Health & Place 35 (2015) 157–165

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Health & Place

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Blue space geographies: Enabling health in place

Ronan Foley a,n, Thomas Kistemann b

a Department of Geography, Maynooth University, Rhetoric House, Maynooth, Co. Kildare, Ireland b University of Bonn, Institute for Hygiene and Public Health, Sigmund-Freud-Straße 25, 53105 Bonn, Germany

a r t i c l e i n f o

Article history: Received 29 May 2015 Received in revised form 13 July 2015 Accepted 17 July 2015 Available online 1 August 2015

Keywords: Blue space Health Water Therapeutic landscapes Enabling place Salutogenesis

x.doi.org/10.1016/j.healthplace.2015.07.003 92/& 2015 Elsevier Ltd. All rights reserved.

esponding author. ail address: [email protected] (R. Foley).

a b s t r a c t

Drawing from research on therapeutic landscapes and relationships between environment, health and wellbeing, we propose the idea of ‘healthy blue space’ as an important new development Com- plementing research on healthy green space, blue space is defined as; ‘health-enabling places and spaces, where water is at the centre of a range of environments with identifiable potential for the promotion of human wellbeing’. Using theoretical ideas from emotional and relational geographies and critical un- derstandings of salutogenesis, the value of blue space to health and wellbeing is recognised and eval- uated. Six individual papers from five different countries consider how health can be enabled in mixed blue space settings. Four sub-themes; embodiment, inter-subjectivity, activity and meaning, document multiple experiences within a range of healthy blue spaces. Finally, we suggest a considerable research agenda – theoretical, methodological and applied – for future work within different forms of blue space. All are suggested as having public health policy relevance in social and public space.

& 2015 Elsevier Ltd. All rights reserved.

1. Geographies of water and health

There has been a resurgence of interest in water within human geography. Recent writing on oceans, coasts and inland water bodies consider historic and contemporary relations between humans, water and the sea (Wylie 2005; Mack, 2011; Ryan, 2012; Anderson and Peters, 2014; Brown and Humberstone, 2015). New strands in cultural geography document water-based activities, practises and cultures such as surfing and diving (Merchant, 2011; Game and Metcalfe, 2011; Anderson, 2014). Yet this aqueous focus has an established literature in health geography. Relationships between water, health and place were central to early therapeutic landscapes research (Williams, 2007; Foley, 2010). Watering-pla- ces like Bath and Lourdes inspired Wil Gesler's development of a concept associated with the cultural production of places with healing reputations (Gesler, 1992, 1993, 2003). In health geography and environmental psychology, substantial literatures on green space environments emphasise their potential to promote health and wellbeing (Korpela and Hartig, 1996; Mitchell and Popham, 2007; Richardson and Mitchell, 2010, Mitchell, 2013; Mitchell, Pearce and Shortt, 2015). There are frequent incidental reflections of blue space within the green; in rivers, lakes and coasts (Herzog, 1984; Hansen-Ketchum et al. 2011; Richardson et al. 2013; Amoly et al., 2014). Traditional landscape ‘gazes’ are potentially shifting

horizons from green to blue, deepened through embodied en- gagements with waterscapes (Herzog, 1984; Strang, 2004; Wylie 2007; Anderson and Peters, 2014). The time is ripe therefore, to pay more specific attention to blue space and extend the scope spatially, methodologically and in inter-disciplinary ways as part of a broader hydro-social set of therapeutic geographies (Parr, 2011; Rose, 2012; Throsby, 2013; Budds and Linton, 2014).

The specific idea of healthy blue space has been bobbing around for some time within health geography. Research by the Blue Gym project in the South-West of England, has documented the value of the coast for citizen health and wellbeing (Depledge and Bird, 2009; White et al., 2010; Wheeler et al., 2012). Parallel research by the Bonn WHO Collaborating Centre for Health Promoting Water Management emphasised the same for inland water, especially ‘urban blue’ and established initial links to public health practise (Kistemann et al., 2010; Völker et al., 2012; Völker and Kiste- mann's, 2011) review of environmental health and blue space re- cognised literal and metaphorical components of ‘upstream’ health (Antonovsky, 1996). Historically blue space was central to the development of spas, baths and other healing water spaces across a range of cultures and settings (Smith and Puczkó, 2009; Foley, 2010). Experimental work in environmental psychology documented the restorative effects of water while more con- temporary research identified experiential accounts of active and affective healing engagements and encounters in blue space (Herzog, 1984; Kaplan and Kaplan, 1989; Kaplan, 1995; Conradson, 2005a; Williams, 2007; Foley, 2010; Hansen-Ketchum et al., 2011;

R. Foley, T. Kistemann / Health & Place 35 (2015) 157–165158

Rose, 2012). A re-discovery of water within wider public health is evident in the promotion of coasts, rivers and lakes as spaces of leisure, exercise and recovery (Andrews and Kearns, 2005; Con- radson, 2005a; Wylie, 2009; Thompson-Coon et al., 2011). Such spaces can be explored at a range of scales, though critically, specific therapeutic encounters are always contingent and un- certain in their health benefits (Conradson, 2005a; Collins and Kearns, 2007; Duff, 2012). Finally, while green space research has gained traction in public health policy, we feel that blue space has similar potential for enabling health that has been significantly under-explored (De Vries et al., 2003; White et al. 2013).

What do we mean by healthy blue space? We suggest one definition as; ‘health-enabling places and spaces, where water is at the centre of a range of environments with identifiable potential for the promotion of human wellbeing’. The term blue is chosen given its established associations with oceans, seas, lakes, rivers and other bodies of water. We fully recognise the myriad shades and forms (grey, brown, dark, oily, muddy, clear) that are recognisable dimensions of water bodies at different scales. Despite these ‘palettes of place’, we suggest that blue is the colour most people associate with the medium (Strang, 2004). The colours green and blue blur in writings on healthy environments, though we see strong overlap between the two (De Vries et al., 2003; Coombes et al., 2010). Yet there are understandable place differences be- tween parks or woods and lakes or oceans and such nuances are important to consider.

This special issue consists of six papers from Europe and Oceania that explore how blue space has been conceptualised and inhabited for a range of potentially therapeutic outcomes (Foley, 2010). Most draw from therapeutic landscapes research and de- velop the idea in theoretically focused ways. The papers primarily utilise qualitative methodologies though with some quantification (Völker and Kistemann). Two New Zealand-based papers (Cole- man and Kearns; Kearns, Collins and Conradson), focus on is- landness via different routes, namely ageing-in-place and carceral geographies associated with illness recovery (Randall et al., 2014). Papers from Denmark and Germany (Thomas; Völker and Kiste- mann) consider overlaps between green and blue space in Eur- opean urban settings, where informants describe and evaluate the importance of blue space relative to the green; documenting place-specific components that inform how they are differently perceived and used. Two final papers from Ireland and Switzerland (Foley; Lengen), consider physical, emotional and imaginative wellbeing encounters with blue space. All are framed to consider their salutogenic potential, embrace the prospect of bringing the idea of ‘blue space’ into a public arena and reach out to other subjects, especially public health, psychology and urban planning, to develop a working agenda for contemporary and historic re- search on blue space as an enabler of health and wellbeing (Fleuret and Atkinson, 2007).

1 The WHO Collaborating Centre was set up in 2001as a multidisciplinary team from geography, environmental medicine, psychiatry, public health, biology and education.

2. Writing healthy blue space

Therapeutic landscapes have been defined as, ‘a geographic meta- phor for aiding in the understanding of how the healing process works itself out in places (or in situations, locales, settings, milieus)’ (Gesler, 1992: 743). Given many therapeutic landscapes have identifiable ‘blue space’ settings; the working out of healing processes in such spaces is a key starting point (Gesler, 1992; Williams, 1998, 2007; Foley, 2010). Wil Gesler's foundational work on the subject noted that; ‘One particular aspect of the physical environment that has been a source of healing for many societies is water’ (Gesler, 1992: 737). His studies of Bath identified well-established associations between the town's hot springs and its commodification as a healing site. Here the source of health came directly from the water; pumped, both literally and

metaphorically, by different historical users (Roman, Georgian, Victor- ian) for a range of curative/rehabilitative purposes (Gesler, 1998). Other studies, especially of Lourdes, considered how healthy place production was driven by sacred water framed as medicinal (Gesler, 1996).

As the subject developed in scope (Kearns and Gesler 1998; Gesler, 2003), blue space remained a significant part of the narrative (Wil- liams, 1998, 2007). Palka (1999) discussed wilderness as an exemplary therapeutic setting, within which water (lake, river, waterfall) emerged as a significant healing component. Other research identified historical associations between healing and mineral waters within hot springs and wider spa cultures (Geores, 1998; Foley et al., 2011).Ongoing connections between the blue space idea and contemporary spa and wellness research sustain commodifiable links to different forms of water (Smith and Puczkó, 2009). Specific blue space settings for therapeutic encounters were also identified; lakes in Canada (Wilson 2003; Williams, 2007), river banks in Germany (Völker and Kiste- mann, 2011, 2013) and different coasts around the world (Andrews and Kearns, 2005; Collins and Kearns, 2007; Kearns and Collins, 2012).

From environmental psychology research, elements of both green and blue space were identified as significant in showing how nature emerged as a significant component of healing en- vironments (Ulrich, 1979, 1983; Kaplan and Kaplan, 1989; Calo- giuri and Chroni, 2014). In particular, research on attention re- storation theory, landscape preference studies and favourite pla- ces, all identified ways by which natural environments affected wellbeing, including stress reduction, faster illness recovery and long-term improvement in individual health (Herzog, 1984; Ka- plan, 1995; Korpela and Hartig, 1996; Hartig and Staats, 2003; Velarde et al. 2007). For. example, experimental research in Fin- land using a perceived restorativeness scale (PRS), identified a range of specific places, including those associated with water, that were associated with improved wellbeing (Korpela and Hartig, 1996). By providing evidence of their curative efficacy, such green/ blue space elements became influential in the design of formal and informal care settings such as hospitals, clinics and retreats as well as in wider urban design (Kaplan, 1995; Gesler et al., 2004; Con- radson, 2005a, 2005b; Curtis et al., 2007). Different forms of water – still, flowing, raging, spiritually charged – were additional built components, particularly in retreat, CAM and contemporary spa settings (Conradson, 2007; Hoyez, 2007; Lea, 2008; Foley, 2010; Little, 2013). Hoyez's study of ‘yogic landscapes’ showed how therapeutic landscapes were reproduced and globalised; within which sacred water and wider ‘blue settings’ of water and sky were considered essential components in the (re)production of wellbeing. Finally, aspects of the nature of water itself, especially its still contemplative features, have also been prominent in cul- tural geography research on wellness and the restoration of phy- sical and mental health (Strang, 2004; Conradson, 2007; Lea, 2008; Duff, 2011; Foley, 2011).

Research involving authors in this issue has significantly de- veloped the subject. A systematic literature review by the Bonn ‘Blue’ WHO-CC1, summarised relationships between inland water and health/wellbeing and identified strands associated with per- ception and preference, landscape design, emotions, restoration and recreation (Völker and Kistemann, 2011). The cited studies drew from experimental, quantitative and cross-sectional methods but identified a need for more qualitative, multi-faceted and inter- disciplinary work. Völker and Kistemann (2011, 2013) also ex- tended the therapeutic landscape idea theoretically to incorporate four broad space dimensions; active, social, symbolic and experi- ential. The UK-based Blue Gym initiative identified a range of

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important dimensions of coastal geographies related to mental, physical and social wellbeing (DePledge and Bird, 2009; White et al., 2010, 2011, 2013; Asbullby et al., 2013). Here the English coast was specifically reframed as a public and socially produced space for health promotion, illness prevention and improved health and wellbeing (Wheeler et al., 2012). Methodologically the research drew from national and local surveys to develop em- pirical knowledge on how coastal health was produced and de- veloped; driven by a multi-disciplinary team drawn from health psychology, geography, public health and anthropology. Key out- comes demonstrated how health was linked to reduced stress and increased physical activity (Wheeler et al., 2012). Other health geographers considered relationships between water and health in historic coastal settings (Foley, 2010). Here the reputation of healing waters, evident in historic seaside resorts, demonstrated how blue space therapeutic assemblages developed through a mix of social, economic, entrepreneurial and affective routes (Andrews and Kearns, 2005; Foley, 2010)

Theoretically, there has been a ‘relational turn’ within health geographies research (Parr, 2004; Conradson, 2005a; Cummins et al., 2007; Duff, 2010; Andrews et al., 2014). Through that re- search, the sometimes complex theoretical discourses associated with ANT (actor-network theory), more-than-representational theories and mobilities thinking are slowly acquiring a healthy blue tinge (Lorimer, 2005; Foley, 2011; Gatrell, 2013; Andrews et al., 2014; Kearns, 2014). Clear tensions exist between applied and theoretical health/place work that reflects splits between material descriptive accounts and more critical philosophical writing (Creswell, 2013; Kearns, 2014). Duff (2011) particularly argues for the need for meaningful accounts that merge the the- oretical and empirical to show how place shapes therapeutic outcomes. One area where the two productively meet are emo- tional and psychotherapeutic geographies (Philo and Parr, 2003; Davidson et al., 2009). Through studies focused on phobic/philic geographies, different approaches that combine theory and ma- teriality demonstrate how health may or may not be enabled in place (Duff, 2010; Parr and Davidson, 2010; Doughty, 2013; Philo, 2014). Different culture and condition-specific, embodied, gen- dered and experiential accounts are drawn from within both green and blue space to provide more nuanced understandings of how enabling places work and how theoretical ideas on relational place are central to those articulations (Foley, 2011; Duff, 2012; Mer- chant, 2011; Doughty, 2013; Pitt, 2014).

Post-medical geographies of health have also drawn from in- novative thinking in health philosophy to develop new perspectives. An essential aspect of the cultural turn saw health geography shift from biomedical towards social models (Kearns, 1993). Health pro- motion, developed strategically through the Ottawa Charter (WHO World Health Organisation, 1986), extended that narrow biomedical approach and recognised broader and more critical holistic under- standings of health (Williams, 2010; Lovell et al., 2014). Social, political and socio-ecological models of health and disease have been widely adopted that additionally focus attention on place (Illich, 1976; White, 1981; Kearns and Moon, 2002). Interestingly salutogenesis, a concept developed by Antonovsky (1979) and central to health promotion theory, has so far played a limited role in health geography, in part due to his very limited engagement with place. Antonovsky's key research emphasis was on what causes health (salutogenesis), not disease (pathogenesis). According to Antonovsky (1987) all humans are posi- tioned somewhere on an ease/dis-ease continuum between total ab- sence of health (H�) and total health (Hþ) and conceptually saluto- genesis means the movement towards Hþ. Through two additional concepts, generalised resistance resources and ‘sense of coherence’ (SOC), Antonovsky identified a set of culturally-framed life-course factors that enabled human health. The SOC comprised three com- ponents; comprehensibility (cognitive), manageability (behavioural),

and meaningfulness (emotional); all implicitly but not explicitly con- nected to where people live. Some aspects of the ‘salutogenic um- brella’ have been adopted by health geography, i.e. social capital, cul- tural capital, empowerment, resilience, coping (Benz et al., 2014). But a more direct articulation on how particular types of places or en- vironmental conditions are or become salutogenic is almost com- pletely absent (Ergler et al. 2013; Benz et al., 2014, especially Fig. 1). How blue space can be specifically framed against salutogenesis and extend its geographical potential, underpins many of the papers in this special issue (Lindström and Eriksson, 2005).

Another concern for critical health geography is the need to make research more policy relevant (Parr, 2004). A number of recent inter- national documents have created a robust policy backbone for links between environments and health. WHO Europe, through its Health- For-All (HFA) strategy, adopted a common health policy that re- cognised the dependence of human health on a wide range of en- vironmental factors, covering both direct effects and more indirect psychosocial factors, such as urban development and land use (WHO 1994). According to the European Charter (WHO (World Health Or- ganisation), 1989) every individual was entitled to an environment conducive to the highest attainable level of health and wellbeing. The UN Agenda 21 (UN, 1992) additionally demanded improved environ- mental quality and policies to protect and promote human health worldwide (WHO, 1993). Most recently Shanahan et al. (2015) iden- tified a fundamental shift in public health discourse that encompassed the diverse potential benefits of nature and open spaces. However, limited understanding of which components of nature deliver which health benefits still impedes an effective integration of nature into health policy (Calogiuri and Chroni, 2014). As a result, policy frame- works tend to employ broad provision-based targets such as proximity of natural spaces to residential areas, minimal size, or size per capita (English Department of Health, 2010; Scottish Government Directorate for Built Environment, 2009; US National Park Service Health and Wellness Executive Steering Committee, 2011). We share the vision of Shanahan et al. (2015) in calling for interdisciplinary research that brings together ecologists and health scientists to more fully uncover the mechanisms by which nature benefits human health.

Public Health professionals are increasingly aware of the re- levance of health geography research to their work (Dummer, 2008). Research into the health-promoting effects of blue spaces is a promising area for further engagement as it is already on the agenda of many current planning initiatives through earlier en- vironmental psychology research (Kaplan, 1995). Post-industrial uses for former water sites have received renewed attention within regeneration and sustainability initiatives, especially in urban settings (Hoyle et al., 1988; Kistemann et al., 2010). Planners around the world have recognised the ‘added value’ of water sites (Wakefield, 2007), in part because blue space is relatively cheap to produce and maintain but also due to its potential social and health benefits (Luttik, 2000; Kistemann et al., 2010). A more ex- plicit valuing of the coast may also help position ‘blue space’ re- search as firmly into the public health arena as existing work on green space and obesogenic environments (Collins and Kearns, 2007). This special issue offers practical and theoretical ap- proaches that provide more differentiated understandings of the relevance of blue space for public health policy (Mitchell and Popham, 2007; Richardson et al., 2012; Andrews et al., 2012).

3. Thematic discussion: relational geographies of healthy blue space

All six papers in this special issue are, explicitly or implicitly, inspired by an overarching salutogenic vision of the ‘enabling’ dimensions of blue spaces. If we combine ‘salutogenesis’ and SOC dimensions of cognitive, behavioural and emotional health more

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directly with dimensions of ‘place’, this opens up interesting per- spectives for future health geographical research. In better un- covering how and why blue spaces and places matter for health and wellbeing, we identify four sub-themes; embodiment, inter- subjectivity, activities and meanings, that contribute to more nuanced discussion of salutogenic associations within the papers.

3.1. Geographies of embodiment: a place for healthy/unhealthy bodies

Relationships between the body, health and place remain im- portant in culturally-shaped health geographies (Dorn and Laws, 1994; Hall, 2000; Moss and Dyck, 2003; Longhurst, 2005; Crad- dock and Brown, 2010). Bodies have material, discursive and imaginative components linked to physical and mental health and these are relevant in blue space. A range of intriguing metaphors emerge from the papers in terms of how bodies physically engage with, by and in water (Völker and Kistemann; Foley). Specific ac- tivities are stimulated by mobile and embodied inhabitations of water (Wareham et al., 2002; Duff, 2010). While the physical act of swimming, for example, provides established health benefits as- sociated with exercise, Foley argues there are immersive benefits in being active in blue space that are less measurable, but still speak to the idea of physical health. For Völker and Kistemann, there are self-identified physical benefits for bodies in urban blue spaces that are considered as having different, and conceivably, better effects than in nearby green spaces. Here again there is a blurring of space, as there are green-alongside-blue settings of river and lake-side that incorporate both forms.

Mental associations can also improve wellbeing, especially in blue space settings like lakes or coasts (Kearns and Collins, 2012). The idea of a ‘feel-for-water’ was identified in a number of papers, with Lengen specifically considering the imaginative aspects of blue space encounter. For her respondents, a feel for water, and indeed the colour blue, was not always positive, with darker shades associated with poorer mental health states. Yet the quality of the blue, shaped by light, shade, setting and reflection, were identified in several papers as important positive components that reflected a variety of moods. Associations between mental health, emotion, memory and blue space were also evident (Coleman and Kearns, Lengen), where blue space was a factor in a positive emotional attachment developed across the life course (Casey, 2001; Budruk and Stanis, 2013). For Coleman's respondents on Waiheke Island, the importance of the view of water, or the mark of it on the horizon, gave their lives greater value and meaning and supported a healthy ageing in ‘thick-place’ (Casey, 1993). In the urban settings of Cologne, Düsseldorf and Copenhagen (Völker and Kistemann, Thomas), that feel was evident in preference for the blue linked to the particular character of water and its imaginative impact, reflecting earlier landscape preference research (Herzog, 1984).

Several of the papers considered bodies of difference within blue space (Dorn and Laws, 1994; Hall, 2000; Longhurst, 2005; Chouinard, 2010; Parr and Davidson, 2010). There were a range of healthy/unhealthy bodies involved running across a perceived and measured ‘salutogenic’ range (Andrews et al., 2012). One char- acteristic of blue space is its capacity to embrace bodies of differ- ence in ways that are gently enabling. People with a range of physical disabilities can find it difficult to actively interact with green space; something that research on green space design, walkability and obesogenic environments arguably overlooks (Andrews et al., 2012). Yet bodies of difference can be explicitly enabled in blue space, in part through immersion within water (Foley; Kearns, Collins and Conradson; Coleman and Kearns) or through a more mental immersive engagement with an environ- ment that takes one outside oneself (Thomas; Lengen; Völker and

Kistemann). The papers provide accounts by different bodies from different types of blue space; gendered (Thomas), carceral (Kearns, Collins and Conradson), aged (Coleman and Kearns, Foley) or mentally impaired (Lengen). In those accounts we can better un- derstand the salutogenic continuum through engagements with blue space to envisage more inclusive understandings of multiple bodies of health in place. Finally a concern for how bodies were managed on Rotoroa Island, linked to a specific connection with alcohol abuse (Kearns, Collins and Conradson), referenced the Foucauldian definition of ‘managed/governmental bodies’ and wider debates on representation within embodiment (Foucault, 1979; Longhurst, 2005; Craddock and Brown, 2010). Considering how bodies of difference are enabled in freer ways in blue space is a core concern for most of the papers.

3.2. Relational spaces of inter-subjective encounter

A concern with inter-subjectivity is evident in all the papers. Drawing from relational geographies, the papers explore re- lationships between different subjects and between subjects and place (Cummins et al., 2007; Lorimer, 2008; Pile, 2010; Ash and Simpson, 2014). Such work has had some attention in health geography, especially in relation to emotional geographies (Con- radson, 2005b; Davidson et al., 2009; Wood and Smith, 2004). Yet a concern for inter-subjectivity remains under-developed and the papers provide useful empirical examples that flesh out inter- subjective components of place attachment and orientations to- wards health (Duff, 2010; Budruk and Wilhelm Stanis, 2013). In particular, descriptions of inter-subjective encounters extend thinking around the subject–object relationship to consider mul- tiple subjects relating to multiple objects in blue space (Bingley, 2003; Ash and Simpson, 2014).

For Foley, the exploration of health and wellbeing in swimming places considers how an inter-weaving of individual and group meanings and shared life course histories provide an experiential affective power that emerges specifically from encounters in blue space (Pussard, 2007). Swimmers as subjects swim within water- as-object that is mobile, enclosing and productive in health terms (Evans and Allen-Collinson, 2014). That sense of an inter-sub- jective experience is also evident in the urban papers (Völker and Kistemann, Thomas), where communal interactions also have enabling effects. In walking, sitting, eating and contemplating by the River Rhine, the multiple subjects reflect a mobile blue space that contains embodied flows (Pitt, 2014). For Thomas the en- counter may not always be a positive or health-promoting one, and it is important to recognise that negative aspects of inter- subjectivity associated with the presence of other subjects – en- gendering shame, fear, disapproval – can be by-products of public blue space encounters. All of the studies speak to what Philo (2014) refers to as ‘insecure’ bodies, and this inter-subjective as- pect emerges in many of the accounts.

The remaining papers (Coleman and Kearns, Foley, Lengen and Kearns, Collins and Conradson) identify more affective and emo- tional dimensions of inter-subjectivity (Davidson et al., 2009). For each, place energies that are mobile, material and imaginative, are experienced in blue spaces to produce what Duff (2010) broadly describes as affective atmospheres. For Lengen, her respondents reflect on imagined landscapes that move them; emergent from memory and their own experiences of people and place. For Co- leman and Kearns, the affective power of Waiheke Island as home, community and refuge, sets out a deep affection for blue space through shared feelings of care between subject and object (Casey, 1993). Here Tuan's (1990) term topophilia can be ea

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