Returning to the river: the salutogenic model as a theory to explore the relation between outdoor activities and health

ABSTRACT

An ongoing discussion is a debate about the benefits of outdoor activities for health, where a narrowness regarding the benefits as a matter of curing or preventing disease has been questioned. Hence, there is an urgent need to theorize further the relationship between outdoor activities and health with robust theoretical frameworks that can guide research and practice, taking different aspects of human-nature relations into account. In the paper, a critique of pathogenic perspectives of health is forwarded, as well as a critique of an anthropocentric human centeredness of health. Instead, a salutogenic model and the metaphor of the swimmer in the river is used to discuss the relation without being restricted to health as the absence of disease or to human health and wellbeing. In the paper, seven different relations, or salutogenic questions, are provided, moving from the swimmer in the foreground, to swimmers in the river to finally foregrounding the river.

KEYWORDS:

• Salutogenesis
• outdoor education
• friluftsliv
• health
• more-than-human health

Introduction

Why do people stay healthy? (Antonovsky, 1979, p. 35)

An ongoing discussion within many academic fields, such as education, psychology, public health, tourism, and sport science, is a debate about the benefits of outdoor activities for health (for reviews, see, e.g. Coventry et al., 2021; Hanna et al., 2019; Janowski et al., 2021; Mathias et al., 2020; Pomfret et al., 2023). This discussion has often focused on the outdoors as an environment for increased physical activity, prevention of mental illness, and as a form of therapy. This, in many ways, reflects an assumption in research that the outdoors, or activities in the outdoors, can be seen as a beneficial space to prevent disease and cure humans of various illnesses. Hence, humans should, in this way, use outdoor environments for instrumental and anthropocentric purposes as a setting for individual health and wellbeing (see Maller et al., 2006). Parallel, there is also an academic discussion regarding how the relation between being in the outdoors and human health or wellbeing can or should be conceived in different contexts in terms of what wellbeing is, how it can be measured, and, as a consequence, its relation to health (see Houge Mackenzie & Brymer, 2020; Pritchard et al., 2020; Richardson et al., 2021; Roberts et al., 2020).

At the same time, as this special issue is proof of, the taken-for-grantedness and narrowness regarding the benefits of outdoor activities for health as mainly a matter of curing or preventing disease has been questioned (Backman & Svensson, 2022; Brymer et al., 2019; Maller et al., 2006). Also, how this relation theoretically should be understood or explored has been under scrutiny where, for example, positive psychology (Houge Mackenzie & Brymer, 2020), sustainable tourism theory (Hanna et al., 2019), and socio-ecological theory (Maller et al., 2006) have been suggested as ways to move beyond deficit, and risk-focused, models of health and instead focus on nature more holistically as a resource for human health. However, as stated in the special issue call, research is just ‘beginning to consider the importance of societal systems, individual differences, and the person-environment relationship (Brymer et al., 2019)'.

So, even if there are critical voices and new accounts of human-nature relations, for example, that the involvement of place-responsiveness can benefit both people and environment (Mikaels, 2017, 2018; Wattchow & Brown, 2011) or that adventurous nature sports can foster mental and physical wellbeing (Houge Mackenzie & Brymer, 2020), there is an urgent need to further theorize and discuss the relation between outdoor activities and health, not the least in educational contexts. Hence, what is missing is robust theoretical frameworks that can guide research and practice, taking different aspects of human-nature relations into account without being restricted to health as the absence of disease or to human health and wellbeing. Such frameworks can help identify central gaps in knowledge beyond curing or preventing disease, facilitate the development of research designs, support the studies’ claims, and make cumulative knowledge production regarding the relation between outdoor activities and health more rigorous.

The purpose of this conceptual paper is thus to provide a theoretical basis for continual discussions about the relation between outdoor activities and health in research and practice. This is done through a critique of the dominance of pathogenic perspectives of health as well as a critique of an anthropocentric human-centeredness of health. Further, a salutogenic approach is used to offer alternate ways to discuss health issues in relation to outdoor activities. We will here use Antonovsky’s (1996) metaphor of the swimmer in the river to discuss the relation beyond risk prevention and individual health and wellbeing. In the article, we subsequently would like to add richness to the discussion about the relation between outdoor activity and health, conceptually providing new meanings to healthy human-nature relations.

The relation between outdoor activities and health—some historical and conceptual perspectives

The relationship between outdoor activities and health in terms of relations to nature has concerned people in different ways for a long time, often with a notion that if we live in harmony with nature, we are in good health (Quennerstedt et al., 2021; Richardson et al., 2021). One example is romantic ideas and critique of civilisation inspired by Rousseau, where a simple life close to nature contrasted with an unhealthy urban life. Health here becomes a philosophical vision and an idealistic idea of how to live a good life.

The human-nature relationship is, at the same time, a highly contested topic and, as such, evokes complex and sometimes contradictory responses. Nature may not only be one of the most complicated words in the English language but, according to Macnaghten (2019), also linked to many of the key concepts underpinning Western thought. Even in mediaeval times, there was ambiguity in people´s relationship to nature. This ambiguity was captured in two singular and essentially competing representations: that of nature as God’s absolute ruler who possesses such powers of destiny impossible to escape; and that of God’s creation as Mother Earth, who nurtures and provides for the needs of humanity. A dichotomy into such singular natures helped make sense of everyday life and, consequently, people’s health. When times were good, nature was personified as a mother, a goddess who provided and nurtured. However, in times of famine and plague, nature became personified as a jealous and unpredictable emperor (see Macnaghten & Urry, 1995).

Thurfjell (2020) further argue that in pre-modern peasant society, the relationship between people and nature was gendered. Men and women had different duties around the farm and in the household, which regulated their interactions with the landscape. Furthermore, women’s relationship with nature was affected by the limitations that patriarchal societal conventions entailed, and health risks of unwanted pregnancy and violence were constantly present. Consequently, wild nature was not available to women in the same way as it was to men.

Today, the relationship with nature is highly influenced by the development and growth of industrial society, where the fundamental societal shift brought by industrialisation, urbanisation, and modernisation has created a new view of nature. The old peasant society was replaced by an urban and industrialised society characterised by individualism, faith in reason, and secularisation. These societal shifts have ruptured many people’s relationships with nature, and the notion of perceiving oneself as separate from nature while acknowledging its dependency has led to complicated relationships with the natural world. Nature can be amazing but also harsh and hostile, and certain environments pose challenges for humans due to their geographic location and particular conditions, including toxic chemicals from human activities, weather patterns, and topographical features (Ewert et al., 2021).

Research on the relation between outdoor activities and (human) health

In the last two decades, a growing body of literature has suggested that interactions with nature are integral to maintaining and enhancing human health and wellbeing (e.g. Pritchard et al., 2020; Richardson et al., 2021; Roberts et al., 2020). In fact, there is evidence to support that a close relationship with nature has been acknowledged as a fundamental human psychological need that must be satisfied to experience complete wellbeing (Richardson et al., 2021). At the same time, climate change is the most significant global health threat facing the world in the 21st century. Any threat to the health and vitality of ecosystems is thus a threat to human health since the two are inextricably linked. But what does research explicitly addressing this relation reveal?

Studies on the relationship between outdoor activities and health display a variation in how health and wellbeing are conceptualised. Themes in the literature are, for example, physical and mental balance, immersion and transformation, and personal development (Pomfret et al., 2023). One of the most influential strands is the interpretation of health in terms of physical activity levels (Coventry et al., 2021, Janowski et al., 2021; McCurdy et al., 2010; E. Mygind, 2007; Romar et al., 2019). For example, in recent reviews, physical activity is emphasised as a core dimension of outdoor adventurous activities (Janowski et al., 2021), and it is concluded that there are higher levels of physical activity in natural environments in comparison to other comparable environments (L. Mygind et al., 2019). At the same time, another review argues that they found little evidence of improved physical health in nature-based interventions (Coventry et al., 2021). Some studies also indicate that increased physical activity levels in the outdoors can affect health, such as improved self-esteem and mental health (Cotterill & Brown, 2018). E. Mygind (2007) and Romar et al. (2019) have explicitly focused on the effects of the outdoor environment on young people’s physical activity. They found that physical activity levels among primary school children are significantly higher when school is arranged through outdoor learning than in a traditional indoor school context.

Another strand focuses on the relationship between outdoor activities and mental health (Gustafsson et al., 2012; Jepsen Trangsrud et al., 2022; Mutz et al., 2019; Pomfret et al., 2023). For example, in an intervention study by Gustafsson et al. (2012), they found that education in outdoor settings could be beneficial for school children’s mental health and more likely so for boys compared to girls. Further, a study by Mutz et al. (2019) confirmed the hypothesis that adolescents’ participation in a 10-day program focusing on outdoor adventurous activities would decrease their screen time and lead to changes in stress levels, hedonic balance, and life satisfaction. Jepsen Trangsrud et al. (2022) found that participating in outdoor activities seems to support the recovery of persons with eating disorders in that the outdoor environment and the outdoor practice ‘facilitated a dynamic and relational space for reflecting on and recognising one’s needs’ (p. 175). In a systematic review of the benefit of immersive nature experiences on various aspects of health, L. Mygind et al. (2019) also revealed that nature experiences benefitted mental health in terms of academic and cognitive performance, resilience, self-esteem, and self-efficacy. Further, participation in outdoor adventurous activities has proven beneficial for improved sleep, reduced stress levels, and more mental energy (Pomfret et al., 2023).

Closely related to mental health is the therapeutic function that outdoor and adventure activities can have for behaviour and health (Pomfret et al., 2023), particularly for socially marginalised groups and indigenous youth (Fernee et al., 2021; Jeffery & Hensey, 2022; Mathias et al., 2020; Pryor et al., 2005; Ritchie et al., 2015). After a 12-month wilderness therapy program in Norway, adolescents with fragile life stories were found to have made progress in various ways due to the group treatment. The authors claim that ‘most participants seemed to exert greater independence and agency in their lives’ (Fernee et al., 2021, p. 79). In a study by Ritchie et al. (2015), indigenous adolescents in Canada (ages 12–19) took part in a 12-day adventure leadership course. The purpose was to establish whether the program could promote resilience and wellbeing among the participants. It was found that the program evoked feelings of connectedness that made them aware of their surroundings and who they were as a person. In a review of literature focusing on the physiological and psychological benefits of forest bathing, Mathias et al. (2020) highlighted new perspectives for education and medicine related to the outdoors and nature. Further, Pryor et al. (2005) have shown that bush adventure therapy can promote health and wellbeing for individuals with health vulnerabilities.

In conclusion, this brief overview displays a quite medicalised, so-called pathogenic picture of the relation between outdoor activities and (human) health. The use of nature and the outdoors for increased physical activity, prevention of mental illness and in the form of therapy reflects that being in the outdoors is understood as a way to cure humans from illness or to prevent illness and that humans are to use outdoor environments for, individual, instrumental, and anthropocentric purposes. The fact that nature and the outdoors are often seen as a resource for human health (see, for example, Maller et al., 2006) is a notion that we will critically discuss further in this paper.

Perspectives on health

Undoubtedly, health in general has many different meanings, from wellbeing and societal public health issues to health prescriptions and not being sick or obese (Antonovsky, 1987; Mittelmark et al., 2022). Meanings of health are also intimately connected to views of what it means to be human as well as other central values within, for example, philosophy, religion, politics, and science (Tones & Green, 2004). In this vein, Wright and Burrows (2004) argue that ‘clearly “health” is a term used in diverse ways, linked to particular value systems, world views and socio-political, economic and cultural contexts’ (p. 216). Consequently, health constitutes a taken-for-granted part of society and people’s lives, where different conceptions of health can be said to compose one of the more fundamental properties of people’s lives.

In Western societies, a biomedical—scientifically normative—perspective on human health has dominated our thinking and practices (Mittelmark et al., 2022; Quennerstedt, 2019). At the same time, not the least during the 20th century, other views of health have been introduced. An example is the classic definition of health from the World Health Organisation (WHO). Here, health is depicted as a positive goal and described as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946, p. 1).

The definition was very innovative for its time and has had an immense impact on the debate around issues of health. At the Ottawa conference in 1986, WHO further developed their position on health and health promotion, stating that:

Health is created and lived by people within the setting of their everyday life: where they learn, work, play and love. Health is created by caring for oneself and others, by being able to take decisions and have control over one’s life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members. (WHO, 1986, p. 2)

In the Ottawa Charter, health is described as a resource created and developed in a relation between the individual and the social, cultural, and natural environments the individual inhabits. Further, in the 2005 WHO Bangkok charter, health promotion is also closely connected to, among other things, human rights, solidarity, equal opportunities, global development, infrastructure, and sustainability. Hence, at least at a policy level, health can be said to encompass almost all areas of society.

Pathogenic and salutogenic notions of health

Many descriptions of what health is or isn’t start in a form of normality, where health equals a human being’s normal condition. The inevitable consequence in policy as well as in practice is then a focus on deviations from this normality or how to prevent risks in relation to these deviations. This is sometimes discussed as pathogenic (= origins of disease) perspectives of health (Antonovsky, 1979, 1987; Quennerstedt, 2019).

If one is ’naturally’ healthy, then all one has to do to stay that way is reduce the risk factors as much as possible … [and] … facilitate and encourage individuals to engage in wise, low risk behaviour. (Antonovsky, 1996, p. 13)

These deviations (i.e. not health) have either been scientifically normative, for example, in relation to medical science or psychoanalysis, or morally normative, for example, as correct behaviour, male gender, heterosexuality, or normal body weight and shape.

In scientifically normative views, health becomes a condition in absence of disease, and health is then a goal and a static condition achievable through avoiding diseases or risks with diseases (Quennerstedt, 2019). These pathogenic perspectives tend to focus on and, as the overview of research above reveals, ask questions relating to how outdoor activities in an instrumental sense can cure or prevent various individual medical and psychological conditions threatening the ‘normality’ in terms of absence of risk, disease, and not normal behaviour. As Antonovsky (1996) reminds us, efforts regarding health should then be directed towards reducing these risks by using or encouraging outdoor activities so people engage in wise, low risk behaviour where a healthy use of the outdoors becomes ‘risk-free’ and used as risk prevention or for curing disease.

In morally normative views of health, at least today, health becomes an attractive surface and a fit and fat-free body, and deviations from the unattainable ideals in society are constituted as unhealthy and, in some cases, even immoral (Fitzpatrick & Tinning, 2014). These pathogenic perspectives are more uncommon in relation to the outdoors but, when highlighted, tend to focus on and ask questions about obesity and how outdoor activities can prevent individuals from becoming overweight. Also, the picture of young and fit people performing fitness routines or quite adventurous outdoor activities is abundant in various media. It is important here to note that scientifically normative perspectives are often amalgamated with moral norms with regard to human health. Historically, homosexuality is an apt example, which, at least in Sweden, was defined as a disease up until as late as 50 years ago. Here, moral norms regarding sexuality are blended with a psychological, allegedly scientific diagnosis. Today, the same can be said about body shape and form and so-called over-weight bodies as unhealthy (Quennerstedt, 2019). So, when outdoor activities are advocated as a method for combatting obesity, scientific and moral norms go hand in hand.

In line with Antonovsky (1979, 1987, 1996), and within outdoor research following Houge Mackenzie and Brymer (2020) and Maller and colleagues (2006), we maintain that two major weaknesses with pathogenic, deficit-oriented notions of health are: (i) the dichotomous classification of disease versus health, medicalising human existence assuming that health is a static condition that can be achieved by avoiding disease, and (ii) the inevitable concentration on deficits and risk factors threatening this normality and therefore often blaming the victim. Instead, Antonovsky (1987) urged research and practice to ‘move beyond post-Cartesian dualism and look to imagination, love, play, meaning, will and the social structures that foster them’ (Antonovsky, 1987, p. 31).

Hence, following Antonovsky’s advice and in line with the ideas from WHO (1986) regarding health being ‘created and lived by people within the setting of their everyday life: where they learn, work, play and love’ (p. 2), other theories have emerged as a critique against primarily biomedical notions of health. These theories take their point of departure from a philosophical standpoint different from such pathogenic perspectives. The theories can, as Antonovsky (1987) reminds us, be termed salutogenic (= origins of health), and the common denominator is a critique and strong resistance towards health being defined in a dualistic manner as the opposite of disease or not normal behaviour (Lindström & Eriksson, 2010, Mittelmark et al., 2022; Quennerstedt, 2019). In salutogenic theories, health is not something you either have or do not have. Instead, it is, as Antonovsky (1987, 1996) argues, about different degrees of health on a continuum created and sustained in an ongoing process (Lindström & Eriksson, 2010). In this sense, everyone is in some way always healthy, and many aspects that promote or prevent health development can be encompassed. As Antonovsky maintain, ‘ … we are all terminal cases. But as long as there is a breath of life in us, we are all in some measure healthy’ (Antonovsky, 1987, p. 50). Diseases can, of course, affect people’s health also in a salutogenic perspective, but diseases are regarded as separate processes applicable in certain situations as something that hinders health development. It is consequently possible to have a disease and still be healthy. However, in relation to our ambition in this paper, still, most salutogenic theories are delimited to human health and wellbeing (see, e.g. Hanna et al., 2019; Pomfret et al., 2023).

The salutogenic model and the metaphor of the river

In this section, we use the metaphor of the river to move beyond the dichotomous division between health and disease and follow Quennerstedt’s (2019) suggestions that we should: ‘free health from death, disease, risk, and deficits, [and] free health from only being understood as a singular noun signifying a human being’s normal condition’ (p. 2). For this, we will use Antonovsky’s (1996) metaphor of the swimmer in the river to discuss the relation between outdoor activities and health without being restricted to health as the absence of disease or, consequently, to human health and wellbeing.

In 1992, the health sociologist Aaron Antonovsky, in a WHO seminar in Copenhagen, discussed the metaphor of the river often used within public health. With it, he tried to elucidate his ideas about health and a salutogenic model of health as a guide for health promotion. In the following paper (Antonovsky, 1996), he deliberated the preoccupation in curative medicine with rescuing swimmers from drowning downstream in a wild and raging river (see, e.g. Mitten et al., 2018) and preventive health efforts to stop people from falling into the river upstream (see, e.g. Maller et al., 2006). This also entails a fixation on what happens downstream without necessarily asking questions about how they ended up there in the first place. Instead, as Antonovsky argued from a salutogenic perspective, nobody is actually on the shore, ‘we are all, always, in the dangerous river of life. The twin question is: How dangerous is our river? How well can we swim?’ (Antonovsky, 1996, p. 14). As Antonovsky elaborates:

… my fundamental philosophical assumption is that the river is the stream of life. None walks the shore safely. Moreover, it is clear to me that much of the river is polluted, literally and figuratively. There are forks in the river that lead to gentle streams or to dangerous rapids and whirlpools. My work has been devoted to confronting the question: Wherever one is in the stream – whose nature is determined by historical, social-cultural, and physical environmental conditions – what shapes one’s ability to swim well?.” (Antonovsky, 1987, p. 90)

Hence, we cannot explore health by focusing on people (swimmers) as though they are not in the river (the environment), and we would add that we cannot explore human health without taking the health of the river into consideration.

The metaphor is thus used to describe the salutogenic health continuum between ease at one end (up-stream) and dis-ease¹ at the other (down-stream). On this continuum between up-stream and down-stream, health is understood as a dynamic and ever-present relation between the swimmer and the water where resources, e.g. how outdoor activities, nature connectedness or nature as such, can be found in the river, with the swimmer, or in the relation between the swimmer and the river. Importantly, the swimmer is not merely located in the river. Instead, it should be understood as a functional relation, where both the swimmer and the river are in a constant process of becoming the swimmer and the river they are or as healthy as they are. The meanings made in the outdoors thus form our way of being in the world, where the individual (the swimmer), as well as nature (the river), are essential in terms of the meanings attached to experience. This is described further by Quennerstedt (2019) in terms of:

To continue the relational aspects of the metaphor, an Olympic swimmer in a strong current might be down river (i.e., more towards dis-ease), and a half decent swimmer in a calm part of the river might be more upstream (i.e., more towards ease). The question is instead why they both are in their particular parts of the river in the first place and how they can keep their relative positions in it. What is at stake in education is thus the kind of swimmer we are to become and the kind of river that is in the making. (p. 5)

What the metaphor helps with for our endeavour is that it opens up for different questions about the relation between outdoor activities and health than what would be possible within a narrower pathogenic perspective. In his writings, Antonovsky suggested salutogenic questions like: ‘Why do people stay healthy?’ (1979, p. 35) or ‘What can be done in this community, factory, geographic community, age or gender group?’ (1996, p. 16) for them to stay healthy. In relation to outdoor activities (using the river metaphor), salutogenic questions that could be asked are, for example; (i) how can outdoor activities play a part in strengthening the ability to swim, (ii) how are outdoor activities part of the river the swimmer is in, (iii) how can outdoor activities guide swimmers to a different part of the river, (iv) how can being in the outdoors constitute a different and healthier part of the river, (v) how can swimmers recognise or change their part of the river, (vi) how can we change the river we are in for the better of the whole river and the quality of the water, and (vii) how can we act in sustainable ways protecting the river we all live in? This will be further discussed and illustrated in the following. But first, a couple of words on critiques towards salutogenic perspectives in this context.

Critique of salutogenic theories in relation to outdoor activities

Critical concerns have also been raised with salutogenic notions of health (see Mittelmark et al., 2022). Quennerstedt and Öhman (2014), for example, argue that salutogenic approaches can be understood and practised in relation to neoliberal societies where also salutogenic research can be understood as individualistic and decontextualised, making McCuaig and Quennerstedt (2018) ask: where is the river in salutogenic research? The question is whether salutogenesis as a model actually disputes the idea of an individual responsibility for health in terms of the individual being both the problem and the solution if it fails to take political, societal, and environmental concerns (issues of the river) into consideration. Quennerstedt and Öhman (2014) further argue that:

… if people are always struggling towards the ‘more health’ end of a continuum (up river), then health will become a never-ending struggle (for the swimmer). (p. 199)

Within a society where a focus is on individual responsibility and a constant demand for development, the consequences can be a ‘total healthification of people’s entire existence, in that everything becomes a choice about health’ (p. 200) on a never-ending continuum. In this vein, Antonovsky (1996) also highlights that particularism, such as undemocratic societies, patriarchies, or fundamentalism, can potentially lead to good health, but only for those with power. Antonovsky instead promotes pluralism, equity, and democratic participation as routes to making the river, and thus the possibility for better health for all, more forthcoming.

The relation between outdoor activities and health and the metaphor of the river

Using a salutogenic model to conceptually discuss the relation between outdoor activities and health in research and practice entails a focus on the swimmer and the river but, most importantly, on the different relations between them. As Antonovsky reminds us—you can never take the swimmer out of the river. Hence, in the following, we will highlight what we so far have described theoretically and add richness by asking salutogenic questions about the relation between outdoor activities and health, moving from the swimmer in the foreground to swimmers in the river to finally foregrounding the river in this relation.

How can outdoor activities play a part in strengthening the ability to swim?

The relation between outdoor activities and health, foregrounding the health of the individual, is probably the most common way to explore and understand this relation. In our overview of research, this is visible where outdoor activities are highlighted as leading to higher levels of physical activity (E. Mygind, 2007; Romar et al., 2019), reduced risks for a number of diseases (McCurdy et al., 2010), affecting mental health (Jepsen Trangsrud et al., 2022; Mutz et al., 2019), psychological wellbeing (Hanna et al., 2019), activity-based personal and social development (Hartmeyer & Mygind, 2016; Lohr et al., 2021) as well as providing a suitable environment for children’s motor development (Roberts et al., 2020). With regard to physical activity, the outdoor environment has been claimed to provide better opportunities than indoor environments. This is the case for quantity as well as for quality, for example, in terms of developing body awareness or the affordances for movement included in the outdoor environment. Green spaces have also been associated with better self-perceived general health and better mental health. Health is then about maintaining and strengthening individuals’ psychological, physical, social, and cognitive abilities that can help in the river of life (Houge Mackenzie & Brymer, 2020; Pomfret et al., 2023).

Another example of how outdoor activities play a part in strengthening the ability to swim is how outdoor activities can support children’s motor development. In a study by Fjørtoft (2004), the values of playing in complex and challenging natural environments are explored. Fjørtoft contends that natural landscape features influence children’s motor development by providing opportunities for varied play, for example, climbing trees, moving in fields and in the forest, hiding, or rock climbing. This improved balance and coordination in the investigated group and contained irreplaceable values of children’s play in nature.

Within this relation, outdoor activities become a method or motive for mainly physical and psychological health, and nature and the relation to nature thus constitute the backdrop for activities like hiking, running, swimming, skiing, climbing, or playing.

How are outdoor activities part of the river the swimmer is in?

Outdoor activities often form a significant part of people’s lives. In Sweden, where the authors are based, the proportion of residents (age 16–84) who have engaged in common outdoor activities such as gardening, walking, hiking, and outdoor bathing at least once during a period of 12 months varies between 65–85%.

Besides the non-organised outdoor activities described above, outdoor activities in organised forms are conducted within different organisations. In Sweden, for example, the Swedish Sports Confederation involves most children and young people, and many sports are outdoor sports. The dominant public discourse is that sports and physical activity are suitable for people’s health. Still, critical perspectives, for example, regarding early specialisation and lack of equal opportunity, are becoming more and more highlighted. These critical perspectives have not (yet) been visible to the same extent in the organised Swedish Outdoor Movement. This organisation includes 1,8 million members in Sweden, and about 300,000 of them are children and young people. In conclusion, The Swedish Sports Confederation and The Swedish Outdoor Movement form a significant part of how outdoor activities are a part of people’s daily lives in Sweden.

Outdoor education in the school context is another example that illustrates how outdoor activities are part of all young people’s daily lives. In Sweden, outdoor education (friluftsliv) in schools is contextualised within physical education. One challenge related to outdoor education in Swedish schools is how to avoid the logic of the sport that dominates outdoor education and the failure to include perspectives such as sustainable development or place-responsive pedagogy (Mikaels, 2018). Another challenge highlighted is how to combine national ideas about outdoor education (friluftsliv) in Scandinavia with outdoor cultural traditions from other countries through schooling (Backman, 2018).

Within this relation, outdoor activities and being outdoors are understood as a natural part of people’s everyday lives and, as such, constitute an aspect of what it is to live a healthy life.

How can outdoor activities guide swimmers to a different part of the river?

An important question in this relation is what guidance there is for people to find environments that can strengthen their specific preferences for outdoor activities. Outdoor organisations can here have the resources to customise outdoor activities according to individual preferences, but only some people are members of an outdoor organisation. When considering that preferences for outdoor activities are related to socio-economic and cultural background, one realises that the health potential of outdoor activities is not accessible to everyone. For outdoor activities to be a more potent contributor to health, they should be made accessible and easily adjustable, primarily for those currently not in the outdoor movement.

Those not involved in outdoor organisations can be helped to identify and recognise which parts of the river, or which outdoor logic (Backman & Svensson, 2022), that matches with their preferences. To counteract the socially stratified reproduction of outdoor activities, it is essential to start at a young age, in compulsory schooling, in a context where socio-economic background is as weakly predictable for later outdoor preferences as possible (Backman, 2018). Exposure to outdoor environments and experiences at a young age does not automatically mean you ‘learn to love’ the outdoors. However, regardless of whether a child likes outdoor experiences in school or not, they can incorporate embodied memories of outdoor contexts, outdoor situations and perhaps also of body movements in these contexts and situations. This experience can potentially make the threshold less of an obstacle when people potentially resume outdoor activities later in life.

Considering the previously discussed example of outdoor education in schools, this context has excellent potential for guiding young people to find what outdoor activities match their preferences. Contexts for outdoor education in schools, not the least physical education, can improve in offering a variety of outdoor activities if the goal is for outdoor education to be inclusive (Backman, 2018). Besides learning of the preventive effects of outdoor activities, outdoor education can give children and young people a chance to experience and reflect on the intrinsic values of outdoor activities and learn that outdoor activities can serve purposes of meaningfulness and environmental awareness (see also Houge Mackenzie & Brymer, 2020; Janowski et al., 2021).

Within this relation, different organised and unorganised outdoor activities can act as a vehicle in terms of how being involved in activities in the outdoors can support or encourage people to live healthier lives, i.e. to change the life circumstances they currently inhabit.

How can being in the outdoors constitute a different and healthier part of the river?

The relation between outdoor activities and health, where being in the outdoors constitutes a different and healthier part of our environment, is about nature as a place for unique experiences involving intrinsic values with being outdoors that cannot be found in urbanised society (Sandell & Öhman, 2010). Being in nature can then offer an escape or an antidote to everyday life where feelings of connectedness to nature (Houge Mackenzie & Brymer, 2020; Ritchie et al., 2015) and existential dimensions of human-nature relations like experiences of meaningfulness are foregrounded (Quennerstedt et al., 2021). Here, contact with nature is a goal in itself, offering calmness, harmony, and spirituality (Trangsrud et al., 2022), but also a reverence for nature, thus constituting a healthier part of the river in terms of making sense of human-nature relations.

Lund Fasting and Høyem (2022), for example, highlight how experiences of freedom, joy and wonder in surrounding nature were important when their participants looked back at experiences of being in the outdoors, while Loeffler (2019) highlighted experiences of a spiritual connection to nature and landscapes as imperative. Another example is how Cumbo and Welch (2023) describe ‘environmental attunement’ that includes 'local First Nations ways of knowing and cultivating a place-consciousness that is relational to movement, healing and wellbeing with a sensitivity to the complex interrelationships between nature and culture with the un/built environment and landscapes.’ (p. 669).

One particularly illustrative example of how being in the outdoors constitutes a different and healthier part of the river is friluftsliv (life in the free air), which is a particular outdoor activity involving a simple life close to nature. In a study of adolescents’ experiences of friluftsliv, Haaland and Tønnessen (2022) revealed three essential aspects. First, as a departure from everyday life, the adolescents in residential care homes experienced friluftsliv as something unique, where they were ‘coming closer to nature and noticing how the natural environment looks and feels different compared to everyday life’ (p. 218). Second, the participants experienced that nature provided an environment where social relations were inclusive and inviting, including feeling more connected to nature. Third, nature as a different existence, where the participants, in a sense, are forced to relate to natural environments, actively engaging in outdoor activities, and, as a consequence, start to notice the natural environments surrounding them.

Within this relation, it is the outdoors and the relation to nature, and not the activities done in the outdoors, that is important for how being in the outdoors constitutes a different and healthier part of the river.

How can swimmers through the outdoors recognise or change their section of the river?

This relation is about how people, through being in the outdoors, can notice, recognise, and change their local environments towards becoming more healthy environments. Or, to put it differently, how outdoor activities that involve creating a more profound knowledge and understanding of how the outdoors may strengthen the relations between people and place (Houge Mackenzie & Brymer, 2020). Let us begin by taking a closer look at the words recognise and change in the sub-heading as we try to make sense of the ’dangerous river of life.’ These words describe actions, i.e. what the subject is doing or feeling. Therefore, depending on how we recognise or perceive the river, as a playground or as unique places rich in local meaning and significance, this will have implications for how we position ourselves in relation to the river and the more-than-human world.

A potential risk with recognising nature as an arena or playground is that the natural world is reduced to merely a backdrop for human-centred activities. Another risk of recognising nature merely as an arena or playground is that it may promote and reinforce anthropocentric worldviews rather than challenging them. Moving beyond an anthropocentric notion of seeing nature as ‘the other’ involves an ontological turn towards an empathetic response to the cultural, historical, and ecological conditions of places and possibilities for a different and more nuanced relationship with the natural world.

The key role that the natural environment plays in maintaining and enhancing our mental health and wellbeing has been proposed as a fundamental human psychological need that must be satisfied to experience complete wellbeing (Houge Mackenzie & Brymer, 2020). Empirical studies have suggested that nature connectedness, engagement with nature through simple activities, indirect engagement with nature, and knowledge and study of nature are beneficial to human health and wellbeing (Richardson et al., 2021). However, it is worth noting that the way people experience or emotionally connect with the natural world is neither simple nor uniform and varies between individuals and cultures.

Within this relation, health is about how people notice, connect to, and potentially change their local environments or the perception of their natural environment in different ways.

How can we change the river we are in for the better of the whole river and the quality of the water?

This relation entails a stronger focus on the environment and how actions of humans affect the more-than-human world through changed ideas about human-nature relations. One example of how we may change the way we recognise the wellbeing effects of human-nature relationships is through employing a place-responsive approach. Place-responsiveness is a potential health resource for the benefit of the health of both people and the environment, where the intrinsic values of nature are highlighted. Viewing humans as responsible caretakers of the more-than-human world challenges anthropocentric discourses where humans are seen as superior to nature and, therefore, entitled to use and control it. By recognising nature as a vital materiality on which life depends, place-responsiveness builds on the notion that humans and nature are entangled on a plane of immanence. However, it is worth noticing that flattened ontological or materialist frameworks have been critiqued for de-emphasising the agency of people and politics and for not engaging in Indigenous issues of land and place (Tuck & McKenzie, 2015).

In this context, place-responsiveness is about deepening the knowledge and understanding of the relationships between people and place. It’s about being attentive and curious about the places we dwell in or visit. It can be a nearby city park or a forest area in the local vicinity, seascapes, or mountain landscapes. Attention and curiosity are directed towards the cultural, historical, and ecological conditions of different places. Each place is unique and has its own story as well as environmental challenges (Mikaels, 2018). It is about becoming responsive to how humans affect and, in turn, are affected by natural places. It is also about engaging in stories belonging to places and creating our own stories from an embodied engagement with and in places. An initial curiosity towards place may open further discussions and more critical questions to be asked, including, but not limited to, questions about environmentally sustainable human-nature relationships.

In this relation, the health of the natural environment is more in focus. Nature is considered to have intrinsic values, and emphasis is directed towards how people can change actions, behaviours, and structures for the betterment of the environment.

How can we act in sustainable ways protecting the river we all live in?

Regarding how we can act in sustainable ways protecting the environment we all live in, the relation between outdoor activities and health is here, putting the river, i.e. the health of the planet, exclusively in focus. It is about environmentally sustainable human-nature relations, viewing all humans collectively as responsible caretakers of the more-than-human world (Houge Mackenzie & Brymer, 2020). As Sandell and Öhman (2013) put it, the aim is to offer or to be ‘a voice of nature’ (p. 44).

Much research highlights sustainability and health issues in terms of risk, for example, in the 2022 report of the Lancet Countdown on health and climate change (Romanello et al., 2022). In this report, topics like heat, drought, extreme weather, food security, biodiversity loss, unsustainable consumption of natural resources, ecosystem degradation, and other climate change risks for health are put forward (see also Pörtner et al., 2022). It is about healthy ecosystems where an unhealthy planet equals unhealthy people. In relation to outdoor activities, it is about the risks of being in the outdoors but also the value of green spaces in relation to urban spaces. However, this relation is also about sustainable, healthy futures and how different outdoor activities can be part of protecting the active and acting river we all live in. This entails a collective responsibility for the river both now and in the future, including solidarity and justice with other people globally as well as with future generations.

Outdoor activities can then be a possible vehicle for societal change where a well-used illustration of this relation is the model of outdoor education and environmental concern suggested by Sandell and Öhman (2013). They propose five different paths of how outdoor activities, here as nature experiences, can be understood as roads towards sustainability. Two of these paths relate more specifically to the issues highlighted in this relation. One of the two paths involves a radical engagement with environmental problems regarding issues of power and how environmental politics, complemented with encounters with nature through outdoor activities, could be used to protect nature. The other of the two paths entail experiences in the outdoors as an aim supporting comprehensive environmental perspectives and ‘the need to feel at home in nature as a way towards a deeper environmental engagement’ (p. 49). This path involves how the intrinsic values of outdoor activities are essential for understanding non-human aspects of the environment and the health of the planet and how values ‘found in nature provide inspiration and reference frames that could put mainstream society into perspective and lead to reflections about the need for alternative progress’ (p. 49).

Within this relation, it is the health of the river, i.e. the planet, that is foregrounded in terms of environmentally sustainable human-nature relations. Nature can here be regarded as an actor for health in, through and about outdoor activities in a broad sense.

Returning to the river—health and the outdoors in times of climate change

The purpose of this conceptual paper has been to provide a theoretical basis for discussions about relations between outdoor activities and health in research and practice. As shown, previous research has primarily, but not exclusively, focused on outdoor activities as healthy in terms of increased physical activity, prevention of mental illness and in the form of therapy. This entails seeing the outdoors as a backdrop for individual, instrumental, and anthropocentric purposes.

We have instead used Antonovsky’s (1996) metaphor of the swimmer in the river to discuss the relation providing new meanings to healthy human-nature relations. This is in line with Houge Mackenzie and Brymer (2020) and Hanna et al. (2019), who argued for not being restricted to health as the absence of disease but also adding not being limited to human health and wellbeing. Since we, in this perspective, can never take the swimmer out of the river, we asked questions about the relation between outdoor activities and health, moving from the swimmer in the foreground to swimmers in the river to finally foregrounding the river. Hence, we cannot explore health by focusing on people as though they are not in the river, and we cannot explore health without taking the health of the river into consideration since both the swimmer and the river are in a constant process of becoming the swimmer and the river they are.

The seven different relations we propose using salutogenic theory and salutogenic questions could hopefully inform outdoor practices so that more complex ideas of health can be adopted, not the least in times of climate change. This entails looking at the many pedagogically good things done in outdoor activities and outdoor education and discussing them in relation to health, from the effect on motor development and how we can create healthier connections between people and places to promoting environmentally sustainable human-nature relations in a changing world.

What we suggest could also hopefully inform research, providing a robust theoretical framework for further scientific discussions regarding the relation between outdoor activities and health. The most important conclusion here is that salutogenic theory encourages us to ask other kinds of questions. Questions empirical research could focus on include, but are not limited to, how nature could be understood as part of living a healthier life, how people can notice and change their behaviours for the better of the environment, or how the health of the planet in different ways is affected by environmentally sustainable human-nature relations. A second important consequence is in relation to the claims of future salutogenic research. Here, salutogenic theory helps put various empirical studies regarding the relationship between outdoor activities and health in a larger system. Hence, by taking different aspects of human-nature relations into account, the suggested relations, using the river metaphor, can guide research in identifying central gaps in knowledge beyond curing or preventing disease, facilitate the development of more innovative research designs, support the claims of the studies, and also make cumulative knowledge production regarding the relation between outdoor activities and health more rigorous.

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No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Mikael Quennerstedt

Mikael Quennerstedt is a professor in Physical Education and Health at The Swedish School of Sport and Health Sciences (GIH). His main research interests are in teaching and learning in school physical education, embodied learning, subject content in educational practices, and salutogenic perspectives on health education.

Erik Backman

Erik Backman is Associate Professor at the School of Health and Welfare at Dalarna University, Falun, Sweden and at the Department of Primary and Secondary Teacher Education at Oslo Metropolitan University in Norway. His main research interest is in educational and sociological perspectives of physical education, physical education teacher education, outdoor education, and environmental education. For Backman the work with this paper was supported by MISTRA (Stiftelsen för miljöstrategisk forskning) within the research program Mistra Sport and Outdoors.

Jonas Mikaels

Jonas Mikaels is a senior lecturer of outdoor studies at the Swedish School of Sport and Health Sciences (GIH). His research interests include examining human-nature relations through posthuman theorizing. His most recent publications employ a relational materialist approach as a way of challenging dominant taken-for-granted ways of seeing and knowing the world towards providing new possibilities of embodied relations to place(s). He designs and teaches on many undergraduate and postgraduate courses in outdoor studies and is interested in pedagogic practice in outdoor education. He is a keen skier, kitesurfer and yogi.

Notes

1. Important to note the hyphen Antonovsky used in dis-ease!