue space on ones
commute to work was associated with a higher probability of spending
time in and around blue spaces, there was no signicant additional effect
on this form of incidental exposure on either general health or mental
health once indirect (view) and intentional (recreational) visits were
taken into account. This lack of effect is in contrast to a study that
suggested that daily commuting through natural environments in gen-
eral (including green and blue spaces) was associated with better mental
health than commutes without natural features (Zijlema et al., 2018).
However, this study did not control for indirect and intentional expo-
sure; and without such controls commuting through blue space in the
Garrett et al. (2019b) paper was also associated with signicantly better
mental and physical health.
As with viewsheds, we suspect that innovations in analyzing street
views will enable further work exploring incidental contact. For
instance, in a study by Helbich et al. (2019), older adults in Beijing were
less likely to show signs of depression if their local neighourhood had
both green and blue views at the street level. Crucially, there were no
signicant effects for satellite estimates, suggesting that the on the
ground views may be more important than basic amount of land
covered.
M.P. White et al.
Environmental Research 191 (2020) 110169
4
2.4. Intentional exposure and health and well-being outcomes
Although there are now several studies which look at the relation-
ships between intentional blue space visits, most of these focus on the
short-term immediate stress reduction potential of specic visits rather
than more global mental health. As such, these studies are reviewed
below in section 3.3 on ‘restoration. In terms of the potential longer-
term benets discussed here, Garrett et al. (2019b) did include a mea-
sure of blue space visit frequency and measures of general and mental
health in their Hong Kong study. They found that visiting a blue space
for recreation at least once a week was associated with better mental
health. This is consistent with research documenting positive effects of
regular recreational visits to natural environments in general on out-
comes including blood pressure (Shanahan et al., 2016), self-reported
general health (White et al., 2019), depression (Cox et al., 2017,
2018), vitality (van den Berg et al., 2016), eudaimonic well-being
(White et al., 2017), life satisfaction (Laffan, 2018), and general
mental well-being (Kruize et al., 2020).
One type of repeated intentional visit to blue spaces that is receiving
more research attention is outdoor (or wild) swimming. Wild swimming
can reduce fatigue (Huttunen et al., 2004), promote mental health
(Foley, 2015, 2017; Denton and Aranda, 2019), and may be able to be
used in treating major depressive disorder (MDD, van Tulleken et al.,
2018). There is also tentative evidence that it can promote immune
functioning (Tipton et al., 2017), treatment of inammation-related
conditions (Huttunen et al., 2004; Tipton et al., 2017) and support
higher insulin sensitivity (Gibas-Dorna et al., 2016). Individuals who
swim outdoors regularly also report experiencing increased connection
to place and the natural environment (Denton and Aranda, 2019; Foley,
2015, 2017), which may in turn lead to behaviours aimed at protecting
the health promoting aspects of these blue spaces.
2.5. Exposure, planetary health and pro-environmental behaviours
Although we know of few studies which have explored exposure to
blue spaces and the kind of individual and community level pro-
environmental behaviours which could be benecial for planetary
health, there are nonetheless some indications. Milfont et al. (2014), for
instance, found that New Zealanders who lived closer to the coast had
greater belief in climate change and, greater support for government
regulation of carbon emissions. The authors argued this was because the
risks of climate related events such as storms, oods and sea level rise
were more salient for coastal dwellers. A recent English study with over
24,000 participants found that living near the coast (<5 km vs. >20 km)
was associated with higher likelihoods of a number of
pro-environmental behaviours including: recycling, buying local/-
seasonal produce, walking/cycling instead of using a car for short
journeys, and being a member of an environmental organisation (Alcock
et al., 2020). Importantly, the associations were mediated by not just the
frequency with which the participants visited natural environments such
as the coast, but also how connected they felt with the natural world.
Living near the coast was associated with greater psychological
connection to the natural world, and in turn this greater connection was
associated with more pro-environmental behaviours.
Feeling more connected to the natural world also accounted for the
results of a controlled laboratory study that experimentally manipulated
nature exposure and explored the effects on a pro-environmental
behaviour with direct relevance to the health of blue space environ-
ments. Zelenski et al. (2015) showed participants an informative video
of either urban street architecture in New York or blue/green spaces (i.e.
BBCs Planet Earth) before asking them to play a shing simulation
game. Participants showed greater self-regulation and shed less
intensively following the nature than the urban videos, with the effect
signicantly mediated thorough increased nature connectedness. A
related nding was found following a visit to a large aquarium in the UK
where visitors who were provided with additional information on sh
stock sustainability were more likely to make sustainable sh choices in
a later simulated restaurant scenario (Wyles et al., 2013). Whether or
not the effects of such short-term exposures in experimental studies last
in the mid-to long-term, the kind of timeline needed for real environ-
mental effects, is less clear.
3. Mechanisms/pathways
This section focuses on the centre of Fig. 1 and the pathways and
mechanisms linking exposure to outcomes, using Markevych et al.s
(2017) three broad, but inter-related, mechanisms of mitigation, insto-
ration and restoration. Although positive emotional states, which may
build creativity and resilience (Fredrickson, 2001), might be included
under instoration, for clarity we reserve discussion of emotional and
cognitive states to the restoration pathway.
3.1. Mitigation (harm reduction)
Urban heat island. With average global temperatures set to rise, urban
settings are particularly vulnerable because they both generate and
retain heat more than natural settings (Heaviside et al., 2017). Blue
spaces, especially in the urban context, offer important temperature
regulation processes, absorbing heat during the day when air tempera-
tures exceed water temperatures and releasing heat during the night
when water temperatures exceed air temperatures (Gunawardena et al.,
2017). In a review of 27 urban blue space versus non-blue comparison
sites (mostly in China, Japan and South Korea), V¨
olker et al. (2013)
found an average cooling effect of 2.5 K during MayOctober. Cooler
temperatures were observed across a broad range of aquatic environ-
ments including rivers, lakes, wetlands, ponds and the sea, and across a
range of climate zones including maritime, subtropical and tropical. The
capacity of urban blue space to mitigate urban heat islands has also been
shown to be connected with positive human health impacts such as re-
ductions in heat-related mortality amongst vulnerable populations in
Portugal who live within 4 km of water (Burkart et al., 2015).
Noise. In itself water can signicantly increase the level of sound in
an environment, so in that sense it may have the opposite effect of green
space which may absorb sound (Rådsten-Ekman et al., 2013). The
question however is whether these aquatic sounds counts as ‘noise(i.e.
unwanted sound). In a number of experimental studies water-based
sounds, either in isolation (Thoma et al., 2013, 2018), or in combina-
tion, with other natural sounds such as birdsong (Alvarsson et al., 2010;
Annerstedt et al., 2013), tend to reduce experimentally induced stress
faster than either urban sounds, silence, or conditions that were spe-
cically designed to reduce stress such as calming music (Thoma et al.,
2013, 2018). Adding pleasant water sounds (e.g. stream, waterfall, sea)
to unpleasant trafc sounds (effectively increasing the overall volume)
can also improve positivity ratings (Rådsten-Ekman et al., 2013). Thus,
while an advantage of green spaces is that they may mitigate noise, blue
spaces may actually increase sound but nonetheless result in more
positive health states if these water sounds effectively ‘drown outmore
unpleasant sounds such as trafc. Nevertheless, although waterscapes in
themselves are unlikely to be damaging for hearing, when combined
with background trafc noise, for example, they may tip the cumulative
sound levels over a safe threshold, so this would need to be investigated
before adopting such interventions.
Air pollution. The picture for blue spaces and air pollution is highly
complex and a detailed discussion is beyond the scope of this paper.
Several papers have looked at the effect of sea breezes in terms of po-
tential pollution dispersal (e.g. Clappier et al., 2000; Grossi et al., 2000;
Liu and Chan, 2002), for instance, but conclude that the exact wind
direction and speed, the spatial layout and height of urban buildings, as
well as the type of pollution (e.g. NO
3
vs. ozone), all play a role. Further,
there are several sources of air pollution emanating from blue spaces,
most obviously from diesel powered shipping (e.g. Viana et al., 2014),
but also from industries sited on the shores of waterbodies which in
M.P. White et al.
Environmental Research 191 (2020) 110169
5
addition to direct waste-disposal practices result in air-borne pollution
(e.g. Wong et al., 2003). However, this is not the ‘faultof blue spaces per
se, it is how people use these spaces that is the issue. Nonetheless, it
seems unlikely that blue spaces have the kind of direct air pollution
mitigation effects that green spaces might have. Nonetheless green
spacesneed water to maintain their greenness, thus ultimately water is
needed for even greenspaces ability to reduce air pollution (Salmond
et al., 2016).
Aerosols and negative ions. Taking the sea airfor ones health has
been recommended by physicians for centuries (e.g. Reed, 1884; For-
tescue Fox and Lloyd, 1938). Recent research in both coastal and inland
waters, especially high force waterfalls (Grafst¨
atter et al., 2017), sug-
gests that the mists and sprays created in these settings may help reduce
breathing difculties, e.g. among children with asthma, in part through
reduced inammation and improved lung function (Gaisberger et al.,
2012). Although the precise mechanisms are still not fully understood
some authors claim that the negative ions produced by crashing water
(e.g. Kolarz et al., 2012) may also play a role. The direct effects of
negative ions on human health are disputed (Perez et al., 2013), how-
ever there is some evidence of lower depression scores at high-density
exposure, which is consistent with lower stress reported by partici-
pants in Grafst¨
atter et al.s (2017) study of exposure to waterfalls (versus
similarly attractive alpine settings) in Austria. Given that the benets to
lung function may last for several months post exposure (Gaisberger
et al., 2012), further high quality research in this area seems warranted.
Aerosolized toxins. A different issue, with respect to aerosols concerns
aerosolized toxins, e.g. brevetoxins, that come from ‘harmful algal
blooms(Fleming et al., 2011). Natural water bodies contain a wide
variety of micro-organisms which can become airborne in water spray at
critical places such as waterfalls and ocean shores (Asselman et al.,
2019). In some instances, for example Florida Red Tide caused by the
dinoagellate Karenia brevis, the organisms produce potent natural
toxins. These toxins can cause or aggravate symptoms among those with
asthma (Kirkpatrick et al., 2011; Fleming et al., 2011). However, it has
also been argued that at low concentrations some of these toxins (as well
as other substances in marine aerosols) may have positive effects on
health. For instance, there is evidence that yessotoxin produced by
marine dinoagellates such as Protoceratium reticulatum, may reduce
inammation and improve immunoregulation (Asselman et al., 2019;
Moore, 2015). The possibility that, at low levels, these blue space
aerosolized toxins may be benecial for health echoes arguments in the
greenspace literature (Rook, 2013; Kuo, 2015) with respect to some
airborne tree compounds (e.g. phytoncides, Li et al., 2009; Li, 2010). Far
more research is needed, however, to fully understand these processes.
Solar irradiance. Finally, blue spaces are also associated with higher
levels of solar irradiance, leading to higher ultraviolet exposure of those
exposed. On the one hand this can increase the risk of skin cancer
(Stenbeck et al., 1990), but it can also lead to higher vitamin D synthesis
which is associated with a reduced risk of certain auto-immune and
cardio-vascular diseases, some cancers, and poor mental health (Cherrie
et al., 2015). Clearly, individual behaviors are key with respect to time
of day, exposure duration, self-protection measures etc.
3.2. Instoration (capacity building)
In an early review of 36 small-scale survey studies and experiments,
V¨
olker and Kistemann (2011) identied four ‘dimensions of appropria-
tionwhich relate to the way blue spaces are perceived and interacted
with to achieve ‘salutogenic(i.e. health promoting) potential. They
labelled these: ‘activityspace, ‘experiencedspace, ‘social space, and
‘symbolic space; and they approximate respectively to blue spaces as
places to engage in physical activity, to build positive emotions/me-
mories, to engage in positive social relations, and to form attachment
bonds and personal meanings to specic locations.
Encouraging physical activity. Greater levels of physical activity
among people who live near the coast or other waterside locations is one
of the strongest ndings in the blue space literature (Gascon et al.,
2017). Many of the early studies were conducted in Australia and New
Zealand, and suggested that people who lived near the coast had higher
levels of self-reported physical activity, mostly walking (Ball et al., 2007;
Bauman et al., 1999; Humpel et al., 2004; Wilson et al., 2011; Witten
et al., 2008). Although subsequent research in England (White et al.,
2014a) and France (Karusisi et al., 2012; Perchoux et al., 2015) provided
further support, studies in the US (Gilmer et al., 2003) and China (Ying
et al., 2015) found no differences among those who lived close to, versus
further from, blue spaces. Although statistical power may have been an
issue, as these two studies had relatively small samples compared to the
others, the Ying et al. (2015) study is particularly important because it
used pedometer measures and thus had a more objective measure of
physical activity. In a similar vein, a recent paper by Garrett et al. (2020)
in England found statistically higher self-reported physical activity
among those living at the coast, but also no difference in objectively
measured physical activity using accelerometers among a sub-sample.
Again, power issues may have been a factor due to the reduced
sub-sample, but it does raise the issue that self-reported ndings may be
biased among those who live near water for some reason.
What is clearer, is that much of the activity in blue spaces, at least in
developed countries, is not water-based but occurs on land, e.g. beach
walks (Elliott et al., 2018; White et al., 2016b); and it is this activity that
predominantly explains any link between coastal proximity and health
(Pasanen et al., 2019). There is also experimental and survey evidence
that when people undertake exercise in blue spaces, they tend to exer-
cise for longer than in green or urban settings (Elliott et al., 2015), in
part because perceptions of time are different (White et al., 2015). At-
tempts have been made to put economic values on blue space activities
by calculating how the level of physical activity undertaken there is
likely to improve health and well-being (Papathanasopoulou et al.,
2016; Vert et al., 2019a). This kind of framing is particularly important
for policy makers who have to make budgetary decisions, such as for
local urban planners when considering river regeneration interventions
(Vert et al., 2019b), or those in charge of marine spatial planning who
need to be aware of the ‘valueof such recreational activities (Elliott
et al., 2018).
Supporting positive social relations. There is growing evidence that
compared to greenspaces, blue spaces may be particularly important for
promoting positive social relationships. Qualitative studies in Germany
(V¨
olker and Kistemann, 2015), Iran (Vaeztavakoli et al., 2018), Ireland
(Foley, 2015), and the UK (Ashbullby et al., 2013; Bell et al., 2015), all
found evidence suggesting that blue space environments are ideal lo-
cations for people to spend high quality time with friends and family. In
the words of a participant in the study of Irans Isfahans Niasarm canal:
When the weather is good, the canal is full of people from the neighborhood.
Women, children, and old people all prefer to socialize together alongside the
canal(Vaeztavakoli et al., 2018, p. 13). Survey data also suggest that
spending time with others is a key motivation for visits to both coastal
(Elliott et al., 2018) and inland (de Bell et al., 2017) waters, and a study
in Spain suggested that social support was higher for those who had
access to blue, but not green, spaces (Triguero-Mas et al., 2015).
Building place/nature connectedness. Although not in Markeyvch
et al.s (2017) original model, we believe place/nature connectedness is
nonetheless an important potential instoration pathway. People have a
deep innate need to feel connected to other people or something bigger
than themselves (Baumeister and Leary, 1995). When interpersonal
connections are lacking or attenuated, connections/attachment to pla-
ces (Scannell and Gifford, 2010) and natural environments in particular
(Clayton, 2003) may buffer people against the poor mental health that
tends to be associated with loneliness (Cartwright et al., 2018). Korpela
and colleagues (e.g. Korpela et al., 2010, 2020), in particular, have
conducted research exploring peoples ‘favourite places, the places that
have particular meaning for them, and ones where they often go to ‘feel
better or self-regulate their emotional states. Importantly such
emotional states seem to be particularly enhanced in blue space settings
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Environmental Research 191 (2020) 110169
6
(MacKerron and Mourato, 2013; White et al., 2013a), and they are also
among many peoples favourite places (Korpela et al., 2010; Vaeztava-
koli et al., 2018). Nonetheless, it is also important to recognise that there
are socio-demographic inequalities in blue space access (Haeffner et al.,
2017), and as such it may be difcult for marginalized groups (e.g.
persons with disabilities) to ‘learn to loveblue spaces, especially if
historically they have only had access to more dangerous ones (Bell
et al., 2019).
Nature connectedness can be considered as both an enduring
dispositional trait (some people tend to feel more connected to nature
than others in general) and as a more ephemeral state (the same indi-
vidual can feel more or less connected depending on context [Capaldi
et al., 2014]). People who live at the coast tend to have higher trait
nature connectedness (or appreciation, Alcock et al., 2020); and visits to
blue spaces, especially those of high quality, tend to be associated with
higher levels of state nature connectedness (Wyles et al., 2019). We
know of only one published study that adapted a standard nature
connectedness tool (the Inclusion of Nature in the Self scale, Schultz,
2001) to focus exclusively on blue spaces (Hignett et al., 2018). This
study measured childrens marine connectedness, as well as health and
pro-environmental outcomes, before and after a multi-week surf pro-
gramme. Although there were benets for key health outcomes such as
resting heart rate and pro-environmental behaviors, these were not
mediated by improved marine connectedness. Further studies are
needed that explore marine and inland water connectedness in partic-
ular, as something different from nature connectedness in general.
3.3. Restoration (capacity restoration)
In terms of restoration two inuential theories argue that modern
urban environments in particular pose demands on our emotional
(Stress Reduction Theory, Ulrich et al., 1991) and cognitive/attentional
(Attention Restoration Theory, Kaplan & Kaplan, 1989) resources, that
need opportunities to recover and ‘re-charge. Both theories argue that
non-threatening nature environments (including potentially blue
spaces) offer many of the characteristics for supporting such restoration
from stressful and cognitively demanding situations.
Stress reduction. As early as 1981, Ulrich (1981) demonstrated that
experimental exposure to aquatic versus green space scenes may be
particularly relaxing by measuring neural oscillations in the 812 Hz
spectrum (i.e. alpha waves) using an electroencephalograph (EEG). He
suggested that the fact that alpha during the water exposures was on
average lower than during the vegetation scenes may be due to the
attention-holding properties of the water views(p. 546). In a subsequent
study Ulrich et al. (1991) showed that watching natural scenes
(including an aquatic one) could help participants recover faster (as
measured using galvanic skin response, heart rate and frown muscle
activation) from a stressful situation than watching urban scenes.
However the green space and blue space scenes were collapsed for
analysis due to similar effects, so it did not appear that blue space had
any marginal advantage.
Since these early studies by Ulrich and colleagues, work in terms of
blue space has tended to explore the self-reported mood states of those
making intentional recreational visits to a range of urban, green and
blue spaces, under the assumption that many recreational visitors to
nature are urban residents with habitually high levels of arousal and
stress. Comparisons of visits across a range of contexts has repeatedly
shown that blue spaces are among the most restorative contexts (Barton
and Pretty, 2010; White et al., 2013a), with a study by MacKerron and
Mourato (2013) being particularly persuasive. These authors developed
an iPhone app (Mappiness) which contacted people at several points
during the day over several days to ask how they were feeling, tagging
their responses to their geolocations. Results found that people were
happiest in marine/coastal settings, but that inland waters were more
similar to green spaces such as woodlands and grasslands.
A few experimental studies have also looked at emotions in relation
to physical activity in urban, blue and/or green/control settings. Vert
et al. (2020), found that subjective well-being and feelings of vitality
among ofce walkers taking an experimentally selected blue space walk
during lunchtime were higher than following either an urban walk or
seated control condition. However, two similar walking studies (Gidlow
et al., 2016; Triguero Mas et al., 2017) and a simulated cycling study
using an indoor bike and large outdoor screen projections (White et al.,
2015) found that while blue space walks/cycles were associated with
better mood outcomes than an urban walk/cycle, green space activity
provided similar benets. Finally, in-depth qualitative studies (e.g. Bell
et al., 2015) have tried to uncover why people report feeling less stressed
in aquatic settings, with people reporting that the light, the soundscapes,
the quickly changing patterns, and/or meaningful histories and personal
associations are all potentially important.
Cognitive Restoration. Despite the large number of studies that have
looked at the potential of green spaces to restore depleted cognitive
ability, predominantly attention (Ohly et al., 2016; Stevenson et al.,
2018), there have been very few studies which have looked at blue
spaces in particular. Nevertheless, several important experimental
studies that compared ‘nature and ‘urbansettings (e.g. Berman et al.,
2008; Berto, 2005; van Hedger et al., 2019) actually used predominantly
blue space imagery and/or sounds in their ‘nature conditions, but sys-
tematically (though presumably accidently) excluded water from their
‘urbanconditions (White et al., 2010). Thus ndings that exposure to
the ‘naturalimages/sounds results in better performance on a range of
attentional tests, might be better framed in terms of blue spaces than
nature in general. Although, as with Ulrich et al. (1991) it may be that
natural spaces without water may have been as good, we suspect that
these researchers chose natural environments containing water because
they intuitively felt that the presence of water added to the potentially
restorative effects (Kaplan and Kaplan, 1989).
Two experimental studies, one lab-based (Emeld and Neider, 2014)
and one eld based (Gidlow et al., 2016) did attempt to explore impacts
of urban versus specically blue space exposure on cognitive outcomes.
Emeld and Neider (2014) found no improvements on a range of
cognitive tasks after viewing blue space images and/or listening to blue
space sounds compared to comparable urban (non-blue) stimuli. How-
ever, given that there was no prior cognition depletion task over and
above completing the tools themselves, it may be that people were not
sufciently depleted to begin with to allow for restoration (Hartig et al.,
1991). Gidlow et al. (2016) compared Backward Digit Span scores
before and after a 30 min walk in either urban, green or blue space (a
river path) settings, as well as employing a delayed post-test 30 min after
the walk. The pre to delayed post-test comparison suggests that only in
the blue space condition did BDS scores improve signicantly. Further
research differentiating blue from green spaces with respect to attention
restoration is needed to clarify these and other ndings.
4. Effect modiers
Following Hartig et al. (2014), who identied two types of effect
modier of the relationships between nature in general and health, we
identify similar potential modiers for blue spaces in particular; and
categorise them as situational (pertaining to environmental circum-
stances) and individual (pertaining to the individual being exposed to
the blue spaces). The role of modiers is shown at the top of Fig. 1.
4.1. Situational
Blue space type. Much of the blue space and health research has
focused on marine/coastal settings (White et al., 2016a; Gascon et al.,
2017). However, there are also studies that focus on rivers (de Bell et al.,
2017; Vert et al., 2019; V¨
olker and Kistemann, 2013), canals (Vaezta-
vakoli, 2018), and lakes, both large (Pearson et al., 2019) and small
(Pearson et al., 2019; V¨
olker and Kistemann, 2015). When looked at
independently it is hard to compare different types of blue space, but a
M.P. White et al.
Environmental Research 191 (2020) 110169
7
few studies have included both marine and inland waters in the same
research. Elliott et al. (2020) nd similar distance decay effects for the
relationships between home location and visits to coasts and lakes. Both
White et al. (2013) and McKerron and Mourato (2013) found that people
reported being more relaxed and happier, respectively, in coastal than
inland water settings, at least in England.
Quality. Objective water quality, in both inland and marine waters, is
vitally important for a range of health and well-being outcomes (Land-
rigan et al., 2018; Fleming et al., 2019). The European Union, for
instance, has an extensive programme for monitoring water quality at
over 22,000 coastal and inland designated bathing waters across Europe
(European Environment Agency, 2019: https://ec.europa.eu/enviro
nment/water/water-bathing/index_en.html). One of the chief threats
to health comes from human and animal faecal matter in the water
which carries harmful pathogens including bacteria such as Escherichia
coli (E. coli) which can lead to gastrointestinal and other illnesses (Prüss,
1998). Further, perceived quality, irrespective of actual quality, is also
important because it can inuence behaviour leading to either avoid-
ance of waters that are of good quality (Vert et al., 2019), or exposure to
waters that are of poor quality (Rowles et al., 2018). As early as 1980,
the World Health Organisation recognised that perceived quality could
affect the psychological benets of interacting with blue spaces (WHO,
1980).
In one of the earliest studies to look at the importance of perceived
water quality systematically, Wilson et al. (1995) showed participants
photographs of different waterscapes with and without photo-shopped
signs of pollution (e.g. foam), algal blooms, etc. As expected, the im-
ages with indicators of poor water quality were consistently rated less
positively and people said they would be less likely to use them for
recreation purposes, irrespective of the fact that they were given no
objective data on water quality. In a similar study Wyles et al. (2016)
experimentally manipulated the amount and type of litter on a beach
and showed images of these to participants. Although all forms of litter
reduced preference ratings of the scene, visitor generated litter (e.g. food
cartons) had a more negative impact than shing litter (e.g. discarded
nets). Therefore, it is necessary to consider perceptions of blue space
quality alongside more objective indicators when considering the im-
pacts on health and well-being.
Other indicators of blue space quality include actual and perceived
levels of biodiversity. For instance, in a study of over 4500 visits to
natural environments in England (Wyles et al., 2019), nature connect-
edness and experienced well-being/stress reduction were higher in
marine settings that had some form of protected or designated status (e.
g. Site of Special Scientic Interest) indicating higher objective quality
in terms of biodiversity. Although the association between actual and
perceived biodiversity at inland (Dallimer et al., 2012) and coastal
(White et al., 2017b) blue spaces is weak, again perceived biodiversity is
related to more positive ratings, higher feelings of well-being, and
greater intentions to visit (Dallimer et al., 2012; White et al., 2017b).
Several experimental studies that deliberately manipulated levels of
marine biodiversity have also demonstrated greater interest in more
biodiverse blue spaces (Fairchild et al., 2018), and greater perceived
stress reduction from more biodiverse settings (Cracknell et al., 2018).
Nevertheless, in an aquarium study with different levels of biodi-
versity, although physiological data did suggest that adding some
biodiversity to an empty aquarium was benecial for stress reduction in
terms of heart rate and blood pressure, greater levels of biodiversity did
not result in more substantial benets suggesting there was not a linear
dose-response effect (Cracknell et al., 2016). More research is needed to
explore these patterns in more detail, including qualitative approaches
to understand how, for instance, the importance of blue space biodi-
versity changes over the life-course (e.g. feeding the ducks might
become more important when one has small children [Bell et al., 2018]).
Weather. The weather is arguably a more important factor for blue
space than green space exposure. Blue spaces become especially
attractive in hot and sunny conditions since, as noted in section 3.1
above, they tend to be cooler, but possibly less attractive in rainy or
windy conditions. Supporting this suggestion, landscape preferences in
an experimental study using photographs were more affected by the
weather for blue spaces than for either green or urban ones (White et al.,
2014b). Analysis of over 40,000 visits to different natural settings in
England also suggested that people are likely to do more physical ac-
tivity under warmer temperatures at the coast, but not at inland waters
(Elliott et al., 2019). It is also important, to take into account the context
when considering the weather. In England, temperatures are relatively
low compared to California, where lower than mean temperatures at the
beach were seen as preferable and more restorative (Hipp and Ogun-
seitan, 2011), precisely because it was not ‘too hot.
Country/cultural context. Systematic reviews of inland blue spaces
(Volker and Kistemann, 2011), home proximity to blue space (Gascon
et al., 2017), and blue activity interventions (Britton et al., 2020) sug-
gest that most studies have been conducted in high income countries
including Europe, the US, Australia and New Zealand, Japan and China.
Similar issues exist in the green space literature where the vast majority
of research has also been conducted in high-income countries. More
work is needed in low to middle income countries were water quality
may be less regulated (Borja et al., 2020) and threats to health and
well-being from water-borne diseases, jellysh, parasites, predators (e.g.
crocodiles), as well as the risk of drowning, may be heightened (WHO,
2014).
4.2. Individual
The green space and health literature is replete with papers exploring
the moderating role of individual level differences such as age (Astell--
Burt et al., 2014), gender (Richardson and Mitchell, 2010) and ethnicity
(Gentin, 2011). One of the most important is socio-economic status, with
a number of studies suggesting that the benets of green space are
greater for poorer than richer individuals (Mitchell and Popham, 2008;
Mitchell et al., 2015). As noted in Section 2.2, a similar effect has been
found with respect to home proximity to the coast, with the relationship
to general health being stronger for those in more deprived communities
(Wheeler et al., 2012), and the relationship to mental health stronger for
those in lower income households (Garrett et al., 2019b). Less work,
however, has been conducted to explore other factors such as age,
gender and ethnicity, and how these may interact with blue space
exposure to affect health and well-being.
Age. Some blue space studies have been conducted with specic age
groups. Amoly et al. (2014) explored 710 year old Spanish childrens
emotional coping and behaviour, as well as symptoms of Attention
Decit Hyperactivity Disorder (ADHD, Amoly et al., 2014), as a function
of time spent in different settings. The more time the children spent at
the beach in the last 12 months, the fewer emotional problems and more
pro-social behaviors they exhibited, but there were no associations with
ADHD symptoms (Amoly et al., 2014). Crucially, pro-social behaviours
were only related to beach, but not green space, time. This nding
echoes adult studies suggesting that blue spaces seem to be particularly
important for supporting good quality social relationships. A further
study explored childhood obesity in England and found that children
who lived near the coast, especially rural coasts, were less likely to be
obese than children who lived inland, possibly because of more physical
activity (Woods et al., 2016).
At the other end of the age spectrum, several blue space studies have
focused on older adults. As noted in Section 2.3, Dempsey et al. (2018),
Garrett et al. (2019a), and Helbich et al. (2019) all report positive as-
sociations between having blue space views from the home or local
streets and general and mental health, respectively, among older adults.
Coleman and Kearns (2015) have argued that blue space views become
increasingly important as people get older and mobility issues emerge.
As both Aspinall et al. (2010) and Finlay et al. (2015) point out, how-
ever, although water features are an attractor for older people to public
places, other factors such as accessibility, feelings of safety and the
M.P. White et al.
Environmental Research 191 (2020) 110169
8
presence of facilities (such as toilets and benches) tend to be considered
as even more important. Although it is often hard to disaggregate the
effects of green and blue space, including for older adults (de Keisjzer
et al., 2019), blue spaces do offer certain characteristics, such as heat
reduction potential that may be particularly important in older age
(Burkart et al., 2015).
Gender. Elliott et al. (2018) found that females in England were more
likely to visit beach settings, while men were more likely to visit inland
waterways. Similar ndings were reported in Spain, where extensive
visitor observations reported more than twice as many men than women
using an urban river pathway (Vert et al., 2019b). Nevertheless, the
proportion of women increased slightly, and proportion of men
decreased slightly, following extensive renovations, perhaps because the
improvements increased perceptions of safety (Vert et al., 2019b).
Further, the activities engaged in at blue space settings also show sys-
tematic differences: while women are more likely to engage in activities
such as paddling and sunbathing, they are less likely to report shing or
water sport activities, with the exception of swimming which is similar
across both genders (Elliott et al., 2018). Differences in activities are
important because they are associated with different levels of energy
expenditure (Vert et al., 2019a); and since it tends to be the higher en-
ergy activities which are likely to be undertaken by men, women may be
missing out on health-related physical activity gains from a more diverse
set of activities in blue spaces.
As Britton and colleagues point out (Britton, 2017; Britton et al.,
2018) this may, in part, reect a certain ‘masculinityassociated with
many water-based activities such as surng, which may put some
women off from engaging with them in the rst place, or undermine
their enjoyment of them when being patronised or actively discouraged
by men. However, apart from these more physically active endeavours,
there is little evidence in the broader literature that men and women
benet differently from blue space exposures. Again, the issue is prob-
ably about ensuring fair, equitable, and respectful access to all, rather
than trying to conduct lots of further research which sets out to
demonstrate that the two genders react differently to blue spaces.
Ethnicity. There is evidence that individuals from minority ethnic
backgrounds in the US tend to visit blue spaces less than their white
counterparts (Leeworthy, 2011; Wolch and Zhang, 2004), even if they
live nearer them (Haeffner et al., 2017). There is also evidence that this
may have deep historic roots in racial segregation (Bell et al., 2019;
Hollenbeck, 2016), as opposed to perceptions that the potential benets
to their health and well-being are any less (Bush, 2016). In part the issue
may be related to the fact that individuals from minority ethnic groups
are less likely to be able to swim than their white counterparts (Pilgaard
et al., 2019), and thus drownings also tend to be higher (Wiltse, 2007).
In other contexts, blue spaces may have even deeper historical roots
linked to cultural identity and practices. Wheaton et al. (2020), for
instance, discuss traditional M¯
aori beliefs and practices with respect to
the natural world, and blue spaces in particular, in Aoterea, New Zea-
land. While many colonial European settlers in New Zealand see the
coastal waters as places of recreation and leisure, M¯
aori communities in
Aoterea have a concept called kaitiakitanga,which is similar to a sense
of guardianship towards the natural world for the good of both future
generations but also the natural world in and of itself (Selby et al.,
2010). Relationships between blue spaces and health/well-being among
these traditional marine communities, as well as among many other
island nations and coastal communities today, may be quite different
from those where most of the research has been conducted to date and
thus further work is needed to explore these issues.
5. Actions/interventions/changes
Aware of some benets of blue spaces for the promotion of good
health and well-being, policy makers, planners, and practitioners
around the world have implemented numerous actions, initiatives and
changes to improve safe access to high quality water environments.
Although many of these actions are multi-faceted and operate at several
levels, our model (bottom of Fig. 1) groups them loosely into three types:
a) national or international societal-level interventions; b) local/
regional infrastructure interventions; and c) personal level interventions
with specic groups of people. We recognise that there are thousands of
infrastructure projects to improve water quality as well as regulations to
reduce discharges of pollution etc. into inland and marine waters, but
these are beyond the scope of the current work because their aim is
predominantly to reduce harm, rather than promote benets per se
(WHO, 2003).
5.1. Societal actions
One example relates to improved quality. The EU, for instance, has a
multi-country initiative to monitor bathing water quality, and in Section
4.1 we discussed this in the context of understanding how differences in
quality might affect peoples willingness to use bathing waters for health
promoting recreation. Here, we point out that although the programme
is mainly to reduce harms (i.e. exposure to faecal matter in the water), it
is also consciously trying to promote the use of these setting for active,
healthy recreation, i.e. intentional exposure (EEA, 2019). Until the
introduction of the rst EU Bathing Water Directive in 1976 (EU, 1976),
there were large quantities of uncontrolled or partially controlled dis-
charges of a range of pollutants into bathing waters across the continent.
The directive identied a range of indicators by which bathing water
quality could be assessed, with the current focus on levels of microbial
pollution, especially E. coli and Enterococci emerging after the 2006
revision, based on the best available epidemiological evidence of harm
from these bacteria (EU, 2006). As a direct consequence of the original
and revised directives, bathing water quality in the EU and similarly
monitored countries such as Albania and Switzerland, has improved
dramatically and use of these spaces increased (EEA, 2019).
A second type of national level intervention is improved access. In
the UK, Section 9 of the Marine and Coastal Access Act 2009 (UK Gov-
ernment, 2009) states that: Natural England and the Secretary of State
must secure the following objectives: 1) a route for the whole of the
English coast which consists of one or more long-distance routes along which
the public are enabled to make recreational journeys on foot or by ferry, and
… 2) that, in association with that route , a margin of land along the length
of the English coast is accessible to the public for the purposes of its enjoyment
by them, except to the extent that the margin of land is relevant excepted
land(Paragraph 296,). In other words, the Act called for a 2800 mile
long England Coast Path that allowed access to the entire coast sur-
rounding the country, with a few exceptions (e.g. military and power
facilities). The aim was quite explicit, to increase direct exposure to the
coast through improved access, which, based on the evidence discussed,
may in turn inuence a range of health and well-being outcomes.
5.2. Local/regional actions
A recent review of local blue space interventions that were planned
and designed to improve access to coastal and inland waters around the
world by Bell (2019) found 172 recent high prole examples (e.g. had
won awards). These included design interventions such as waterfront
promenades, conversion of former docks, and improved access to
bathing waters. Many of the interventions were designed to improve the
aesthetic quality of the area (to make them more attractive for visitors)
and/or to explicitly encourage physical activity (e.g. by encouraging
walking, cycling and swimming). Several sites where entry into the
water was undesirable due to safety (e.g. canalized rivers) were never-
theless designed to improve the visual experience and promote relaxa-
tion by building seating and viewing platforms of various types. Many of
these were designed to specically facilitate the kind of social in-
teractions discussed in Section 3.2.
Although the benets to health and well-being of such improvements
may seem self-evident, Bell and colleagues (Bell et al., 2020) have
M.P. White et al.
Environmental Research 191 (2020) 110169
9
developed a range of assessment tools to more systematically assess their
impacts. These range from detailed assessments of blue space environ-
mental quality (Mishra et al., 2020), to observational tools designed to
specically observe how people interact with these blue space in-
terventions, and local community surveys that are conducted before and
after the interventions take place to assess change (Bell et al., 2020).
Further details on these resources, can be found on the Horizon 2020
funded ‘BlueHealthproject website https://bluehealth2020.eu/resou
rces/toolbox/, which also links to a WHO co-designed tool for deci-
sion makers attempting to weigh up the risks and benets of blue spaces
for health and wellbeing. Results using these novel assessment tools
across a range of local interventions are expected soon.
5.3. Personal actions
A wide range of programs have been developed to specically in-
crease peoples exposures to safe blue spaces, primarily to engage in
water sports or so called ‘blue gymactivities (Depledge and Bird, 2009).
A recent systematic review of 33 such programs (Britton et al., 2020)
suggests they are mainly targeted at people experiencing difculties of
some kind such as post-traumatic stress disorder (e.g. among army
veterans), breast cancer, cognitive impairments, and broader mental
health issues (Britton et al., 2020). The most common intervention ac-
tivity was surng, followed by dragon boat racing, sailing, kayaking,
and shing. About half of the interventions took place in marine, and
half in inland waters. As many of the studies were qualitative in nature,
or if quantitative had relatively small sample sizes, nding clear benets
to health and well-being was difcult. Nonetheless, several suggestive
ndings emerged including improvements in self-esteem and social re-
lationships. Although there were some indications of improved physical
health, the authors suggest these were probably more due to the nature
of the activities undertaken, rather than attributable to the blue spaces
themselves; and they called for more systematic assessments of such
interventions using standardized tools in future.
A very different type of personal blue space intervention for health
and well-being has also been investigated in indoor health and care fa-
cilities, following on from the pioneering work of Ulrich (1984), who
found that recovery from surgery was quicker among those in hospital
rooms with green space views. In practice, many indoor nature-based
interventions have used images and sounds of blue spaces (e.g. Kweon
et al., 2008; White et al., 2010). Particularly popular historically have
been aquariums, which can help people recover from stress (Cracknell
et al., 2017), as well as help people manage subsequently stressful sit-
uations (Wells, 2005), such as electroconvulsive therapy (ECT) (Barker
et al., 2003) more effectively. They have also been used in dementia
care, where they have been found to help calm older adults, as well as
encourage healthy levels of eating and the promotion of social in-
teractions (Edwards and Beck, 2002).
Another area where blue spaces have been used deliberately is in
dental care. In a study by Katcher et al. (1984), patients awaiting dental
treatment showed greater relaxation and lower anxiety levels ahead of
treatment if they had been watching an aquarium, compared to sitting
quietly with no stimulus or being asked to focus on a waterfall picture.
Extending this logic, Tanja-Dijkstra et al. (2018) used Virtual Reality
(VR) technology to enable patients to undertake a simulated walk along
a beach during treatment in a randomized controlled trial. Patients wore
a head mounted display and were able to navigate along a digital
reconstruction of a local beach using a hand-held controller. Patients
who ‘walkedalong the beach reported lower levels of pain and anxiety
than those in the standard care condition and also reported lower pain
and anxiety than those who were able to walk around a clean and
pleasant virtual city. The distraction from treatment that engaging in a
VR walk was not sufcient in itself; it was important that it took place in
a blue space setting.
6. Summary and limitations
Research into the potential health and well-being benets of living
near, and spending time in and around, ‘green spaceis widespread
(Twohig-Bennett and Jones, 2018; Markevych et al., 2017; van den
Bosch et al., 2017; van den Berg et al., 2015). However, much of the
earlier green space research effectively classied blue spaces as a form of
green space and assumed the relationships would be similar. To some
extent this is true. Blue spaces do appear to offer similar benets in terms
of mitigation of urban heat island effects, support for physical activity
(instoration), and the potential to help people de-stress, calm and relax
(restoration). Further, green and blue spaces rarely occur in isolation so
it is not always easy to untangle them. Green spaces need sources of
water to remain green, and many blue spaces are part of green infra-
structure (e.g. park lakes, canal towpaths, sand dunes etc.). Neverthe-
less, blue spaces within these landscapes have their own set of risks and
benets for human health and well-being and it is important to recognise
these issues as distinct.
Many of the benets of blue spaces are obvious, the need for fresh-
water for drinking and irrigation, the existence of food sources (e.g.
sh). The aim of the current chapter was not to revisit these already
well-documented benets but to summarise some of the more subtle, but
potentially no less important benets, or salutogenic effects, for human
health and well-being. To help navigate the literature we developed a
conceptual model (Fig. 1) to reect how research into these salutogenic
effects are inter-connected. The framework drew on several existing
frameworks from the green space and health literature to identify types
of exposure (e.g. indirect, incidental and intentional Keniger et al.,
2013), pathways linking exposure to outcomes (mitigation, instoration,
restoration, Markevych et al., 2017), and situational (e.g. weather) and
individual (e.g. age) effect modiers (Hartig et al., 2014). But it also
went beyond these models by recognising the importance of
pro-environmental outcomes associated with blue space exposure (e.g.
Milfont et al., 2014; Alcock et al., 2020), nature connectedness (e.g.
Martin et al., 2020), and feedback loops from health outcomes to ac-
tions, interventions and changes that are undertaken to increase
exposure.
A strength of the reviewed literature was the breadth of research
methodologies used including: large scale epidemiological studies (e.g.
Gascon et al., 2017); longitudinal work (White et al., 2013); visitor
surveys (Barton and Pretty, 2010); experience sampling methods
(MacKerron and Mourato, 2013); laboratory experiments (e.g. Ulrich
et al., 1991), eld experiments (e.g. Gidlow et al., 2016), randomized
controlled trials (e.g. Tanja-Dijkstra et al., 2018); infrastructure in-
terventions (e.g. Vert et al., 2019a/b); behavioural interventions (Brit-
ton et al., 2020); and in-depth qualitative work (Bell et al., 2015). The
range of methods reects the highly inter-disciplinary nature of the
work to date with collaborations between natural, behavioural and so-
cial scientists. Results are not all clear cut, but there is evidence across
these mixed methodologies that access to safe, clean and attractive blue
spaces has a range of potential health and well-being benets, due to a
variety of mechanisms (e.g. lower temperatures, increased physical ac-
tivity, lower stress, encouraging quality time with friends and family),
and for a wide range of people.
Nevetheless we remain cautious. Because of its breadth, the review
lacked depth, and we were unable to conduct the kind of systematic
literature searches, thorough quality appraisals, or quantitative meta-
analyses of specic studies that papers with smaller, more targeted
research questions are able to conduct (cf Britton et al., 2020; Gascon
et al., 2017; V¨
olker and Kistemann, 2011). Consequently, relevant
literature may have been missed, and we recognise that our selection is
indicative but by no means exhaustive. Studies with null or negative
effects, which do not nd a link between blue space exposure and pos-
itive health and well-being outcomes in particular may have been
missed, because it is often harder to nd such studies (e.g. may require
grey literature searches). We also did not attempt to provide estimates of
M.P. White et al.
Environmental Research 191 (2020) 110169
10
the balance of evidence across multiple studies (e.g. effect sizes), again
because our overview was too broad to conduct this systematically. We
leave such efforts to future work that is able to concentrate on a specic
part of our proposed model in more detail and acknowledge that at this
stage our review was more about providing an overarching structure
than an attempt to provide denitive answers about the level of quan-
titative support for these associations.
We also recognise that most of the studies reviewed here were con-
ducted in middle to high-income countries, mainly in North America,
Europe and Australasia. Studies such as Vaeztavakoli et al.s (2018) in
Iran are the exception rather than the rule. Given that the majority of the
worlds population lives in Asia, Africa and South America further
investigation into the potential salutogenic benets of blue spaces for
these populations is crucial, especially when blue space risks such as
ooding, drowning, and disease may be more pronounced in these
countries.
A key limitation of our review was that we did not explore the risks in
any detail or attempt to compare or trade-off the benets and the risks
more generally. We recognise that these risks affect millions around the
world annually. Mitigation of them is often at the heart of substantial
engineering projects to, for instance, channelize/canalise rivers, as well
as eliminate water altogether (e.g. swamp drainage to reduce mosquito
numbers and malaria risk). Ultimately, whether interacting with blue
spaces is good for health and well-being will depend on weighing up
these risks with the benets discussed. At this stage, however, it is too
early to conduct such an integrative syntheses, in part due to the partial
nature of the benets literature.
7. Concluding comments
The aim of the current narrative review and synthesis was to provide
an overview of the growing, but highly disparate, literature that informs
our understanding of the potential benets to health and wellbeing from
exposures to aquatic (blue space) environments such as rivers, lakes and
the coast. The aim was not to provide denitive answers but rather to
outline the breadth of work conducted to date and structure it into a
framework that could be used to better identify research gaps and future
opportunities. Such a framework, we believe, can also help researchers
think more about critical points where risks and benet trade-offs for
health and well-being can occur, considerations of which may be espe-
cially important for blue space settings.
CRediT Statement
Mathew P. White: Conceptualization, Writing - original draft,
Funding acquisition. Lewis R. Elliott: Writing - review & editing. Mireia
Gascon: Writing - review & editing. Bethany Roberts: Writing - review &
editing. Lora E. Fleming: Writing - review & editing, Funding
acquisition.
Declaration of competing interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Acknowledgements
Support for the writing of this manuscript was provided by the
BlueHealth project, funded by the European Unions Horizon 2020
research and innovation programme under grant agreement No 666773.
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