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Background: The benefits of nature for our health have been an increasing research focus in recent years. In the context of a global increase in mental health diagnoses, the potential health benefits of nature have attracted attention. One practical nature treatment is to walk in nature. However, evidence for this practice on mental health has not been comprehensively appraised to date. This systematic review synthesized the effects of nature walks for depression and anxiety, and evaluated the methodological rigor of studies. Methods: Academic databases including ProQuest, PsycINFO, Science Direct, and Google Scholar were utilized to identify eligible articles, which were examined using the Newcastle-Ottawa Scale. Results: Of 385 articles initially retrieved, 12 studies met all the eligibility criteria (nine pre-post within-subject studies, two quasi-experimental studies and one experimental between-subjects study). These studies demonstrated that nature walks were effective for state anxiety but not generalized anxiety and the effects for depression were inconsistent. Conclusions: Findings indicate that nature walks may be effective for mental health, especially for reducing state anxiety. However, the quality of the included studies varied, and small sample sizes were small, suggesting a need for more rigorous and large-scale research.
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Effect of Nature Walks on Depression and Anxiety:
A Systematic Review
Yasuhiro Kotera * , Melinda Lyons, Katia Correa Vione and Briony Norton
Citation: Kotera, Y.; Lyons, M.;
Vione, K.C.; Norton, B. Effect of
Nature Walks on Depression and
Anxiety: A Systematic Review.
Sustainability 2021,13, 4015.
Academic Editor: Takahide Kagawa
Received: 5 March 2021
Accepted: 2 April 2021
Published: 4 April 2021
Publisher’s Note: MDPI stays neutral
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Human Sciences Research Centre, University of Derby, Derby DE22 1GB, UK; (M.L.); (K.C.V.); (B.N.)
The benefits of nature for our health have been an increasing research focus in recent
years. In the context of a global increase in mental health diagnoses, the potential health benefits
of nature have attracted attention. One practical nature treatment is to walk in nature. However,
evidence for this practice on mental health has not been comprehensively appraised to date. This
systematic review synthesized the effects of nature walks for depression and anxiety, and evaluated
the methodological rigor of studies. Academic databases including ProQuest, PsycINFO, Science
Direct, and Google Scholar were utilized to identify eligible articles, which were examined using the
Newcastle–Ottawa Scale. Of 385 articles initially retrieved, 12 studies met all the eligibility criteria
(nine pre-post within-subject studies, two quasi-experimental studies, and one experimental between-
subjects study). These studies demonstrated that nature walks were effective for state anxiety but not
generalized anxiety and the effects for depression were inconsistent. Findings indicate that nature
walks may be effective for mental health, especially for reducing state anxiety. However, the quality
of the included studies varied, and sample sizes were small, suggesting a need for more rigorous and
large-scale research.
Keywords: nature walk; state anxiety; PRISMA; nature-based intervention; systematic review
1. Introduction
In recent years, there has been increasing interest in the psychological and physiologi-
cal benefits for individuals of spending time in nature [
]. Some of this interest is likely
to have been motivated by acknowledging the damage from harmful human activities on
our planet’s fragile ecosystems and a keenness to attempt to reverse the harm [
] as well as
from individual experiences of the simple benefits of enjoying time outside [
]. Spending
time in nature and feeling connected to nature have positive impacts on people’s mental
health and wellbeing [
]. There is evidence that undertaking physical activity in nature
can provide benefits above and beyond the benefits from the physical activity, through an
increased connection to nature. The scope of physical activities examined embraces activi-
ties from the extremes of “free solo” climbing and kayaking [
] to less strenuous activities
such as bird-watching or watching nature documentaries on TV [
] and the most popular
“middle-ground” activities involving spending time in nature without strenuous activity
including walking in nature. Nature-based interventions are potentially cost-effective
treatments [
] that can provide multiple benefits [
] and are potentially accessible to a
range of people providing there is adequate provision of public greenspace [
]. Forest
bathing (shinrin-yoku) has received particular attention because it is often free and more
accessible than established health interventions [
]. Other nature-based interventions,
including walking in nature, have been demonstrated to have positive wellbeing impacts,
including reducing stress levels [
]. Likewise, conducting a nature walk in a group re-
duced stress from stressful life events [
]. However, as for any therapy, there is still a need
to understand how health benefits manifest before nature-based activities could be utilized
Sustainability 2021,13, 4015.
Sustainability 2021,13, 4015 2 of 17
in practice [
]. A substantial increase in the research base is required before nature-based
activities can be prescribed alongside established therapies [9].
There is an urgent need for effective and cost-effective treatments for mental health
conditions [
]. Mental health is a global and growing health challenge. In 2017, an esti-
mated 792 million people were affected by mental health issues worldwide [
]. Since then,
the COVID-19 pandemic and associated widespread socio-economic changes are leading
to a mental health crisis globally [
]. Of the conditions assessed in 2017, anxiety and
depression were the most prolific disorders reported, affecting 284 million and 264 million
people, respectively [
]. Both of these conditions have increased prevalence during the
COVID-19 pandemic [16,17].
Anxiety encompasses a range of disorders including Generalized Anxiety Disorder,
Panic Disorders, and Social Anxiety Disorders. These disorders can hinder a person’s
ability to function normally, impacting job and academic performance, and personal
relationships [
]. During the COVID-19 pandemic, Hamilton and Coates [
] surveyed
6430 people in the UK and identified that almost half of the sample reported high anxiety,
with anxiety scores showing a marked increase from pre-pandemic scores. As for many
mental health conditions, anxiety is under-diagnosed, and there is a noted treatment gap for
anxiety globally [
]. Even where treatment has been prescribed, it still may not be reliable
or wholly effective. The main pharmacological treatments (most usually SSRIs (selective
serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors))
have significant potential for adverse effects and drug-drug interactions [
]. Psychological
therapies, such as CBT (Cognitive Behavioral Therapy), are recognized to have good efficacy
but are still most effective when used in combination with pharmacological treatments [
Considering the long experience of testing and patient use of these medications, there is a
need for different thinking about mental health therapy—perhaps toward a nature-based
treatment approach.
During the COVID-19 pandemic, it was estimated that almost one in five adults expe-
rienced some form of depression, doubling from around one in ten prior to the pandemic
with more than half of adults who experienced some form of depression also report-
ing high levels of anxiety [
]. Recognized symptoms include feeling sad or being in
a depressed mood, loss of interest or pleasure in activities once enjoyed, loss of energy,
and feeling worthless or guilty [
]. Treatments usually include talking therapies and
medications such as TCAs (tricyclic antidepressants), SSRIs (selective serotonin reuptake
inhibitors), and SNRIs (serotonin-norepinephrine reuptake inhibitors). However, some
of these do not yield the intended improvements. Many of the pharmacological treat-
ments have unpleasant side effects [
]. Furthermore, even with the extensive testing and
long history of use of these conventional treatments, patients with depression can both
improve and remit unexpectedly [
]. As for anxiety, these challenges suggest a need
to explore new ways of thinking about therapy for depression, such as those offered by
nature-based treatments.
The COVID-19 pandemic placed a heavy burden on health services including mental
health services [
]. The main psychological and pharmacological therapies are heavily
reliant on limited and often costly resources, leading to delays in treatment. While some
service providers have responded creatively to the shortfall during the pandemic, for
example, by moving CBT online to sustain the care processes [
], it is clear that mental
health systems need further innovation [
]. Greater need and reduced availability should
drive attention toward free and publicly accessible therapies that are not reliant on the
availability of professional care processes. This rationalizes a need to consider the efficacy
of nature-based therapies in a specific way.
Here, we systematically reviewed the literature for evidence of the effect of nature
walks on anxiety and depression outcomes. Nature walks are walks on a trail in a natural
setting such as forests, woodlands, or parks [
] that can take any time from 15 min [
to a few hours [
]. Nature walks can be undertaken by diverse populations (e.g., cancer
survivors [
], university students [
]) and conducted in any season of the year [
Sustainability 2021,13, 4015 3 of 17
We focused on nature walks as an example of a nature-based therapy because they are
simple and low-risk to undertake and potentially accessible to many people [
]. As
these practical aspects are crucial in the delivery of treatment, the mental health effect of
nature walks was chosen to be evaluated in this review.
2. Materials and Methods
This systematic review followed the preferred reporting items for systematic review
and meta-analysis guidelines (PRISMA [
]) to review the literature in an organized
manner and assess the quality of evidence for the psychological effects of nature walks.
Klassen, Jadad, and Moher’s framework [
] was used to help maintain the validity of our
findings, considering question, criteria, missing articles, quality of the studies, assessment,
and results. The extended version of the PICO (population, intervention, control, and
outcomes) format [
] was created to establish a researchable question by focusing on
four key components [
]. The primary research questions for this systematic review are
(i) “How effective are nature walks for depression and anxiety?” and (ii) “What quantity
and quality of evidence has been reported?”
2.1. Literature Search
Following a consultation with a subject librarian [
], four research databases—
ProQuest, PsycINFO, Science Direct, and Google Scholar—were accessed via EBSCO to
conduct a comprehensive literature search, focusing on where, when, who, how, what, and
why [
]. Articles published before 31 October 2020 were considered in this systematic
review. Three hundred and eighty-three articles were retrieved with search terms “nature”
AND “walk” AND “psychology*” (n= 333) as well as “forest” AND “walk” AND “psy-
chology*” (n= 50) in the title and abstract (other words such as “grassland”, “coastal”,
“greenspace”, and “woodland” were searched combined with “walk” AND “psychology*”;
however, only a small number of articles were retrieved, and none were eligible). Addi-
tionally, manual reference searches in published reviews [
] identified two articles [
Of a total of 385 articles, 44 were duplicates and therefore were removed. Three hundred
and forty-one articles were screened for title and abstract, and 45 articles were reviewed in
full text, which identified 12 articles that met all eligibility criteria (Figure 1). The co-author
Y.K. completed the literature search, which was then reviewed by the co-author K.C.V.
Sustainability 2021, 13, x FOR PEER REVIEW 3 of 20
survivors [32], university students [33]) and conducted in any season of the year [31,34].
We focused on nature walks as an example of a nature-based therapy because they are
simple and low-risk to undertake and potentially accessible to many people [35,36]. As
these practical aspects are crucial in the delivery of treatment, the mental health effect of
nature walks was chosen to be evaluated in this review.
2. Materials and Methods
This systematic review followed the preferred reporting items for systematic review
and meta-analysis guidelines (PRISMA [36]) to review the literature in an organized man-
ner and assess the quality of evidence for the psychological effects of nature walks. Klas-
sen, Jadad, and Moher’s framework [37] was used to help maintain the validity of our
findings, considering question, criteria, missing articles, quality of the studies, assessment,
and results. The extended version of the PICO (population, intervention, control, and out-
comes) format [38] was created to establish a researchable question by focusing on four
key components [39]. The primary research questions for this systematic review are (i)
“How effective are nature walks for depression and anxiety?” and (ii) “What quantity and
quality of evidence has been reported?”
2.1. Literature Search
Following a consultation with a subject librarian [40,41], four research databases—
ProQuest, PsycINFO, Science Direct, and Google Scholar—were accessed via EBSCO to
conduct a comprehensive literature search, focusing on where, when, who, how, what,
and why [42,43]. Articles published before 31 October 2020 were considered in this sys-
tematic review. Three hundred and eighty-three articles were retrieved with search terms
“nature” AND “walk” AND “psychology*” (n = 333) as well as “forest” AND “walk
AND “psychology*” (n = 50) in the title and abstract (other words such as “grassland”,
“coastal”, “greenspace”, and “woodland” were searched combined with “walk” AND
“psychology*”; however, only a small number of articles were retrieved, and none were
eligible). Additionally, manual reference searches in published reviews [43,44] identified
two articles [40]. Of a total of 385 articles, 44 were duplicates and therefore were removed.
Three hundred and forty-one articles were screened for title and abstract, and 45 articles
were reviewed in full text, which identified 12 articles that met all eligibility criteria (Fig-
ure 1). The co-author Y.K. completed the literature search, which was then reviewed by
the co-author K.C.V.
Figure 1. PRISMA flow diagram of the article selection process.
Figure 1. PRISMA flow diagram of the article selection process.
Sustainability 2021,13, 4015 4 of 17
2.2. Selection of Studies and Outcomes
In order to be further analyzed, articles needed to (a) include a nature walk only,
(b) measure depression and/or anxiety, (c) report an empirical intervention study (i.e.,
pre- and post-intervention scores of depression/anxiety), and (d) be published in a peer-
reviewed academic journal written in the English language. Articles were excluded if they
(a) included other nature-based interventions (e.g., shinrin-yoku), (b) did not measure
either depression or anxiety, (c) used a single-participant design (i.e., case studies), and
(d) did not examine an intervention (e.g., articles that only introduced and/or discussed
concepts or research protocols) (see Table 1).
Table 1. Extended PICO for this review.
Review Questions
(i) How Effective Are Nature Walks for Depression and Anxiety?
(ii) What Quantity and Quality of Evidence Has Been Reported?
Inclusion Criteria Exclusion Criteria
Population Any population
Intervention Nature walk only Involving other nature-based interventions
(e.g., shinrin-yoku)
Comparator Any comparator including
Outcomes Depression and anxiety Other outcomes
Study Design Empirical intervention studies
Single case studies, cross-sectional studies, qualitative
studies, reviews, discussion articles, articles introducing
Other Published in a peer-reviewed
academic journal in English
2.3. Data Extraction and Synthesis
The co-author Y.K. conducted all the searches and reviewed all the search results. If
the title and abstract of the article suggested a match with the eligibility criteria, the articles
were shortlisted for further analysis (n= 45). The co-author K.C.V. reviewed the selection
process to minimize any potential bias. After K.C.V.’s review, full texts of the shortlisted
articles were appraised by both co-authors independently, who then discussed and agreed
which articles met the eligibility criteria. No additional eligible articles were identified in
forward and backward reference searches.
Using a data extraction table, developed by Sturt et al. [
], key information of in-
cluded studies was presented: publication details (authors, year, and country), study
design and setting, participant characteristics, details of demographic data, intervention
details, outcome measures, and study findings (see Table 2).
2.4. Quality Scoring: Assessing the Risk of Bias
The Newcastle–Ottawa Scale (NOS) was used to appraise the methodological quality
and risk of bias [
]. Star marks (0–9) were used to indicate the quality scoring for each
study (high risk: 0–3, medium risk: 4–6, low risk: 7–9) regarding: (a) representativeness
of study group selection (four stars maximum), (b) comparability of groups (two stars
maximum), and (c) ascertainment of either the exposure or outcome of interest (three
stars maximum). Because the NOS was originally designed for medical research, some
adjustments were made in this review focusing on nature walk: (a) the word “exposure”
was changed to “intervention” (e.g., “Ascertainment of intervention”), (b) “Demonstration
that outcome of interest was not present at start of study” to “Demonstration that the
measured outcome was assessed before the intervention”; and (c) a star was given if the
outcome was measured using a validated psychometric scale, instead of medical records,
in the first item of “Outcome” (i.e., “Assessment of Outcome”).
Sustainability 2021,13, 4015 5 of 17
Table 2.
Study details of selected articles exploring the effects of nature walk on depression and anxiety (to be used in Results) (for details on “Nature/Urban exposure” and “Season”, see
Appendix A).
No. Year Author(s) Country Sample and Setting Intervention Details Nature/Urban Exposure Season Measures Findings
1 2020 Lesser et al. [32] Canada 9 adult cancer survivors
(8 females and 1 male).
2 trail walks per week
(2.5 h a week) for
8 weeks with a hiking
Forest—sloped area. Not recorded.
Disorder-7 and
Visual Analog
Significant reduction
in state anxiety but not
in generalized anxiety.
2 2020
Janeczko et al. [
75 university students
(nonclinical) divided
into either taking a walk
in apartment suburbs;
green suburbs;
coniferous forest; or
deciduous forest.
2-km walk (30 min)
keeping distance to each
other, not allowed to
Urban: A1: single-family
dwellings with more
greenery. A2:
multi-family buildings
with less greenery.
Forest: B1: coniferous
forest; B2: deciduous
One day. Late
Profile of Mood
States (POMS)
Depression was
reduced in all groups
from pre- to post-walk.
No difference was
found among groups.
3 2019 Koselka et al. [48] USA
38 participants (age
range 18–35; 22.9 +
4.6 years; 20 females and
18 males; nonclinical)
divided into (i) 50-min
nature walk, (ii) 50-min
walk on busy road, and
(iii) activity of daily
living. Crossover design.
50-min walk at
moderate-intense pace
with 9 days of washout
Busy road;
forest. Not recorded.
State-Trait Anxiety
Inventory (STAI)
Nature walk reduced
state anxiety.
4 2019 Song et al. [31] Japan
12 female university
students (age of the
approaches sample
(n= 60) was 21.0 ±
1.3 years) walked for
15 min either in a forest
or urban environment.
15-min nature walk and
urban walk crossover
next day.
Six locations, with a
paired city and
secondary forest site
(mixed oak woodlands).
Summer. POMS and STAI
Nature walk reduced
depression and
anxiety, and state
anxiety significantly
more than urban walk.
5 2018 Hassan et al. [33] China
60 nonclinical university
students (30 females and
30 males; mean age, 19.6
±1.42 years) randomly
allocated to a 15-min
nature or urban walk.
15-min nature walk and
urban walk crossover
next day.
Urban area;
bamboo forest.
One day. Season
not specified. STAI Nature walk reduced
state anxiety.
Sustainability 2021,13, 4015 6 of 17
Table 2. Cont.
No. Year Author(s) Country Sample and Setting Intervention Details Nature/Urban
Exposure Season Measures Findings
6 2018 Song et al. [49] Japan
585 Japanese male
students (Age 21.7 ±
1.6 years) walked for
15 min either in a
forest or urban
Crossover next day.
15-min nature walk
and urban walk
crossover next day.
City areas were either
downtown or near a
train station; “Safe,
forest areas.
Summer. POMS and STAI
Nature walk
reduced depression
and anxiety, and
trait anxiety
significantly more
than urban walk.
7 2016 Korpela et al.
13 depression patients
(9 females and
4 males; age range
29–59 years, M = 48,
Md = 52 years).
2-h walk a week for
8 weeks
Park with a lake and
ornamental plantings;
urban woodland.
Recruitment in
Beck Depression
Depression reduced
from pre- to
post-walk, and
post-walk to
3-month follow-up.
8 2015 Bratman et al.
60 nonclinical adults
(33 females and
27 males, total mean
age = 22.9 years)
randomly assigned to
nature or urban
individual walk for
50 min.
Participants were told
to take good pictures
to blind the
intervention. Nature
group comprised
30 participants
(18 females and
12 males, total mean
age = 22.8), and urban
group also comprised
30 participants
(15 females and
15 males, total mean
age = 22.9).
Urban walk: adjacent
to a major road.
Nature walk:
grassland, scattered
shrub, and oak trees.
Equal spread
across autumn,
winter, spring,
and summer.
Nature walk
reduced anxiety,
relative to urban
walk (separate data
on state and trait
anxiety were not
9 2015 Song et al. [52] Japan
20 middle-aged
individuals (58.0 ±
10.6 years) walked for
17 min either in a
forest or urban
Crossover next day.
17-min nature walk
and urban walk
crossover next day.
City; coniferous
Not recorded
(however, the
temperature of
the forest was 24
C and urban
was 28 C).
Nature walk
reduced depression
and anxiety
significantly more
than urban walk.
Sustainability 2021,13, 4015 7 of 17
Table 2. Cont.
No. Year Author(s) Country Sample and Setting Intervention Details Nature/Urban
Exposure Season Measures Findings
10 2015 Song et al. [53] Japan
23 male university
students (age 22.3 ±
1.2 years) walked for
15 min either in a
forest or urban
Crossover next day.
15-min nature walk
and urban walk
crossover next day.
Park that contained
many hardwood trees
and a large pond;
urban residential area.
(October) POMS and STAI
Nature walk
reduced depression
and anxiety
significantly more
than urban walk.
11 2014 Marselle et al.
1516 participants (66%
were female, and 88%
were aged 55 years or
older) who had
attended at least one
session in the Walk
for Health (WfH)
program responded
to online survey.
WfH attendee who
continued to walk
during the 13-month
of the research period
was defined as Nature
Group Walker, and
those who did not as
Non-Group Walker.
1081 Nature Group
Walkers and
435 Non-Group
Walkers were
Nature: “natural and
semi-natural places,
green corridor,
farmland, urban
green space, coastal,
or a mixture of any of
the above”.
Not recorded.
10-item Major
Group nature walk
reduced depression
from T1 to T2.
12 2013 Song et al. [55] Japan
13 male university
students (nonclinical)
aged 22.5 ±3.1 years
divided into park
walk and city walk.
Crossover design.
15-min walk in urban
parks and city
Urban park—treed;
city area.
One day.
Late autumn
Nature walk
reduced anxiety
(both POMS and
STAI) but not
Sustainability 2021,13, 4015 8 of 17
3. Results
3.1. Characteristics of the Studies
Of the 12 included studies, nine were pre-post within-subject studies [
], two were quasi-experimental studies [
], and one was an experimental between-
subjects study [
]. Study location varied considerably (see Table 2), six studies were
conducted in Asia (China and Japan), three were in North America (USA and Canada) and
in Europe (England, Finland, and Poland). Nine of the studies compared a nature walk
with an urban walk, one compared a nature walk with no walk, and one study included
the assessment of the outcomes in a typical day that did not involve walking in any of
the settings.
Regarding the psychological outcomes, eight of the included studies assessed anxiety
through either the Generalized Anxiety Disorder-7 or the State-Trait Anxiety Inventory;
two studies assessed depression using either the Beck Depression Inventory-II or the Major
Depressive Inventory, and six assessed mood using the Profile of Mood States. Sample sizes
were generally small (<100) for all but the Song et al. [49] and Marselle et al. studies [54].
Overall, the studies demonstrated that nature walks were successful in reducing state
anxiety [
], but the effects on generalized, trait anxiety were mixed [
In six studies, a significant reduction in depression was also observed [
However, Janeczko et al. [
] reported a reduction in depression regardless of the type of
walking (nature or urban). In fact, the impact of nature walking on depression appears to
be less consistent and was not observed by Song et al. [55].
Regarding the environments where nature walks were undertaken, eight studies were
in a forest or woodland [
], three studies included more than one type of
nature [
], and one study was in a predominantly grassland environment [
]. There
were water features present near the route in three studies [
]. Forest types varied
considerably between studies, including a bamboo forest [
], deciduous trees [
and coniferous forest [
], and four studies did not provide enough detail to determine
the type [
]. Three studies were undertaken in autumn [
], three were in
spring/summer [
], one study spanned four seasons but indicated little seasonal
variation in the region [51], one likely varied but was not specified [54], and three did not
specify, although images and descriptions implied trees were in leaf [32,33,48,52].
3.2. Risk of Bias
The risk of bias of the 12 included studies was deemed to be medium to high (see
Table 3). Five studies were deemed medium-risk [
], especially due to a
lack of a control group and for assessing the follow-up immediately after the interven-
tion. In only three of these studies was the representativeness of the sample adequately
addressed [
]. Bratman et al.’s [
] scored particularly well in comparability.
Marselle et al. [
] had the largest sample amongst all selected studies (n>1000), but
the experimental group was twice as large as the control group, and the researchers did
not measure the outcome before the intervention.
Finally, seven studies were deemed to have a high risk of bias [
]. Two
studies conducted a within-subject design with small samples [
]. None of the studies
assessed the outcome before the intervention and only tested the effect immediately after
the intervention, not considering long-term effects.
Sustainability 2021,13, 4015 9 of 17
Table 3. Assessment of risk of bias for intervention studies.
Bias Category Selection Comparability Outcome
Number of
Stars (0–9)
Author (Year)
Representativeness of Exposed Cohort
Selection of Non-Exposed Cohort
Ascertainment of Intervention
Demonstrate Outcome Assessed before Intervention
Comparability of Cohorts on Basis of Design (*) or Analysis (*)
Assessment of Outcome
Follow-Up Long Enough
Adequacy of Follow-Up
Lesser et al. (2020) [32] * * * 3
Janeczko et al. (2020) [
* * * * * 5
Koselka et al. (2019) [48] * * * * 4
Song et al. (2019) [31] * * 2
Hassan et al. (2018) [33] * * 2
Song et al. (2018) [49] * * 2
Korpela et al. (2016) [50] * * * * * 5
Bratman et al. (2015) [
* * * ** * 6
Song et al. (2015) [52] * * 2
Song et al. (2015) [53] * * 2
Marselle et al. (2014) [
* * * * * 5
Song et al. (2013) [55] * * 2
* (star mark) indicates that the study addressed the assessment item.
4. Discussion
This systematic review examined the quality and extent of evidence in studies in-
vestigating the effects of nature walks on depression and anxiety. Only 12 studies were
identified focusing specifically on an empirical evaluation of this intervention and reported
in English language peer-reviewed journals. Nature walks were found to reduce state
anxiety consistently but not generalized anxiety. There were no clear effects of nature walks
on depression in these studies. The small sample size and large variation in approach to
the studies mean it is not possible to draw conclusions about the type of nature walk that
would be most beneficial or who would benefit most from these.
The health benefits of spending time in nature [
] and of walking [
] are
well established. This review has found there are very few studies focusing specifically
on walking in nature for two specific mental health outcomes: anxiety and depression.
Consistent with studies focused just on walking, the effects on anxiety and depression
reported in studies included in this review were positive or neutral [
]. As reported
in a meta-analysis on forest bathing [
], anxiety was the one mental health condition
for which nature walks were consistently reported to be beneficial. More specifically,
the current review identified that nature walks were effective for state anxiety but not
for generalized anxiety. This may be explained by the soothing effects of phytoncides,
Sustainability 2021,13, 4015 10 of 17
antimicrobial organic compounds released from plants [
], which are known to reduce
stress and anxiety [
]. Indeed, phytoncides were also related to reduced depression
on a self-report measure [
]; however, more robust biological evidence supports a link
between phytoncides and anxiety [
]. Further research is needed to examine these specific
pathways through which nature walks provide mental health benefits.
A number of reviews looking at the physical and mental health benefits of walking
have identified a lack of consistency in study design and could therefore not draw strong
conclusions about the benefits and most effective interventions [
]. This challenge
is reflected in our review, where studies varied substantially in the participant group
composition and the intervention details. Participant groups included people with pre-
existing physical health conditions (cancer [
]), pre-existing mental health conditions
(depression [
]), any participant (but health controlled for [
]), or primarily healthy
subjects. Variation in participant groups made drawing any conclusions particularly
difficult in relation to depression outcomes, which were examined in only three studies.
Marselle et al. [
] found group walks in nature to be a strong predictor of lower depression
symptoms, while two studies focused on individuals found opposite effects of nature
walks on depression symptoms [
]. It is possible that walking in a group was the
important aspect of Marselle et al.’s study [
], although Janeczko et al. [
] also found
lowered depression symptoms on individual walks, and previous work has similarly
found inconclusive results of the benefits of group over individual activity [
]. A previous
systematic review has found walking to reduce depression symptoms [
] and that exercise
more generally is important in reducing depression symptoms [
], and it may be that
the act of walking rather than the environment the walk is in is what is important for
depression. There is insufficient evidence from the studies included in this review to draw
a robust conclusion.
The details of the intervention varied between studies. Lesser et al. [
] involved
walks up notable slopes, while two studies noted the route was flat [
]. Walk duration
varied from 2.5 h a week over multiple weeks [
] through to a single, 15-min route [
Janeczko et al. [
] found walking duration to have an important effect on all outcomes,
indicating these interventions are not comparable. The appropriate time “dose” of walking
is not well understood [
], and our review suggests the methodological approach needs
to be strengthened in future studies. This information is available for exercise more
generally [
], and methodological approaches could be extrapolated to the nature walk
context. None of the studies in this review compared walking to other treatment approaches
(pharmacological treatments or psychological therapies) although previous work has
suggested that treatment of depression with exercise may be most effective when combined
with a pharmacological approach [
]. Another aspect of the studies related to time is
the duration of effect. None of these studies assessed long-term effects of any of the
interventions, although one did indicate the study was a pilot, and the intention was to
follow up with a longitudinal study [48], which would be a welcome addition.
A key benefit identified for nature-based therapies is that they are free and publicly
accessible, in principle. Nature is not equally accessible to everyone, however [
], and
even where some form of nature is available it is not always of the same “quality” [
]. In
working toward recommendations for nature-based health interventions, it is important
to understand what nature is most beneficial to address both equity of provision and
to consider health outcomes in the context of other functions and benefits provided by
both greenspace [
] and blue space [
]. It was not possible in this study to look for
effects of particular types of natural environment as the environment varied considerably
between studies, from the broad vegetation type (e.g., forest vs. grassland), the inclusion
of additional features (e.g., water), and the season of study (autumn vs. spring/summer)
(Appendix A). There is a growing body of literature suggesting that people’s response to
nature varies depending on very specific measures of the environment, including vegetation
structure [
], leaf color and shape [
], season [
], perceived biodiversity [
], and
infrastructure on and management of the site [
]. Within the included studies, only
Sustainability 2021,13, 4015 11 of 17
one directly controlled for different aspects of the environment in their site selection [
and only a subset measured additional features of the environment [
]. In most
of the reviewed studies, it is not possible to separate out the influence of the different
aspects of the environmental conditions in the walking environments that may have
been providing any benefit. For example, two studies compared a nature walk with a
walk by a busy road [
]. These two environments differ on a wide range of metrics
including temperature, humidity (measured in Song et al. [
], Hassan et al. [
], and
Janeczko et al. [
]), light levels (measured in Song et al. [
]), noise pollution (measured
in Janeczko et al. [
]), air pollution, physical disturbances (e.g., passing cars), colors,
and shapes of the visual landscape. To parse out the relative importance of these features,
studies testing the different elements of the environment would be beneficial. Future studies
addressing the types of vegetation, vegetation context (including associated infrastructure),
the season, and the levels of biodiversity most beneficial for achieving health benefits from
nature walks would be important contributions to the literature [74,80,83].
As outlined above, the studies included in this review were not sufficiently comparable
in study design, participant selection, or intervention approach to draw robust conclusions
about the benefits of nature walks as an intervention for anxiety or depression. The
consistently positive effect of nature walks on state anxiety measures combined with the
medium to high risk of bias in the majority of studies included in this review suggest a
need for more targeted research in order to develop recommendations for health practice.
Despite the small number of studies, three continents were included (Asia, North America,
and Europe). Variation in effect between continents, country, and climatic region is an area
where future research would be beneficial. Consistent patterns across regions could be
sought by focusing on the environmental conditions and specific measures of the natural
environment (as above). None of the studies were randomized controlled trials. One study
did blind the participants to the purpose of the study. The mental health benefit of walking
in nature is a growing area of research and is reflected in the publication dates of the studies
included in this review, six of which were published in the last four years and all published
within the last nine years. There is a great deal of scope for undertaking more controlled
studies on this intervention for this area to continue to develop.
This review had four primary limitations. The first is that only studies published
in English-language academic journals were included. The number of studies missed
because of this is not known. The second is focusing on articles that are studying walks
exclusively. This strengthens the conclusions as the results can be confirmed to focus
on walks, but studies that report outcomes of nature walks in conjunction or addition
to other interventions may have been missed (e.g., studies that combined walking and
viewing [
]). The third limitation is in the specific aims of the included studies. While
the broad goal of all studies was to look at the effects of a nature or forest walk, the
variation in how these were measured reflects differences in the specific aims. Nine of
the studies focused on comparing the relative effects of a nature walk in contrast to an
urban walk [
], two studies compared measures before and after a
walk [
] and one study compared walking to not walking [
]. As the literature on
this topic grows, teasing apart these different comparisons would be worthwhile. Lastly,
this study did not focus on “park walks”, as the richness of nature can be significantly
limited in some parks: indeed, some of the included nature walk studies in this review were
conducted in the park; however, the richness of nature was reported. Close examination of
park walk literature can offer additional insights.
5. Conclusions
The 12 studies identified through this review focused specifically on the effects of
nature walks on anxiety and depression and suggest that state anxiety can be reduced
through nature walks. The effect of nature walks on generalized anxiety was mixed. The
evidence for effects of nature walks on depression symptoms was inconclusive. The low
number of studies with high variability in the subjects and the type of nature subjects were
Sustainability 2021,13, 4015 12 of 17
exposed to in these studies suggest more work is required. Given the global challenges to
healthcare systems of anxiety and depression and the relatively cost-effective treatment
intervention of a walk in nature, the establishment of a more robust research base on this
topic is warranted.
Author Contributions:
Conceptualization, Y.K.; methodology, Y.K.; validation, Y.K., M.L., K.C.V.,
and B.N.; formal analysis, K.C.V.; investigation, K.C.V. and B.N.; data curation, K.C.V. and B.N.;
writing—original draft preparation, Y.K., M.L., K.C.V., and B.N.; writing—review and editing, Y.K.,
M.L., K.C.V., and B.N. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not Applicable.
Informed Consent Statement: Not Applicable.
Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix A
Table A1.
Selected articles exploring the effects of nature walk on depression and anxiety with study details. Full study
details are in Table 2of the main text. Here, “Location” is added, and “Nature/Urban exposure” and “Season” are expanded
to include more detail from the papers.
No. Year Author(s) Country Location Nature/Urban Exposure Season
1 2020 Lesser et al. [32] Canada
Participants from
Fraser Valley, British
Columbia, Canada
“Lush green old growth forest”.
Not recorded. Description
suggests trees are in leaf.
2 2020 Janeczko et al.
[47]Poland Warsaw
Urban: A1 “among single-family
buildings with lots of greenery”,
“noticeably higher level of noise, the
presence of a wide two-lane street,
dominating apartment blocks and a
smaller share of green space”, green
ratio = 12.62%; A2 “multi-family
buildings dominated and the share of
greenery was smaller”, “a quiet
community with detached houses and
green areas”, green ratio = 10.5%.
Forest: B1: Kabaty Forest coniferous
forest, “species composition is
dominated by pines accompanied by
oaks and a share of younger birches
and a multitude of limes”, green ratio
= 0.58%; B2: Sobieski Forest,
deciduous forest, “dominated by
broadleaved species, with an old
forest, 120–160 years old, and
numerous types of trees, such as oaks,
pines, and beeches”, green ratio = 0.0%.
Sample photos and aerial images
One day.
Late autumn (November).
Outdoor temperature 10 a.m.
9.2 C at 10 a.m. in urban
areas, 8 C in the forest. Also
recorded: pressure, wind
speed, humidity, sound, and
Sustainability 2021,13, 4015 13 of 17
Table A1. Cont.
No. Year Author(s) Country Location Nature/Urban Exposure Season
3 2019 Koselka et al. [48] USA Evanston, IL
Both started “parking lot of Harms
Woods (George F. Nixon Woods”
Busy road “crossed Harms Road . ..
and walked east, on the sidewalk of
Old Orchard Road. This road is a busy
4 lane road that passes over Interstate
94 as it approaches a large shopping
mall approximately 1 km away”.
Forest preserve. “Participants assigned
to walk in the forest walked north
from the parking lot on a
well-groomed gravel trail into the
woods along the North Branch Trail
. . . , which follows the Chicago River
. . . . After walking north for
approximately 500 m, they crossed a
footbridge over the river then walked
south on the graveled trail for
approximately 750 m . . . . Distances
walked along both routes varied
depending on each participants’ pace.”
Sample photos included.
Photos indicate trees are in
4 2019 Song et al. [31] Japan
Six locations: Iwate,
Gifu, Hyogo, Ibaraki,
and Kanagawa
(2 locations)
Each location had one city site, one
forest site.
Forests: Iwate (secondary forest (red
pine and oak) and
artificial forest (larch)); Motosu
(secondary forest (oak
and cherry)); Hyogo (secondary forest
and maple)); Ibaraki (secondary forest
pine and oak)); Kanagawa 1
(secondary forest (red
pine and oak)); Kanagawa 2
(secondary forest (oak)
and artificial planting
Summer (5 August to
6 September). Variable
conditions. Also recorded:
weather, temperature,
humidity, and illuminance.
5 2018 Hassan et al. [33] China Chengdu
Urban area “that included many
traditional buildings”.
“Well-managed” bamboo forest
Sample photos included.
One day.
Season not specified.
Temperature: 22 C in the
bamboo forest; 27 C in the
urban site.
Humidity also recorded.
6 2018 Song et al. [49] Japan 52 locations all over
Japan (map provided)
City areas were either downtown or
near a train station; “safe,
well-maintained” forest areas,
representative of the region.
7 2016 Korpela et al. [50]
Park area: “a lakeside arboretum with
flowerbeds, bushes and old trees
surrounding a nineteenth-century
former manor house”.
Urban woodland: “area with old trees
and views over the lake is on a ridge
with a 19200s sight-seeing tower”.
Both within three km of the city center.
Recruitment in spring.
8 2015 Bratman et al.
[51]USA San Francisco Bay
Urban walk: “a main thoroughfare
through Palo Alto, a busy street with
three-to four lanes in each direction
and a steady stream of traffic (El
Camino Real)”.
Nature walk: “a park near Stanford
University (known as “The Dish”)
along a paved path through grassland
with scattered shrubs and oak trees”.
Both on “fairly level ground”.
Sample photos included.
Equal spread across autumn,
winter, spring, and summer.
Little climatic variation
between seasons due to
location. Season not analyzed.
Not raining.
Sustainability 2021,13, 4015 14 of 17
Table A1. Cont.
No. Year Author(s) Country Location Nature/Urban Exposure Season
9 2015 Song et al. [52] Japan Nagano
City; coniferous forest with Japanese
cypress trees (Akasawa Shizen
Kyuyourin; Akasawa natural
recreation forest). Image provided.
Not recorded. Average
temperature: forest was 21.4
C, urban was 28.1
C. Humidity also recorded.
10 2015 Song et al. [53] Japan Chiba
Park (Kashiwa-no-ha Park) that
contained many hardwood trees (e.g.,
maple, tulip trees, cherry trees, and
chestnut) and a large
pond; urban residential area.
Autumn (7, 15, 16 October).
Variable weather.
Temperature: park 18.0 ±1.7;
city 19.2 ±1.9.
Humidity and illumination
also recorded.
11 2014 Marselle et al.
Whole country.
Nature: “natural and semi-natural
places, green corridor, farmland, urban
green space, coastal, or a mixture of
any of the above”.
Not recorded.
12 2013 Song et al. [55] Japan Chiba
Urban park. Kashiwanoha Park. Treed.
City area.
Images provided.
One day.
Late autumn (November).
“Trees in the park had either
lost their leaves or the leaves
had turned red or yellow”.
Sunny. Temperature: 14.0 C
in the city, 13.8 C in the park.
Humidity and intensity of
illumination also reported.
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... A growing number of reviews and meta-analyses supports the link between nature exposure and depression [11][12][13][14][15][16]. For instance, short-term exposure to natural environments has shown positive but small effects on depressive mood [16]. ...
... Moreover, previous reviews adopted a restricted scope regarding nature exposure. For instance, they focused on one type of natural environment, such as forests [14,15], or a specific intervention, such as nature walks [13] and gardening [14]. Interestingly, no previous literature review was restricted to patients with clinical depression. ...
... This concurs with meta-analytic evidence that PA conducted in natural settings is associated with greater positive effects on depression compared to indoor exercise [76]. Previous evidence showing the benefits of NBIs for depressive symptoms mostly relied on studies with healthy subjects and clinical populations of patients without a formal diagnosis of depression [12][13][14][15][16]77]. The present review builds upon that literature and expands that knowledge to the few intervention studies comprising patients with clinical depression. ...
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Recent lifestyles changes have favored increased time in contact with screens and a parallel reduction in contact with natural environments. There is growing awareness that nature exposure and screen time are related to depression. So far, the roles of how these environmental lifestyles affect depressive symptoms and disorders have not been reviewed simultaneously. The aim of this review was to gather the literature regarding the role of nature exposure and screen time in depression. An emphasis was made on clinical samples of patients with well-defined depression and the different methodological approaches used in the field. A second goal was to suggest an agenda for clinical practice and research. Studies were included if they assessed depressive symptoms in patients with a clinical diagnosis of depression. An overview of the published literature was conducted using three scientific databases up to December 2021. Several interventions involving nature exposure have shown positive effects on depressive symptoms and mood-related measures. The most consistent finding suggests that walks in natural environments may decrease depressive symptoms in patients with clinical depression. Less researched interventions, such as psychotherapy delivered in a forest or access to natural environments via virtual reality, may also be effective. In contrast, fewer observational studies and no experimental research on screen time have been conducted in patients with clinical depression. Thus, recommendations for practice and research are also discussed. Scarce research, diverse interventions, and several methodological shortcomings prevent us from drawing conclusions in this area. More high-quality experimental research is needed to establish interventions with proven efficacy in clinical depression. At this stage, it is too early to formulate practice guidelines and advise the prescription of these lifestyles to individuals with depression. The present findings may serve as a basis to develop strategies based on nature exposure and screen time targeting clinical depression.
... However, NSs are considered effective in reducing state-anxiety, and may have a lower influence on trait-anxiety and symptoms of depression or other psychological disorders [14]. In turn, Berman et al. [15] presented NS anxiety as a preponderant factor in the assessment of the perceived risk in adventure programs involving risk, being extremely important for the emotional safety of the activity and, consequently, for physical safety. ...
... Marques et al. [27] reinforced the idea of the importance of sports practice, which brings about beneficial effects in terms of healthy habits, social integration, in addition to all physiological aspects that benefit from sports practice, and concluded that sports in a leisure context significantly decrease anxiety levels in practitioners, as classified by the rafting activity When we correlated the amount of weekly physical activity in our sample with the trait-anxiety, we did not find a correlation (p-value > 0.05), which is not in agreement with the literature found [14]. ...
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This study aimed to (i) analyze the levels of state-anxiety of rafting customers, before and after the activity; and (ii) characterize the levels of trait-anxiety and the amount of physical activity performed weekly by clients of a rafting activity. The sample had 100 subjects of a nature sports company, in the rafting activity, with a mean age of 33.27 ± 10.10 years, with 44% female and 56% male participants. They were evaluated in two moments M1 (pre-activity) and M2 (post-activity). In M1, the STAI-State-Anxiety questionnaire and the IPAQ-International Physical Activity Questionnaire (short version) were applied. In M2, the STAI Form 1 State-Anxiety questionnaire was applied again, followed by the STAI trait-anxiety. The results showed no correlation between the amount of weekly physical activity and levels of trait-anxiety (rho(100) = −0.144; p-value = 0.152), thus not corroborating with the existing literature. Regarding state-anxiety, we found that in 55% of cases, it decreased with the practice of rafting, which suggests that the practice may have an anxiolytic effect and promote the well-being and relaxation of participants promoting, in this way, the sustainability of the rafting activity.
... A fundamental issue in this area is sample size and statistical power Kotera et al., 2021;Stier-Jarmer et al., 2021). The sample sizes in the studies reviewed by Roberts et al. (2020) were generally small and very small in Frontiers in Psychology | ...
... Some of the quantitative studies had larger samples (but mean n < 100); however, typically these did not report on statistical power. Similarly in the review on forest bathing by Kotera et al. (2021), sample sizes were small, less than 100. Small samples can be problematic given that power to detect effects may be insufficient and often becomes an issue when looking to detect assumed small effect sizes. ...
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There is growing interest in nature-based interventions (NBI) to improve human health and wellbeing. An important nascent area is exploring the potential of outdoor therapies to treat and prevent common mental health problems like depression. In this conceptual analysis on the nature–depression nexus, we distil some of the main issues for consideration when NBIs for depression are being developed. We argue that understanding the mechanisms, or ‘active ingredients’ in NBIs is crucial to understand what works and for whom. Successfully identifying modifiable mediating intervention targets will pave the way for interventions with increased efficacy. We highlight a non-exhaustive list of five clinically relevant putative, candidate mechanisms which may underly the beneficial effects of NBIs on depression: stress, rumination, mindfulness, sleep and exercise. We also make the case that when developing NBIs it is important to not neglect young people, explore personalised approaches and focus on both treatment and prevention approaches. To achieve these aims methodologically rigorous programmes of clinical research are needed that include well-powered and controlled experimental designs including randomised controlled trials, qualitative research, longitudinal studies and large prospective cohorts.
... Although depression and anxiety demonstrate high diagnostic comorbidity and are strongly correlated in both clinical and non-clinical self-report samples, they are conceptually distinct constructs [32,33]. Depression is characterised by feelings of sadness, emptiness, irritability, hopelessness, emotional and motivational deficits [34], and is often linked to problems with relationships, work, physical health and suicidal behaviour [35]. Anxiety is distinguished by excessive worry and fear and associated behavioural disturbances [34]. ...
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As the awareness of mental health increases worldwide, how to improve mental health has begun to be discussed in many countries. Stress is known to cause diverse physical and mental health problems including psychopathologies. On the other hand, our previous studies identified that self-compassion, kindness and understanding towards oneself, is a key component for good mental health in many populations including Japanese workers. The government reports that Japanese workers suffer from high rates of mental health problems. However, the mechanism of how self-compassion helps their mental health remains to be evaluated. Accordingly, this study aimed to elucidate how self-compassion intervenes pathways from stress to psychopathologies, namely depression and anxiety. One hundred and sixty-five Japanese workers completed an online survey regarding self-compassion, depression, anxiety and stress. Correlation and path analyses were conducted. These four variables were significantly inter-related. While self-compassion mediated the pathway from stress to depression, it did not mediate the pathway from stress to anxiety. These exploratory insights assist in understand the mechanism of how self-compassion improves mental health, and inform effective methods to implement self-compassion interventions to the Japanese workforce.
... A systematic review revealed an unfortunate outcome, that many young people are reluctant to seek help from formal mental health services (9). Visiting nature, which is a leisure activity, has a positive impact on mental health (10) by decreasing depression, anxiety (11), and stress (12,13). As such, visiting nature may be an effective treatment approach for young people, whose health and psychological wellbeing are associated with autonomy needs gratification (14,15). ...
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It is known exposure to and connectedness with nature is beneficial for psychological wellbeing and stress relief. However, many factors hinder people, including young adults, from utilizing natural resources for healing. The present study indicates using a motivational enhancement approach and additional motivational elements in public messaging to address ambivalence toward nature exposure successfully results in favorable impacts on belief, intention, recall of positive nature elements, and perceived stress. Because this study coincided with the development of the COVID-19 pandemic in Taiwan, it offers a valuable opportunity for exploring how effective the motivational indicators were at different stages of the pandemic, as well as how connectedness to nature can explain perceived stress. In measuring motivation, we captured the essential elements of mobilizing young adults to connect with nature while also exploring potential expansion of behavioral indicators. We discuss how to foster inspiration during a pandemic to enhance connectedness to nature.
... In the last few years, there has been an increased interest in the health benefits of spending time in nature [8,9]. Contact with nature and health have been linked in three interconnected domains -reducing harm from exposure to environmental hazards such as noise; restoring capacities diminished by stress and constant stimuli; and building new capacities to interact socially with others and do new things [10]. ...
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Background Mental health conditions are one of the largest burdens of disease in Australia and globally. There is a need to seek innovative and alternative interventions that can prevent and alleviate mental health symptoms. Nature-based interventions (NBIs), namely programs and activities where individuals engage with natural environments with the aim of improving their health and wellbeing (e.g., nature walking groups), may be such an alternative. This study aimed to explore the perceptions of mental health clinicians on the potential benefits of, and barriers to, implementing NBIs within a community mental health setting. Methods This study used a qualitative, exploratory research design. Fifteen mental health clinicians were recruited from the Illawarra Shoalhaven Local Health District, Australia, and interviewed (September–October 2021) about their perceptions of NBIs within mental health settings. The semi-structured interviews were analysed using an inductive thematic approach and managed with NVivo. Results Mental health clinicians viewed spending time in nature as relaxing, refreshing, and therapeutic. Many described it as part of their lifestyle and encouraged consumers to engage in nature-based activities on their own time. If NBIs were to be introduced as part of mental health services, clinicians expressed willingness to promote them to their consumers. Clinicians listed many potential benefits of NBIs for mental health consumers including improved mood, calmness and relaxation, a sense of empowerment, and social connections. Despite these benefits, clinicians were concerned about a variety of barriers to NBIs including consumers’ mental health symptoms such as anxiety or lack of motivation, scepticism, and geographic accessibility, as well as organisational barriers such as policies around safety risk. Conclusion Responding to the individual and organisational factors that could hinder the implementation of NBIs while building on the existing evidence of the positive impact of nature on health and wellbeing and, as demonstrated in this study, mental health clinicians’ interest and supportiveness of NBIs, mental health services should consider the implementation of NBIs as part of routine practice.
... In Taiwan, 15.1% of a community sample reported depressive symptoms, with younger age (those in an age group of 20 to 44) being a variable significantly related to a higher depression rate [3]. Apart from psychiatric and psychological interventions as treatments, systematic review and meta-analysis has revealed the effects of nature-based interventions on mental health [4], depression, and anxiety [5]. There is demand for more evidence-based support of the long-term outcomes and effects on behavior that nature-based programs produce [6], as well as demand for more evidence-based encouragement for people to be physically active in nature [7,8]. ...
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Empirical evidence of nature’s benefits to cognitive and emotional well-being is emerging. In this study, 48 Taiwanese young adults (24 indoors and 24 outdoors in urban greenspace) completed four weekly 45 min exposure sessions. The study explores whether the outdoor group surpasses the indoor group in cognitive and emotional well-being and nature connectedness. There were no significant differences for the indoor group across different measurements of rumination and connectedness to nature. However, the outdoor group displayed a significant reduction in rumination post-test compared to the one week prior and the first session. Similarly, for sessions two, three, and four and one month post-test, the outdoor group’s connectedness to nature was significantly higher than pre-test. Specific autobiographical memory was enhanced while overgeneral autobiographic memory was reduced during the third and fourth sessions, though these changes were not sustained at one-month follow-up. Surprisingly, both groups yielded similar results in decreased depression, anxiety, and stress. A significantly higher number of outdoor group participants had employed nature exposure for coping with stress or emotions after the program. We discuss the implications of this for counseling services for young adults and highlight future research possibilities, including formulating a nature-exposure protocol and a program evaluation for consolidating evidence-based nature prescription.
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Recently, there has been an increase in feelings of loneliness and mental health conditions among adolescents. Within this population, parenting teens are at an increased risk for these conditions. Outdoor experiences are shown to be an antidote to loneliness and a way to promote social connectedness by amplifying the processes for supporting social relationships. In 2020–2021, we piloted the 8-week Meeting in Nature Together program (MINT) at a charter school for pregnant and parenting teenagers in Colorado, USA. MINT aimed to promote relatedness and nature connection for students ages 14 to 19. MINT included online and in-person group meetings with educational content, creative activities, discussion, park excursions, mindfulness activities, journaling, and nature photography. Here, we ask, can a school-level nature-based social intervention reduce loneliness among pregnant and parenting teens by promoting and sustaining social connections? How acceptable is MINT to participants? Methods included audiovisual recording transcriptions, surveys, and observation field notes. Results suggest that MINT fostered social connections through a tailored nature-based intervention delivered to a typically isolated community in culturally sensitive, developmentally appropriate ways. MINT proved feasible and effective as participants reported high levels of satisfaction and interest in continuing to engage in activities promoted in MINT.
Background While walking in nature has been shown to improve affect in adults from the community to a greater extent than walking in urban settings, it is unknown whether such benefits apply to individuals suffering from depression. Using a parallel group design, this randomized controlled trial examined the effects of a single walk in nature versus urban settings on negative and positive affect in adult psychiatric outpatients diagnosed with major depressive disorder (MDD). Method Participants recruited from a psychiatric outpatient clinic for adults with MDD were randomly assigned to a nature or urban walk condition. Thirty-seven adults (mean age = 49 years) completed a single 60-minute walk. Negative and positive affect were assessed using The Positive and Negative Affect Schedule or PANAS at 6 time points: before the walk, halfway during the walk, immediately post-walk, at home before bedtime, 24 h post-walk, and 48 h post-walk. Results Controlling for baseline levels of affect before the walk, individuals who walked in nature experienced overall lower levels of negative affect, F(1, 35.039) = 4.239, p = .047, compared to those who walked in urban settings. Positive affect did not differ across walk conditions. Limitations The generalizability of results are limited by the small sample size and the presence of more female than male participants. Conclusions Walking in nature might be a useful strategy to improve negative affect in adults with MDD. Future research should investigate different ways to integrate the beneficial effects of nature exposure into existing treatment plans for psychiatric outpatients with MDD.
The current lifestyle is characterize by an ever-increasing deficit of physical activity, which results in a reduction in the fitness of the population and a demonstration of health complications that are associated with reduced fitness. One of the most effective and safest physical activities is walking, which, with sufficient load intensity, significantly reduces the physical deficit, but also has a number of health benefits and significantly affects the preconditions for physical activity. In addition to physical fitness and health, walking also affects an individual's psyche, depression, aggression and anxiety. In the communication, we present an overview of the formative and preventive effects of walking as well as the principles of designing a walking-based exercise program.
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The current pandemic of the coronavirus disease 2019 (COVID-19) has negatively impacted medical workers’ mental health in many countries including Japan. Although research identified poor mental health of medical workers in COVID-19, protective factors for their mental health remain to be appraised. Accordingly, this study aimed to investigate relationships between mental health problems, loneliness, hope and self-compassion among Japanese medical workers, and compare with the general population. Online self-report measures regarding those four constructs were completed by 142 medical workers and 138 individuals in the general population. T-tests and multiple regression analysis were performed. Medical workers had higher levels of mental health problems and loneliness, and lower levels of hope and self-compassion than the general population. Loneliness was the strongest predictor of mental health problems in the medical workers. Findings suggest that Japanese medical workplaces may benefit from targeting workplace loneliness to prevent mental health problems among the medical staff.
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Forest Bathing, where individuals use mindfulness to engage with nature, has been reported to increase heart rate variability and benefit wellbeing. To date, most Forest Bathing studies have been conducted in Asia. Accordingly, this paper reports the first pragmatic controlled trial of Forest Bathing in the United Kingdom, comparing Forest Bathing with a control comprising an established wellbeing intervention also known to increase heart rate variability called Compassionate Mind Training. Sixty-one university staff and students (50 females, 11 males) were allocated to (i) Forest Bathing, (ii) Compassionate Mind Training or (iii) Forest Bathing combined with Compassionate Mind Training. Wellbeing and heart rate variability were measured at baseline, post-intervention and three-months follow-up. There were improvements in positive emotions, mood disturbance , rumination, nature connection and compassion and 57% of participants showed an increase in heart rate variability. There were no significant differences between conditions, showing that Forest Bathing had equivalence with an established wellbeing intervention. The findings will help healthcare providers and policy makers to understand the effects of Forest Bathing and implement it as a feasible social prescription to improve wellbeing. Future research needs to involve clinical populations and to assess the effects of Forest Bathing in a fully powered randomised controlled trial.
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The impact on the Profile of Mood States (POMS) of both walking in forest environments and viewing forest landscapes has already been demonstrated in previous research conducted by the authors of this paper. In both walking and viewing, decreases in tension-anxiety (T-A), depression-dejection (D), anger-hostility (A-H), fatigue (F), and confusion (C) were observed and an increase in vigor (V) was observed in forest environments when compared to urban environments. Walking and viewing exhibited similar tendencies, however the responses were quantitatively different. This study re-analyzes the POMS scores of 57 young Japanese women with specific reference to the differences between walking in and viewing forest environments. First, a comparison was made of POMS scores after walking and after viewing. F and C scores were found to be smaller after walking than after viewing, while the V score was larger after walking than after viewing. No significant differences were found in T-A, D, and A-H scores after either walking or viewing. The POMS scores in urban environment also exhibited the identical results. These results suggest that the act of walking has the psychological effect of increasing vigor and reducing some negative emotions, such as fatigue and confusion, regardless of environment. Second, to separate the walking effect from the environmental effect, the difference in forest and urban environment POMS scores was determined for each subject, and comparisons were then made between walking and viewing. The results reveal a significantly larger V score when walking than when viewing. Walking and viewing did not exhibit significant differences in other POMS scores. These results suggest that vigor is more enhanced by walking in forest environments than when viewing forest landscapes. This study, therefore, revealed the specific effects of walking in forest environments.
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Background Cancer survivorship results in an increased number of physical and psychosocial health issues. Engaging in physical activity in natural environments is often thought of as restorative. Despite the potential benefits of engaging in physical activity in natural environments there are no sustainable community-based programs for cancer survivors that employ this form of physical activity. This study aims to evaluate the impact of an 8-week trail-walking (TW) program on anxiety in a population of adult cancer survivors. Methods The TW program consisted of two trail walks per week for 8 weeks led by a hiking guide. Individuals were eligible to participate if they were 19 years or older, were a cancer survivor, were not on active immunotherapy, and had medical clearance from their physician for physical activity. While 12 participants signed up for the program, 9 participants ( N = 9, 8 F, 1 M) completed the program. A mixed methodology included pre-and-post quantitative program surveys and post-program interviews. Questionnaires measured generalized anxiety, sleep disturbances, self-efficacy, self-esteem, psychological well-being and depression as well as pre-and-post hike state anxiety. Data was analysed using paired t-tests. Interviews were transcribed verbatim and an inductive thematic analysis was conducted to consolidate meaning and identify themes using NVivo 11 software. Results Average attendance was 74% of the 16 hikes. There was no significant reduction in the primary outcome of generalized anxiety ( p = .38). There was a significant reduction in perceived stress after 8-weeks ( p = .03) and a significant reduction in state anxiety after TW ( p < .001). None of the other secondary outcomes were statistically significant ( p > .05). Four overarching themes, or benefits, emerged from qualitative data analysis: (a) benefits of program design (b) physical benefits, (c) psychological benefits, and (d) social benefits. Conclusions These findings demonstrate the utility of a TW program for cancer survivors in order to promote physical, psychological and social health. Feasibility of a TW program would be contingent on access to natural areas for TW and an instructor-led program with other cancer survivors.
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Background The acknowledgment of the mental health toll of the COVID-19 epidemic in healthcare workers has increased considerably as the disease evolved into a pandemic status. Indeed, high prevalence rates of depression, sleep disorders, and post-traumatic stress disorder (PTSD) have been reported in Chinese healthcare workers during the epidemic peak. Symptoms of psychological distress are expected to be long-lasting and have a systemic impact on healthcare systems, warranting the need for evidence-based psychological treatments aiming at relieving immediate stress and preventing the onset of psychological disorders in this population. In the current COVID-19 context, internet-based interventions have the potential to circumvent the pitfalls of face-to-face formats and provide the flexibility required to facilitate accessibility to healthcare workers. Online cognitive behavioral therapy (CBT) in particular has proved to be effective in treating and preventing a number of stress-related disorders in populations other than healthcare workers. The aim of our randomized controlled trial study protocol is to evaluate the efficacy of the ‘My Health too’ CBT program—a program we have developed for healthcare workers facing the pandemic—on immediate perceived stress and on the emergence of psychiatric disorders at 3- and 6-month follow-up compared to an active control group (i.e., bibliotherapy). Methods Powered for superiority testing, this six-site open trial involves the random assignment of 120 healthcare workers with stress levels > 16 on the Perceived Stress Scale (PSS-10) to either the 7-session online CBT program or bibliotherapy. The primary outcome is the decrease of PSS-10 scores at 8 weeks. Secondary outcomes include depression, insomnia, and PTSD symptoms; self-reported resilience and rumination; and credibility and satisfaction. Assessments are scheduled at pretreatment, mid-treatment (at 4 weeks), end of active treatment (at 8 weeks), and at 3-month and 6-month follow-up. Discussion This is the first study assessing the efficacy and the acceptability of a brief online CBT program specifically developed for healthcare workers. Given the potential short- and long-term consequences of the COVID-19 pandemic on healthcare workers’ mental health, but also on healthcare systems, our findings can significantly impact clinical practice and management of the ongoing, and probably long-lasting, health crisis. Trial registration NCT04362358 , registered on April 24, 2020.
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Objectives: Previous pandemics have resulted in significant consequences for mental health. Here, we report the mental health sequelae of the COVID-19 pandemic in a UK cohort and examine modifiable and non-modifiable explanatory factors associated with mental health outcomes. We focus on the first wave of data collection, which examined short-term consequences for mental health, as reported during the first 4-6 weeks of social distancing measures being introduced. Design: Cross-sectional online survey. Setting: Community cohort study. Participants: N=3097 adults aged ≥18 years were recruited through a mainstream and social media campaign between 3 April 2020 and 30 April 2020. The cohort was predominantly female (n=2618); mean age 44 years; 10% (n=296) from minority ethnic groups; 50% (n=1559) described themselves as key workers and 20% (n=649) identified as having clinical risk factors putting them at increased risk of COVID-19. Main outcome measures: Depression, anxiety and stress scores. Results: Mean scores for depression ([Formula: see text] =7.69, SD=6.0), stress ([Formula: see text] =6.48, SD=3.3) and anxiety ([Formula: see text] = 6.48, SD=3.3) significantly exceeded population norms (all p<0.0001). Analysis of non-modifiable factors hypothesised to be associated with mental health outcomes indicated that being younger, female and in a recognised COVID-19 risk group were associated with increased stress, anxiety and depression, with the final multivariable models accounting for 7%-14% of variance. When adding modifiable factors, significant independent effects emerged for positive mood, perceived loneliness and worry about getting COVID-19 for all outcomes, with the final multivariable models accounting for 54%-57% of total variance. Conclusions: Increased psychological morbidity was evident in this UK sample and found to be more common in younger people, women and in individuals who identified as being in recognised COVID-19 risk groups. Public health and mental health interventions able to ameliorate perceptions of risk of COVID-19, worry about COVID-19 loneliness and boost positive mood may be effective.
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The biodiversity crisis demands greater engagement in pro‐nature conservation behaviours. Research has examined factors which account for general pro‐environmental behaviour; that is, behaviour geared to minimizing one's impact on the environment. Yet, a dearth of research exists examining factors that account for pro‐nature conservation behaviour specifically—behaviour that directly and actively supports conservation of biodiversity. This study is the first of its kind to use a validated scale of pro‐nature conservation behaviour. Using online data from a United Kingdom population survey of 1,298 adults (16+ years), we examined factors (composed of nine variable‐blocks of items) that accounted for pro‐nature conservation behaviour. These were: individual characteristics (demographics, nature connectedness), nature experiences (time spent in nature, engaging with nature through simple activities, indirect engagement with nature), knowledge and attitudes (knowledge/study of nature, valuing and concern for nature) and pro‐environmental behaviour. Together, these explained 70% of the variation in people's actions for nature. Importantly, in a linear regression examining the relative importance of these variables to the prediction of pro‐nature conservation behaviour, time in nature did not emerge as significant. Engaging in simple nature activities (which is related to nature connectedness) emerged as the largest significant contributor to pro‐nature conservation behaviour. Commonality analysis revealed that variables worked together, with nature connectedness and engagement in simple activities being involved in the largest portion of explained variance. Overall, findings from the current study reinforce the critical role that having a close relationship with nature through simple everyday engagement plays in pro‐nature conservation behaviour. Policy recommendations are made. A free Plain Language Summary can be found within the Supporting Information of this article. A free Plain Language Summary can be found within the Supporting Information of this article.
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Shinrin-yoku (forest-bathing), immersing oneself in nature using one's senses, has been receiving increased attention internationally. While most of the existing studies have focused on physical health, this systematic review and meta-analysis examined the mental health benefits of shinrin-yoku (i.e., depression, anxiety, anger), using the PRISMA guidelines (PROSPERO registery: BLINDED). Articles in English were retrieved on research databases including PubMed/MEDLINE, PsycINFO, Science Direct, and Google Scholar. Of 481 articles retrieved, twenty met the inclusion criteria (eight non-randomised and twelve randomised controlled trials). All studies were conducted in Asia and Europe and used a variety of different bathing approaches (e.g., breathing, walking, yoga). While noting a need for more rigorous research and more extensive follow-up assessments, the findings indicate that shinrin-yoku can be effective in reducing negative mental health symptoms in the short-term (large effects, g> .80); particularly, the effects on anxiety were largest. Overall, forest bathing improved depression, anxiety and anger in the short-term but there were a number of moderators of the effects. More careful examination of shinrin-yoku practices are needed; longer follow-up with participants from a range of countries along with greater examination of potential mechanisms of action are needed for shinrin-yoku to be accepted into mainstream interventions.
Objective The purpose of this systematic review is to evaluate the effect nature exposure has on stress as measured by physiologic markers and self-report. Design Researchers searched PubMed and JSTOR. Randomized control trials and cross-sectional studies were included if they met the following criteria: 1) included a clinical cohort and controls, and the intervention was nature exposure, either real or simulated; (2) utilized measurements of sympathetic activity or perceived stress; (3) study population consisted of greater than thirty male and female volunteers. Twelve studies were included for data extraction and review. Setting Researchers conducted this review at University of South Florida Morsani College of Medicine. Main outcome measures Researchers measured perceived stress through the Perceived Stress Scale (PSS) and Depression, Anxiety, and Stress Scale (DASS). Phsiologic stress was measured by salivary cortisol, blood pressure (BP), subgenual prefrontal cortex (sgPFC) activation on functional magnetic resonance imaging (fMRI), skin conductance level (SCL), heart rate variability (HRV), muscle tension, heart period, pulse transit time, amygdala and perigenual anterior cingulate cortex (pACC) activation on fMRI, respiratory sinus arrhythmia (RSA), and pre-ejection period (PEP). Results This review found an inverse relationship between nature exposure and various physiologic markers of stress in all 7 studies measuring physiologic stress. Perceived stress was also affected by higher exposure to nature as indicated by lower self-reports on the PSS and DASS in 5 out of 6 studies measuring perceived stress. Conclusions Nature exposure has been widely shown to have a positive effect in reducing stress, both perceived and physiologic.