A combined diving and mindfulness program as a catalyst for behavioural change in adults with obesity: a qualitative study

Abstract

Purpose

The Bathysmed^® program combines scuba diving with mindfulness meditation and sophrology techniques. The effects of this program on emotional eating in adults with obesity was studied in a recent randomized controlled trial. Here, we aimed to understand the lived experiences of patients with obesity who participated in the program.

Methods

This qualitative phenomenological study interviewed volunteers from the BathysMed arm of the trial. Ten semi-structured individual interviews were analyzed using a semio-pragmatic analysis method with triangulation.

Results

Four categories emerged: 1) the protocol offered disconnection, awe of the underwater world, and transformation of sensory stimuli. This created a meditative experience that fostered mindfulness in daily life. 2) Combined with psychological and dietary support, it raised awareness of psychological disorders and had a therapeutic effect, promoting engagement in the care process. Overcoming difficulties during this experience increased self-esteem and reduced self-stigmatization. 3) Awareness of emotional eating and better management of emotions and stress was a catalyst for behavioral changes: reduced food compulsions, increased physical activity, and pursuit of change. 4) The conditions of the intervention influenced participants' unique experiences. The group had a distinct beneficial effect.

Conclusions

The combined diving and mindfulness program is a synergistic, innovative approach with multidimensional benefits for adults with obesity. The program could be integrated into comprehensive management of chronic conditions to promote lifestyle changes.

1. Introduction

The management of obesity requires a multidimensional approach involving therapeutic lifestyle changes and non-drug interventions, including dietary, psychological, and physical activity modifications (World Health Organisation, 1997; WHO, 2022). Key factors must be assessed, notably the presence of eating behaviour disturbances and the patient's perception of stigmatisation (Alberts et al., 2012).

Eating behaviour can be disrupted by stress and emotions (Groesz et al., 2012). Emotional eating refers to changes in food consumption in response to emotional states rather than hunger and satiety cues (Braden et al., 2018; Macht, 2008). It has been identified as a mediator between depression and obesity (Konttinen et al., 2019). Individuals with obesity face social stigmatisation and self-stigmatisation, which is the internalisation of negative weight-related attitudes directed at oneself (Pearl & Puhl, 2018). It has negative effects on mental health, eating behaviour, and weight gain (Pearl et al., 2021). A vicious circle can then be observed: obesity, a source of self-stigmatisation, generates negative emotions that favour eating behaviour disturbances, leading to weight gain. The bidirectional association between depression and obesity is also underpinned by biochemical mechanisms (Plackett, 2022).

In response, mindfulness meditation has shown numerous benefits: reduction of anxiety and depressive symptoms and perceived stress (Keng et al., 2011), decrease in emotional eating and binge eating (O’Reilly et al., 2014). Its effects on weight seem lesser (Sosa-Cordobé et al., 2022). Physical activity is a cornerstone of obesity management. It is associated with weight loss, improvement in eating behaviour, and quality of life (Oppert et al., 2021). For patients with obesity, weight-bearing activities like those performed in aquatic environments may be preferable.

Scuba diving allows for a greater reduction in perceived stress than other physical activities under similar conditions (Beneton et al., 2017). This activity is similar to meditation by naturally inducing a state of mindfulness (Gibert et al., 2022) and enhancing parasympathetic system activity through slow and deep breathing (Schipke & Pelzer, 2001). A protocol combining scuba diving with mindfulness meditation techniques (Bathysmed® protocol) is an innovative programme to potentiate the benefits brought by each of these activities. This protocol demonstrated encouraging results in reducing post-traumatic stress symptoms (Gibert et al., 2022).

The benefits of scuba diving, with or without mindfulness, had not previously been studied in individuals with obesity. In this context, individuals with obesity were offered to participate in the Bathysmed® protocol, followed by virtual reality sessions of the dives. The randomized controlled trial (RCT) evaluated the effects of this protocol on emotional eating, self-stigmatisation, quality of life, perceived stress, and BMI in adults with obesity (Griffiths et al., n.d.). Complementary to the statistical analysis, the objective of this phenomenological study was to understand the effects of the Bathysmed® protocol from the lived experience of individuals with obesity included in the trial.

2. Methods

2.1. Study setting

The Bathysmed® protocol combines scuba diving with exercises inspired by mindfulness meditation, cardiac coherence, and sports mental preparation. The study protocol is described in detail elsewhere (Griffiths et al., n.d.). Ten scuba diving sessions, two in a swimming pool and eight in the sea near Marseille, France were spread over five weeks September–October 2022. Diving instructors were trained in the Bathysmed® protocol. Each session began with: Diving theory and safety points, Theory of stress, emotions, and reassurance behaviours (understanding the pathology and its mechanisms), Presentation of diving exercises (to overcome constraints in advance: complex underwater communication), Practice of meditation and sophrology exercises on land (to be reproduced underwater). The diving sessions consisted of three phases: A static phase with several exercises to reach a modified state of consciousness, specific work during the dive focusing on either the body, the mind, or levels of mindfulness; and a final phase with exploration and return to the surface and debriefing of feelings.

Virtual individual reviviscence sessions were conducted by the participants at home for five weeks (20−30 min, two to three times a week). They watched similar dives through a virtual reality headset combined with audio and a regulator mouthpiece, recreating underwater breathing.

The participants also received standard care at the primary care centre. This included medical, psychological, and dietary consultations as needed, and adapted physical activity.

2.2. Study type

This was a phenomenological semiopragmatic study reported in accordance with COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines (Tong et al., 2007), based on semi-structured individual interviews (Supplementary File 1).

2.3. Population

Individuals with obesity who participated in the Bathysmed® protocol of the RCT were included (Griffiths et al., n.d.). Thirty participants in the “intervention” group were voluntarily invited to participate during a meeting or via email (KG, AEH, GR) in February 2023. Purposive sampling was conducted from these volunteers. Participants were selected to obtain maximum variability according to characteristics collected through a pre-inclusion questionnaire: age, sex, BMI, overall diving experience, prior experience with scuba diving and/or mindfulness meditation, and socio-professional category.

2.4. Data collection

Semi-structured individual interviews were conducted between April and by two authors (AEH, male; GR, female), both general practice trainees. At the time of the study, they had completed the Diplôme de formation approfondie en sciences médicales (DFASM, equivalent to an MSc level) and held a Master's degree in Health Engineering. They were trained in the explicitation interview method (Bedin et al., 2019). The investigators maintained a reflexive attitude (journal) and did not know the participants. Reflexivity was supported by several procedures (see Supplementary File 2), including the use of preconception journals, participant-informed communication practices, and iterative adaptation of the interview guide.

A phenomenological interview guide, centred on the participants' lived experience with the Bathysmed® protocol, was developed from a literature review and authors expertise (Supplementary File 3). The first question asked about the participant's motivation to participate in the study; the second question addressed their perceptions of the Bathysmed® diving and their expectations. The third question explored the participant's lived experience during the diving programme. The fourth question aimed to identify changes observed in the participants' lives. The final question synthesized key elements retained from this experience and perspectives.

The first two test interviews validated the interview guide and were included in the analysis. A question about virtual reality was added after five interviews, as was often mentioned by participants.

Interviews were conducted face-to-face, either at the participant's home or workplace. Investigators made notes and audio recordings. Interviews were transcribed and reviewed by both investigators. Participants did not receive interview transcripts or preliminary findings. However, throughout the interview, the explicitation method allowed for immediate clarification and iterative reformulation, ensuring that the participant's meaning was accurately captured and understood during the exchange. A pseudonymized coding system was used.

2.5. Data analysis

A semio-pragmatic analysis (Fracso et al., 2022) was conducted using NVIVO V14.23. This method categorizes the lived experiences of the studied phenomenon through repeated reading of verbatims. The verbatims were divided into meaning units, which were grouped into themes, linked together to emerge categories. Continuous comparison of data from different interviews allowed for the generalisation of categories. Triangulation was performed at each stage by comparing the independent results of two investigators (AEH and GR) with those of an expert in semi-pragmatic phenomenology (AOE). A heuristic map organized the themes into categories, which were then arranged in a phenomenological statement (Supplementary File 4). One author performed analysis manually, another with NVIVO, for triangulation of methods.

Semiopragmatic analysis is a phenomenological approach with which experience collected in verbatim records can be categorized (Table 1). They integrate thematization with semiotic coding, through a process of constant comparison.²⁷

Table 1.

Participant characteristics.

Parti-cipant	Age range (years)	Sex	BMI (kg/m²)	Overall diving experience	Previous practice of		Socio-professional category	Interview duration (min)
					Scuba diving	Mind-fulness meditation
P1	30−40	M	36	Good	Yes	No	Unemployed	35
P2	40−50	F	36	Good	No	Yes	Chartered accountant	18
P3	≥60	F	36	Mixed	No	No	Chartered accountant	24
P4	50−60	F	36	Good	Yes	Yes	Unemployed	60
P5	40−50	F	37	Mixed	No	No	Lawyer	23
P6	50−60	F	40	Good	No	No	Restaurant employee	24
P7	40−50	F	34	Good	No	No	Unemployed	22
P8	30−40	F	31	Good	No	No	Co-manager of a business	42
P9	50−60	F	45	Good	No	Yes	Computer specialist	39
P10	50−60	F	33	Good	No	Yes	Sociology teacher	33

Data were collected and analysed simultaneously, enabling iterative adjustments to the interview guide. Data collection ceased upon data saturation.

2.6. Ethics approval

The study was conducted in accordance with the principles of the Declaration of Helsinki (1964, and its later amendments). Ethical approval was obtained from the Institutional Review Board of Ile-de-France III (Approval number: BTY-2022-05-OBEDIVE). In accordance with French legislation, the choice of ethics committee was assigned through a national randomisation procedure to ensure independence and impartiality. Written informed consent was obtained from all participants prior to their inclusion in the study.

3. Results

3.1. Participant characteristics

Among the thirty participants of the Bathysmed protocol, twelve completed the preliminary questionnaire. Ten interviews were conducted to reach data saturation. The average duration was 32 min. Participants' characteristics are detailed in Table 1.

3.2. Phenomenological analysis

Four categories emerged from the analysis (Table 2).

Table 2.

Categories derived from the analysis of the lived experience of the combined diving mindfulness protocol by individuals with obesity.

Category 1	The protocol was a meditative experience, changing the perception of time and introducing mindfulness in daily life.
Category 2	Acted as a therapy, raising awareness of psychological disorders, reducing self-stigmatisation, and enhancing self-esteem by engaging patients in a care process.
Category 3	The awareness of emotional eating and the management of emotions facilitated by the diving programme were catalysts for behavioural change.
Category 4	The conditions of the diving programme intervention influenced unique experiences of the participants.

Each category is presented as a phenomenological statement incorporating all sub-categories. Figure 1 summarizes the effects of the protocol on people with obesity. Tables per category containing verbatim for each sub-category are available (Supplementary File 4).

Figure 1.

Effects of the Bathysmed® therapeutic diving protocol based on the lived experience of individuals with obesity.

• 1.The protocol was a meditative experience, changing the perception of time and introducing mindfulness in daily life.

The protocol was a moment of “disconnection from the world” (P1), bringing “calmness” (P4). Through mindfulness exercises this sensation could be rediscovered daily to “disconnect” (P5) and “recenter on oneself” (P8). This led to feeling “calmer” and even “more organized” (P6). By offering this disconnection, the protocol taught to “live fully in the present moment” (P9). There was a sensation of “time distortion” (P9): the diving session could “pass quickly” (P6) or seem “incredibly long” (P9). This experience altered the perception of time in daily life: “taking time to do things calmly works just as well, if not better” (P1). A state of self-awareness during diving was facilitated by a transformation of sensory stimuli underwater, akin to a “sensory deprivation tank” (P4). It was a “different overall sensory experience” (P8), a “world of silence” (P10). One felt “weightless” (P7) and could “forget the body” (P9).Thus, the protocol induced a meditative state, sourced from various elements of the experience. For some, “conditioning” (P10) through sophrology and meditation exercises was “really effective” (P8). For others, freely exploring the underwater world “swimming among schools of fish” (P8) was (P4) “similar to meditation” (P9). This left pleasant “memories” (P8) to recall later.

• 2.The protocol acted as a therapy, raising awareness of psychological disorders, reducing self-stigmatisation, and enhancing self-esteem by engaging patients in a care process.

The protocol led to an awareness of psychological disorders, such as “a state of constant stress” (P9), and had a “therapeutic” effect: leaving “problems at the bottom of the water” (P8). This effect manifested differently depending on personal situations: improved mood: “I felt great,” (P4) and reduced anxiety: “anxiety. which I no longer feel” (P9).It also permitted the release of “traumas” (P6) and increased “stress tolerance” (P9). By learning to react calmly to stressful situations encountered while diving, participants acquired “psychic tools” like “breathing to calm down,” which could be “transposed into daily life” (P5). A process of refocusing on oneself to learn to “listen to one's sensations,”“accept one's limits,” and be “kinder” to oneself (P8). This better self-knowledge (P10) helped define priorities: “focus on what's really important” (P8). Altered social and professional relationships through better “self-assertion,” and controlled reactions in case of disagreement (P7).

These benefits encouraged participants to engage in a care process. The protocol was “a step” (P6) allowing to “unlock” oneself to pursue “psychological work” (P8).The experience pushed participants to overcome fears and difficulties, gaining “confidence” (P10) in their abilities, enhancing self-esteem. Initially, there was apprehension towards a new activity,: “am I capable?” (P6). For some, there was an added “fear of the sea” (P6). The first diving sessions confronted participants with “limits” (P9). Gradually, "this apprehension disappeared" (P10), leading to “more pleasure, less effort” (P4), made possible by the secure guidance of instructors (P1). Ultimately, it was a “challenge for oneself” (P10) that, once overcome, brought a sense of “victory” (P5). Being able to dive despite thinking “it was impossible” (P3) “because of the weight” showed there was self-stigmatisation with activity limitations: “realising there are many things I don't try” (P9). Understanding this, along with enhanced self-esteem, encouraged “trying many more things” (P8).

• 3.The awareness of emotional eating and the management of emotions facilitated by the diving programme were catalysts for behavioural change.

The protocol helped participants identify "the sensation of hunger or its absence" (P8) and emotional eating: “we are stressed, we eat” (P1). This was a prerequisite for reducing food “compulsions” (P2), made possible by better “emotion management” (P5) using techniques learned during dives (P5). “Less stress” (P8) and “better sleep” (P7) also contributed to improving eating behaviour. Finally, “acceptance” (P1) reduced guilt associated with overeating, thereby reducing emotional eating. For some, there was “no change” (P4) in their diet, though other aspects of their lifestyle were altered.

The protocol acted as a lever towards physical activity. Participants wanted to “continue diving” (P9) after this positive experience. They also engaged in other sports: “I go to the gym and …do boxing” (P5). The removal of self-limitation due to obesity and increased self-confidence (category 2) likely promoted this behavioural change. For an experienced diver, this experience taught new diving methods “by taking time, it's even more enjoyable” (P1). Finally, the experience sparked a desire for change among some, who wanted to modify “the entire framework of life,”: “it's just the beginning of a new life” (P8).

• 4.The conditions of the diving programme intervention influenced unique experiences of the participants.

Each participant's experience was unique (P5), depending on their life context (such as psychiatric conditions) and their motivations for participating in the RCT. For many, it was a “unique opportunity” to dive (P6), driven by “curiosity” (P10). For others seeking a “solution to their weight problem,” “it was better to try everything. it could only be beneficial” (P5).The experience of obesity and “the gaze of others” was heterogeneous (P1). While some were “quite comfortable in their body” (P2), others had a more conflicted body image that persisted after the protocol (P5) or improved: “now I don't care” (P6). Doing this activity with a group of obese individuals “allowed to relativize” self-image, but there was also a risk of group stigmatisation (P1).P3 was “overall disappointed” by the protocol related to “all the constraints,” including discomfort with the equipment: “with all the diving gear, we weigh much more,” “the wetsuit was horrible,” a difficulty shared with other participants. Diving sessions generated fatigue and pain, posed difficulties for memorising exercises, and psychological issues, such as “panic attacks.” On an organisational level, “being away from home for 5 consecutive weekends with a young child was not easy” (P8).The effects of the protocol had a unique temporal aspect. For some, the effects “didn't really last over time” (P2) after the protocol. Once the “dynamic” created by the close repetition of diving sessions stopped, it was difficult to impose the “rigour” (P2) of regular mindfulness practice. Prolonging or repeating the protocol might be needed for lasting effects (P2). For others, the beneficial effects persisted “in the long term” (P5). Others perceived the effects only later, after personal work and appropriation of the tools: “those experiences were raw material” (P8).

The usefulness of psychological and dietary follow-up alongside diving was evident. It enhanced the effects of the protocol and vice versa: "it all worked together" (P1).

Virtual reality allowed “reliving the dives” (P5) and “recapturing the sensations” (P9): “calmness,” the “bubble” (P6). Its effect depended on individual expectations: “I didn't seek diving, I sought calm" (P6). It was a way to “extend the effect without going back into the water” (P5), integrating this practice into daily life (P6). Moreover, there was no apprehension of actually going into the sea (P5). However, it did not work for everyone, as the device needed “improvement” (P1).

The “group effect” (P1) was beneficial independently of the diving. It helped break isolation (P6) by sharing the experience of a common condition and supporting each other (P10). It also created lasting “social bonds”: “it helped me make a group of friends” (P6).

4. Discussion

This study helped understand the effects of the Bathysmed® protocol based on the lived experiences of adults with obesity included in the trial. The protocol was a meditative experience that facilitated mindfulness in daily life. Coupled with psychological and dietary follow-up, it had a therapeutic effect that engaged obese individuals in a care process and was a catalyst for behavioural change.

To our knowledge, this is the first study on the effects of scuba diving combined with mindfulness meditation in adults with obesity. The qualitative results presented here are consistent with those of the quantitative study (Griffiths et al., n.d.), which showed a decrease in emotional eating, self-stigmatisation, perceived stress, and an improvement in quality of life among the diving group participants compared to the control group. Few qualitative studies have examined the effects of scuba diving in other populations: patients with physical disabilities (Santiago Perez et al., 2023) and veterans suffering from physical/psychological injuries (Morgan et al., 2019; Walker & Kampman, 2022). Their results contain similarities to our study.

4.1. Mindfulness in diving and daily life

The Bathysmed® protocol, by introducing mindfulness meditation before and during the diving session, amplified the intrinsic meditative effect of scuba diving. Veterans' diving accounts (Morgan et al., 2019; Walker & Kampman, 2022) highlight a theme of being fully present and disconnecting. This was facilitated by the concentration required for diving, changes in sensory stimuli and a sense of time distortion. The Bathysmed® protocol in obese individuals had an additional effect: it gave them access to mindfulness in daily life.

4.2. A therapeutic effect that engages in care

The therapeutic effect of diving on the psychological level was also found among divers with physical disabilities (Santiago Perez et al., 2023) and veterans suffering from post-traumatic stress disorder, who saw improvements in anxiety, mood, and sleep (Gibert et al., 2022; Morgan et al., 2019; Walker & Kampman, 2022). By raising awareness of their psychological difficulties and the potential for improvement, the protocol engaged participants in a care process.

4.3. A beneficial effect on self-esteem and self-stigmatisation

Diving represented a challenge for people with physical disabilities (Santiago Perez et al., 2023) and injured veterans (Morgan et al., 2019). In our study, participants also overcame fears, acquired new skills, and built confidence, which strengthened their self-esteem. The supervision played a key role in building participants' confidence and led to a reduction in participants' self-stigmatisation. This was key to behavioural change: no longer self-limiting because of their weight and daring to try new activities. In a study on a multidisciplinary lifestyle modification programme for obese individuals, lack of self-confidence and self-stigmatisation were among the main barriers to change (Piana et al., 2013).

4.4. A catalyst for behavioural change

Emotional eating was another barrier to change (Piana et al., 2013). The combined mindfulness-diving protocol helped participants identify their hunger sensations and the emotional component of eating. By learning to manage their emotions and stress, they were able to improve their eating behaviour. Similar effects are described elsewhere (Katterman et al., 2014; Lattimore, 2020). By developing attention to their own feelings, the protocol promoted a holistic lifestyle change, including physical activity through increased enjoyment, creating a virtuous circle.

For some participants in our study, a pursuit for deeper change was triggered, seeking a "new life." This aligns with other studies (Santiago Perez et al., 2023): some people with disabilities reorganized their lives around diving. This study also highlighted that scuba diving was a "transformative" experience (Duerden et al., 2018), with high impact, combining emotion, discovery, and change.

4.5. A constraining intervention with unique experiences

This experience brought different benefits depending on each participant's specific difficulties. For example, some observed no diet change but experienced other benefits. One participant had a generally negative experience, attributed to several factors: difficulty remembering exercises, disappointing diving sites, physical fatigue, and pain. There is a discrepancy between her experience and that of veterans and people with disabilities who reported pain relief from diving (Morgan et al., 2019; Santiago Perez et al., 2023). This participant was slightly older than the others (60 years) and experienced a flare-up of knee arthritis during the study, which may partly explain the differences.

Scuba diving requires specific equipment and is physically intense. This participant's experience suggests that this intervention is not suitable for everyone. It may be necessary to select individuals who could potentially benefit from a combined mindfulness diving protocol, using criteria yet to be defined.

4.6. Variable temporal aspect

The temporal aspect of effects are variable. The RCT reported effects up to 8 months after the start of the protocol. The qualitative study examined the effects later, between 6 months−1 year after the protocol. For some, the initial effects did not last, while for others, changes were long-lasting. Previous literature has not investigated long-term effects of diving. For veterans, after the 10−14 days diving intervention some experienced a psychological relapse. The long-term effects of mindfulness were uncertain (Solhaug et al., 2019; Sosa-Cordobé et al., 2022).

The continuation of psychological and dietary follow-up after the programme may have helped prolong the benefits. Virtual reality diving is an accessible way to relive aspects of the experience. Studies with virtual reality protocols for patients with obesity were inconclusive (Tatnell et al., 2022).

4.7. A distinct group effect

Group socialisation was beneficial independent to the protocol, thanks to the sharing of experiences and common goals, consistent with other populations (Morgan et al., 2019; Santiago Perez et al., 2023). The group was a resource for implementing therapeutic lifestyle modifications, similar to a bariatric programme (Tarrant et al., 2017). Psychological connection with other patients, a sense of shared social identity, social support, and a collective view of problems encouraged lifestyle changes.

4.8. Strengths and limitations

Strengths of our study lie in the diversity of experience of the participants and the authenticity of responses. One participant (P3) reported a predominantly negative experience, describing fatigue, logistical burdens, physical pain, and episodes of panic. While most found the equipment manageable, she described it as “even heavier” and “horrible,” and struggled to memorize breathing techniques. Yet, she also mentioned moments of insight regarding emotional eating, using breathing to “cut off hunger.” This internal ambivalence highlights that meaningful variation in lived experience is not demographic but phenomenological (Dahlberg et al., 2024). It underlines the need for flexible, tailored interventions.The average duration of interviews of 32 min and the few modifications made to the guide, validated by two test interviews, testify data collection quality. Triangulation of different data treatment methods improved results reliability. The semiopragmatic coding system is the only qualitative analysis technique that allows the experiential data to be put in logical order until the categories are saturated, reinforcing credibility, dependability and confirmability of results by limiting interpretation bias.

Limitations include a lack of diversity on sex: only one man was interviewed, however 87% of the RCT study participants were women. Women are more likely to seek solutions for weight loss (Cooper et al., 2021). Interviews were conducted 6 to 13 months after the protocol and may have caused memory bias. However, this allowed the exploration of longer-term effects.

5. Conclusion

This combined diving-mindfulness protocol can be integrated into a comprehensive obesity care plan for adults with obesity. It promotes behavioural change for diet and physical activity, essential pillars in managing this chronic condition. The RCT demonstrated reduced emotional eating, self-stigmatisation, perceived stress, and improved quality of life. This qualitative approach provided a more in-depth understanding of the processes and suggests broader benefits, on a psychological and socio-relational level, engaging participants in a care process and as a catalyst to change. These effects seem to be mediated by the introduction of mindfulness in daily life, improved psychological state and self-esteem, and learning to manage emotions and stress. The protocol removes barriers to lifestyle modifications.

The similarities between the effects observed in adults with obesity, those with physical disabilities, and veterans suggest that this intervention could be beneficial in other chronic diseases could be experimented with other populations. The duration of effects after the intervention remains uncertain. Future studies could determine the timing or repetition of additional sessions to maintain long-term effects. Access to diving is limited by the financial and organisational means necessary for its implementation, and although virtual reality session could compensate further studies are needed to explore the benefits.

Supplementary Material

Supplementary material

Supplementary Information 2 Reflexive procedures

Supplementary material

Supplementary File 3 interview guide

Supplementary material

COREQ supplementary file 1

Supplementary material

Supplementary File 4 Verbatims

Biographies

Dr Griffiths is an academic general practitioner at the General Practice Departement University of Montpellier, with research interests in health literacy and patient empowerment.

Dr El Housseini is an academic general practitioner at the General Practice Departement University of Montpellie.

Dr Gentiane Richer is a general practitioner at the General Practice Departement University of Montpellier.

Vincent Meurice is a diving instructor and President of BathysMed, with a strong research interest in the benefits of diving.

Frederic Beneton is co-founder of BathysMed.

Pr Michelet is a professeur of anaesthetics at the University Hospital in Marseille, with a personal interest in the benefits of diving. He acts as a scientific advisor for Bathysmed.

Dr Oude Engberink is an academic general practitioner at the General Practice Departement University of Montpellier, with an expertise in qualitative research (conceptor of phenomenological research, semio-pragmatic analysis), author of a qualitative methodological book and numerous international research publications.

Funding Statement

The randomized controlled trial was supported by the BPI France grant (N° 4021591/1). No additional funding was used for the qualitative study. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. (Bpifrance)

Supplemental material

Supplemental data for this article can be accessed at https://doi.org/10.1080/17482631.2025.2571942.

Acknowledgements

The authors would like to thank all participants in the trial, the trial researchers, clinicians and supporting staff at the trial site.

Author contributions

KG: Conceptualisation, Methodology, Formal Analysis, Writing- original draft. AEH: Investigation, Data Curation, Formal Analysis, Writing- original draft. GR Investigation, Data Curation, Formal Analysis, Writing- original draft. VM: Project Administration, Validation FB: Project Administration, Validation, Writing- Review and editing, PM: Investigation, Validation, Writing Review and editing. AOE: Conceptualisaiton, Methodology, Formal Analysis, Writing Review and editing.

Disclosure statement

FB and VM are BathysMed® founders. PM is BathysMed® scientific advisor. The qualitative study design (KG, AOE, AEH, GR) was independent. KG, AOE, AEH, GR report no competing interests.

Data sharing

Data (French anonymous verbatim) are available upon request from the corresponding author.