The effect of cognitive behavior therapy-based "forest therapy" program on blood pressure, salivary cortisol level, and quality of life in elderly hypertensive patients

Mood and physiological effects of visual stimulation with images of the natural environment in individuals with depressive and anxiety disorders

BACKGROUND

Nature therapies are gaining attention as non-pharmacological treatments for depressive and anxiety disorders, but research on their effectiveness in patients is limited. This study investigates the mood-improving effects of visual stimulation with natural environmental images in patients with depressive and anxiety disorders.

METHODS

We conducted a randomized crossover comparison trial involving 60 right-handed adult participants with depressive or anxiety disorders and receiving outpatient treatment. Visual stimuli of natural environments consisted of green-themed nature images, while the control stimuli featured urban scenes dominated by buildings. The stimulation lasted for 3 min, during which orbital prefrontal brain activity was measured using a 2-channel Near-infrared Spectroscopy (NIRS) system, and heart rate variability was assessed using fingertip accelerated plethysmography.

RESULTS

Mood enhancement effects were observed in both the depressive and anxiety disorder groups following visual stimulation with nature images. In the depression group, orbital prefrontal oxygenated hemoglobin concentration significantly increased after visual stimulation with nature images, while there were no significant changes in the anxiety group. However, in the anxiety group, a correlation was found between reduced orbital prefrontal oxygenated hemoglobin in response to nature images and increased mood-enhancement. Furthermore, the severity of depressive symptoms did not significantly affect the intervention effects, whereas heightened anxiety symptoms was associated with a smaller mood enhancement effect.

DISCUSSION

Our study demonstrates the benefits of nature image stimulation for patients with depressive and anxiety disorders. Differential orbital prefrontal brain activity impacts notwithstanding, both conditions exhibited mood enhancement, affirming the value of nature image stimulation.

The effect of forest-based health and wellness on the stress-relieve of middle-aged people

In order to explore the impact of experience in forest-based health and wellness (FHW) on the stress of middle-aged people, 12 participants aged 35-39 were selected to conduct a 3-day/2-night study on FHW experience in Wencheng, Wenzhou. Huawei bracelets were used to monitor participants' movement, pulse and blood pressure and their mood state was measured before and after the health care experience using the Profile of Mood States (POMS) scale. After the FHW experience, the lowest value of bracelet stress appeared on the second day of the experience for men and women. The total mood disturbance (TMD) decreased by 38.8 points on average, which significantly improved the positive mood and relieved the stress. The decompression effect of the FHW experience showed some variability among individuals. Furthermore, there were gender differences in alleviation of fatigue and puzzlement, which was greater for females than males.

Effects of forest walking on physical and mental health in elderly populations: a systematic review

There is a growing awareness that spending time in nature is associated with improvement of well-being; nevertheless, the prescription of forest bathing is still limited. The aim of this systematic review was to explore the physiological and psychological benefits of different forest therapies on healthy and pathological elderly populations (>60 years) to identify the most-effective type, duration, and frequency of these interventions. A search for literature was carried out in December 2021 using PubMed, EMBASE, ResearchGate, Google Scholar and Web of Science. Grey literature was searched as well. After removal of the duplicates, within the 214 articles identified, ten met the inclusion criteria. The methodological quality of the selected studies was rated. Forest walking, alone and in combination with other activities is the most effective intervention. The selected studies reported a positive impact on physical components, including reduction in blood pressure and heart rate and improvements in cardiopulmonary and neurochemical parameters. Favorable modifications have also been noted in the psychological field, with improvements in depression, stress levels and in quality of life perception. In conclusion, forest walking may play an important role in promoting physical and mental health in healthy and pathological elderly populations. However, the lack of high-quality studies limits the strength of the results, calling for more trials.

Cognitive-behavioral therapy for treating hypertension: a systematic review and meta-analysis

The aim of the study is to investigate whether cognitive behavioral therapy (CBT) can help in reducing blood pressure (BP) in patients with hypertension, both systolic blood pressure (SBP) and diastolic blood pressure (DBP), this being the primary outcome. This was a systematic review with a meta-analysis that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The keywords used for the searches were CBT and hypertension and their respective synonyms, and were applied to the Pubmed, EMBASE and Web of Science databases. Eligibility and data extraction were performed by two independent researchers. They assessed the risk of bias using the Cochrane's RoB 2 tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the evidence. The data was pooled on the basis that all the analyses had a random effects model. Twenty-two studies were included in this review. In the meta-analysis, 11 studies were included in the analyses of the BP outcomes (SBP and DBP), five studies were included in the follow-up evaluation, and two studies in the body mass index (BMI) analysis. The searches included a total of 2897 patients. The studies presented a high risk of bias and very low quality of evidence. We observed an effect of -0.65 (95% CI: -0.91; -0.39) for CBT-based interventions on SBP with high heterogeneity (I2 85%) and a higher effect of -0.78% (95% CI: -1.13; -0.43) on DBP with even greater heterogeneity (I2 92%). We observed that CBT did have an effect on reducing BP and BMI in hypertensive adults. However, due to the considerable heterogeneity between the studies, the high risk of bias, and the low overall quality of evidence, confidence in these findings should be limited.

Forest therapy using virtual reality in the older population: a systematic review

Introduction

As life expectancy increases, more attention needs to be paid to their mental and physical condition. Many older patients are also bedridden, which makes some treatments, like in vivo exposure to natural environments, more difficult to be applied. This study aimed to systematically review articles that include interventions combining virtual reality and forest environment, targeting a sample of older people.

Methods

Based on PRISMA guidelines, we conducted a literature search in three databases (EBSCO, PubMed, and Scopus), plus gray literature (OpenGrey). We considered only studies that used forest settings via virtual reality and included a sample with age ≥ 65.

Results

After the screening and eligibility stages, 7 articles have been included.

Discussion

The study underlines the need to implement research in this direction to standardize effective procedures that can be used to improve the mental and physical health of the older people and caregivers, while also reducing social costs.

Forest Bathing Increases Adolescents' Mental Well-Being: A Mixed-Methods Study

Previous research has demonstrated that practicing forest bathing has significant positive effects on adult psychological well-being. Considering the ongoing adolescents' mental health crisis of increasing anxiety and depression, determining whether forest bathing has similar effects on adolescents is an important expansion of forest bathing research. This study investigated the possibility that forest bathing could improve adolescents' mental well-being and sought to determine participants' experiences of forest bathing. It used a convergent, parallel, mixed-methods design that was partially co-created with 24 participants aged 16-18 as part of a youth participatory action research (YPAR) project in which participants practiced forest bathing three times over 3 weeks. As measured using the Warwick-Edinburgh Mental Well-Being Survey, the mean participant mental well-being increased significantly after forest bathing, with moderate to large effect sizes. Participants described reduced stress and increased feelings of relaxation, peace, and happiness. These findings correlate with previous forest bathing research involving adult participants. It is recommended that educators and others who work with adolescents consider forest bathing as a simple, low-cost way to improve adolescents' mental well-being.

The effectiveness of nature-based therapy for community psychological distress and well-being during COVID-19: a multi-site trial

During the COVID-19 pandemic, the world population faced various mental health challenges, highlighting a need for new community-based psychosocial interventions. This study aimed to investigate the effectiveness and feasibility of Nature-Based Therapy (NBT) for the community experiencing psychological distress during the pandemic. A multi-site trial comparing NBT and control groups was conducted in Korea with 291 participants exhibiting mild to severe depression or anxiety. A total of 192 participated in 30 sessions of therapeutic gardening, while 99 remained in the control group. Psychological distress and well-being were assessed using seven measures of depression, anxiety, daily activity, life satisfaction, mindfulness, stress, and loneliness. The effect sizes (Cohen's d) of NBT compared to the control group were medium to large: depression (0.583), anxiety (0.728), daily activity (1.002), life satisfaction (0.786), mindfulness (0.645), stress (0.903), and loneliness (0.695). Multilevel analysis revealed significant Time × Group interaction effects for all measures. Pearson correlation (r = - 0.28 to 0.71) showed that changes in all variables correlated significantly with each other, with small to large effect sizes. Therapeutic alliance at post-test positively moderated the intervention effects on the outcomes. We concluded that NBT is a promising psychosocial intervention for treating psychological distress for community dwellers.

Effects of Linpan nature therapy on health benefits in older women with and without hypertension

Background

Nature therapy can significantly benefit the physiology and psychology of middle-aged and older people, but previous studies have focused on forest environments. The restoration potential of rural environments in urban fringe areas, which are more accessible to older people on a daily basis, has not been fully studied. This study assessed the effects of nature therapy on the physical and mental health of older women in a rural setting (locally known as Linpan) in the urban fringe area of Chengdu, China.

Methods

We recruited a total of 60 older women (65.3 ± 5.5 years old) living in cities for 3 days of nature therapy in the winter (30 subjects) and spring (30 subjects), including 20 hypertensive patients.

Results

The results showed that the overall blood pressure, pulse and sleep dysfunction rating scores of the participants were significantly lower than the pretest levels, and the finger blood oxygen saturation, mid-day salivary alpha-amylase and cortisol were increased post-treatment. Increases in these biomarker indicates and increase in stress. There were significant differences in the changes in systolic blood pressure between the hypertension group (HTN) and the normal group (normal) (HTN decreased by 8.8%, normal decreased by 5.4%), salivary alpha-amylase content (HTN decreased by 0.3%, normal increased by 16.9%), and sleep dysfunction rating scores (HTN decreased by 59.6%, normal decreased by 54%). The decreases in systolic blood pressure and pulse in the winter group were higher than those in the spring group by 1.8 and 4.4%, respectively, while the increases in salivary alpha-amylase content and salivary cortisol content were lower than those in the spring group by 11.7 and 11.2%, respectively, and the decrease in sleep dysfunction rating scores was lower than that in the spring group by 7.1%.

Conclusion

Our study concluded that nature therapy based on various health activities in the Linpan has significant health effects on older women. It can regulate blood pressure and pulse in older women, relieve cardiovascular disease, improve sleep quality. Meanwhile, older women with high blood pressure experienced a more significant effect than the healthy group.

Association between Low Urban Neighborhood Greenness and Hypertensive Disorders of Pregnancy

OBJECTIVE

Urban neighborhood greenness is associated with greater cardiovascular health in the general population, and with better pregnancy and neonatal outcomes. Hypertension in pregnancy is a leading cause of maternal mortality and long-term cardiovascular morbidity and mortality in women. We sought to examine the association between greenness and hypertensive disorders of pregnancy.

STUDY DESIGN

This study is a secondary analysis of a prospective cohort study of 1,943 women who received prenatal care from December 2013 to December 2016 at a single, urban, and tertiary academic medical center in Philadelphia, PA. Greenness measure was quantified via residential tree canopy cover within circumferential buffers of 100- and 500-meter radii around participants' homes. Associations between greenness and hypertensive disorders of pregnancy (defined as gestational hypertension or preeclampsia) were estimated by using multilevel logistic regression accounting for maternal sociodemographic information (race-ethnicity, insurance status, and age) medical history (diabetes, body mass index, smoking history, and parity), neighborhood deprivation index, and including 1,225 Philadelphia residents for whom key exposure and outcome data were available.

RESULTS

At baseline, the participants' mean (SD) age was 27.5 (5.9) years, (range: 14-44 years). The majority of participants were non-Hispanic Black (857, 70.2%). Participants with less residential tree canopy cover were significantly more likely to have hypertensive disorders of pregnancy. The multivariable-adjusted odds ratio of hypertensive disorders of pregnancy among participants with less than 10% compared with those with greater than 30% tree canopy cover was 2.14 (95% confidence interval [CI]: 1.11-4.15) within 100-meter buffer.

CONCLUSION

In our cohort, greenness was associated with lower hypertensive disorders of pregnancy odds. Our findings add to evidence that greenness may confer health benefits and warrant further investigations in identifying whether there is a causal pathway through which greenness may be protective against hypertensive disorders of pregnancy.

KEY POINTS

· Low residential tree canopy is associated with increased risk of hypertensive disorders of pregnancy. · 100-meter buffers are most sensitive in identifying associations between tree canopy and HDP risk. · The role of greenness against hypertensive disorders of pregnancy should be further studied experimentally.

Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: a systematic review

Nature prescriptions are gaining popularity as a form of social prescribing in support of sustainable health care. This systematic review and meta-analysis aims to synthesise evidence on the effectiveness of nature prescriptions and determine the factors important for their success. We searched five databases from inception up to July 25, 2021. Randomised and non-randomised controlled studies featuring a nature prescription (ie, a referral or an organised programme, by a health or social professional, to encourage spending time in nature) were included. Two reviewers independently conducted all steps of study selection; one reviewer collected summary data from published reports and conducted the risk of bias assessment. Random-effect DerSimonian-Laird meta-analyses were conducted for five key outcomes. We identified 92 unique studies (122 reports), of which 28 studies contributed data to meta-analyses. Compared with control conditions, nature prescription programmes resulted in a greater reduction in systolic blood pressure (mean difference -4·82 mm Hg [-8·92 to -0·72]) and diastolic blood pressure (mean difference -3·82 mm Hg [-6·47 to -1·16). Nature prescriptions also had a moderate to large effect on depression scores (post-intervention standardised mean difference -0·50 [-0·84 to -0·16]; change from baseline standardised mean difference -0·42 [-0·82 to -0·03]) and anxiety scores (post-intervention standardised mean difference -0·57 [-1·12 to -0·03]; change from baseline standardised mean difference -1·27 [-2·20 to -0·33]). Nature prescriptions resulted in a greater increase in daily step counts than control conditions (mean difference 900 steps [790 to 1010]) but did not improve weekly time of moderate physical activity (mean difference 25·90 min [-10·26 to 62·06]). A subgroup analysis restricted to studies featuring a referring institution showed stronger effects on depression scores, daily step counts, and weekly time of moderate physical activity than the general analysis. Beneficial effects on anxiety and depression scores were mainly provided by interventions involving social professionals whereas beneficial effects on blood pressures and daily step counts were provided mainly by interventions involving health professionals. Most studies have a moderate to high risk of bias. Nature prescription programmes showed evidence of cardiometabolic and mental health benefits and increases in walking. Effective nature prescription programmes can involve a range of natural settings and activities and can be implemented via social and community channels, in addition to health professionals.

Effects of Urban Forest Therapy Program on Depression Patients

Depression is a common serious mental health condition that can have negative personal and social consequences, and managing it is critical for treating depression patients. Forest therapy is emerging as a promising non-pharmacological intervention to improve mental health. However, although the effectiveness of forest therapy programs using forests far from the city has been proven, it is not well known that urban forests can be easily accessed in daily life. Therefore, this study aimed to examine the effects of an urban forest therapy program on depression symptoms, sleep quality, and somatization symptoms of depression patients. To evaluate this, a randomized controlled trial (RCT) design was employed. A total of 47 depression patients participated in this study (22 in the urban forest therapy program group and 25 in the control group). The Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HRSD), the Pittsburgh Sleep Quality Index (PSQI), and the Patient Health Questionnaire-15 (PHQ-15) were administered to each participant to assess the effects of the urban forest therapy program. The results of this study revealed that depression patients in the urban forest therapy program had significantly alleviated depression symptoms and improved sleep quality and somatization symptoms compared to the control group. In conclusion, this study demonstrates the possibility that the urban forest therapy program could be used as an effective non-pharmacological treatment to alleviate depression disorder.

Is altitude a determinant of the health benefits of nature exposure? A systematic review and meta-analysis

Introduction

Nature exposure is a widely accepted option for promoting public health owing to the recent surge of scientific evidence. However, the actual settings to facilitate this initiative is yet to be extensively reviewed. In this systematic review, we have aimed to provide an up-to-date summary of interventional studies investigating the psycho-physiological effects of forests and urban forests, including details on their physical settings, and investigate an effect-modifying role of altitude and summarize data on the magnitude and shape of the association.

Methods

A keyword search using five electronic academic databases (PubMed, Embase, PsycINFO, Web of Science, and Scopus) was conducted to identify relevant articles published in English from the inception year to the end of February 2022. The methodological quality was evaluated using the ROBINS-I or ROB2 tool, depending on the study design. Meta-regression and random effects model were jointly used to examine the relationship between altitude and health outcomes.

Results

We included 27 eligible studies and 31 cases extracted from 19 studies were used for the meta-analysis. In the meta-regression, we observed a non-linear association between altitude and psycho-physiological effects. Altitude had a positive quadratic association with anxiety (p < 0.000, adjusted R ² = 96.79%), depression (p < 0.000, adjusted R ² = 98.78%), and fatigue (p < 0.000, adjusted R ² = 64.74%) alleviating effects. Conversely, altitude demonstrated a negative non-linear association with the blood pressure-lowering effect (p = 0.009, adjusted R ² = 32.83%). Additionally, the thermal index (THI) and illuminance (lx) levels were significantly associated with effect sizes of psychological restoration.

Discussion

This review provides moderate-certainty evidence for an effect-modifying role of altitude. The meta-regression results suggested the optimal and minimal altitude ranges for psychological restoration and physiological relaxation, respectively. Despite some limitations, the study findings provide a significant basis for utilizing altitude, which is easily accessible and simple, to promote the health benefits of nature-based initiatives.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022310894, identifier: CRD42022310894.

Stimulated Parotid Saliva Is a Better Method for Depression Prediction

BACKGROUND

Saliva cortisol is considered to be a biomarker of depression prediction. However, saliva collection methods can affect the saliva cortisol level.

OBJECTIVE

This study aims to determine the ideal saliva collection method and explore the application value of saliva cortisol in depression prediction.

METHODS

30 depressed patients and 30 healthy controls were instructed to collect saliva samples in the morning with six collection methods. Simultaneous venous blood was collected. Enzyme-linked immunosorbent assay was used to determine the cortisol level. The 24-observerrated Hamilton depression rating scale (HAMD-24) was used to assess the severity of depression.

RESULTS

The significant differences in saliva cortisol levels depend on the saliva collection methods. The level of unstimulated whole saliva cortisol was most correlated with blood (r = 0.91). The stimulated parotid saliva cortisol can better predict depression. The area under the curve was 0.89. In addition, the saliva cortisol level of the depression patients was significantly higher than the healthy controls. The correlation between the cortisol level and the HAMD-24 score was highly significant. The higher the saliva cortisol level, the higher the HAMD-24 score.

CONCLUSIONS

All the above findings point to an exciting opportunity for non-invasive monitoring of cortisol through saliva.

Effect of Oral Administration of Lactiplantibacillus plantarum SNK12 on Temporary Stress in Adults: A Randomized, Placebo-Controlled, Double-Blind, Parallel-Group Study

Mouse studies have reported anti-stress effects of Lactiplantibacillus plantarum SNK12 (SNK). Specifically, oral SNK administration increased mRNA levels of hippocampal neurotrophic factor and gamma-aminobutyric acid receptor in mice with sub-chronic mild stress-induced social defeat; moreover, it improved depressive behavior. We aimed to evaluate the efficacy of SNK ingestion against stress in healthy adults. We used the Uchida–Kraepelin test for the stress load, with a low-dose (50 mg/day), high-dose (150 mg/day), and placebo groups (dextrin). The primary outcome was the psychological evaluation as measured by the Profile of Mood States 2nd Edition (POMS2) using total mood disturbance (TMD) scores. The secondary outcomes were the score of each POMS2 item, salivary cortisol as a stress marker, and autonomic balance with the low frequency (LF)/ high frequency (HF) ratio. Compared with the placebo group, the SNK ingestion group showed significantly lower TMD scores. Additionally, compared with the placebo group, the high-dose group showed significantly lower scores for Tension-Anxiety and Confusion-Bewilderment, while the low-dose group showed significantly lower Anger-Hostility scores, salivary cortisol levels, and LF/HF scores. Our findings suggest that SNK ingestion could relieve stress (negative feelings, anxiety, tension, embarrassment, confusion, anger, and hostility) resulting from the temporary load caused by work and study.

The benefits of nature-based therapy for the individual and the environment: an integrative review

Purpose

This review aims to identify the commonly used nature-based therapies, the cohorts that benefit from these interventions, and the potential environmental impact of nature-based therapies.

Design/methodology/approach

An integrative review methodology was taken. The literature was analysed and synthesised through thematic analysis.

Findings

Three themes emerged from the analysis: categories of nature-based therapies; benefits of nature-based therapies; and the gains from nature-based therapies are not universal. Evidence of physiological, psychological, social, vocational and quality of life benefits from participation in nature-based therapies was evident in the literature. However, there was insufficient empirical evidence of the benefits for the environment.

Practical implications

Occupational therapists assist populations across the life course. Consequentially, they can be found working in a diverse range of clinical contexts. This review asserts that nature-based therapies could be a positive addition in many of these contexts. Further, while engagement in activities in natural environments is frequently used by occupational therapists practicing within institution environments, there is evidence to support its use in community service models and potentially in public health strategies.

Originality/value

This integrative review brings together evidence on a diverse range of nature-based therapies, cohorts, associated benefits and factors that influence these. The lack of empirical evidence on the benefits of nature-based therapies for the environment is acknowledged as a gap in the literature

Forest Bathing Is Better than Walking in Urban Park: Comparison of Cardiac and Vascular Function between Urban and Forest Parks

Forest bathing is beneficial for human health. To investigate whether walking in forest or urban parks affects cardiovascular functions (CVFs), the present study was conducted in five forest trails in the Xitou Experimental Forest and in five urban parks in Taipei city. We recruited 25 adult volunteers for an observational pilot study in forest parks (n = 14) and urban parks (n = 11). CVFs were assessed by measuring the arterial pressure waveform using an oscillometric blood pressure (BP) device. The baseline and paired differences of systolic BP (SBP), central end SBP, heart rate, left ventricle (LV) dP/dt max and cardiac output in participants were lower before and after walking in a forest park than those in an urban park. In addition, the systemic vascular compliance and brachial artery compliance of those who walked in a forest park were significantly higher compared with those in an urban park. Linear mixed models demonstrated lower levels of SBP by 5.22 mmHg, heart rate by 2.46 beats/min, and cardiac output by 0.52 L/min, and LV dP/dt max by 146.91 mmHg/s among those who walked in forest compared to those in an urban park after controlling covariates. This study provides evidence of the potential beneficial effects of walking exercise in forest parks on CVFs.

Nature-Based Interventions for Psychological Wellbeing in Long-Term Conditions: A Systematic Review

Background: With the global burden of disease increasing, particularly in relation to often preventable chronic diseases, researchers and clinicians are keen to identify interventions that can mitigate ill health and enhance the psychological wellbeing of people living with long-term conditions (LTCs). It is long established that engagement with nature can support human health and wellbeing, and in recent years, nature-based interventions (NBIs) have been advanced as of potential benefit. This review thus sought to systematically appraise published evidence of the application of NBIs to address psychological wellbeing for those living with LTCs. Methods: A systematic search of three databases, PsycINFO, MEDLINE and SCOPUS, was undertaken, and the BestBETs quality assessment checklist was used to appraise methodological quality of elicited studies. Results: Of 913 studies identified, 13 studies (12 using quantitative methods, one qualitative) were used. Included papers reported use of a variety of psychological outcomes alongside more circumscribed physiological outcomes. Quality appraisal showed modest robustness, some methodological weaknesses and a dominance of application in developed countries, yet synthesis of studies suggested that reported psychological and physiological outcomes present a strong argument for NBIs having a promising and positive impact on psychological wellbeing. Conclusions: NBIs have positive psychological and physiological impacts on people with LTCs, suggesting they may be a suitable addition to current maintenance treatment. Future research should focus on minimising study bias and increasing the potential for cross-cultural applications.

A tranquil virtual reality experience to reduce subjective stress among COVID-19 frontline healthcare workers

OBJECTIVE

The novel coronavirus-19 (COVID-19) has taken an immense physical, social, and emotional toll on frontline healthcare workers. Research has documented higher levels of anxiety, depression, and burnout among healthcare workers during the pandemic. Thus, creative interventions are needed now more than ever to provide brief, accessible support to frontline workers. Virtual reality is a rapidly growing technology with potential psychological applications. In this study, we piloted a three-minute Tranquil Cinematic-VR simulation of a nature scene to lower subjective stress among frontline healthcare workers in COVID-19 treatment units. We chose to film a nature scene because of the extensive empirical literature documenting the benefits of nature exposure and health.

METHODS

A convenience sample of frontline healthcare workers, including direct care providers, indirect care providers, and support or administrative services, were recruited from three COVID-19 units located in the United States. Inclusion criteria for participation included adults aged 18 years and older who could read and speak in English and were currently employed by the healthcare system. Participants viewed a 360-degree video capture of a lush, green nature preserve in an Oculus Go or Pico G2 4K head-mounted display. Prior to viewing the simulation, participants completed a brief demographic questionnaire and the visual analogue scale to rate their subjective stress on a 10-point scale, with 1 = 'Not at all stressed' to 10 = 'Extremely stressed.' We conducted paired t-tests to examine pre- and post-simulation changes in subjective stress as well as Kruskal-Wallis tests and Mann-Whitney U tests to examine differences by demographic variables. All analyses were conducted in SPSS statistical software version 28.0. We defined statistical significance as a p-value less than .05.

RESULTS

A total of 102 individuals consented to participate in the study. Eighty-four (82.4%) participants reported providing direct patient care, 73 (71.6%) identified as women, 49 (48.0%) were between the ages of 25-34 years old, and 35 (34.3%) had prior experience with VR. The pre-simulation mean stress score was 5.5±2.2, with a range of 1 to 10. Thirty-three (32.4%) participants met the 6.8 cutoff for high stress pre-simulation. Pre-simulation stress scores did not differ by any demographic variables. Post-simulation, we observed a significant reduction in subjective stress scores from pre- to post-simulation (mean change = -2.2±1.7, t = 12.749, p < .001), with a Cohen's d of 1.08, indicating a very large effect. Further, only four (3.9%) participants met the cutoff for high stress after the simulation. Post-simulations scores did not differ by provider type, age range, gender, or prior experience with virtual reality.

CONCLUSIONS

Findings from this pilot study suggest that the application of this Tranquil Cinematic-VR simulation was effective in reducing subjective stress among frontline healthcare workers in the short-term. More research is needed to compare the Tranquil Cinematic-VR simulation to a control condition and assess subjective and objective measures of stress over time.

Effect of Forest Therapy on Depression and Anxiety: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to summarize the effects of forest therapy on depression and anxiety using data obtained from randomized controlled trials (RCTs) and quasi-experimental studies. We searched SCOPUS, PubMed, MEDLINE(EBSCO), Web of science, Embase, Korean Studies Information Service System, Research Information Sharing Service, and DBpia to identify relevant studies published from January 1990 to December 2020 and identified 20 relevant studies for the synthesis. The methodological quality of eligible primary studies was assessed by ROB 2.0 and ROBINS-I. Most primary studies were conducted in the Republic of Korea except for one study in Poland. Overall, forest therapy significantly improved depression (Hedges’s g = 1.133; 95% confidence interval (CI): −1.491 to −0.775) and anxiety (Hedges’s g = 1.715; 95% CI: −2.519 to −0.912). The quality assessment resulted in five RCTs that raised potential concerns in three and high risk in two. Fifteen quasi-experimental studies raised high for nine quasi-experimental studies and moderate for six studies. In conclusion, forest therapy is preventive management and non-pharmacologic treatment to improve depression and anxiety. However, the included studies lacked methodological rigor and required more comprehensive geographic application. Future research needs to determine optimal forest characteristics and systematic activities that can maximize the improvement of depression and anxiety.

Can Different Forest Structures Lead to Different Levels of Therapeutic Effects? A Systematic Review and Meta-Analysis

In recent decades, forests have expanded from natural resources for conservation and production to health-promoting resources. With the growing body of evidence supporting the therapeutic effects of forests, the number of investigations on the relationship between forest characteristics and therapeutic effects have increased. However, quantitative synthesis of primary studies has rarely been conducted due to a limited number of health studies including forest description and high heterogeneity of forest variables. In this study, we conducted a systematic review and meta-analysis to evaluate the relationship between the forest structure and the therapeutic effect. We systematically searched the studies examining the therapeutic effects of forests with different stand density and canopy density and synthesized the results. As a result of subgroup analysis, we found that stand density modifies the therapeutic effects. Emotional and cognitive restoration showed greatest improvement in low-density forests with a stand density of less than 500/ha and the therapeutic effects diminish as the stand density increases. The impact of canopy density was not found due to a lack of studies reporting canopy density. Although some limitations remain, the findings in this study have great significance in providing the basis for establishing management strategies of forests for therapeutic use.

Physiological and Psychological Assessments for the Establishment of Evidence-Based Forest Healing Programs

This study aimed to establish a health and medical foundation for forest healing programs and provide a basis for developing an evaluation system for such programs. While the number of visitors to forests and interest in forest healing effects are increasing, few studies have examined the various indicators of the persistent changes in forest healing effects. Therefore, this study conducted pre-, post-, and follow-up experiments on 87 health and clinical indicators in a sample of 88 adolescent participants. The relationships between pre-, post-, and follow-up experiment results for each indicator were analyzed. Of the 87 indicators, 46 showed significant changes, including systolic blood pressure, diastolic blood pressure, cholesterol, serotonin, vitamin D, CD16+CD56 count, interferon-γ, resilience, and self-esteem. The findings are significant for studying diverse participants and indicators and lay the foundation for developing forest healing programs by clarifying aspects such as the indicators suitable for short-term observation versus the indicators requiring long-term observation. Based on these analyses, the results of this study are expected to be useful when conducting research to establish an evidence-based forest healing program in the future.

The efficacy of cognitive behavioral therapy-based interventions on patients with hypertension: A systematic review and meta-analysis

Recently, the benefits of cognitive behavioral therapy (CBT)-based interventions for patients with hypertension have been recognized, but there has been no systematic review that has comprehensively analyzed the efficacy of CBT on health outcomes in this population. We aimed to explore the therapeutic effect of CBT-based interventions on hypertension patients through a meta-analysis. Relevant randomized controlled trials (RCTs) were obtained by searching electronic databases. The primary outcomes were physiological indicators (blood pressure, blood lipid profile). Secondary outcomes were psychological indicators (anxiety, depression), and the quality of sleep. Stata version 15.0 software was used to analyze the results. A total of 15 RCTs were included. The main analysis revealed that CBT-based interventions reduced systolic pressure: -8.67 (95% CI: -10.67 to -6.67, P = 0.000); diastolic pressure: -5.82 (95% CI: -7.82 to -3.81, P = 0.000); total cholesterol levels: -0.43 (95% CI: -0.76 to -0.10, P = 0.010); depressive symptoms: -3.13 (95% CI: -4.02 to -2.24, P = 0.000); anxiety symptoms: -3.63 (95% CI: -4.40 to -2.87, P = 0.000); and improved quality of sleep: -2.93 (95% CI: -4.40 to -1.47, P = 0.000). Additionally, the results of subgroup analysis indicated that long-term group-based CBT-based interventions were particularly beneficial for blood pressure management in hypertension patients. CBT-based interventions are effective in reducing systolic pressure, diastolic pressure, total cholesterol levels, anxiety symptoms, depressive symptoms, and improving quality of sleep in hypertension patients.

Influence of Informal Education in the Forest Stand Redevelopment Area on the Psychological Restoration of Working Adults

Background and Objectives: Nowadays, a significant part of the human population lives and works in urban agglomerations. Limited contact with nature, polluted air, stress, and a sedentary work style all contribute to problems with the physical and mental health of a considerable number of city dwellers. There are many studies indicating the positive, restorative properties of natural environments, such as forests, on human well-being. Our aim was to investigate whether suburban commercial forests in combination with informal environmental education can bring restorative properties to people, especially those who are economically active. Materials and Methods: Four psychological questionnaires were used to determine the restorative properties of a suburban commercial forest on young active people: the Profile of Mood Scale (POMS), the Positive and Negative Affect Schedule (PANAS), the Restorative Outcome Scale (ROS), and the Subjective Vitality Scale (SVS). The experiment involved 60 participants who took forest baths (the act of spending time in a forest and opening your senses to the natural surroundings to experience feelings of peace and wellbeing) in a suburban commercial forest surrounding Świdnik, a city of 40,000 inhabitants located directly next to Lublin (a provincial city with a population of 339,811). The volunteers were divided into three groups; Group A walked an educational route with educational boards (route A1). Group B walked another route with a forest educator who described various forest management activities conducted in this forest (route A2). Group C walked alone, without an educator, along route A2. All three groups arrived at the site of forest stand redevelopment as the end of their route. After a short 10-min exposure to this site, the volunteers again completed the psychological questionnaires. Results: Our study clearly indicates a positive effect from forest bathing in suburban commercial forests. Both the walk with a forest educator and the walk along the educational trail supported psychological recovery for the participants of the experiment, which shows that informal environmental education carried out in forests can be successfully combined with forest bathing, supporting the positive effects of this activity.

Forest Therapy Alone or with a Guide: Is There a Difference between Self-Guided Forest Therapy and Guided Forest Therapy Programs?

There are generally two types of forest therapy. One is to walk or view the forest alone without a guide, and the other is to be accompanied by a guide. This study aimed to investigate the healing factors and health benefits of self-guided forest therapy and guided forest therapy programs and examine the differences in characteristics between interventions. Thirty-seven undergraduate students participated in a randomized experiment (19 in the self-guided forest therapy and 18 in the guided forest therapy program). Data were collected from 111 self-reported essays after each intervention (three essays per person). Results revealed that the forest healing factors contained four categories in common: auditory element, visual element, tactile element, and olfaction element. Forest therapy's health benefits included five categories in common: change of mind and body, introspection, change of emotion, cognitive change, and social interaction. Among the typical differences, the self-guided forest therapy group mentioned more keywords related to introspection than the guided forest therapy program group. On the other hand, the guided forest therapy program group mentioned more keywords associated with the change of emotion and social interaction than the self-guided forest therapy. Our findings show that self-guided forest therapy provides an opportunity for self-reflection to focus on and think about one's inner self. On the other hand, guided forest therapy programs provide positive emotional changes and promoting social bonds through interaction with others. Therefore, because the effects that can be obtained vary depending on the type of forest therapy, participants can utilize forest healing to suit the desired outcomes.

Greenness-air pollution-physical activity-hypertension association among middle-aged and older adults: Evidence from urban and rural China

BACKGROUND

Although some evidence suggests that residential greenness may prevent hypertension in urban areas, limited attention has been paid to urban-rural disparities in the association of greenness with hypertension in rapidly urbanizing developing countries.

OBJECTIVES

The current study investigated the association between the amount of neighbourhood greenness and hypertension among middle and older aged people in Chinese urban and rural areas. It further examined whether PM_2.5 (particulate matter ≤2.5 μm in aerodynamic diameter) concentrations, physical activity, and body mass index (BMI) mediated the association of greenness with hypertension.

METHODS

We used data from 11 486 adults aged 50 years or above within the first wave of the Study on Global Ageing and Adult Health in China during 2007-2010. Hypertension was assessed by criterion-based measures of blood pressure. Residential greenness was characterized by satellite-derived Normalized Difference Vegetation Index. We employed multilevel generalized structural equation models to estimate the association between neighbourhood greenness and hypertension in urban and rural areas. Serial mediation models have been performed to test potential pathways linking greenness to hypertension.

RESULTS

In rural areas, a greater amount of residential greenness was directly associated with a decrease in the odds of hypertension (odds ratio = 0.51, 95% confidence interval 0.29-0.89). No direct association was observed in urban areas (odds ratio = 1.33, 95% confidence interval 0.94-1.89). Serial mediation models showed that the association of greenness with hypertension was completely mediated by PM_2.5 concentrations in urban areas, while the association of greenness with hypertension was only partially mediated by PM_2.5 concentrations and serial PM_2.5 concentrations-physical activity path in rural areas. There was no evidence that physical activity, air pollution-BMI path, air pollution-physical activity-BMI path, and physical activity-BMI path mediated the association in both urban and rural areas.

CONCLUSIONS

Higher neighbourhood greenness was directly associated with a lower prevalence of hypertension among middle and older aged adults in rural China but not in urban areas. The association of greenness with hypertension was completely mediated by air pollution (without any mediation effect of physical activity and BMI) in urban areas. In contrast, the association was partly mediated by air pollution, physical activity, and other unobservables in rural areas. Further longitudinal studies are warranted to prove a cause-and-effect association, which may help policymakers and practitioners to conduce effective interventions to prevent and control the prevalence of hypertension and the attendant disease burden.

Psycho-Electrophysiological Benefits of Forest Therapies Focused on Qigong and Walking with Elderly Individuals

We developed two distinct forest therapy programs (FTPs) and compared their effects on dementia prevention and related health problems for older adults. One was focused on Qigong practice in the forest (QP) and the other involved active walking in the forest (WP). Both FTPs consisted of twelve 2-h sessions over six weeks and were conducted in an urban forest. We obtained data from 25, 18, and 26 participants aged 65 years or above for the QP, WP, and control groups, respectively. Neuropsychological scores via cognition (MoCA), geriatric depression (GDS) and quality of life (EQ-5D), and electrophysiological variables (electroencephalography, bioimpedance, and heart rate variability) were measured. We analyzed the intervention effects with a generalized linear model. Compared to the control group, the WP group showed benefits in terms of neurocognition (increases in the MoCA score, and alpha and beta band power values in the electroencephalogram), sympathetic nervous activity, and bioimpedance in the lower body. On the other hand, the QP group showed alleviated depression and an increased bioimpedance phase angle in the upper body. In conclusion, both active walking and Qigong in the forest were shown to have distinctive neuropsychological and electrophysiological benefits, and both had beneficial effects in terms of preventing dementia and relieving related health problems for elderly individuals.

Greenspace Interventions, Stress and Cortisol: A Scoping Review

Background: Engaging with nature can profoundly impact psychological and physiological health of persons across the lifespan. Greenspace interventions (GSI) encompass a broad range of strategic, nature-based activities for overall health and wellbeing. Within the past 20 years there has been a growing interest in the access to and management of greenspace to mediate the deleterious impact of acute and chronic stress, particularly, physiologic biomarkers of stress such as cortisol. Objective: This review aims to describe the impact of greenspace interventions on cortisol, to present the current state of the science on GSIs as they impact cortisol, and to uncover any limitations of current research strategies to best inform future research. Methods: A scoping methodology was conducted to systematically study this emerging field and inform future research by mapping the literature based on the GSI category, interventional design, cortisol metrics, and subsequent analysis of cortisol. Conclusion: Considerable heterogeneity in research design, aim(s), interventional strategy, and cortisol metrics were identified from a total of 18 studies on GSIs and cortisol outcomes. While studies demonstrated a potential for the positive association between GSIs and stress relief, more rigorous research is needed to represent GSIs as an intervention to mitigate risks of stress.

The Influence of Forest Activities in a University Campus Forest on Student's Psychological Effects

This study aimed to examine the psychological effects of forest activities in a campus forest. A pre-test and post-test control group design was employed to evaluate the psychological effect of forest activities in a campus forest. A total of 38 participants participated in this study (19 in the forest activities group; 19 in the control group). The Profile of Mood State (POMS) questionnaire, the Concise Measure of Subjective Well-Being (COMOSWB), and the modified form of the Stress Response Inventory (SRI-MF) were administered to each participant to assess psychological effects. This study revealed that participants in the forest activities intervention group had significantly positive increases in their mood, stress response, and subjective well-being, comparing with those of control group participants who did not partake in any forest activities. In conclusion, the implementation of forest activities in a campus forest is an efficient strategy to provide psychological well-being benefits to college students.

Forest Bathing Always Makes Sense: Blood Pressure-Lowering and Immune System-Balancing Effects in Late Spring and Winter in Central Europe

Various formats of forest bathing have been receiving increasing attention owing to their perspectives in health promotion and the treatment of chronic lifestyle diseases. The majority of field studies are still being conducted in the Far Eastern region, and they often make psychological assessments mainly in the green season. In our pretest–posttest field experiment, twelve healthy, working-age volunteers participated in a 2-h leisurely forest walking program, first in the green season (May) and then in the winter season (January), in the Mecsek Hills, next to Pécs, Hungary. Systolic blood pressure decreased after the trips both in late spring and in the winter. Based on changes in the expressions of CD69, an early activation marker, NKG2D, a major recognition receptor, perforin, granzyme B, and TIM-3, an inhibitory immune checkpoint molecule, on CD8+ cytotoxic T, NK, NK^dim, NK^bright, and NKT cells, we detected the stimulation of NK^bright cells and activation of all examined immune cell subsets in the green season. In the winter, a slight activating and an interesting balancing effect regarding TIM-3 could be observed considering our finding that basal (pretest) TIM-3 expression by NK cells was significantly lower in the winter. Our work expands the knowledge on and potentials of forest medicine.

Effects of exposure to immersive videos and photo slideshows of forest and urban environments

A large number of studies have demonstrated the benefits of natural environments on people's health and well-being. For people who have limited access to nature (e.g., elderly in nursing homes, hospital patients, or jail inmates), virtual representations may provide an alternative to benefit from the illusion of a natural environment. For this purpose and in most previous studies, conventional photos of nature have been used. Immersive virtual reality (VR) environments, however, can induce a higher sense of presence compared to conventional photos. Whether this higher sense of presence leads to increased positive impacts of virtual nature exposure is the main research question of this study. Therefore, we compared exposure to a forest and an urban virtual environment in terms of their respective impact on mood, stress, physiological reactions, and cognition. The environments were presented via a head-mounted display as (1) conventional photo slideshows or (2) 360[Formula: see text] videos. The results show that the forest environment had a positive effect on cognition and the urban environment disturbed mood regardless of the mode of presentation. In addition, photos of either urban or forest environment were both more effective in reducing physiological arousal compared to immersive 360[Formula: see text] videos.

Disentangling the Diversity of Forest Care Initiatives: A Novel Research Framework Applied to the Italian Context

In the effort to advance the knowledge of and disentangle the diversity of emerging forest-based initiatives for wellbeing, we propose (1) an umbrella definition (i.e., forest care initiatives (FCIs)), (2) a custom-made repository to collect and systematize information on FCIs in Italy, and (3) discuss a categorization scheme to cluster initiatives into three main categories according to target users, substitutability of the forest ecosystem, and the specificity of the health contributions to which they are aimed. We analyzed 232 initiatives, showing a lively panorama of Italian FCIs, mainly provided by private entities and civil society. FCI developments appear to be occasions for, but are not restricted to, rural and marginal areas delivering inclusive wellbeing services to a wide target user group and business opportunities. However, due to the novelty of this area of investigation, further research is needed to account for benefits and opportunities and to increase knowledge on enabling forest environments.

Possibilities for Harmonisation between Recreation Services and Their Production within the Forest Sector—A Case Study of Municipal Forest Enterprise Hradec Králové (CZ)

This paper deals with the possibility of harmonising the needs of society and the possibilities of the forest property manager. The Municipal forest enterprise of the city of Hradec Králové (MLHK) in the Czech Republic (CZ) is an example of this principle, which proves that the intensive development of a recreational service is possible without limiting this principle. The forest enterprise manages 3707 ha of forest in the immediate vicinity of the city with 92,000 inhabitants. The forest enterprise pays the city rent and makes a profit. The data were obtained by analysing the economic data of the surveyed company, the annual observation of the forest attendance, the surveys of the characteristics of the forest visitors and the surveys of selected 16 companies (from seven countries) managing the forests of some European cities. The main results concerning MLHK are as follows: the share of recreational service costs in the total costs of the forestry activities is 19.7%. The recreational services of the forest are financed from 71.5% from revenues from the sale of raw wood, 17.5% from revenues from the sale of sand from its own quarry, 3.9% from revenues from the recreational services and 7.1% from subsidies. The operation of the gravel quarry contributes to the economic result of the forest enterprise roughly by an amount corresponding to the costs of the recreational services. An average annual forest attendance is 243 people/ha. The inhabitants of the city account for 61.5% of the visitors, 20.4% of the visitors live within a distance of up to 30 km, and 18.1% of the visitors live at a distance of more than 30 km. The main results of the survey among the forest enterprises managing the forests of the selected European cities are as follows: the share of costs for the recreational services in the total costs of the forestry activities is 21–72% for cities with a population of over 100,000, and 3–14% for cities with less than 100,000 inhabitants. As a source of financing recreational services, the forest enterprises from mentioned cities with over 100,000 inhabitants, the money especially came from the city budget (70–100%). Forest enterprises from cities under 100,000 inhabitants stated that they fund a recreational service with 95–100% of the revenues from the sale of raw wood. Data on the MLHK show that it is possible to finance a recreational forest service from its own resources if this is the owner’s priority. However, this only applies under certain conditions, such as that, in addition to the income from forest management, there are other sources of income (in this case, sand mining or subsidies from public programmes). If the forest owner did not have these resources, they would have to pay for the recreational service from their own other resources (e.g., from the city budget).

Perceived Loudness Sensitivity Influenced by Brightness in Urban Forests: A Comparison When Eyes Were Opened and Closed

Soundscape plays a positive, health-related role in urban forests, and there is a competitive allocation of cognitive resources between soundscapes and lightscapes. This study aimed to explore the relationship between perceived loudness sensitivity and brightness in urban forests through eye opening and closure. Questionnaires and measuring equipment were used to gather soundscape and lightscape information at 44 observation sites in urban forested areas. Diurnal variations, Pearson’s correlations, and formula derivations were then used to analyze the relationship between perception sensitivity and how perceived loudness sensitivity was influenced by lightscape. Our results suggested that soundscape variation plays a role in audio–visual perception in urban forests. Our findings also showed a gap in perception sensitivity between loudness and brightness, which conducted two opposite conditions bounded by 1.24 dBA. Furthermore, we found that the effect of brightness on perceived loudness sensitivity was limited if variations of brightness were sequential and weak. This can facilitate the understanding of individual perception to soundscape and lightscape in urban forests when proposing suitable design plans.

Effect of Forest Therapy for Menopausal Women with Insomnia

Female hormone changes during menopause can affect the autonomic nervous system, circadian rhythm, and secretion of cortisol/melatonin, resulting in a vulnerability to insomnia. In this light, therapy has been gaining attention as a way to reduce stress hormones by stabilizing the autonomic nervous system. Thus, this study aims to objectively and scientifically analyze the impact of forest therapy in postmenopausal insomnia patients. The forest therapy program lasted 6 days, wherein 35 postmenopausal women performed activities such as trekking, leg massages, stretches, and bathing in warm and cold water. They also underwent serologic tests, participated in polysomnography (PSG), and answered sleep questionnaires before and after the program. Further, a statistical analysis compared the results. Serologic tests showed a significant reduction of cortisol from 10.2 ± 3.79 to 7.75 ± 2.81, while PSGs showed how sleep efficiency increased to 89.3 ± 4.3% (p < 0.01), and how waking after sleep onset reduced to 47.4 ± 22.3 min (p < 0.01). The total sleep time also increased to 428.5 min and sleep latency was 11.1 ± 11.0 min. Despite its limitations, forest therapy could be a good alternative to nonpharmacological treatment for mitigating insomnia in postmenopausal women.

Forest and Wellbeing: Bridging Medical and Forest Research for Effective Forest-Based Initiatives

Research Highlights: This review gives an overview of existing literature on the emerging topic of human wellbeing-forest contact nexus and provides a preliminary framework linking forests to wellbeing by highlighting key variables affecting this relationship. Background and Objectives: Existing literature reveals the psychological, physiological and social wellbeing benefits of contact with forest ecosystems; however, the role of forests in this relationship remains largely unexplored. The objectives of this review are twofold: (i) to provide an overview of the contributions of forest experiences to human wellbeing and the related interplay with forest ecosystems and (ii) to identify knowledge gaps to inform future research and systematize information available for forest managers and planners to support the development of effective forest-based initiatives. Materials and Methods: A scoping review was performed with a five-phase method integrating a systematic approach on Scopus, Web of Science and PubMed databases and snowball search. Studies were analyzed using a descriptive-analytical method. Results: Overall, 93 papers were included in the review. These are mainly from health-related sciences providing limited information for forest managers, planners and practitioners. Four main underlying variables of the forest-wellbeing relationship are identified: interaction, forest features, sensorial dimension of the forest and individual traits and reactions. Conclusions: Forest-based initiatives provide good opportunities for supporting public health and time spent in contact with forests seems to have a “health-bonus”. Whether and to what extent forest management can contribute to this is still poorly investigated. There is the need to better study causal relationships between specific forest features, type of interactions, frequency and “dose” of experiences, individual reactions and needs and wellbeing effects to maximize benefits from forest-based initiatives.

Effects of forest bathing on pre-hypertensive and hypertensive adults: a review of the literature

The aim in this literature review was (1) to explore the physiologically and psychologically therapeutic benefits of forest bathing on adults suffering from pre-hypertension or hypertension, and (2) to identify the type, duration, and frequency of an effective forest bathing intervention in the management of pre-hypertension and hypertension, so as to provide directions for future interventions or research. The electronic databases PubMed, Cochrane Library, CINAHL, PsyINFO, and the China Academic Journals (CAJ) offered through the Full-text Database (CNKI) were searched for relevant studies published from the inception of the databases to April 2019. Of the 364 articles that were identified, 14 met the criteria for inclusion in this review. The synthesis of the findings in the included studies revealed that forest bathing interventions were effective at reducing blood pressure, lowering pulse rate, increasing the power of heart rate variability (HRV), improving cardiac-pulmonary parameters, and metabolic function, inducing a positive mood, reducing anxiety levels, and improving the quality of life of pre-hypertensive or hypertensive participants. Forest walking and forest therapy programs were the two most effective forest bathing interventions. Studies reported that practicing a single forest walking or forest therapy program can produce short-term physiological and psychological benefits. It is concluded that forest bathing, particularly forest walking and therapy, has physiologically and psychologically relaxing effects on middle-aged and elderly people with pre-hypertension and hypertension.

Urban Trees and Human Health: A Scoping Review

The urban forest is a green infrastructure system that delivers multiple environmental, economic, social and health services, and functions in cities. Environmental benefits of urban trees are well understood, but no review to date has examined how urban trees affect human health. This review provides a comprehensive summary of existing literature on the health impacts of urban trees that can inform future research, policy, and nature-based public health interventions. A systematic search used keywords representing human health, environmental health, and urban forestry. Following screening and appraisal of several thousand articles, 201 studies were conceptually sorted into a three-part framework. Reducing Harm, representing 41% of studies, includes topics such as air pollution, ultraviolet radiation, heat exposure, and pollen. Restoring Capacities, at 31%, includes attention restoration, mental health, stress reduction, and clinical outcomes. Building Capacities, at 28%, includes topics such as birth outcomes, active living, and weight status. The studies that were reviewed show substantial heterogeneity in purpose and method yet indicate important health outcomes associated with people’s exposure to trees. This review will help inform future research and practice, and demonstrates why urban forest planning and management should strategically promote trees as a social determinant of public health.

The Psychological Effects of a Campus Forest Therapy Program

This study aimed to examine the psychological effects of a campus forest therapy program. To evaluate these, pre-test and post-test control group design was employed. A total of 38 participants participated in this study (19 in the campus forest therapy program group, and 19 in control). The Profile of Mood State (POMS) questionnaire and Modified form of the Stress Response Inventory (SRI-MF) were administered to each participant to assess psychological effects. The results of this study revealed that participants in the campus forest therapy program group had significantly positive increases in their mood and stress response compared with those of control group participants. In conclusion, the campus forest therapy program is an efficient strategy to provide psychological health benefits to university students and our study can inform decision-makers on the priority of the campus forest program in societal efforts to promote psychological well-being among university students.

Physiological and Psychological Effects of Watching Videos of Different Durations Showing Urban Bamboo Forests with Varied Structures

This study illustrated the physiological and psychological effects of watching videos of different durations showing bamboo forests with varied structures. Physiological indicators, including EEG (electroencephalogram), blood pressure, skin conductance, and pulse, were monitored in 180 Chinese university students (mean age: 20.72 ± 2.56 years) while they were watching bamboo videos. Before and after watching the videos, their psychological indicators, including positive and negative moods, were measured using the Profile of Mood States questionnaire. After watching the bamboo videos of different durations, all of the physiological indicators responded to the stimulation after only 1 min. The indicators showed different trends at 1, 3 and 5 min. EEG decreased and then was maintained at a stable level after 1 min, and the high β, low β, and α waves had no significant differences between 1, 3 and 5 min. Blood pressure dropped to a stable state after 3 min, and the decline was significantly different greater after 3 min than after 1 min. Skin conductance increased for 1 to 5 min, and it did not stabilize after a long time (5 min). Pulse decreased after 1 min but increased after 5 min. After watching the videos with bamboo of varying structures, the physiological and psychological indicators showed significantly different changes. Skin conductance significantly increased (mean value: 6.78%), and the amount of sweat was more effectively reduced, thereby reducing tension, when the students viewed videos of sympodial bamboo forests compared with monopodial bamboo forests. Bamboo forests with a higher canopy density (0.83–0.85) could significantly decrease α waves (mean value: 1.50 Hz), relaxing the human body. High β and low β waves showed greater decreases, with tension reduced more effectively, when bamboo forests with a low tilt ratio (< 1.5%) were viewed. Bamboo forests with neat undergrowth could have more beneficial physiological and psychological effects on the human body.

Measures to Promote Rural Healthcare Tourism with a Scientific Evidence-Based Approach

The present study aimed to evaluate the effects of physical activities on human health in forests in countryside and rural areas. The test experiment was conducted in a countryside forest, whereas the controlled experiment was conducted in an urban area where the study participants resided. A total of 22 participants (aged 20.9 ± 1.3 years) were evaluated in this study. Heart rate variability and salivary cortisol level were used as indices of physiological conditions, and semantic differential method, profile of mood states (POMS), and state-trait anxiety inventory (STAI) were used to evaluate the participants' emotional states. The participants were asked to walk around forest and urban areas for 15 min. The results were as follows. As compared to the urban area, in the forest area, (1) the power of the high-frequency (HF) component of the heart rate variability (HRV) was significantly higher; (2) low-frequency (LF)/(LF + HF) was significantly lower; (3) salivary cortisol level was significantly lower; (4) the participants felt more comfortable, natural, relaxed, and less anxious and showed higher levels of positive emotions and lower levels of negative emotions. Consequently, walking in the forest area induces relaxing short-term physiological and psychological effects on young people living in urban areas.

How Should Forests Be Characterized in Regard to Human Health? Evidence from Existing Literature

The potential of forests as a source of health has been addressed by the scientific community and is now being considered in national forest strategies, management plans and policies. Studies identifying the mechanisms by which forest characteristics may induce these effects on human health are nevertheless scarce. This systematic review of literature on forests and human health with real-life human exposure was conducted to assess the extent to which forests have been studied and described in detail and the extent to which relationships between forest variables and health effects have been reported. The analysis underlines the lack of forest descriptions in 19.35% of the 62 studies selected for review as well as the high heterogeneity of forest variables’ description. Patterns among the articles could not be identified correlating the broader forest variable (forest type) and the most studied health variables identified (blood pressure, pulse rate or/and cortisol levels). These findings, together with previous ex situ researches, suggest the need to ameliorate and incorporate more accurate descriptions of forest variables within human health studies to provide data for forest management and the potential use of these habitats for preventive medicine and clinical practice guidelines.

The Effects of a Forest Therapy Programme on Mental Hospital Patients with Affective and Psychotic Disorders

The positive effect of forest bathing on the mental health and wellbeing of those suffering from post-traumatic stress disorder or experiencing stress has been proven. It is not known, however, how 'forest therapy' affects the mental health of people who are treated in a psychiatric hospital for affective or psychotic disorders. Potentially, forest therapy could bring many benefits to these people. To test the potential effectiveness of this therapy, a quasi-experiment was carried out in a psychiatric hospital in Olsztyn (north Poland). In the summer and autumn of 2018, the patients of the psychiatric hospital in Olsztyn participated in forest therapy interventions. The proposed forest therapy consisted of participating in one hour and forty-five minutes walks under the supervision of a therapist. Subjects filled out the Profile of Mood States Questionnaire (POMS) and the State Trait Anxiety Inventory (STAI-S) before and after the study. In the case of a group of patients with affective disorders, forest therapy had a positive effect on nearly all POMS scale subscales, with the exception of the 'anger-hostility' subscale, which did not change its values significantly after the intervention. In these patients, the greatest impacts were noted in the subscales 'confusion' and 'depression-dejection'; the level of anxiety measured with the STAI-S scale also significantly decreased. In the case of patients with psychotic disorders, the values of the 'confusion' and 'vigour' subscales and the STAI-S scale exhibited the greatest changes. These changes were positive for the health of patients. Regarding the 'fatigue' subscale, no significant changes were observed in patients with psychotic disorders. The observed changes in psychological indicators in psychiatric hospital patients with both kinds of disorders indicate that the intervention of forest therapy can positively affect their mental health. The changes observed in psychological indicators were related to the characteristics of the given disorder.

Combined Effect of Walking and Forest Environment on Salivary Cortisol Concentration

We investigated the effects of walking in a forest environment on salivary cortisol concentrations. Seventy-four young male participants walked for 15 min in forested and urban environments, and saliva was collected before and after walking. Our previous study reported salivary cortisol concentrations after walking only. This study was aimed at clarifying the combined effects of walking and environment by comparing post-walking data with pre-walking data. Walking in a forest environment decreased mean cortisol concentration from 9.70 to 8.37 nmol/L, whereas walking in an urban environment barely changed mean cortisol concentration, from 10.28 to 10.01 nmol/L. Two-way repeated analysis of variance revealed a significant interaction effect between the environment and walking (p < 0.001) in addition to the main effects of each (p < 0.001 and p = 0.001, for walking and environment, respectively). For further analysis, the proportion of participants who exhibited decreased cortisol after forest-walking was compared with the previously reported proportion of participants who exhibited decreased cortisol after viewing forest landscapes. Although the proportion of positive responders was slightly higher after walking (69%) than it was after viewing (60%), this difference was not statistically significant (p = 0.093). The present study revealed a significant combined effect of walking and the environment on cortisol concentrations.

Facial Expressions of Visitors in Forests along the Urbanization Gradient: What Can We Learn from Selfies on Social Networking Services?

People’s satisfaction towards the experience in forests is one of most important feedbacks that forest park managers need to meet positive visitors’ experiences. Although the drawbacks of questionnaire methodology are obvious for data collection from self-reported scores at the landscape scale, few alternative methods have been proposed. In this study, nine urban forest parks along the urbanization gradients in three capital cities of Northeast China were targeted to investigate their visitors’ selfies from social networking services (SNS) by assessing facial expressions. A total of 935 photos with location records were obtained from the SNS platform of Sina Micro-Blog in a social hot-event of ‘Golden Week Holidays of National Day of China’ of 2017. Images were recognized by FireFace software to assess scores of neutral, happy, sad, angry, surprised, scared, disgusted, and contempt expressions. Data were ranked in descending order and analyzed by Friedman’s test, correlation analysis, and Poisson regression. Visitors in downtown-forests showed fewer negative expressions at the most northern city than at the southern most one. The negative expressions tended to be alleviated with the increasing distance of forest parks from downtown. However, when the distance reached over 10 km no geographical effect was found. Female visitors showed positive emotional expressions to urban forests while male visitors showed no response. In conclusion, using data from SNS, this study found an experience in forest park less than 10 km from the downtown of a northern city resulted in female visitors showing the most positive expressions.

The Effect of Recreation in a Snow-Covered Forest Environment on the Psychological Wellbeing of Young Adults: Randomized Controlled Study

Forest recreation can be successfully conducted for the purpose of psychological relaxation, as has been proven in previous scientific studies. During the winter in many countries, when snow cover occurs frequently, forest recreation (walking, relaxation, photography, etc.) is common. Nevertheless, whether forest therapy conducted in a forest environment with a snow cover will also have a positive effect on psychological indicators remains unknown. Furthermore, male subjects frequently participate in forest therapy experiments, whereas females are rarely involved. Thus, in this study, the effectuality of forest recreation during winter and with snow cover was tested on 32 young females. For these reasons, the experiment involved 15 min periods of relaxation in a forest environment or in an urban street environment, in addition to a pre-test under indoor conditions (randomized controlled study). Four psychological questionnaires Profile of Mood States (POMS), Positive and Negative Affect Schedule (PANAS), Restorative Outcome Scale (ROS), Subjective Vitality Scale (SVS)) were administered to participants before and after interventions. Results showed that participants’ levels of negative mood, as measured by different aspects of the POMS questionnaire (tension/anxiety, anger/hostility, depression/dejection, confusion, and fatigue), decreased after exposure to the forest environment. In contrast, both tension/anxiety and anger/hostility increased in the urban street environment. The indicator of negative affect from the PANAS questionnaire also increased after exposure to the urban street environment, whereas the indicator of positive affect based on PANAS was higher in the forest environment than in the urban street environment. Restorativeness and subjective vitality exhibited higher values after exposure to the forest environment in comparison to those from the control and pre-test. The changes in these indicators demonstrate that forest recreation in the snow during winter can significantly increase psychological relaxation in females, as well as show that recreation can be successfully conducted under these winter conditions.

The Influence of Forest Resting Environments on Stress Using Virtual Reality

To explore the effects of different types of forest environments for forest therapy, this study focused on forest resting environments. Seven representative forest resting environments found in field research in Beijing were used as independent variables and were shown to subjects by a virtual reality (VR) video. Stress level was used as the dependent variable, and blood pressure, heart rate, salivary amylase, and the Brief Profile of Mood States (BPOMS) were used as physiological and psychological indicators. A between-subjects design was used in the experiment. A total of 96 subjects were randomly assigned to each environment type, and only one type of forest resting environment was observed. Through the relevant sample t-test and one-way analysis of variance, the pre- and post-test data of the indicators were analyzed. This study found that all the seven different types of forest resting environments can produce stress relief effects to some extent. Different types of forest resting environments have different effects on relieving stress. The most natural environment does not have the most significant effect on stress relief. A water landscape has a positive effect on the relief of stress. The conclusions of this study are conducive to the better use of the forest environment for forest therapy services.

A Systematic Review and Meta-Analysis of Nature-Based Mindfulness: Effects of Moving Mindfulness Training into an Outdoor Natural Setting

Research has proven that both mindfulness training and exposure to nature have positive health effects. The purpose of this study was to systematically review quantitative studies of mindfulness interventions conducted in nature (nature-based mindfulness), and to analyze the effects through meta-analyses. Electronic searches revealed a total of 25 studies to be included, examining 2990 participants. Three analyses were conducted: Nature-based mindfulness interventions evaluated as open trials (k = 13), nature-based mindfulness compared with groups in non-active control conditions (k = 5), and nature-based mindfulness compared with similar interventions but without contact with nature (k = 7). The overall combined psychological, physiological, and interpersonal effects from pre- to post-intervention were statistically significant and of medium size (g = 0.54, p < 0.001). Moderation analyses showed that natural environments characterized as forests/wild nature obtained larger numerical effects than environments characterized as gardens/parks, as did informal mindfulness compared with formal mindfulness. The small number of studies included, as well as the heterogeneity and generally low quality of the studies, must be taken into consideration when the results are interpreted. PROSPERO registration number: CRD42017065639.

Effects of forest bathing (shinrin-yoku) on levels of cortisol as a stress biomarker: a systematic review and meta-analysis

Forest bathing is a traditional practice characterized by visiting a forest and breathing its air. This review aims to investigate the effects of forest bathing on levels of salivary or serum cortisol as a stress biomarker in order to understand whether forest bathing can reduce stress. Medline/PubMed, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar were systematically searched for relevant articles. The quality of included trials was assessed following the criteria of the NIH dedicated tools. Afterwards, a qualitative and quantitative synthesis of retrieved evidence was performed. A total of 971 articles were screened; 22 of them were included in the systematic review and 8 in the meta-analysis. In all but two included studies, cortisol levels were significantly lower after intervention in forest groups if compared with control/comparison groups, or a significant pre-post reduction of cortisol levels was reported in the forest groups. The main results of the meta-analysis showed that salivary cortisol levels were significantly lower in the forest groups compared with the urban groups both before (MD = - 0.08 μg/dl [95% CI - 0.11 to - 0.05 μg/dl]; p < 0.01; I² = 46%) and after intervention (MD = - 0.05 μg/dl [95% CI - 0.06 to - 0.04 μg/dl]; p < 0.01; I² = 88%). Overall, forest bathing can significantly influence cortisol levels on a short term in such a way as to reduce stress, and anticipated placebo effects can play an important role in it. Further research is advised because of the limited available data.

Physiological and Psychological Effects of Viewing Forests on Young Women

Research Highlights: This study demonstrated that viewing forest landscapes induced physical and mental health benefits on young women. Background and Objectives: The health-promoting effects of spending time in forests have received increasing attention; however, there is a lack of evidence-based research investigating the effects of spending time in forests on women. This study aimed to evaluate the physiological and psychological effects of viewing forest landscapes on young women. Materials and Methods: The experiments were conducted in six forests and six city areas and included 65 women (mean age, 21.0 ± 1.3 years). Participants viewed a forest and a city area for 15 min, during which their heart rate variability and heart rate were measured continuously. Blood pressure and pulse rate were measured before and after the viewing. After the viewing, participants’ psychological responses were assessed using the modified semantic differential method, Profile of Mood States (POMS), and the State–Trait Anxiety Inventory (STAI). Results: Compared with viewing city areas, viewing forest landscapes was associated with significantly higher parasympathetic nervous activity and lower sympathetic nervous activity and heart rate. Moreover, scores of the comfortable, relaxed, and natural parameters and vigor subscales of POMS were significantly higher with forest viewing. The scores of negative feelings, such as tension–anxiety, depression–dejection, anger–hostility, fatigue, and confusion, were significantly lower, as were scores for the total mood disturbance observed using POMS and the anxiety dimension observed using STAI. Conclusions: Viewing forest landscapes resulted in physiological and psychological relaxations in young women.