1 Department of Human Studies, LUMSA University, Rome (Italy)
2 “Inclusion, health, and care” Rome Littoral Foundation, Ostia, Rome (Italy)
3 Department of Psychological, Pedagogic, Physical education, and Education Sciences, Palermo University, Palermo (Italy)
4 Department of Developmental and Educational Psychology, Universidad Autónoma de Madrid, Madrid (Spain)
* corresponding author: Lucia Sideli, via di Porta Castello 44, Roma. L.sideli@lumsa.it
Abstract:
This systematic-review investigated the impact of adapted sailing activities on individuals with disabilities, including those arising from psychiatric disorders and developmental and physical disabilities.
Background: Psychosocial disabilities encompass a range of conditions that affect psychological and social functioning, often resulting in diminished quality of life and social impairment. The marine environment, particularly sailing, has been identified as a unique setting for rehabilitative experiences, fostering wellbeing and group cooperation.
Methods: A systematic literature review was conducted using the PICO(S) framework, focusing on individuals with psychiatric disorders, and developmental and physical disabilities. The targeted intervention was adapted sailing activities, and the outcomes included quality of life and functional and symptomatic recovery. Out of an initial pool of 89 articles, 15 underwent title screening, and 8 were selected after abstract screening. An additional 7 articles were identified through manual searching, resulting in a total of 15 articles included in this review.
Results: The reviewed studies explored the impact of sailing interventions on different populations, including individuals with psychiatric disorders, and oncological and neurological diseases. Findings consistently demonstrated positive effects of adapted sailing activities on quality of life and well-being of individuals with disabilities. However, it is noteworthy that the outcomes were assessed post-intervention, whereas sustaining long-term effects requires further investigation.
Conclusion: Collectively, the studies highlighted the transformative potential of sailing experiences across various psychiatric disorders and developmental and physical disabilities.
Keywords: Sailing, Quality of Life, Recovery, Functioning, Mental Health, Disabilities.
Introduction
In recent years, adapted physical exercise and sports activities have gained prominence as an innovative approach to enhance the quality of life and well-being of individuals with a wide range of disabilities, including physical impairments and psychiatric disorders (Mura et al. 2014; Hardoy et al. 2011). This growing interest has been fueled by the recognition that the marine environment provides a unique setting where challenges, learning, group cooperation, and contact with nature can converge to create an extraordinary therapeutic experience (Recio et al. 2013; Hegelmann 1991).
Physical activities both “above” and “below” the sea (e.g., swimming, sailing, snorkeling, and diving) promote the development of emotion and self regulation abilities, needed to cope, in addition to physical fatigue, also with challenging emotions of fear and anxiety. Open sea sports pose particular challenges due to the scarcity of reference points, the unpredictable nature of marine conditions, and the sensation of confronting something vast, deep, and powerful (Lo Verso 2023). Consequently, sea sports tend also to foster cooperation and social support proving to be an excellent backdrop for psycho-social rehabilitative activities that necessitate both individual commitment and team-work. A Sicilian saying goes “In the sea, none is left alone” and it illustrates the ethos of maritime culture, which emphasizes solidarity and the absence of borders or barriers, highlighting the shared humanity among individuals (Lo Verso 2022, Lo Verso 2023).
Psychosocial disabilities encompass a range of conditions that influence an individual’s psychological and social functioning resulting either from mental health disorders (e.g., schizophrenic, mood, anxiety, and stress-related disorders), developmental disabilities (e.g., autism spectrum disorders or neurocognitive disorders) or physical disabilities (e.g., related to cardiovascular, neurological or oncological disease) that may affect daily life, working, and social functioning of those affected and reduce their quality of life (QoL) (World Health Organization 2019; American Psychiatric Association 2013).
Quality of Life (QoL) is a comprehensive concept that integrates various dimensions, including physical, psychological, social, and economic aspects contributing to the individuals’ or groups’ well-being (WHO 1995). QoL can be influenced by various psychological and social factors, including self-esteem and self-efficacy, social support, and social attitudes toward mental disorders (Angermeyer et al., 2014; Herens et al., 2016). Engaging in adapted physical exercise and sports activities, particularly if in a marine environment, can significantly influence the QoL of individuals with psychosocial disabilities (Hale et al. 2021; Marquez et al. 2020; Vagetti et al. 2014). This influence might be mediated by psychological and social factors, such as self-esteem and social support (Carta et al. 2014b; Mastronuzzi et al. 2022; Mirandola et al. 2020; Sancassiani et al. 2017b; Shoenberg et al. 2021).
Recovery is multifaceted concept, referring to the process that makes able individuals affected by mental health disorders and physical disease to live a fulfilling life in the community, despite the limitations imposed by the condition (Anthony 1993; Rodgers et al. 2006; Substance Abuse and Mental Health Services Administration 2006). As such, recovery extends beyond symptom reduction or remission (Vita & Barlati 2018), encompassing the attainment of adequate psychosocial functioning, and the capacity to modify personal beliefs, attitudes, behaviours, objectives, and values, to live a meaningful life while coping with their conditions and disabilities (Ahmed et al. 2012; Ellison et al. 2018; Leamy et al. 2011). Adapted physical activities, particularly those in the marine environment, might contribute to pathways to recovery for individuals with psychosocial disabilities, by promoting personal and social abilities (e.g, cognitive flexibility, problem solving, and cooperation), as well as fostering shared values of persistence and hope, amidst the physical and emotional challenges of navigation (Broadbent & Swalwell 2018; Rapsey & Pilcher 2022; White et al. 2016).
As already stated, marine activities may have beneficial effects on a range of somatic and mental health conditions (Breihan 2007; White 2020). Adapted sailing refers to a specialized form of sailing that is accessible to individuals with diverse physical and cognitive abilities. Rooted in the principles of inclusivity and empowerment, adapted sailing employs various modifications and accommodations to ensure that people with disabilities can actively participate and enjoy the unique experience of sailing. This form of sailing often involves the use of specially designed boats and equipment that cater to the specific needs and challenges of individuals with disabilities. Adapted sailing programs may include features such as modified seating arrangements, customized control systems, and assistive devices to enable individuals with limited mobility or other impairments to engage fully in the sailing experience (Breihan 2007; White 2020). The philosophy behind adapted sailing goes beyond providing a recreational activity; it aims to promote independence, build confidence, and foster a sense of achievement among participants. By breaking down barriers and offering tailored support, adapted sailing empowers individuals to explore their capabilities and engage in a sport that might otherwise seem inaccessible (Duarte & Culver 2014; O’ Flynn et al. 2021).
To our knowledge, literature about the beneficial effects of adapted sailing has not been summarized yet. In this review, we will examine the potential impact of adapted sailing activities for individuals with disabilities, including those with physical impairments and psychiatric disorders. The primary objective of this review is to shed light on the current state of the art in this field and describe the impact of such interventions on quality of life, psychological functioning, and recovery. The secondary objective is to explore emerging trends, differences in study populations, and potential methodological limitations. Furthermore, we aim to identify research gaps and to suggest possible future directions for the development of more effective adapted sailing interventions.
Methods
A systematic literature was carried out according to the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) statement (Moher et al. 2015) to assess the potential impact of adapted sailing activities for individuals with various psychosocial disabilities, including those those related to psychiatric disorders and to physical disease.
In structuring our review, we applied the PICO(S) framework, systematically addressing key components, i.e. Population, Intervention, Comparator, Outcome(s), and Study design. Our focus was on individuals dealing with psychiatric disorders, and developmental and physical disabilities. The intervention of interest was adapted sailing activities, encompassing activities related to sailing, boating, or navigation tailored to individuals with disabilities. The outcomes under study included quality of life and functional and symptomatic recovery. This review includes both qualitative and quantitative study design (i.e., experimental, quasi-experimental, or longitudinal studies).
Search Strategy and eligibility criteria
An initial search was conducted in September 2023 in four electronic databases (PUBMED, Ebscost Psychology and Behavioral Sciences Collection, APA PsycInfo, ERIC) from inception to 2023, using relevant keywords. An additional manual search was carried out among selected articles’ and reviews’ reference list to maximize the coverage of the review.
Keywords used for the search were related to sailing-related intervention (i.e., sailing or shipping) combined with the following somatic and mental health conditions (autism spectrum disorder, Asperger, intellectual developmental disorder, developmental disability, neurological disabilities, mental disorder, psychiatric disorder, depression, anxiety, posttraumatic stress disorder, PTSD, phobia, ADHD, schizophrenia, and psychosis) and the following outcomes (quality of life, QOL, wellbeing, recovery, psychological functioning, functioning, psychological adjustment, adjustment, mental health, and psychiatric symptoms).
The included articles had to meet the following inclusion criteria: 1) pertaining to studies conducted on individuals with mental disorders or physical disabilities; 2) examining the effects of adapted sailing activities to improve quality of life, and functional and symptomatic recovery; 3) published in English language; 4) including adult or adolescent samples.
Studies were excluded if: 1) they did not report data from qualitative or quantitative studies (e.g., opinion paper, case series or case report) or 2) they were not original articles (e.g., review or proceeding). Two independent reviewers screened titles, abstracts, and full-text articles for eligibility. Possible discrepancies were discussed with the senior author.
Results
Out of pool of 89 records resulting from the electronic search, 15 were selected for further consideration. Abstracts of the 15 selected articles were reviewed to assess their suitability for inclusion, resulting in the retention of 8 articles. An manual search was conducted to identify additional relevant articles, leading to the inclusion of 7 more articles. Finally, 15 articles met the inclusion criteria and were included in the narrative synthesis (Figure 1).
Figure 1. Study selection process according to PRISMA flowchart
Table 1. Summary of study findings
| AUTHOR AND YEAR | SAMPLE | INTERVENTION | STUDY DESIGN | COMPARISON | MEASURES | RESULTS |
| Qualitative studies on individuals affected by mental health disorders | ||||||
| Rapsey & Pilcher, 2022 | N=5 patients with First Episode of Psychosis (FEP) | A series of outdoor activities, including a residential sailing adventure for six days | Qualitative study | No control group | Quality of life assessed with an audio recorded semistructured interview of 10 questions analysed using inductive thematic analysis | The study identified four key themes related to participants’ learnings about them selves during the project. Participants’ reported that adventure therapy, specifically sailing, was associated with four themes: “enhanced self-perception”, “building friend-ships and being part of a shared experience”, “navigating and overcoming new challenges”, and “working together as a team”. |
| White et al., 2016 | N=11 patients with substance abuse disorders | A five-days sail training | Qualitative study | No control group | In-depth semi-structured interviews pre- and post-voyage (between one and 11 weeks after the intervention) analysed using a two-stage inductive thematic analysis | The study identified three themes and 14 sub-themes through the analysis of participants’ pre-voyage anticipations, the on-board voyage experience, and self-attributed changes. Participants identified self- attributed changes in four main areas: “self-insight, perseverance and inner strength”, “social skills”, “increased confidence”, “impact of the voyage on recovery” and “new plans and horizons” |
| Quantitative studies on individuals affected by mental health disorders | ||||||
| Carta et al., 2014a | N = 20 patients with schizophrenia, affective psychoses, or severe personality disorders (group A) | Monthly group meetings, weekly social skills training and leisure sessions on a sailing ship, and classes about sea life for six months per group | Crossover randomized controlled trial | N = 20 patients who did not initially participate in the sailing rehabilitation program (group B) | Symptomatic recovery assessed using the BPRS, functional recovery assessed using the HoNOS and the GAF assessed at 1, 6 and 12 and at the 6- -month follow-up (only group A) | The sailing rehabilitation program was associated with symptomatic (89% improve in BPRS for group A vs. 10% for group B , χ2= 15.11, p < .0001; after the crossover 15% vs. 100% χ2= 22.44, p < 0.0001). The same trend was observed for functional recovery (HoNOS: 83% vs. 15%, χ 2 = 20.59, p < 0.0001; after the cross-over 11% vs. 93% χ2= 18.97, p < 0.0001; GAF: 72 % vs. 0, χ2= 18.86, p < .0001; after the cross-over 33% vs. 100%, χ2= 12.96, p < .0001). Benefits at the 6-month follow up were assessed only for group A, with negative results |
| Carta et al., 2014b | N = 20 patients with schizophrenia, affective psychoses, or severe personality disorders (group A) | Monthly group meetings, weekly social skills training and leisure sessions on a sailing ship, and classes about sea life for six months per group | Cross-over randomized controlled trial | N = 20 patients who did not initially participate in the sailing rehabilitation program (group B) | Physical, psychological, social, and environmental quality of life assessed using the WHOQOL-Bref assessed at 1, 6, 12 and at the 6-and the 12-month follow-up | The time x group interaction suggested that sailing rehabilitation program was associated with improvement in the physical ( F= 63.90, p < 0.0001), psychological (F = 10.65, p = 0.002) and environmental QOL domain, (F= 34.17, p <0 .0001), but not in the social domain, (F = 0.49, p = 0.48). These effects were no longer evident at the 6-and the 12-month follow-up |
| Marchand et al., 2018 | N=22 veterans with medical, psychiatric, and/ or substance abuse diagnoses | A 3- session sailing adventure therapy (SAT), once per month for a total of three months | Pilot study | N= 22 age- and gender- matched controls who participated in a residential SUD Treatment as Usual (TAU), but not in SAT | Changes in either positive or negative affect assessed using the PANAS | The SAT was associated with non-significant changes in both positive (29.9 vs. 32.3, p = 0.351) and negative affect (16.2 vs. 15.6, p = 0.605) |
| Marchand et al., 2019 | N=21 veterans with medical, psychiatric, and/ or substance abuse diagnoses | A 5-session sailing experience included in the mindfulness training and nature exposure (MT/ NE), once per week over a five-week period | Pilot study | No control group | State and trait anxiety assessed using the STAI- Y-6 item | The sailing experience was associated with a significant decrease of state anxiety (43.55 vs. 33.27, t = 2.49, p =0.032) |
| Sancassiani et al., 2017a | N = 33 patients with schizophrenia, affective psychoses, or severe personality disorders (group A) | A structured 3-month sailing course, two times per week | Cross-over randomized controlled trial | N = 18 participants initially involved in rTAU (group B) | Symptomatic and functional recovery assessed using the CGI-S, the HoNOS, and the GAF; Biological and Social Rhythms assessed with and the BRIAN | The time x group suggested that the sailing rehabilitation program was associated with functional recovery (GAF, F=3.74, p = 0.059; HoNOS: F=6.93; p=0.011). However, no effect was found either on symptomatic recovery (CGI: F = 0.36, p =0.553) or on bio-social rhythm regulation (F =0.48, p = 0.490) |
| Sancassiani et al., 2017b | N = 33 patients with schizophrenia, affective psychoses, or severe personality disorders (group A) | A structured 3-month sailing course, two times per week | Cross-over randomized controlled trial | N = 18 participants initially involved in rTAU (group B) | Quality of life assessed using the SF-12, sense of coherence and self-efficacy measured by the SOC and the GSES | The sailing rehabilitation program was neither associated with improvement in QOL (F = 0.240, p = 0.627) nor in sense of coherence (F = 0.866, p = 0.357). However, it was related to a significant improvement in self-efficacy (F = 6.41, p = 0.015) |
| Zabag et al., 2019 | N = 17 participants with PTSD | A 4 hour per week structured sailing rehabilitation intervention for one year
Vs unstructured sailing activity (sailing as an hobby) Vs session per week year sailing intervention, with one 4-hour, while the Control-Sailing group engaged in a similar amount of sailing as a hobby. |
Longitudinal study | N = 22 participants with PTSD involved in rehabilitation as usual
N = 18 healthy controls involved in unstructured sailing activity (sailing as an hobby) N = 20 healthy controls not involved in any treatment |
Symptomatic recovery assessed using the PTSD Check List, the BDI, and the STAI | The sailing rehabilitation intervention was associated with significant reduction in PTSD symptoms (F= 45.7, p < 0.001) and trait anxiety (F= 10.95, p < 0.001) compared to the PTSD-non-sailing group, and the sailing and non-sailing controls. No significant differences were observed in depressive symptoms and state anxiety. |
| Qualitative studies on individuals affected by physical disabilities | ||||||
| Broadbent & Swalwell, 2018 | N= 94 patients with multiple sclerosis (MS) from 16 different Countries | A 17-month period sailing cruise around the world | Qualitative study | No control group | Online blogs’ contents examined through deductive thematic analysis | The thematic analysis involved 206 blogs posted from 86 participants during and after the experience. The study identifies four main themes: the challenges of the journey, teamwork and camaraderie that arose from sharing a diagnosis in common, reframing mindsets as people acknowledged and adjusted to their diagnosis, and empowerment and personal growth with hope rediscovered. |
| Quantitative studies on individuals affected by physical disabilities | ||||||
| Cappelletti et al., 2020 | N = 58 adolescents with epilepsy | One-week adaptive sailing activities | Longitudinal study | No control group | Quality of Life, assessed using the PedsQL at post intervention, both adolescent and parent versions | The intervention was associated with significant improvements in adolescent-rated overall quality of life (ES = 0.21, p = 0.023) and in two out of four domains, i.e., the physical health (ES =: 0.27, p = 0.006) and emotional functioning (ES = 0.25, p = 0.015). Furthermore, the parent-rated PedsQL showed also improvement in the school functioning domain (ES = 0.81, p = 0.02) |
| Mastronuzzi et al., 2022 | N= 90 adolescents with oncological disease | A five day sailing adventure therapy focused on social engaging | Longitudinal study | No control group | Quality of life and self-esteem assessed using the PedsQL and the TMA at post intervention | The sailing adventure therapy was associated with significant improvements at the end of the experience across all domains of QOL (76 vs. 81; t= 22.39, p=<001) and self esteem (47 vs.52; t= -14.07 p=<001) |
| Mirandola et al., 2020 | N=19 female patients with breast cancer | A one-week adapted sailing experience, based on learning to sail in a crew | Pilot study | No control group | Quality of life assessed using the SF-12, state and trait-anxiety assessed using the STAI-Y at post-intervention and at the 1-week follow up | The sailing experience was associated with a significant increase in psychological QOL (ES = 0.43, p= 0.04). In addition, both the state and trait anxiety were significantly lower at follow-up (ES =0.53, p=0.007; ES= 0.33, p=0.04) |
| Shoenberg et al., 2021 | N=28 patients with a oncological disease | An 8-to-13-day ocean sailing trip | Pilot study | No control group | Quality of life, life satisfaction, and depressive symptoms, assessed using the EORTC QLQ-C30, the FLZ, and the PHQ-9. Self efficacy and social support assessed using the GSE and the ESSI. Outcomes assessed at post intervention and at the 1-, 3- and 6 – month follow ups | The sailing rehabilitation program was associated with significant improvement at the 1-month follow up in global QOL (median 8, IQR [4.3; 10] vs 5.5 [3.3; 7.5]; p < 0.01), particularly in the emotional functioning domain (50 [25; 66.7] vs. 75 [50; 87.5]; p < 0.001). Other improvement were observed in life satisfaction (37 [5.3, 53] vs. 47 [13.3, 72.8], p <0.05) and in depressive symptoms (8 [4.3; 10]) vs. 5.5 [3.3; 7.5]; p < 0.01). No changes were observed in the other outcomes. |
| Sidiropoulos et al., 2022 | N = 58 war veterans with physical (e.g., amputation) and/or psychological disabilities (e.g. psychiatric disorders) | One-day adaptive kayaking and sailing activities | Longitudinal study | No control group | Overall health, quality of life and quality of social life assessed with a three item psychometrically validated ad hoc questionnaire (a modified section of The Influence on Quality of Life Scale assessing the
influence of QoL in athletes with disabilities) |
The intervention was associated with significant improvement in QOL (Z = -4.09, p < 0.0001) across the three domains of perceived quality of life (Standardized Coefficients > 0.85, p < 0.0001). The adaptive physical activity explained 64% variance in quality of life (F = 5.84, p < 0.0001) |
Note: BDI: Beck Depression Inventory; BRIAN: Biological Rhythms Interview of Assessment in Neuropsychiatry; ES: effect size; ESSI ENRICHD Social Support Inventory; CGI-S: Clinical Global Impression – Severity scale; EORTC QLQ-C30 Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer ; FLZ Life Satisfaction Questionnaire; GAF: Global Assessment of Functioning; GSES: General Self Efficacy Scale; HoNOS: Health of the Nation Outcome Scale; PedsQL: Pediatric Quality of Life Inventory;; PTSD: Post-Traumatic Stress Disorder; SF-12: Short Form Health Survey- 12 itesm; SOC: Sense of Coherence Scale; STAI: State–Trait Anxiety Inventory; TMA: Test Multidimensional Test of self-esteem.
Study design and study method
The articles in this study encompassed various types of study designs, mainly quantitative but also qualitative (Broadbent & Swalwell 2018; Rapsey & Pilcher 2022; White et al. 2016). Quantitative study design included cross-over randomised controlled trial (Carta et al. 2014a, 2014b; Sancassiani et al. 2017a, 2017b), longitudinal studies (Cappelletti et al. 2020; Mastronuzzi et al. 2022; Sidiropoulos et al. 2022; Zabag et al. 2019), and pilot studies (Marchand et al. 2018, 2019; Mirandola et al. 2020; Shoenberg et al. 2021). Only a few studies, compared the effect of adapted sailing activities with those of treatment as usual (Carta et al. 2014a, 2014b; Sancassiani et al. 2017a, 2017b; Zabag et al. 2019).
The studies included in the review involved different clinical populations and various adapted sailing activities programs. The clinical populations involved encompass individuals with mental health disorders, including PTSD, mood, psychotic and substance use disorders (Carta et al. 2014a; 2014b; Marchand et al. 2018, 2019; Rapsey & Pilcher 2022; Sancassiani et al. 2017a; 2017b; Sidiropoulos et al. 2022; Zabag et al. 2019), individuals with various type of physical disabilities, including breast cancer (Schoenberg et al. 2021), and epilepsy (Cappelletti et al. 2020), and multiple sclerosis (Broadbent & Swalwell 2018).
The adapted sailing activities varied across studies but primarily involved sailing therapy activities, either as a stand-alone intervention (Broadbent & Swalwell 2018; Cappelletti et al. 2020; Mirandola et al. 2020; Rapsey & Pilcher 2022; Shoenberg et al. 2021; Sidiropoulos et al. 2022; White et al. 2016), or as part of psychological (Marchand et al. 2019), rehabilitative (Carta et al. 2014a, 2014b; Sancassiani et al. 2017a, 2017b; Zabag et al. 2019), or social interventions (Cappelletti et al. 2020; Mastronuzzi et al. 2022; Mirandola et al. 2020; Shoenberg et al. 2021). Only a few studies assessed the long-term impact at follow-up (Carta et al. 2014a, 2014b; Mastronuzzi et al. 2022; Mirandola et al. 2020; Shoenberg et al. 2021).
The most frequent outcome assessed across the studies was quality of life, followed by anxiety and depressive symptoms. The instruments used to measure QOL were mainly self-administered questionnaires (e-g., the Short Form Health Survey- 12 items (SF-12), the Pediatric Quality of Life Inventory (PedsQL); the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) or the Pediatric Quality of Life Inventory (PedsQL)). The instruments used to measure symptomatic and functional recovery included clinician-rated scales (e.g.,the Clinical Global Impression – Severity scale (CGI-S); the Global Assessment of Functioning (GAF), and the Health of the Nation Outcome Scale (HoNOS)), and self-report questionnaire, mainly related to anxiety and depression symptoms (e.g., the Beck Depression Inventory (BDI), the PTSD Check List, and the State–Trait Anxiety Inventory (STAI)).
Study findings by clinical conditions
Overall, seven articles reported the finding of adapted sailing interventions applied to individuals with mental health disorders, whereas eight articles anlysed the results of interventions for individuals with primarily physical disabilities.
Two groups (Marchand et al. 2018, 2019; Zabag et al. 2019) investigated the effectiveness of therapeutic sailing in different groups of individuals who experienced psychological trauma, i.e, to the impact of stressful experience that lead to disorganization and dysregulation of the person’s psychobiological system (Caretti & Craparo 2008). Marchand and colleagues first explored the effect of sailing adventure therapy (SAT) on positive and negative emotions of war veterans with multiple substance use disorders (SUDs) and psychiatric (95%) and medical comorbidities (77%) (Marchand et al. 2018). This study found only a non-significant increase in positive affect and a minor reduction in negative affect (Marchand et al. 2018). In a second study, the same group investigated the impact of a novel complementary intervention, the Mindfulness-Based Therapeutic Sailing (MBTS), combining mindfulness interventions with nature exposure, in the same population (Marchand et al. 2019). The intervention comprised five sessions, combining classroom instruction, with sailing experiences and a mindfulness training. The pilot study suggested that the MBTS was safe (i.e., no injury or accident during the intervention) and feasible (i.e., attendance rates ranging from 80% to 96%). Participants showed significant improvements in state anxiety and trait mindfulness, expressed high satisfaction for the intervention, and suggested an increased duration of the MBST program (Marchand et al. 2019).
Zabag et al. (2019) conducted a retrospective study on a total of 77 patients with PTSD and healthy controls, assessing the impact of a sailing nature adventure intervention (vs. treatment as usual, TAU). The results showed that that individuals with PTSD who participated in sailing intervention reported significantly lower levels of PTSD and trait anxiety symptoms, compared to patients assigned to TAU, as well as to healthy controls assigned either to treatment or to TAU.
Different studies explored the impact of rehabilitative sailing in population with psychiatric disorders (Carta et al. 2014a; 2014b; Rapsey & Pilcher 2022; Sancassiani et al. 2017a; 2017b ), including schizophrenic disorders, affective psychoses, and personality disorders. The qualitative study conducted by Rapsey & Pilcher (2022) delved into the experiences of 5 male adults (age 25 – 38) affected with a First Episode of Psychosis (FEP), who participated in an adventure therapy project, with a particular focus on a sailing. The authors conducted semi-structured interviews that were nalysed using an inductive thematic analysis. Results revealed that the adventure therapy project was associated with significant improvements in various aspects of their self-perception, including self-confidence, positive self-beliefs, and resilience. Moreover, participants reported satisfaction for the capacity to cope with various challenges related to navigation, and for the experience of team-work with the other patients.
Carta et al. (2014a, 2014b) carried out a cross-over randomized controlled trial to investigate the impact of a 6-month sailing-based rehabilitation program on symptomatic and functional recovery and QoL. The study involved 20 patients affected with schizophrenic and affective psychoses and a control group of 20 patients (95% male, age 23-58). The intervention was associated with 89%-100% improve in general psychopathology and 83%-93% improve in psychosocial functioning (Carta et al., 2014a). Furthermore, the intervention was associated with significant improvement in physical, psychological, and evironmental QoL (Carta et al. 2014b).
Sancassiani et al. (2017a, 2017b) carried out another cross-over randomized controlled trial to evaluate the effectiveness of a sailing-based rehabilitative intervention on 33 patients with schizophrenic and affective psychoses and a control group of 18 patients who received rehabilitative Treatment as Usual (“rTAU”). The adapted sailing treatment consisted of a structured 3-month sailing course where participants learned to sail in a crew. Participants showed a high level of satisfaction, acknowledged the positive impact of the sailing course on general health, and showed improved psychosocial functioning and greater self-efficacy, compared to the baseline condition and to the control group. However, the impact on QOL and symptomatic recovery was not statistically significant. The studies by Carta et al. (2014a, 2014b) and Sancassiani et al. (2017a, 2017b) employed a robust cross-over study design, the intervention lasted 3-6 months, and the findings reflected the potential impact of sailing -based rehabilitative interventions on recovery and quality of life. However, the positive effects were not consistent across the studies and were limited to the duration of the intervention.
One qualitative study (Broadbent & Swalwell 2018) and five quantitative studies (Cappelletti et al. 2020; Mastronuzzi et al. 2022; Mirandola et al. 2020; Schoenberg et al. 2021; Sidiropoulos et al. 2022) analysed the potential impact of adapted sailing activities on people with physical disabilities resulting from neurological (Broadbent & Swalwell 2018; Cappelletti et al.,2020) or oncological diseases (Mastronuzzi et al. 2022; Mirandola et al. 2020), and war injuries (Sidiropoulos et al. 2022).
Broadbent & Swalwell (2018) carried out a qualitative study aimed to explore the psychosocial outcomes of a long-term adapted sailing project involving individuals with multiple sclerosis. The researchers analysed the participants’ blogs, written during and after the journey. Major themes included the physical challenges of the journey, team-work experience and mutual understanding and support among the crew members affected with the disease, positive reframing and acceptance, along with empowerment and personal growth. Cappelletti et al. (2020) explored the impact of adapted sailing activities on adolescents with epilepsy. The participants reported a better QoL, compared to baseline, particularly in the physical health and the emotional adjustment. Furthermore, the parent rated QoL measure also showed a positive impact on the school functioning domain.
Three quantitative studies investigated the impact of adapted sailing activities on adolescents and adults with cancer disease. The study conducted by Mastronuzzi et al. (2022) investigated the effect of a 5-days adapted sailing activities on QoL and self.-esteem of 90 adolescents, primarily female, with various types of cancer. The study found a substantial positive effect on both the quality of life and self-esteem of adolescents with cancer, as evidenced by self-report tools and questionnaires administered before and after the sailing experience. Mirandola et al. (2020) proposed a one-week sailing school to nineteen breast cancer survivors (aged 43–68). Participants were satisfied of the sailing experience, although 58% considered it physically challenging. At post intervention participants showed a significant improvement in the mental health QoL domain and a significant reduction in state and trait anxiety. Schoenberg et al. (2021) carried out a monocentric, longitudinal study involving 28 young adults (18-40 years) with an oncological disease. Participants undertook an 8 to 13-day ocean sailing trip. The outcomes assessed included quality of life, satisfaction with life, depressive symptoms, self-efficacy and social support. The results showed significant positive changes in global and emotional QoL, life satisfaction, and depressive symptoms, with evidence at the 1-month follow-up. Furthermore, the improvement in global QoL was still evident at the 3-month follow-up.
Finally, Sidiropoulos et al. (2022) conducted a retrospective chart review on 58 veterans with physical and psychological disabilities who participated in the “Heroes on the Hudson” adapted kayaking and sailing events in 2018 or 2019. The study found that participation in the adapted sporting event had an acute positive influence on the quality of life of the participants.
In summary, these studies collectively highlight the positive impact of sea-based physical activities, such as adapted kayaking and sailing, on the quality of life and common mental health symptoms (e.g., depression and anxiety) of participants across different populations, including war veterans, adolescents and adults with oncological diseases, and adolescents with epilepsy. Furthermore, there are some qualitative and quantitative suggestions of the possible role of self-esteem in mediating the effect of adapted sailing activities on QoL and recovery. Although the majority of these interventions were focused on social engagement and empowerment, the format was significantly heterogeneous ranging from a few days to several months.
Discussion
Synthesis of the study findings
The present review on quality of life and sailing reveals favorable results in the well-being of the participants. The 15 studies included in this systematic review encompassed various clinical populations, intervention methodologies, and outcome measures, providing preliminary data about the potential benefits of adaptive sailing intervention. Thus, despite the varied nature of the samples, the findings consistently indicate positive outcomes. The versatility of adaptive sailing interventions is emphasized as they demonstrate potential benefits across a spectrum of clinical populations, including individuals with mental health disorders and those with physical disabilities.
The included studies employed a mix of quantitative and qualitative methodologies, with a predominant focus on quantitative approaches: randomized controlled trials (RCTs), longitudinal uncontrolled studies, and pilot controlled and uncontrolled studies. Additionally, a few qualitative studies provided valuable insights into the subjective experiences of participants. This methodological diversity underscores the complexity of evaluating the multifaceted outcomes associated with adaptive sailing. The clinical populations targeted in the studies were diverse, ranging from individuals with mental health disorders, including PTSD, mood disorders, and psychosis, to those with physical disabilities such as oncological diseases, neurological disease, and war injuries. Notably, the positive effects of adaptive sailing activities were observed across different clinical populations, suggesting the versatility and potential applicability of this intervention.
However, there is a noticeable gap in the representation of certain populations, with developmental disabilities being notably absent from the reviewed literature. This raises questions about the generalizability of findings to a broader population of youth and adults with psycho-social disabilities and encourage studies on the potential benefits of sailing-based intervention for individuals with intellectual disabilities, autism spectrum disorders, and other neurodevelopmental disorders (Zhao et al., 2021). Moreover, the body of research in this area seems to be relatively limited, with only a few research groups contributing to the available literature, particularly when compared to existing systematic reviews and meta-analyses on the positive effects of other activities, such as physical activities (Teferi et al., 2020; Neil et al., 2020). This scarcity of studies implies that the field of adaptive sailing intervention might still be in its early stages, necessitating additional exploration and investigation.
The interventions widely varied, with adapted sailing activities embedded in psychological programs or as part of broader rehabilitative or social interventions. The most frequent outcomes included quality of life, and functional and symptomatic recovery. Furthermore, a few studies investigated potential mediating factors of the benefit of the intervention, such as self-esteem, self-efficacy, bio-social rhythm regulation, and social support. The tools used for measurement ranged from self-report questionnaires to structured interviews, reflecting the methodological diversity in assessing the impact of the intervention.
Positive outcomes were frequently reported across studies, emphasizing the potential benefits of adaptive sailing activities to influence various facets of well-being. The studies involving patients with mental health disorders consistently reported improved psychopathology, overall functioning, self-esteem, and self-efficacy (Carta et al., 2014a, 2014b; Sancassiani et al. 2017a, 2017b; Zabag et al., 2019). The studies involving individuals with physical disabilities, including veterans with physical injuries and cancer survivors, also demonstrated positive effects on quality of life and common mental health symptoms (Cappelletti et al., 2020; Mastronuzzi et al., 2022; Mirandola et al., 2020; Schoenberg et al., 2021; Sidiropoulos et al., 2022). However, these positive effects were often related to the intervention period.
Limitations
One notable aspect that emerges from this synthesis is the scarcity of studies in this domain. The limited number of investigations underscores the need for more robust and comprehensive research to draw conclusive insights. The heterogeneity of the studied populations, ranging from patients with psychiatric disorders to individuals recovering from physical disabilities, further complicates the generalizability of findings. Each group brings unique challenges and opportunities, necessitating tailored interventions.
Another critical consideration is the heterogeneity of the interventions. The absence of standardized approaches, both in terms of the duration and modalities of interventions, makes it challenging to establish universal guidelines or best practices. Studies varied not only in the duration of sailing programs but also in the specific components of the interventions, such as mindfulness or rehabilitative activities. Furthermore, tailored interventions targeting specific clinical and functional outcomes may enhance the efficacy of adapted sailing activities for specific populations.
Furthermore, the small sample size, the variable presence of control groups, and the lack of control for potential confounders suggest the necessity for robust study designs. Long-term follow-up assessments are crucial to understanding the persistence of benefits beyond the intervention period. To address the sustainability of symptomatic recovery, researchers and practitioners should consider implementing post-intervention support structures, such as follow-up sessions or peer support networks.
In light of these considerations, there is a compelling call for more extensive and standardized research in the field of sailing-based interventions. Future studies should aim for larger sample sizes, diverse yet well-defined populations, and rigorous methodologies. Establishing standardized protocols will not only facilitate more accurate comparisons between studies but also contribute to the development of evidence-based practices.
Conclusions
The findings from this review contribute to the growing body of evidence supporting the positive impact of adapted sailing activities as part of rehabilitative and social interventions in different populations with different types of disabilities and psychopathologies. Although further research is needed to understand the long-term impact and the psychological and social factors contributing to positive outcomes, the reviewed studies suggest the potential of sailing – based interventions to foster positive change and improve the quality of life of individuals with psychosocial disabilities. The results of this review are important for their implications in the design of programs to improve the well-being of different groups.
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