Our vision is for improved individual and community physical and mental health and well-being through enhanced interactions with healthy blue spaces that are sustainably managed.
A European study of the Epidemiology of Mental Disorders found that 25.9% of European participants reported the presence of a mental health disorder (including anxiety and depression) during their lifetime (Alonso et al., 2007). A 2015 estimate suggested that more than €600 billion a year are spent on mental health care in EU Member States (OECD/EU, 2018). In addition, the World Health Organization (WHO) estimated that 77% of the disease burden in Europe arises from non-communicable diseases (NCDs) including obesity, diabetes, heart disease and stroke, many of which can be preventable. These are clearly huge public burdens, and new solutions to these issues will need to be found.
It has been shown that physical activity can impact positively on both NCDs and mental health; and engaging with natural environments may improve mental health indicators (Bowler et al., 2010). This has led to the consideration of ‘nature’ as an alternative or adjunct to medication for some mental health conditions(1); and in some countries the concept of ‘nature prescriptions’ is already being applied. In Papathanasopoulou et al. (2016), the physical health benefits of water-based recreation were estimated to have a value to society of approximately £176 million per year in England alone. The SOPHIE inventory of innovative initiatives(2) showed many examples of therapies improving mental health through exercise near the sea. The health benefits of these therapies have not yet been thoroughly scientifically researched. Better understanding of these health benefits would allow their optimization (e.g. as part of integrated coastal zone management and marine spatial planning practices). Studies for the entire adult population of England concluded that good health and comparatively improved mental health is more prevalent the closer one lives to the coast (Garrett et al., 2019; Wheeler et al., 2012). They also found that the positive effects of coastal proximity were greater among more socioeconomically deprived communities. Similar studies in other parts of Europe should also be conducted.
To date the vast majority of the research looking at the natural environment and human health/well-being has focused on ‘green’ rather than ‘blue’ spaces, meaning that the potential benefits of interacting with ocean, coastal and inland waterway areas are less well understood for most European countries. Some work has been conducted looking at the differences between interaction with green and blue spaces including studies in urban areas in Germany (Völker & Kistemann, 2015), some review articles (Britton et al. 2018) and work conducted within the scope of the BlueHealth Project(3) (Gascon et al., 2017; Grellier et al., 2017). This research now needs to be expanded to cover the rest of Europe, as it is not yet clear whether the same findings will apply for different regions.
There are both risks and benefits involved in any interaction with a blue space, e.g. jellyfish stings, effects of HABs, pollutants and water-borne diseases versus the benefits of physical activity and sea air (Fleming et al., 2019). Research around the benefits has developed in recent years, however just 7.4% of research identified through the SOPHIE systematic review(4) had some focus on human well-being outcomes. This lags far behind research on risks associated with coastal recreation and living. Assessments of how these benefits and risks trade off to inform scenarios of future change are even less well explored. Relevant studies are also heavily focused on mental health or metrics of overall well-being. While numerous other health benefits such as cardiovascular, neurological and respiratory health have been speculated on and inferred, the scale and context of these impacts is not well understood.
The balance of risks and benefits should not only extend to humans but also to the marine environment, ensuring that in generating greater benefit for humans, the additional pressures of increased coastal human activity do not further degrade the environment. Additionally, interaction with degraded environments may in turn reduce the derived benefits, meaning that both humans and the ocean gain from appropriate compromises and innovative initiatives. Using tourism as a driver to improve ocean literacy levels among citizens could dramatically improve their understanding of the risks and benefits to their health from interacting with the ocean; and raise awareness of the actions that they can undertake to mitigate pressure on marine ecosystems, habitats and species. The SOPHIE case study in the Eastern Scheldt demonstrated that this does work. We now need to understand:
- What are the different physical and mental benefits that can be gained from interacting with coastal and ocean areas?
- Why do we gain these benefits, and what are the mechanisms at play?
- Where do we gain these benefits, and are there significant variations between interacting with different kinds of spaces, e.g. with blue spaces in different European regions?
- Who could benefit the most from these interactions, and do they have equitable access to these environments throughout the year?
- How much exposure or what dose is required to gain the benefits, taking into account the quality of the exposure, and the risks that may also be present?
- How will this balance of benefits and risks be affected by the impacts of climate and other global change?
- How do we balance ensuring access to blue spaces with increasing and diverse pressures on coastal and marine ecosystems, and how might that vary regionally?
It is critical to ensure that blue spaces do not carry the burden of additional human activity pressures and consequently suffer further degradation, so ongoing monitoring and protection are needed. However, if appropriate compromises are applied, there could be significant potential realized from this existing natural capital, with health and monetary benefits. Innovation will be critical; for example, it would be unrealistic to bring everyone to the coast, but can we bring the ocean to them e.g. through art, soundscapes, virtual reality experiences, and simulated blue environments(5)?
In order to achieve our blue spaces, tourism and well-being vision, four key research questions that need to be addressed are:
- Based on existing and ongoing UK studies and “green health” research(6), what is the evidence for blue health(7) and well-being impacts across Europe?
- With regards to mechanisms and pathways:
a) Through which interactions (types of activity, duration etc.) with different types of coastal environments and blue spaces does human health and well-being improve?
b) Through which interactions does the risk of disease and/or physical issues increase?
- How does increasing the human use of blue spaces affect the coastal and marine ecosystems and biodiversity?
- How can we optimize OHH interactions in order to obtain physical and mental health and well-being benefits in a sustainable manner for all people and species?
These research questions should be addressed in a clear and logical sequence. In order to ensure understanding before progressing, the first three questions should be addressed together, before the fourth question can be addressed. This will allow a representative body of evidence to be gathered on the component aspects before optimizing the OHH benefits.
The European Commission’s Blue Growth Strategy(8), which identifies five key areas that offer a high potential for economic growth in the marine and maritime sectors in the near future, includes coastal tourism as a key sector. The focus within this strategy is on economic growth and job creation, and these are certainly important for human health and well-being. However, the Strategy does not clearly express consideration of other human or environmental benefits or risks from pursuing this growth. For coastal tourism, typically still a very seasonal activity, the Strategy does specify a need for
“measures that help to improve the tourism offer for low-season tourism and reduce the high carbon footprint and environmental impact of coastal tourism”
but it is not clear how this should be achieved. The OHH research community has a role to play in highlighting the human health benefits of blue activities that could also promote ocean interactions outside of the traditional tourist season (e.g. walks, surfing, diving, sea kayaking, wild swimming etc.).
As previously identified, there are also risks associated with human interactions with blue spaces, and several marine-based policies cover these. One is the Bathing Water Directive(9), which addresses some acute health problems that may arise from swimming in polluted waters. As long as this Directive is implemented as intended, it will support and enhance safe, healthy and beneficial interaction to some extent. However, at present, given the findings of a recent study by the European Environment Agency(10) that showed that there are still a high proportion of “problem areas” in European waters in relation to contamination, there is still some way to go. The Directive only covers official bathing sites and does not include sites such as those within cities that people are increasingly using as a way to cope with climate change-induced heatwaves. In addition, problems such as antimicrobial resistance (AMR) are not currently addressed under the Bathing Water Directive, although the EU One Health Action Plan against AMR(11) does refer to the Water Framework Directive (of which the Bathing Water Directive is a component) more generally. AMR is where microorganisms such as bacteria and parasites develop a resistance to anti-microbial substances such as antibiotics. In the case of marine waters, there is evidence of a risk of exposure to antibiotic-resistant strains of E.coli (Leonard et al., 2015). The European Environment Agency has published findings on knowledge developments in relation to chemicals in European waters(12). Further research is needed to identify additional appropriate risk indicators, data collection and monitoring needs, additional sources of pollutants (e.g. sailing yacht flotillas), and regional or seasonal implementation challenges (e.g. local sewage infrastructures becoming overwhelmed by visitors in peak tourist season). This should take into account the requirements for pollutants that already exist under the Marine Strategy Framework Directive(13).
Maritime spatial planning(14) already includes considerations for tourism and allows for a multi-stakeholder approach that could be expanded to include health and well-being. The OHH research community should further explore this opportunity.
More than 14,000 citizens participating in the SOPHIE survey(15) listed beach/coastal walking, watching the view, sunbathing/picnics and swimming as the top four recreational activities in which they engage that relate to the sea or coast. The survey also demonstrated significant variation by country in how regularly citizens visit the coast. In terms of concern for potential threats to public health and well-being, sewage in bathing water was ranked comparatively highly (6th out of 16) whereas jellyfish swarms, drowning and sunburn/sunstroke were ranked lowest (14th, 15th and 16th respectively). This is important information for defining policy options, and for public outreach and awareness campaigns.
European citizens(16) identified the need to understand public health impacts of the marine environment as a key priority area, and they also felt that improving water quality to lower the risk of skin infections and other infections in humans and the risks posed to human health from degraded and polluted marine environments were important. They also showed concern for the environment in their responses: Reduce tourism – problems such as pollution or plastic deposits in the sea often arise from overuse / people at sea. As a solution, they proposed to create a Culture of Care and pro-environmental practices and encourage the responsible use of oceans and rivers – to ensure the use of the oceans does not harm them. The research to understand how to encourage this responsible use now needs to be done.
It should be noted that public support for more research funding directed to better understanding the health and well-being effects of living by the sea, and of spending leisure time in and around marine environments, was comparatively low, placing them 12th and 13th out of 16. In general, citizens appeared to support reducing risks over demonstrating benefits.
Conversely, based on a survey and deliberation workshops(17), societal stakeholders from a diverse mix of backgrounds relevant to OHH agreed that access and experience of blue space and recognizing human health benefits from the ocean were key priority areas. This demonstrates differences in the priorities of societal stakeholders and citizens. The reason and implications of these differences for both research and policymaking should be further studied.
Ocean literacy(18), or the understanding of the ocean’s influence on people and people’s influence on the ocean, is particularly relevant here because coastal tourism or living by the coast are likely to be the main ways in which the public knowingly interacts with the ocean. Improving ocean literacy levels among citizens could also help to improve their understanding of the risks and benefits to their health from interacting with the ocean. Resources to support ocean literacy development are required, and approaches that engage and then inform the public have been found to be more effective than simply providing information (Owens, 2000). To date it has not been demonstrated that increased knowledge will result in behavioural change, thus awareness alone is not enough, and further research is needed to better understand how interest can be turned into action, such as through relevant experiences. There is a need to share examples of meaningful actions, solutions and best practices in order to help create a culture of care.
One such approach is citizen science, where the general public collaborates with scientists on research projects, generally by supporting data collection and/or analysis (Garcia Soto et al., 2017). In the case of mental and physical well-being and coastal interaction, such projects (along with relevant supporting resources) could improve ocean literacy but they could also help to highlight both the risks and benefits of interacting with the ocean and blue spaces. Many of the innovative initiatives found in the SOPHIE inventory(19), which included citizen science projects, contributed to improved education and public awareness on OHH issues.
In a SOPHIE pilot project(20), ocean-related ecotourism operators offered their clients an opportunity to engage in a citizen science project about their well-being in relation to participating in an activity by or on the sea. The pilot project showed that this is a good way to spread information and increase ocean literacy across a wider audience, with the operators serving as multipliers and advocates. In addition, the tourism operators noted that this approach was also beneficial for their business, where scientific findings showing that the activities were beneficial for health could also help boost their business. To take this further, approaches to engage a wider diversity of blue space users should be explored, in particular those targeting the younger generation who are already demonstrating greater environmental awareness and a willingness to participate.
While some citizens may appreciate the health risks associated with interaction with the ocean (e.g. drowning, jellyfish stings), this awareness can be limited, and may be entirely lacking for some issues (e.g. pollution of water and sand, exposure to water-borne diseases). Further research is needed to find effective ways to pass on these important messages, helping the public to be more aware of the risks and helping communities to reduce negative incidents.